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Focus on Anaemia Care in the Elderly



Working with specialist centres

In many cases, anaemia in older patients has causes (e.g. vitamin deficiency) that can readily be treated in a primary care setting. However, some patients will require referral to a specialist centre. Criteria for referral vary within and across national territories. However, established guidelines should be available to ensure that patients are referred appropriately (Figure 4).



Anaemia is defined as a haemoglobin of < 13g/dl in an adult male or < 11.5g/dl in an adult female. Treatment is determined by its cause - this will be identified through systematic clinical evaluation and supplementary investigation. The patient's symptoms and initial FBC findings (particularly mean corpuscular volume and blood film features) will influence both the urgency and direction of initial clinical investigation.

Iron deficiency should generally be referred to gastroenterology/gynaecology as appropriate for further investigation. Similarly, uncomplicated B12/folate deficiency does not require routine referral to haematology.

The following should be referred urgently for outpatient assessment:

  • Leucoerythroblastic anaemia (based on blood film report)
  • Unexplained progressive symptomatic anaemia
  • Anaemia in association with:
    • splenomegaly or lymphadenopathy
    • other cytopenias

Patients with suspected aplastic anaemia (neutrophils < 0.5 x 109/l, platelets < 50 x 109/l) or acute haemolytic anaemia should be discussed with duty haematologist to arrange appropriate direct assessment

Appropriate investigation in primary care for patients not meeting criteria for urgent referral:

  • Careful history focussing on duration, symptoms, bleeding, diet, drug and family history
  • Blood film examination and reticulocyte count
  • Ferritin, B12 and folate
  • lmmunoglobulins and protein electrophoresis
  • Monitor FBC for evidence of progression over time

Referral for specialist opinion should be considered for:

  • Persistent unexplained anaemia
  • Iron deficiency showing sub-optimal response to oral iron therapy
  • B12 deficiency of uncertain cause requiring further investigation

Figure 4. A sample referral guideline. (Clinical Haematology Guidelines. 2008. From: Accessed 8 May 2012.)

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