What is the appropriate workup and treatment for a 66-year-old male with normocytic anemia?

Normocytic Anemia Workup for 66-Year-Old Male

A comprehensive workup for normocytic anemia in a 66-year-old male should include complete blood count with reticulocyte count, iron studies, vitamin B12 and folate levels, renal function tests, inflammatory markers, and assessment for occult blood loss. 1

Initial Laboratory Evaluation

• Complete Blood Count (CBC) with differential

  • Confirms normocytic anemia (MCV 80-100 fL)
  • Assess for other cell line abnormalities

• Reticulocyte Count

  • Low or normal: Suggests inadequate bone marrow response
  • High: Indicates hemolysis or blood loss 1

• Iron Studies

  • Serum ferritin
  • Transferrin saturation (TSAT)
  • Note: In inflammation, serum ferritin up to 100 μg/L may still be consistent with iron deficiency 2

• Inflammatory Markers

  • C-reactive protein (CRP)
  • Erythrocyte sedimentation rate (ESR)

• Renal Function Tests

  • Serum creatinine, BUN
  • eGFR (anemia can develop with creatinine as low as 2.0 mg/dL) 2

• Additional Tests

  • Vitamin B12 and folate levels
  • Thyroid function tests (hypothyroidism can cause normocytic anemia) 1
  • LDH, haptoglobin, bilirubin (to assess for hemolysis) 2
  • Direct antiglobulin test (Coombs test)
  • Peripheral blood smear examination

Specialized Testing Based on Initial Results

If initial workup is inconclusive:

• Occult Blood Loss Assessment

  • Fecal occult blood test
  • Consider GI endoscopy (especially important in elderly with iron deficiency) 3

• Bone Marrow Examination

  • Consider if diagnosis remains unclear after non-invasive testing
  • Particularly if suspecting myelodysplastic syndrome or other primary bone marrow disorder 4

• Additional Specialized Tests

  • Protein electrophoresis and cryoglobulin analysis 2
  • Glucose-6-phosphate dehydrogenase level
  • Evaluation for paroxysmal nocturnal hemoglobinuria (PNH) 2
  • Assessment for drug-induced causes

Common Causes of Normocytic Anemia in Elderly

1. Anemia of Chronic Disease/Inflammation

   • Associated with chronic infections, autoimmune disorders, malignancy
   • Characterized by normal or elevated ferritin, low TSAT

2. Chronic Kidney Disease

   • Common in elderly patients
   • Decreased erythropoietin production

3. Occult Blood Loss

   • Particularly GI bleeding
   • May present as normocytic before becoming microcytic

4. Myelodysplastic Syndrome

   • More common in elderly patients
   • Consider if other causes excluded

5. Multiple Nutritional Deficiencies

   • Combined iron and B12/folate deficiency can result in normocytic picture 5

Management Approach

Management should target the underlying cause:

• Iron Deficiency

  • Oral iron supplementation as first-line therapy
  • Continue for 2-3 months after hemoglobin normalizes 1
  • Investigate source of blood loss

• Chronic Kidney Disease

  • Consider erythropoiesis-stimulating agents if Hb <10 g/dL
  • Target Hb should not exceed 12 g/dL 1

• Anemia of Chronic Disease

  • Treat underlying condition
  • Consider erythropoiesis-stimulating agents in select cases

• Blood Transfusion

  • Reserve for severe symptomatic anemia
  • Use restrictive transfusion threshold (Hb 7-8 g/dL) in stable patients 1

Common Pitfalls to Avoid

• Assuming anemia is a normal part of aging - it never is and always warrants investigation 5
• Overlooking occult blood loss, particularly GI bleeding
• Inadequate iron replacement (not continuing therapy long enough to replenish stores)
• Failing to consider multiple concurrent causes of anemia in elderly patients 3
• Neglecting to monitor renal function when managing anemia 1
• Performing bone marrow examination before completing non-invasive workup 4

Remember that in elderly patients, multiple factors often contribute simultaneously to anemia, requiring a thorough and systematic approach to diagnosis and management.