Everything you've always wanted to know about anemia but were too weak to ask

Many people recognize the classic symptoms of anemia  pale skin, fatigue, shortness of breath, and weakness. In an older person, however, the first sign of anemia may be a fainting spell, chest pain or confusion. Anemia results when you don’t have enough red blood cells, which carry life-giving oxygen to your body. Many different tissues and organs may suffer, causing a range of signs and symptoms, including dizziness, cold hands and feet, headaches, and a fast heartbeat.

Though not a normal part of aging, mild anemia becomes fairly common with older age and can leave those with it more frail, weak, and prone to falls. More than one in 10 adults has anemia and by age 85, about 20 percent of women are anemic. Here’s what you should know about this blood disorder.

Red blood cells

Anemia occurs if the number of red blood cells in your blood drops below normal, or your red blood cells do not contain enough hemoglobin  the iron-rich protein that gives blood its red color. Hemoglobin is the carrier of oxygen from your lungs to the rest of your body.

Doctors identify anemia by measuring the amount of hemoglobin in your blood. In adults, a hemoglobin (HGB) concentration of 12.3 grams per deciliter or less is considered anemia, although normal values vary between 11 and 15. Another measurement, called hematocrit (HCT), refers to the percentage of blood occupied by red blood cells. By this definition, generally speaking, a person with an HCT of 41 percent or less has anemia.

Causes and types

Anemia isn’t a disease in itself but rather a sign of an underlying problem. Blood loss is one of the most common causes of anemia. Chronic bleeding  bleeding in small amounts over a long time  depletes the body of iron, causing what’s known as iron-deficiency anemia. That’s the most common type of anemia, but there are many others.

• Iron deficiency anemia. Your bone marrow needs iron to make hemoglobin. People with iron-deficiency anemia lack adequate stores of iron to make enough hemoglobin and red blood cells. Women can lose iron and red blood cells during heavy, long menstrual periods, during childbirth or with bleeding from uterine fibroids. In older adults, blood loss usually stems from intestinal diseases, such as ulcers, colon polyps, diverticulitis or cancer. Aspirin or nonsteroidal anti-inflammatory drugs can also cause bleeding.

• Vitamin deficiency anemia. Your body needs the vitamins B-12 and folate to produce adequate healthy red blood cells. If your diet lacks one of these vitamins  or your body can’t absorb B-12 from food  you may develop megaloblastic anemia. With this type, the red cells are large and immature-looking.

• Anemia of chronic disease. Some long-term illnesses can cause anemia by affecting the body’s ability to produce red blood cells. Chronic kidney disease curtails production of a hormone called erythropoietin, which signals the bone marrow to make red blood cells. Inflammatory diseases such as rheumatoid arthritis reduce the bone marrow’s response to erythropoietin, leading to a decrease in red blood cells. Other chronic diseases that can cause anemia include HIV/AIDS, cancer, cirrhosis, and other forms of liver disease.

• Other types. In hemolytic anemia, red blood cells die or are destroyed faster than the bone marrow can replace them. Cancers and cancer-like disorders of the bone marrow, including leukemia and myelodysplastic syndrome, can cause anemia. Other causes include alcohol abuse and severe untreated underactive thyroid (hypothyroidism). Occasionally, there may be multiple causes of the anemia, especially in older people.

Test options

Normal blood smear

To understand what’s causing anemia, your doctor will do a physical exam and talk about your symptoms, diet, alcohol use, medications, and medical, surgical, and family history. You may be referred to a specialist in blood diseases, called a hematologist. Tests and procedures used to learn about anemia include:

• Complete blood count. This is usually the first test to diagnose anemia. A sample of blood is drawn and checked for the amount of hemoglobin (HGB) in your red blood cells; the number of red blood cells, white blood cells and platelets in your blood; the portion of your blood taken up by red blood cells (hematocrit or HCT); and the average size of your red blood cells (mean corpuscular volume or MCV).

• Blood smear. This test examines a blood sample under a microscope for changes in the number, type, size, and shape of blood cells.

• Gastrointestinal tests. To diagnose anemia related to blood loss, your doctor may visually examine your upper or lower digestive tract, or both, using a long, flexible tube with a tiny camera on the end (these tests are called upper endoscopy and colonoscopy). Sometimes an x-ray or special examination with a tiny camera that you swallow (capsule endoscopy) is needed to examine the small bowel, which a scope can’t reach.

• Bone marrow aspiration and biopsy. If the cause of your anemia isn’t clear, or your doctor suspects cancer or another bone marrow disease, he/she may perform a bone marrow biopsy to take a direct look at what’s happening within the “factory” where blood is produced. This involves inserting a hollow needle into your pelvic bone and is usually done under local anesthesia. The sample is examined under a microscope to see if your bone marrow is healthy and making enough blood cells.

Treatments

Treatment for anemia depends on what’s causing it and how severe it is. Your doctor will start by addressing the underlying cause, whether it’s blood loss, inflammation, nutritional deficiencies, infection, alcohol abuse or kidney disease. The goal is to get your red blood cell counts or hemoglobin levels back to normal so that your blood can carry enough oxygen to your body.

Most cases of iron deficiency anemia can be successfully treated by identifying and then correcting the iron loss. That can be done by foods rich in iron, such as fortified cereals and breads, red meats, peas, beans, lentil, eggs, spinach and other dark green leafy vegetables, dried fruits (such as raisins), tofu, fish and shellfish, chicken and pork. Vitamin C helps your body absorb iron. Many fruits and vegetables, including oranges, strawberries, broccoli, peppers, and tomatoes, are good sources of vitamin C.

Some people take iron pills in combination with multivitamins and other minerals that help their bodies absorb iron  however, talk to your doctor before taking iron supplements. If your anemia is caused by a lack of vitamin B-12 and folate, your doctor will recommend supplements.

Treatments for more severe forms of anemia may include blood transfusions, medications to prevent the body’s immune system from destroying its own red blood cells, or a synthetic version of the hormone erythropoietin to stimulate your bone marrow to make more red blood cells.

A more energetic life

Anemia is often mild, but it can take a toll on your quality of life. If you’re feeling tired a lot  especially if you have a chronic medical condition  work with your physician to monitor your complete blood count. Even a small bump in your blood count numbers can give you more energy, help you stay active, and possibly lengthen your life.