What is the best course of treatment for a 60-year-old individual with anemia?

Management of Anemia in a 60-Year-Old Patient

For a 60-year-old patient with anemia, you must first confirm iron deficiency anemia through laboratory workup (hemoglobin, ferritin, transferrin saturation), then initiate oral iron supplementation at 60-120 mg daily while simultaneously investigating for underlying gastrointestinal pathology through upper endoscopy with duodenal biopsy and colonoscopy or CT colonography. 1, 2

Initial Diagnostic Workup

At age 60, anemia warrants thorough investigation as the yield of significant pathology is high, and even mild anemia substantially decreases quality of life and survival in this age group. 1, 3

Essential laboratory tests include:

• Complete blood count with hemoglobin, hematocrit, MCV, and RDW 1
• Serum ferritin (iron deficiency confirmed if <15 μg/dL) 1
• Transferrin saturation 1
• Vitamin B12 and folate levels 3
• Renal function (creatinine, GFR) to assess for chronic kidney disease 1
• Thyroid function tests 2
• Coeliac serology (anti-endomysial antibodies with IgA level) 1

Key diagnostic thresholds:

• Anemia is defined as hemoglobin <12 g/dL in women and <13 g/dL in men 1
• Iron deficiency is confirmed by ferritin <15 μg/dL combined with low hemoglobin 1

Gastrointestinal Investigation

At age 60, both upper and lower GI tract evaluation is mandatory unless a clear non-GI cause is identified, as gastrointestinal bleeding is the most common cause of iron deficiency anemia in this age group. 1, 3

Required investigations:

• Upper endoscopy with duodenal biopsies (to exclude coeliac disease and upper GI pathology) 1
• Colonoscopy or CT colonography (colonoscopy preferred if feasible; CT colonography is acceptable for those with comorbidities making colonoscopy higher risk) 1
• The prevalence of colorectal cancer and dual unrelated pathology increases with age, strengthening the need for complete evaluation 1

Important caveat: Carefully weigh risks versus benefits in patients with significant comorbidities or limited performance status, but at age 60 without major frailty, full investigation is typically appropriate. 1

Iron Replacement Therapy

Start oral iron supplementation immediately upon confirming iron deficiency anemia, even while investigations are ongoing. 1, 2

Oral iron regimen:

• Ferrous sulfate 200 mg three times daily (or ferrous gluconate/fumarate as alternatives) 1
• For better tolerability: 60-120 mg elemental iron daily 1, 2
• Iron absorbs best on an empty stomach, but taking with meals is acceptable if side effects occur 2
• Adding 500 mg vitamin C or taking with meat protein enhances absorption 1, 2

Monitoring response:

• Recheck hemoglobin after 3-4 weeks; expect a rise of approximately 2 g/dL 1
• If no response after 4 weeks despite compliance and absence of acute illness, measure MCV, RDW, and repeat ferritin 1
• Continue iron for 2-3 months after hemoglobin normalizes to replenish iron stores 1, 2

Failure to respond suggests:

• Poor compliance (most common) 1
• Continued blood loss 1
• Malabsorption 1
• Misdiagnosis (consider thalassemia trait in patients of African, Mediterranean, or Southeast Asian ancestry) 1
• Coexisting vitamin B12 or folate deficiency 3

Parenteral Iron Therapy

Consider intravenous iron if:

• Intolerance to at least two oral iron preparations 1
• Documented non-compliance with oral therapy 1
• Malabsorption syndromes 1
• Chronic kidney disease with functional iron deficiency 1

Note that parenteral iron does not produce faster hemoglobin rise than oral iron but is convenient and relatively safe in older adults. 1

Special Considerations for Age 60

Anemia in this age group is often multifactorial, with more than 75% having a specific treatable cause. 3

Common contributing factors include:

• Chronic kidney disease (screen if GFR <60 mL/min/1.73m²) 1
• Chronic inflammatory conditions (may elevate ferritin despite true iron deficiency) 1, 3
• Medications (aspirin, NSAIDs, anticoagulants causing occult GI bleeding) 1
• Nutritional deficiencies (B12, folate, dietary iron) 3
• Myelodysplastic syndrome (consider if refractory to treatment) 1

Follow-Up Protocol

After hemoglobin normalization:

• Monitor hemoglobin and MCV every 3 months for the first year, then annually 1
• Additional oral iron if hemoglobin or MCV falls below normal 1
• Further investigation only necessary if hemoglobin cannot be maintained with supplementation 1
• Resolution of anemia should be achieved within 6 months in 80% of patients 1

Critical pitfall: Do not assume menstrual blood loss or dietary insufficiency as the sole cause at age 60 without excluding GI pathology, as the risk of serious underlying disease is substantial. 1