What is the plan of care for an elderly patient with anemia, indicated by low hemoglobin and red blood cell count?

Plan of Care for Elderly Patient with Anemia

This elderly patient with hemoglobin of 11.6 g/dL requires immediate investigation to identify the underlying cause while simultaneously initiating oral iron supplementation, as any level of anemia warrants investigation in the presence of iron deficiency. 1

Immediate Diagnostic Workup

Essential Laboratory Tests

• Confirm iron deficiency status by checking serum ferritin (most powerful test for iron deficiency) and transferrin saturation to distinguish iron deficiency anemia from anemia of chronic disease 1
• Complete blood count with red cell indices to assess mean corpuscular volume and evaluate bone marrow function 1
• Reticulocyte count to determine if bone marrow response is appropriate 1
• Celiac serology (tissue transglutaminase antibody) should be performed in all patients with iron deficiency anemia 1, 2

Gastrointestinal Investigation Requirements

Upper and lower GI investigations are mandatory in this elderly patient unless there is obvious non-GI blood loss, as gastrointestinal malignancy (colonic or gastric cancer) is a critical cause that must be excluded 1

• Esophagogastroduodenoscopy (OGD) with duodenal biopsies to evaluate for gastric cancer, peptic ulcer disease, and celiac disease 1
• Colonoscopy (preferred over CT colonography) to exclude colorectal carcinoma, as this is superior for detecting bleeding sources 1
• Do not perform fecal occult blood testing as it provides no benefit in iron deficiency anemia investigation 1

The urgency is heightened because lower hemoglobin levels suggest more serious underlying disease 1

Treatment Initiation

First-Line Iron Supplementation

Start ferrous sulfate 200 mg once daily immediately while awaiting diagnostic results 2, 3

• Once-daily dosing improves tolerance compared to multiple daily doses while maintaining effectiveness 2
• Alternative formulations (ferrous gluconate or ferrous fumarate) are equally effective if ferrous sulfate is not tolerated 2
• Add vitamin C 250-500 mg twice daily to enhance iron absorption 2
• Take with meals if gastrointestinal discomfort occurs 3

Expected Response and Monitoring

• Hemoglobin should increase by approximately 2 g/dL after 3-4 weeks of oral iron therapy 2
• Check complete blood count at 3-4 weeks to confirm response 2
• Continue iron for 3 months after hemoglobin normalizes to fully replenish iron stores 2
• Monitor hemoglobin every 3 months for the first year 2

When to Escalate Treatment

Indications for Intravenous Iron

Switch to IV iron if: 2

• Intolerance to at least two different oral iron preparations
• No hemoglobin rise after 4 weeks of adequate oral therapy
• Malabsorption conditions are present (e.g., celiac disease, inflammatory bowel disease)

Preferred IV formulations: ferric carboxymaltose 1000 mg over 15 minutes, with resuscitation facilities available due to anaphylaxis risk 2

Blood Transfusion Criteria

Reserve transfusions only for patients with cardiovascular instability or symptomatic anemia (fatigue, hypotension, chest pain) 1

• Transfusion threshold should be no higher than 8 g/dL in asymptomatic patients 1
• This patient with hemoglobin 11.6 g/dL does not meet transfusion criteria unless symptomatic 1

Critical Pitfalls to Avoid

• Do not stop iron therapy when hemoglobin normalizes—continue for 3 months to replenish stores 2
• Do not fail to investigate the underlying cause while treating with iron supplementation 2
• Do not reassess response before 4 weeks, as earlier evaluation may miss the expected hemoglobin trajectory 2
• Do not assume this is simply "anemia of aging"—elderly patients with anemia require the same thorough investigation as younger patients, particularly to exclude malignancy 1

Special Considerations in Elderly Patients

In elderly patients, anemia is often multifactorial and may involve: 4, 5

• Nutritional deficiencies (iron, folate, vitamin B12)
• Chronic kidney disease (check creatinine and consider erythropoietin levels if GFR is reduced) 1
• Chronic inflammatory conditions
• Medications (NSAIDs are common causes of GI blood loss) 1

The presence of dual pathology (bleeding sources in both upper and lower GI tracts) occurs in 1-10% of elderly patients and should be increasingly considered with advancing age 1