What are the symptoms and treatment options for anemia in different patient demographics, including pregnant women and the elderly?

Symptoms of Anemia

Anemia presents with symptoms ranging from none (often discovered incidentally on laboratory testing) to severe manifestations including fatigue, weakness, shortness of breath, exercise intolerance, lightheadedness, palpitations, and in severe cases, angina or worsening heart failure. 1, 2, 3

Common Clinical Presentations

Asymptomatic Discovery

• Many patients, particularly older adults, are asymptomatic and anemia is discovered incidentally on routine laboratory testing 1
• The absence of symptoms does not exclude clinically significant anemia 1

General Symptoms Related to Decreased Oxygen-Carrying Capacity

• Fatigue and weakness are the most common presenting complaints 1, 2, 3
• Dyspnea (shortness of breath), particularly with exertion 1, 2, 3
• Exercise intolerance and decreased physical capacity 1, 3
• Lightheadedness or dizziness 2, 3
• Palpitations and tachycardia 2, 4

Cardiovascular Manifestations

• Chest pain or angina, particularly in patients with underlying coronary disease 1, 4
• Worsening heart failure symptoms including orthopnea and edema 4, 3
• Tachycardia as a compensatory mechanism 4

Neuropsychiatric Symptoms

• Difficulty concentrating and cognitive impairment 3
• Irritability and depression 3
• Headaches may occur 2

Iron Deficiency-Specific Symptoms

• Pica (craving for non-food items like ice, dirt, or starch) occurs in 40-50% of iron-deficient patients 4, 3
• Restless legs syndrome affects 32-40% of iron-deficient individuals 3
• In children: excessive sleepiness, learning disabilities, diminished attention span, and inappropriate behavior 4

Physical Examination Findings

• Pallor of skin, conjunctiva, or mucous membranes 1, 4
• Tachycardia at rest 4
• Signs of underlying conditions causing blood loss (e.g., gastrointestinal bleeding, heavy menstrual bleeding) 1, 3

Vitamin B12 Deficiency-Specific Neurologic Symptoms

• Bilateral lower extremity weakness and numbness 5
• Tingling sensations (paresthesias) 5
• Ataxia and clumsiness 5
• Decreased sensation in a dermatomal distribution 5
• Hyperreflexia 5
• Alterations to vision and smell 5
• Urinary incontinence 5
• Psychotic episodes in severe cases 5

Severity-Dependent Presentation

The severity and rate of development determine symptom intensity:

• Acute anemia (rapid blood loss) presents with more dramatic symptoms including hemodynamic instability 2
• Chronic anemia may be well-tolerated with minimal symptoms until hemoglobin drops significantly, as physiologic compensation occurs over time 1, 2

Population-Specific Considerations

Pregnant Women

• Symptoms may overlap with normal pregnancy complaints (fatigue, dyspnea) 6
• Iron deficiency affects up to 84% of pregnant women in the third trimester 3

Older Adults

• Anemia is associated with increased morbidity and mortality in this population 1
• Symptoms may be attributed incorrectly to aging or other comorbidities 1
• Lower threshold for cardiovascular symptoms due to decreased cardiac reserve 1

Patients with Chronic Inflammatory Conditions

• Those with inflammatory bowel disease (13-90%), chronic kidney disease (24-85%), heart failure (37-61%), or cancer (18-82%) have high rates of iron deficiency 3
• Symptoms may be masked by or attributed to the underlying condition 6, 3

Critical Warning Signs Requiring Urgent Evaluation

• Hemoglobin <9.0 g/dL in pregnant women warrants referral to a physician familiar with anemia management 6
• Symptomatic patients with hemoglobin ≤8 g/dL may require blood transfusion 1
• Neurologic symptoms (weakness, sensory changes, ataxia) suggest B12 deficiency requiring immediate treatment to prevent permanent damage 6, 5