Algorithm for evaluation and treatment of anemia in older adults. The evaluation and management of anemia in the older adult start with a standard anemia evaluation to exclude easily treatable causes such as nutritional deficiencies and thyroid disease. If easily treatable causes are excluded or residual anemia remains after treatment, then continue to evaluate for other causes of anemia. If all other causes of anemia are excluded, then the patient may meet criteria for UAA. ∗Ferritin levels increase with age and patients with conditions such as chronic heart failure or inflammatory disorders may experience absolute iron deficiency at ferritin levels up to 100 μg/L and as high as 300 μg/L if the TSAT is <20%. ∗∗Folate is an uncommon cause of nutritional deficiencies but can be seen in patients with excessive alcohol use and poor nutrient intake. †Red-flag signs include a MCV of >96 fL, an absolute neutrophil count of <1000 cells/μL, platelet count of <120 × 109/L, a family history of blood cancers, abnormal peripheral smear, significant anemia at <9 g/dL, and worsening unexplained anemia. ††Overlap exists between UAA and ICUS. UAA is a diagnosis of exclusion, made only in older adults, whereas ICUS may be diagnosed in patients of any age with ≥1 cytopenia and clonal hematopoiesis with VAF of ≤2%. We favor UAA categorization in cases with mild anemia (often hemoglobin of <2 g/dL below lower limit of normal), no other cytopenia, no other cause, and if blood and/or BM testing is performed, absence of dyspoiesis or hematologic malignancy. DAT, direct antiglobulin test; MMA, methylmalonic acid.
