What investigations are recommended for a 74-year-old male presenting with headaches and mild anemia (hemoglobin 118g/L)?

Diagnostic Workup for a 74-Year-Old Male with Headaches and Mild Anemia

A comprehensive diagnostic workup is essential for a 74-year-old male presenting with headaches and mild anemia (hemoglobin 118g/L), with gastrointestinal evaluation being the highest priority due to the high risk of occult GI malignancy in this demographic.

Initial Laboratory Evaluation

Complete Blood Count with Indices

• Confirm anemia (Hb 118g/L)
• Assess MCV to characterize anemia morphologically 1:
  • Microcytic (<80 fL): suggests iron deficiency, thalassemia
  • Normocytic (80-100 fL): suggests anemia of chronic disease, renal insufficiency
  • Macrocytic (>100 fL): suggests B12 or folate deficiency

Iron Studies

• Serum ferritin (primary test for iron deficiency) 1
  • <12 μg/dL is diagnostic of iron deficiency
  • 12-100 μg/dL may still indicate iron deficiency with concurrent inflammation

  • 100 μg/dL essentially rules out iron deficiency

• Transferrin saturation (target >20%) 2
• Total iron-binding capacity
• Serum iron

Additional Blood Tests

• Reticulocyte count (to assess bone marrow response) 1
• Vitamin B12 and folate levels
• Renal function tests (BUN, creatinine)
• Erythrocyte sedimentation rate and C-reactive protein (to assess inflammation)
• Hemoglobin A1c (to screen for diabetes)

Gastrointestinal Evaluation

In men over 65 years with iron deficiency anemia, GI blood loss is the most common cause 1, 3. The British Society of Gastroenterology recommends:

• Upper gastrointestinal endoscopy with duodenal biopsies (to rule out celiac disease)
• Colonoscopy (preferred) or barium enema
• These investigations should be performed even in the absence of overt GI symptoms 1

Headache Evaluation

Recent research has shown a significant association between iron deficiency anemia and chronic headaches 4, 5:

• Detailed headache history:

  • Frequency, duration, and characteristics
  • Associated symptoms (visual disturbances, nausea, photophobia)
  • Triggers and relieving factors

• Consider neuroimaging if:

  • New onset headache in elderly
  • Headache with neurological deficits
  • Severe, sudden-onset headache
  • Headache that worsens with position changes

• Screen for temporal arteritis if applicable:

  • Check for scalp tenderness, jaw claudication 1
  • If present, immediate ESR and CRP testing

Additional Considerations

• Medication review to identify potential causes:

  • NSAIDs and anticoagulants (found in 19.6% of elderly with iron deficiency anemia) 3
  • Other medications that may cause GI bleeding

• Assess for occult blood loss:

  • Fecal occult blood testing
  • If negative and iron deficiency confirmed, consider video capsule endoscopy or CT enterography

Management Approach

1. Treat underlying cause of anemia
2. Iron supplementation if iron deficiency confirmed:
   • Oral iron (60-120mg elemental iron daily) 2
   • Continue for 3 months after hemoglobin normalization 2
   • Monitor response (expect Hb increase ≥1g/dL within 14 days) 2

Common Pitfalls to Avoid

• Assuming anemia is simply age-related without thorough investigation
• Failing to investigate GI tract in elderly males with iron deficiency
• Discontinuing iron therapy too early before replenishing stores
• Not considering the relationship between headaches and anemia
• Treating symptoms without identifying the underlying cause

Follow-up

• Repeat CBC and iron studies after 2-4 weeks of treatment
• Complete endoscopic evaluation if not already performed
• Reassess headache symptoms after anemia correction

In this 74-year-old male, the combination of headaches and anemia requires thorough investigation, with particular attention to ruling out gastrointestinal malignancy, which is a common cause of iron deficiency anemia in elderly men 1, 3.