Treatment of Anemia in Older Adults

Initial Diagnostic Approach

The American Gastroenterological Association recommends measuring serum ferritin as the single most useful marker for iron deficiency, with a threshold of 45 mg/dL indicating iron deficiency in anemic patients 3
In patients with inflammatory conditions, ferritin up to 100 μg/L may still reflect iron deficiency due to its acute-phase reactant properties, as suggested by the European Society for Clinical Nutrition and Metabolism 4, 5
The addition of transferrin saturation, soluble transferrin receptor, or reticulocyte hemoglobin is recommended if ferritin is equivocal or inflammation is suspected, according to the American College of Gastroenterology 3, 4
A hemoglobin rise ≥10 g/L within 2 weeks of iron therapy strongly confirms absolute iron deficiency even with equivocal lab results, as stated by the National Institute for Health and Care Excellence 7

The American College of Physicians recommends prescribing one tablet daily of ferrous sulfate (200 mg), ferrous fumarate, or ferrous gluconate for uncomplicated iron deficiency anemia without active inflammation 1, 2, 8, 7
If gastrointestinal side effects occur, reducing to one tablet every other day rather than discontinuing is recommended to maintain efficacy while improving tolerability, as suggested by the European Society of Gastrointestinal Endoscopy 1, 2, 7
Intravenous iron is recommended when active inflammation is present, oral iron is not tolerated, or there is an inadequate response to oral iron after 4 weeks, according to the American Society of Hematology 4, 5, 10

The American Geriatrics Society recommends carefully weighing risks versus benefits of invasive investigations in patients with major comorbidities or limited performance status 1, 2, 8
Consideration of CT colonography as an alternative to colonoscopy is suggested for those unsuitable for invasive procedures, as stated by the National Comprehensive Cancer Network 2, 7
Recognition that anemia of chronic disease can mimic iron deficiency anemia is crucial, with only 11% of fast-track referrals with suspected iron deficiency anemia having confirmed diagnosis, according to the Centers for Disease Control and Prevention 10

Investigation of the small bowel with capsule endoscopy (preferred) or CT/MR enterography is recommended for angioectasias, inflammatory disease, or neoplasms, as suggested by the American Gastroenterological Association 1, 2, 8, 7
Consideration of long-term iron replacement therapy is recommended as an appropriate strategy when the cause is unknown or irreversible, according to the European Society for Clinical Nutrition and Metabolism 1, 2, 8, 7

The National Institute for Health and Care Excellence advises against assuming dietary deficiency as the primary cause in older adults, as chronic disease and gastrointestinal bleeding are far more common 9
The American College of Gastroenterology recommends against using high-dose oral iron regimens, as 100 mg elemental iron daily is as effective as higher doses with fewer side effects 3, 5
The European Society of Gastrointestinal Endoscopy warns against overlooking inflammation as a barrier to oral iron absorption, as oral iron is ineffective regardless of dose due to hepcidin-mediated blockade in active inflammatory states 5, 6