By Eduardo Gonzales, MD

We recently had our 82-year-old father’s CBC, blood sugar, and cholesterol tested. His results are all normal except for his hemoglobin, which is only 11 grams percent. Is he anemic? He is not complaining of easy fatigability or weakness so we are wondering if his hemoglobin is normal for him. Is it normal for elderly people to have anemia? What should we do? —[email protected]

Anemia is very common among the elderly, so common that some think, as you do, that it is a normal consequence of aging. Anemia, however, cannot be considered normal in the elderly because most old people have normal hemoglobin, red blood cell count, and red blood cell volume. Furthermore, in about 80 percent of anemia in elderly people, there is an identifiable cause for the condition.

Anemia refers to a shortage in the oxygen-carrying capacity of blood either because of a diminished number of red blood cells (i.e., the oxygen-carrying cells in blood), or the red blood cells have low content of hemoglobin (i.e., the substance in the red blood cells that bind oxygen). World Health Organization (WHO) criteria for anemia are hemoglobin of less than 12 grams percent in females and less than 13 grams percent in males. By these standards, your father is obviously anemic.

Your father has no symptoms because his anemia is mild (i.e., hemoglobin between 9.5 to 13.0 grams percent). Mild anemia is usually asymptomatic but moderate and severe anemia manifests as easy fatigability, weakness, dizziness or lightheadedness, headache, pallor, cold hands and feet, and sometimes irregular heartbeats and chest pain.

Causes of anemia in old people

Anemia in the elderly is often caused by chronic disease or iron deficiency. Other less common causes are bleeding, vitamin B12 and folate (folic acid) deficiency, and bone marrow disease.

The chronic diseases that produce anemia in the elderly include acute and chronic infections (e.g., TB, chronic urinary tract and fungal infection), kidney or liver disease, chronic inflammatory disorders such as osteoarthritis, rheumatoid arthritis, hepatitis and autoimmune disorders, malignancies (i.e., cancers), and malnutrition.

Iron deficiency anemia, on the other hand, is often brought about in the elderly by poor absorption of iron—a micronutrient that forms part of hemoglobin—in the digestive tract, diet that lacks enough iron, or blood loss due to chronic but asymptomatic internal bleeding such as those caused by frequent intake of non-steroidal anti-inflammatory drugs (NSAIDs) to relieve joint and body pains, and chronic gastrointestinal ulcer.

The management of iron deficiency anemia involves treating the cause of bleeding if there is any, and iron supplementation. Anemia caused by chronic disease, on the other hand, is managed by treating the underlying disorder. Iron supplementation is of no benefit, although a drug, erythropoietin, may be helpful in some patients.

Work-up for anemia in the elderly

Anemia in the elderly is evaluated in the same way as in younger adults, and includes investigation for signs of gastrointestinal bleeding, hemolysis, nutritional deficiencies, malignancy, chronic infection, renal or hepatic disease, and other chronic disease.

Your father’s anemia warrants further study. I suggest you consult an internist who can thoroughly examine him and, if warranted, order pertinent laboratory exams.

If one cause of his anemia is identified, it should be managed or treated accordingly. If no cause can be found, however, you need not worry because most mildly anemic elderly people do well and do not manifest any diminution in quality of life. Just make sure your father eats a balanced diet that includes food items that are rich in iron, folic acid, and vitamins B-12.  Meats, beans, lentils, iron-fortified cereals, dark green leafy vegetables, and dried fruit are rich in iron. Folic acid is abundant in fruits and fruit juices, dark green leafy vegetables, green peas, beans, peanuts, and grain products such as bread, cereal, pasta, and rice. Good sources of vitamin B-12 include meat, fish, dairy products, and soy products.

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