ANEMIA IN THE NURSING HOME
CLINICAL PRACTICE GUIDELINE

 

DISEASE RECOGNITION

  • Hb (blood hemoglobin) < 12g/dL in men; < 11.5 g/dL in women; Hct (hematocrit) < 36%
  • MCV (mean cellular volume) > 100 fL (with or without Hb change)
  • Symptoms of tissue hypoxia: fatigue, headache, dyspnea, angina, light headedness, shortness of breath, new onset CHF
  • Symptoms of anemic hypovolemia: pallor, visual impairment, syncope, tachycardia, SEM
  • Symptoms of neurological change: decreased vibratory sense, decreased proprioception, ataxia, paresthesias, glossitis, restless leg syndrome

WHO definition: <13g/dL in men; <12g/dL in women

 

CONTEXT / / COMMUNICATION

If the resident is moribund and/or has a limited life expectancy no diagnostic work up is expected unless blood transfusions are anticipated to maintain comfort/quality of life. The resident or health care agent should be contacted by the MD or NP to discuss this option.

 

ASSOCIATED RISKS

  • Blood loss from any source both obvious and occult
  • Chronic systemic disease: infection, cancer, connective tissue disorders, chronic kidney disease, liver disease, endocrine failure, myelodysplastic syndrome, DM
  • Poor oral intake of iron rich foods or folate [vegans]
  • Drugs: prolonged Bactrim use, Methotrexate, Dilantin, Hydroxyurea, barbiturates, Colchicine, NSAIDs, steroids, Warfarin, Aspirin, Mysoline

 

PHYSICAL EXAMINATION

  • BP, AP, orthostatic BPs
  • Skin (subconjunctival pallor, jaundice)
  • Tongue (bald, shiny)
  • Cardiac exam (new murmur)
  • Abdominal exam ( attention to liver)
  • Rectal (lesions, stool guaiac)
  • Lymph nodes
  • Neurological exam (sensation, proprioception, gait)

 

DIAGNOSTIC WORK-UP

  • CBC with differential, B12, ferritin, folate, TIBC, serum iron
  • Stools for occult blood        
  • Liver function (if jaundiced or with hepatomegaly)

 

ANEMIA: DIFFERENTIAL DIAGNOSIS

TYPE

Serum
Iron

Ferritin

TIBC

MCV

Peripheral Smear/Other abnormalities

IDA (iron deficiency anemia)

decreased

decreased

increased

NL or decreased

Anisocytosis, hypochromic, microcytic rbcs

AOCD (anemia of chronic disease)

decreased

NL or
increased

decreased

NL or decreased

Usually normal although microcytes may be present

Anemia Of Renal disease

GFR<50%, inability to produce erythropoietin

Decreased

Decreased

Decreased

Decreased

 

Thalassemia
Minor

NL

NL or
increased

NL

decreased

Target cells, poikilocytosis, nucleated RBCs, increased HbA2 on hemoglobin electrophoresis

Folate/
Vitamin B12
Deficiency

NL

NL or
increased

NL

increased

decreased B12, NL or decreased folate, macro-ovalocytes, hypersegmented neutrophils, anisocytosis, poikilocytosis; LDH and indirect bilirubin may be increased

Myelo-
Dysplasia

NL or increased

 

 

NL or increased

Anisocytosis, poikilocytosis, macro-ovalocytes, hyposegemented neutrophils, mild to severe pancytopenia

 

TREATMENT OPTIONS

IDA

  • Correct cause of blood loss
  • Oral iron - Ferrous Sulfate 325 mg QD, follow Hgb and ferritin

AOCD

  • Treat (if possible) any underlying, contributing disorders
  • Treat any co-existing IDA
  • Adequate nutritional support + MOV with Minerals
  • ***Erythropoietin good to fair response

Anemia Of Renal disease

 

  • ***Erythropoietin good response

Thalassemia

Minor

  • Packed RBC transfusions as needed to sustain life (rarely needed)
  • Folic acid 1 mg PO QD

Folate/Vitamin B12 deficiency

  • Replace deficient factor with either
  • Folic acid 1 mg PO QD or
  • B12 (cyanocobalamin) 500mcg 200 mcg SQ or IM QD x 5-7 days then Q week X 4 weeks then monthly
  • Once hematologic parameters WNL may give Nascobal (cyanocoblamanin in aerosol form) 500 mcg 1 spray each nostril Q week
  • Evaluate use of Vitamin C, PPIs, H2 Blockers, Colchicine. anticonvulsants, Metformin and antibiotics- all can lower B12 absorption

Myelodysplasia

  • Packed RBC transfusions as needed to sustain life
  • ***Erythropoietin good response

Erythropoietin: Aranesp, Epogen, Procrit: As of 12/05 new finding with the use of the drugs. Called pure red blood cell aplasia and it leads to an anti-erythropoietin-mediated severe anemia and RBC aplasia. Monitor HGB weekly with initiation of drug and then monthly when stabilized at desired level. If sudden drop in HBG or sudden ineffectiveness of drug stop immediately and do full anemia work up. Then contact manufacturer to arrange for assays for binding and neutralizing the antibodies and to confirm the diagnosis. At this time there is no alternative therapy for those who have developed the anitibody-mediated anemia.

 

References for Anemia:

  1. Bergin, JJ: Anemia: A Strategy for the Work-up in Consultant, June 2002, 869-882.
  2. Blackwell, S., Hendrix, PC: Common Anemias What Lies Beneath in Clinical Reviews, Vol. 11, No.3, March 2001, 53-62.
  3. Blinder, MA: Anemia and Transfusion Therapy in the Washington Manual, 28th Edition, 1995, 402-417.
  4. Davenport, J.: Macrocytic Anemia in American Family Physician, Vol. 53, No. 1, January, 1996, 155-162.
  5. Dharmarajan, TS et al: Vitamin B12 deficiency Recognizing subtle symptoms in older adults in Geriatrics, Vol. 58, No. 3, March 2003, 30-38.
  6. Dharmarajan, TS et al: Does anemia matter? Anemia, morbidity, and mortality in older adults: Need for greater recognition in Geriatrics, Vol. 60, No.60, December 2005, 22-29
  7. FDA.gov/medwatch/safety/2005/safety05.htm#epoetin
  8. Griffith, CJ: Evaluation and Management of Anemia in Advance for Nurse Practitioners, May,1996, 29-35.
  9. Isselbacher, KJ, Braunwald, E., et al: Red Blood Cell Disorders in Harrison's Principles of Internal Medicine, 13th Edition, 1995, 581-587.
  10. Izaks, GJ, Westendorp, RG et al: The Definition of Anemia in Older Persons in JAMA, Vol. 281, No. 18, May 12, 1999, 1-9.
  11. Justice, KM: A Streamlined Workup For Anemia in The Clinical Advisor, April 2001, 32-44.  
  12. Morley, JE, Thomas DR: Diagnosis and Management of Anemia in Long-Term Care, Supplement to Annals of Long-Term Care, August 2003.
  13. Rager, MW: Unusual case of fatigue, dyspnea, and mouth pain in an older woman in The Clinical Advisor, July 2004, 101-102.
  14. Reuben, DB, Grossberg, GT et al: Hematology/Oncology in Geriatrics At Your Fingertips, 1998/99 Edition, 115-118.

MS/11.99
EMS
Revised 1.06

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