Older Patients, Wiser Care
She had anemia "“ and lingering worries about cancer.
The case: The blood work showed moderate anemia
"My regular doctor always tells me the same thing: that my anemia is stable."
Ms. G, an elegantly-dressed woman in her early 70s, pulled copies of the past year's lab results from her purse. I scanned the results, then looked inquiringly at her. This was her first visit with me, and the nurse's note had said, "Wants second opinion."
"So, how were you hoping I could help you today? Any particular concerns?"
"It's the anemia," Ms. G began. "I've had it for a few years now. I feel fine, and my doctor says not to worry about it; he checks my blood work at least three times a year."
She gave me a sheepish smile. "But still, I do worry. I've heard all kinds of things about anemia. That means my red blood cell count is low, right? Isn't that dangerous? Doesn't that mean I could have cancer, even though my colonoscopy last year was fine?
"Doctor, shouldn't something more be done?"
The challenge: A common abnormality that can mean many things
Anemia, as Ms. G already knew, means a person has a lower red blood cell count than is normal. In particular, it means that blood is less able to carry oxygen from the lungs to the rest of the body, since it's the hemoglobin in red blood cells that carries out this important job. When the blood count gets low enough, a person can notice such symptoms as feeling tired or dizzy, or having palpitations.
Although carrying oxygen through the body is essential to staying alive, anemia is paradoxically one of the most common abnormalities found when blood tests are done. This is probably due to two important facts:
1) Most people's bodies can manage with a lower red blood cell count than normal, especially if the body has time to adapt to a lower level. For women, a normal hemoglobin level is at least 12 mg/dL. In Ms. G's case, her hemoglobin level was 10.7 mg/dL: lower than normal, but within a manageable range.
2) Anemia can be a symptom for a long list of varied diseases. To manage this long list of possibilities, doctors often think about anemia in two main categories:
A problem producing red blood cells. The making of red blood cells, which takes place in the bone marrow, can be slowed down by a wide variety of medical problems. In the elderly, two common causes are lack of vitamins, such as iron, and chronic kidney disease. The bone marrow can also be affected directly, by problems such as myelodysplasia (a bone marrow disorder), cancer, or chemotherapy used in cancer treatment. There's even something called "anemia of chronic disease," in which the making of red cells slows even though a chronic disease doesn't seem to be directly affecting the marrow.
A problem losing red blood cells. Normally, red blood cells break down on their own after three months, and their iron is recycled into new blood cells. Losing blood cells more quickly, through bleeding in the stomach or bowel, is a common cause of anemia. Although faster internal bleeding causes red or black stools, the bleeding can also be slow and almost invisible -- and over time even a slow bleed can make a person anemic enough to start feeling lousy. (People also end up iron-deficient, since iron is lost with the blood.) Less commonly, some diseases cause people to lose red blood cells within the body itself.
Sometimes, a person can even have both anemia problems at the same time! (For instance, a colon cancer can cause the bone marrow to slow down, and also cause a slow but steady bleed into the stool.) But in up to 20 percent of older adults, no specific cause for the anemia can be found, even after thorough investigation.
With so many possible causes of anemia, and anemia being such a common abnormality in blood tests, how can a patient or caregiver know what to worry about?
The solution: After checking for treatable causes, follow the cell count.
Fortunately for Mrs. G, she came to my office with the most immediately useful information: results from several blood draws over the previous year. This let me see right away that her anemia was "stable," meaning that her blood count didn't have a downward trend. (It's much more concerning to see a red cell count that's suddenly much lower, or that's been steadily going down.)
I then looked through her blood work results to see if common potential causes had been checked. She had normal levels of iron, B12, folate, and thyroid hormone. She hadn't had abnormal levels of protein in the blood, which can be a sign of disease called multiple myeloma. She'd also had a peripheral smear done, meaning a pathologist had looked at her blood cells under a microscope.
But then I noticed that her labs showed somewhat decreased kidney function over the past year. That, too, had been stable: It hadn't changed much over the past year. "Now, what has your regular doctor told you about your kidneys?" I asked.
"Oh, I should've mentioned that. He did tell me that my kidneys have lost some function. They've been like that for years; he thinks it's because for a long time my high blood pressure wasn't well treated."
"I see. Sounds like we should add chronic kidney disease to your past medical history." I went on to explain to Mrs. G. that kidney disease often causes some anemia, because the kidneys make erythropoetin, a hormone that helps the bone marrow make red cells. This was the most likely cause of her anemia. (Some patients even get treated with erythropoetin substitutes, but this anemia drug may raise the stroke risk in kidney patients, so experts now think only very anemic people should consider these drugs.)
As for the possibility of cancer, I reminded her that no doctor can ever guarantee to a patient that there's no cancer somewhere in the body. But given that she'd had a normal colonoscopy recently and had no other concerning signs or symptoms, such as weight loss, it was unlikely that she'd benefit from more extensive searches for cancer. Besides, I pointed out, although cancer often causes anemia, many anemias end up not linked to cancer.
"So, you don't think my doctor should be doing anything about this anemia?" asked Mrs. G.
"Well, he is doing something," I noted. "He's monitoring you regularly to make sure your anemia and kidneys aren't getting worse. Some doctors call that "˜watchful waiting.' And it's just what I would do if you were my patient."
"It's a relief to know sometimes less can be more," Mrs. G said.
My prescription for caregivers
If anemia, or a low red blood cell count, is diagnosed, ask the doctor to tell you how quickly the cell count is dropping, and what he or she thinks is the cause. You should also ask the doctor whether the anemia is bad enough to expect symptoms.
Know the signs of severe, or worsening, anemia: light-headedness, shortness of breath, a faster heart rate, being pale, and/or getting tired easily. Get prompt medical attention if you're concerned about signs of worsening anemia, or if you notice any black or bloody bowel movements.
New anemia should always trigger a diagnostic evaluation, to look for causes, especially treatable ones. If there's no sign of bleeding from the bowel, most work-ups include checking iron, B12, folate, and thyroid levels. Depending on the circumstances, the doctor may also check blood protein levels, send the blood to be looked at by a pathologist, and/or evaluate further for cancer.
If the red blood cell count isn't very low, and if there aren't other signs of an urgent medical problem, it's common to monitor the red cell count to see how stable the anemia is. How often one is checked usually depends on the details of each person's case. You can ask the doctor to explain why a certain monitoring schedule has been chosen.
Know that after a suitable work-up has been completed, it's often reasonable to manage mild-to-moderate anemia with watchful waiting and regular monitoring.
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