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Anaemia

Iron Deficiency Anaemia

Introduction

Iron deficiency is the second most common cause of anaemia in the elderly in the Western world,1 and the most important cause of anaemia in developing countries. It accounts for nearly half of nutrient deficiency-related anaemia cases diagnosed in older adults.2

Causes

In young women, menometrorrhagia is the main cause of iron deficiency. In the elderly and in the male populations, iron deficiency anaemia is usually the result of chronic gastrointestinal blood loss caused by non-steroidal anti-inflammatory drug (NSAID)–induced gastritis, ulcer, colon cancer, diverticula or angiodysplasia (see Gastrointestinal haemorrhage in the older patient) Chronic blood loss from genitourinary tract cancer, chronic haemoptysis and bleeding disorders may also result in iron deficiency, but these are much less common causes.1

Patients  may become iron deficient because of inadequate intake or inadequate absorption of iron. In such cases, where the deficiency occurs without blood loss, anaemia takes several years to develop.2

Signs and Symptoms

Symptoms depend on how rapidly the anaemia develops. Where the underlying cause is chronic, slow blood loss, the body adapts to the increasing anaemia. Some patients can tolerate extremely low concentrations of haemoglobin (e.g. < 7 g/dl) with remarkably few symptoms. Most patients complain of increasing lethargy and dyspnoea. More unusual symptoms are depression, lack of attention, headaches, tinnitus, and taste disturbance.

Skin, nail, and other epithelial changes may also be seen in chronic iron deficiency. Patients may also complain of angular stomatitis sometimes accompanied by glossitis.

Increasing tachycardia and cardiac failure indicate cardiac decompensation due to worsening anaemia - in such cases prompt remedial action should be taken.3

Diagnosis

The diagnosis of iron deficiency anaemia in the elderly is often difficult owing to the presence of multiple abnormalities. Routine diagnostic tests have low sensitivity in this group of patients. Serum iron and transferrin saturation levels have a limited value in the diagnosis of iron deficiency anaemia in elderly patients.4

Serum ferritin level (normal value: 100-300 ng/mL) is considered the best single test for the diagnosis of iron deficiency because its concentration is proportional to the total body iron stores:1,4

  • Serum ferritin < 15 ng/mL indicates that iron deficiency is highly likely
  • Serum ferritin >100 ng/mL indicates that iron deficiency is unlikely
  • Serum ferritin of 15-100 ng/mL is moderately predictive of iron deficiency anaemia, potentially co-presenting with anaemia of chronic disease

A diagnosis of iron deficiency anaemia requires prompt referral for investigation of the gastrointestinal tract as a possible source of bleeding.1

Treatment and follow-up

All elderly patients with iron deficiency anaemia should have iron supplementation, both to correct anaemia and replenish body stores. For an adequate response to therapy, haemoglobin concentration should rise by 2 g/dl after 3–4 weeks.5 However, treatment should be continued until ferritin levels are normalised, indicating restoration of reserves.

Once levels have normalised, Hb concentration, ferritin and red cell indices should be monitored as follows:6

  • Every three months for 12 months
  • Once after a further 12 months
  • Then, any time that symptoms of anaemia become apparent.

Further investigation is only necessary if the Hb and red cell indices cannot be maintained.6

References

  1. Smith DL. Anemia in the elderly. Am Fam Physician. 2000;62(7):1565-72.
  2. Patel KV. Epidemiology of anemia in older adults. Semin Hematol. 2008 Oct;45(4):210-7.
  3. Frewin R, Henson A, Provan D. ABC of clinical haematology. Iron deficiency anaemia. BMJ. 1997;314(7077):360-3.
  4. Rimon E, Levy S, Sapir A, , et al. Diagnosis of iron deficiency anemia in the elderly by transferrin receptor-ferritin index. Arch Intern Med. 2002;162(4):445-9.
  5. Mukhopadhyay D, Mohanaruban K. Iron deficiency anaemia in older people: investigation, management and treatment. Age Ageing. 2002;31(2):87-91.
  6. Goddard AF, James MW, McIntyre AS, et al. Guidelines for the management of iron deficiency anaemia. Gut. 2011;60(10):1309-16.
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