What is the diagnosis and management plan for an elderly patient with anemia, characterized by low hemoglobin (Hb) levels, iron deficiency, elevated Total Iron-Binding Capacity (TIBC), and high ferritin levels?

Anemia of Chronic Disease (Functional Iron Deficiency)

This elderly patient has anemia of chronic disease with functional iron deficiency, not true iron deficiency anemia—the elevated ferritin (326 μg/L) despite low iron (6) and low TIBC (29) indicates iron is trapped in storage and unavailable for erythropoiesis due to underlying inflammation or chronic disease. 1

Understanding the Laboratory Pattern

This constellation of findings is pathognomonic for anemia of chronic disease:

• Low hemoglobin (82 g/L or 8.2 g/dL) indicates moderate anemia requiring investigation 2
• Low serum iron (6) reflects reduced iron availability for red cell production 2
• Low TIBC (29) is the critical distinguishing feature—in true iron deficiency, TIBC is elevated (>400), but here it is markedly reduced, indicating the liver is not producing transferrin normally due to inflammatory suppression 1
• Elevated ferritin (326 μg/L) confirms adequate or excessive iron stores, ruling out absolute iron deficiency. Ferritin <30 μg/L indicates depleted stores; this patient has 10-fold higher levels 1
• Transferrin saturation will be low but for different reasons than iron deficiency—iron is sequestered in macrophages and hepatocytes, unavailable for erythropoiesis 2

Mandatory Investigations to Identify the Underlying Cause

The priority is identifying the chronic disease driving this pattern:

Inflammatory and Chronic Disease Workup

• C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to quantify inflammation 1
• Renal function (creatinine, eGFR) as chronic kidney disease is a leading cause in elderly patients and affects >20% of those over 85 years 2, 3
• Complete metabolic panel to assess for liver disease, diabetes, heart failure 4
• Thyroid function tests as hypothyroidism causes anemia 5

Malignancy Screening

• Gastrointestinal evaluation is mandatory even with elevated ferritin, as occult GI malignancy can present with mixed patterns in elderly patients 2
• Upper endoscopy with duodenal biopsies to exclude gastric cancer, peptic ulcer disease, and celiac disease (2-3% prevalence in IDA populations) 2
• Colonoscopy or CT colonography as colorectal cancer is common in this age group and dual pathology occurs in 10-15% 2
• Chest X-ray and age-appropriate cancer screening based on symptoms 5

Additional Hematologic Testing

• Vitamin B12 and folate levels as deficiencies are common in elderly and often coexist (multifactorial anemia in >50% of elderly cases) 3, 6, 7
• Reticulocyte count to assess bone marrow response—inappropriately low count suggests marrow suppression from chronic disease 2, 1
• Peripheral blood smear to evaluate for myelodysplastic syndrome, which accounts for unexplained anemia in up to one-third of elderly patients 6, 5

Treatment Strategy

Do NOT Give Oral Iron Supplementation Initially

Oral iron is contraindicated as first-line therapy in anemia of chronic disease—the problem is not iron deficiency but iron sequestration. Giving oral iron when ferritin is 326 μg/L will not correct the anemia and may worsen iron overload in tissues. 2, 1

Treat the Underlying Condition First

• Address the chronic disease once identified (e.g., optimize CKD management, treat infection, control inflammation) 2
• Stop NSAIDs and anticoagulants if possible as these contribute to occult blood loss in elderly patients 2

Consider Intravenous Iron Only in Specific Contexts

• IV iron may be beneficial if functional iron deficiency persists despite treating underlying disease, particularly in CKD or inflammatory bowel disease where hepcidin blocks iron utilization 2
• Erythropoiesis-stimulating agents (ESAs) may be needed in CKD patients with hemoglobin <10 g/dL after optimizing iron status 2

Blood Transfusion Threshold

• Transfuse if hemoglobin <8 g/dL with cardiovascular instability or symptomatic anemia (dyspnea, chest pain, altered mental status) 2
• This patient at 8.2 g/dL is borderline but transfusion should be reserved for symptomatic cases 2

Critical Pitfalls to Avoid

• Do not assume elevated ferritin rules out all need for investigation—elderly patients often have mixed etiologies, and ferritin can be falsely elevated by inflammation while true iron deficiency coexists 2, 3
• Do not delay GI evaluation in elderly patients—age >60 years with any degree of anemia warrants endoscopic investigation as malignancy risk is substantial 2
• Do not accept "anemia of aging" as a diagnosis—approximately 80% of elderly anemia has an identifiable cause that should be treated 7
• Monitor for recurrence every 3 months after correction, as anemia recurs rapidly in chronic disease states 2