Management of Normocytic Anemia in a 76-Year-Old Patient
This 76-year-old patient with normocytic anemia (Hb 10.5 g/dL, MCV 84.7 fL) requires immediate evaluation for iron deficiency despite the normal MCV, followed by bidirectional endoscopy to exclude gastrointestinal malignancy, as elderly patients have high rates of occult GI pathology and dual lesions.
Initial Diagnostic Approach
Confirm Iron Status First
- Measure serum ferritin immediately as it is the most powerful test for iron deficiency, even in normocytic anemia 1
- Check transferrin saturation (TSAT <30% suggests iron deficiency) 1
- In elderly patients, iron deficiency can present with normocytic indices before becoming microcytic 1
- A serum ferritin <15 ng/mL confirms iron deficiency, though higher cutoffs may be needed in inflammatory states 1
Rule Out Other Nutritional Deficiencies
- Measure vitamin B12 and folate levels, as deficiencies can occur in normocytic anemia and are common in elderly patients 2
- Check renal function (creatinine, GFR) as chronic kidney disease is a major cause of normocytic anemia in this age group 1
- Assess thyroid function, as hypothyroidism causes normocytic anemia and is common in elderly populations 1
Gastrointestinal Evaluation (Critical in Elderly)
Bidirectional Endoscopy is Mandatory
All elderly patients with confirmed anemia require both upper and lower GI tract investigation unless there are prohibitive comorbidities 1:
Upper endoscopy with duodenal biopsies to exclude:
Colonoscopy or CT colonography because:
Important Caveats
- Do not accept upper GI findings (esophagitis, gastritis, ulcers) as the sole cause without completing lower GI evaluation 1
- Carefully weigh risks versus benefits in patients with severe comorbidities or limited life expectancy, discussing with patient and family 1
- Stop NSAIDs and antiplatelet agents if possible, but their use should not deter investigation 1
Additional Workup for Normocytic Anemia
Assess for Chronic Disease and Inflammation
- Check inflammatory markers (CRP, ESR) as anemia of chronic disease is common in elderly 1
- Review medication list for drugs causing anemia (azathioprine, sulfasalazine) 3
- Screen for occult malignancy if no GI source found 4
Evaluate Bone Marrow if Unexplained
- Consider myelodysplastic syndrome in elderly patients with persistent unexplained normocytic anemia 1, 4
- Bone marrow aspiration and biopsy may be warranted if other causes excluded 4
Treatment Strategy
Iron Replacement (If Deficiency Confirmed)
Start oral ferrous sulfate 200 mg three times daily 1:
- Expect hemoglobin rise of 2 g/dL after 3-4 weeks 1
- Continue for 3 months after correction to replenish stores 1
- Add ascorbic acid if response is poor 1
- Use parenteral iron only if intolerant to at least two oral preparations 1
Address Underlying Cause
- Treat identified GI lesions (malignancy, celiac disease, ulcers) 1
- Replace vitamin B12 or folate if deficient 2
- Manage chronic kidney disease per guidelines if GFR <60 mL/min/1.73m² 1
Monitoring Protocol
- Recheck hemoglobin at 3-4 weeks to confirm response 1
- If no response: reassess for continued blood loss, malabsorption, non-compliance, or misdiagnosis 1
- Monitor hemoglobin every 3 months for first year, then annually 1
Red Flags Requiring Urgent Action
- Hemoglobin <8 g/dL with symptoms: Consider blood transfusion 4
- Failure to respond to appropriate iron therapy: Pursue further investigation including small bowel evaluation 1
- Transfusion-dependent anemia: Consider enteroscopy for small bowel angiodysplasia 1
Key Pitfalls to Avoid
- Do not assume normocytic anemia excludes iron deficiency—check ferritin regardless of MCV 1
- Do not stop investigation after finding one lesion—dual pathology is common in elderly 1
- Do not attribute anemia solely to "old age"—there is always an underlying cause requiring identification 1, 4
- Do not delay endoscopy in elderly patients unless severe comorbidities truly preclude intervention 1