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Anaemia in older adults
Anaemia in an older adult is not "part of age" — it is linked to falls, frailty, cognitive decline and mortality; about a third of cases come from nutritional deficiency (iron, B12, folate), a third from chronic disease and kidney failure, and a third remain unexplained — and iron deficiency in an older adult is gastrointestinal bleeding until proven otherwise.
Why it matters in the exam
The exam presents an older adult with microcytic anaemia and low ferritin, and asks for the next step: gastroscopy and colonoscopy (bidirectional work-up), not just an iron supplement. According to the American Gastroenterological Association (2020), ferritin below 45 ng/mL diagnoses iron deficiency; with inflammation, ferritin up to 100 with transferrin saturation below 20% still fits deficiency.
Recurring points: B12 deficiency is common in older adults (atrophic gastritis, pernicious anaemia, metformin, PPIs), can cause neuropathy and cognitive decline even without anaemia, and is effectively treated even with high-dose oral B12 (1000–2000 mcg a day); macrocytic anaemia with a fall in other cell lines in an older adult raises suspicion of MDS; oral iron once a day or every other day is absorbed and tolerated better than several doses a day; and the restrictive transfusion threshold — haemoglobin 7 g/dL for most inpatients, and 8 in heart disease or orthopaedic surgery (such as hip fracture).
Even mild anaemia in an older adult justifies a basic work-up, because it signals a problem that can often be treated.
Key points
- Anaemia in an older adult is not normal.
- A third nutritional, a third chronic disease and kidneys, a third unexplained.
- Iron deficiency — gastroscopy and colonoscopy; ferritin below 45.
- B12: metformin and PPIs; neuropathy without anaemia; oral treatment possible.
- Transfusion: haemoglobin 7; 8 in heart disease or orthopaedic surgery.
Summary table
| Type | Clues | Work-up and action |
|---|---|---|
| Iron deficiency | Low MCV, ferritin below 45 (or up to 100 with inflammation and saturation below 20%) | Gastroscopy and colonoscopy; iron once daily or every other day |
| B12 deficiency | High MCV, neuropathy, cognitive decline; metformin, PPI | High MMA confirms; oral B12 1000–2000 mcg |
| Chronic disease and inflammation | Normal or low MCV, normal or high ferritin | Treat the disease |
| Kidney failure | Erythropoietin deficiency | ESA — do not raise haemoglobin above 11.5 routinely |
| MDS | High MCV, fall in other cell lines | Bone marrow examination |
| Transfusion | Haemoglobin 7; 8 in heart disease or orthopaedic surgery | Restrictive approach |
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Sources
- AGA clinical practice guideline on gastrointestinal evaluation of iron deficiency anemia, 2020 — Ferritin cut-off and bidirectional endoscopy
- AABB international guidelines for red blood cell transfusion, 2023 — Restrictive transfusion thresholds
- Hazzard's Geriatric Medicine and Gerontology, 8th edition (2022) — Anemia in older adults
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.