Have you ever been told that you have anemia, or wondered about anemia symptoms?
Or perhaps you noticed the red blood cell count flagged as “low” in the bloodwork report? Or noticed “low hemoglobin” in a doctor’s report?
Anemia means having a red blood cell count that is lower than normal, and it’s very common in older adults. About 10% of independently living people over age 65 have anemia. And anemia becomes even more common as people get older.
But many older adults and families hardly understand anemia.
This isn’t surprising: anemia is associated with a dizzying array of underlying health conditions, and can represent anything from a life-threatening emergency to a mild chronic problem that barely makes the primary care doctor blink.
Still, it worries me that older adults and families don’t know more about anemia. If you or your relative has this condition, it’s important to understand what’s going on and what the follow-up plan is. (I’ve so often discovered that a patient didn’t know he or she had had anemia!) Misunderstanding anemia can also lead to unnecessary worrying, or perhaps even inappropriate treatment with iron supplements.
And since anemia is often caused by some other problem in the body, not understanding anemia often means that people don’t understand something else that is important regarding their health.
Fortunately, you don’t have to be a doctor to have a decent understanding of the basics of anemia.
This post will help you understand:
- How anemia is detected and diagnosed in aging adults.
- Symptoms of anemia.
- The most common causes of anemia, and tests often used to check for them.
- What to ask the doctor.
- How to get better follow-up, if you or your relative is diagnosed with anemia.
You can also watch my video covering Anemia in Aging: Symptoms and Solutions:
Defining and detecting anemia
Anemia means having a lower-than-normal count of red blood cells circulating in the blood.
Red blood cells are always counted as part of a “Complete Blood Count” (CBC) test, which is a very commonly ordered blood test.
A CBC test usually includes the following results:
- White blood cell count (WBCs): the number of white blood cells per microliter of blood
- Red blood cell count (RBCs): the number of red blood cells per microliter of blood
- Hemoglobin (Hgb): how many grams of this oxygen-carrying protein per deciliter of blood
- Hematocrit (Hct): the fraction of blood that is made up of red blood cells
- Mean corpuscular volume (MCV): the average size of red blood cells
- Platelet count (Plts): how many platelets (a smaller cell involved in clotting blood) per microliter of blood
(For more information on the CBC test, see this Medline page. For more on common blood tests, see Understanding Laboratory Tests: 10 Commonly Used Blood Tests for Older Adults.)
By convention, to detect anemia, clinicians rely on the hemoglobin level and the hematocrit, rather than on the red blood cell count.
A “normal” level of hemoglobin is usually in the range of 14-17 gm/dL for men, and 12-15 gm/dL for women. However, different laboratories may define the normal range slightly differently.
A low hemoglobin level — meaning, it’s below normal — can be used to detect anemia. Clinicians often confirm the lower hemoglobin level by repeating the CBC test.
If clinicians detect anemia, they usually will review the mean corpuscular volume (MCV) measurement (included in the CBC) to see if the red cells are smaller or bigger than normal. We do this because the size of the red blood cells can help point doctors towards the underlying cause of anemia.
Hence anemia is often described as:
- Microcytic: red cells smaller than normal
- Normocytic: red cells of a normal size
- Macrocytic: red cells larger than normal
Symptoms of anemia
The red blood cells in your blood use hemoglobin to carry oxygen from your lungs to every cell in your body. So when a person doesn’t have enough properly functioning red blood cells, the body begins to experience symptoms related to not having enough oxygen.
Common symptoms of anemia are:
- fatigue
- weakness
- shortness of breath
- high heartrate
- headaches
- becoming paler, which is often first seen by checking inside the lower lids
- lower blood pressure (especially if the anemia is caused by bleeding)
However, it’s very common for people to have mild anemia — meaning a hemoglobin level that’s not way below normal — and in this case, symptoms may be barely noticeable or non-existent.
That’s because the severity of symptoms depends on two crucial factors:
- How far below normal is the hemoglobin level?
- How quickly did the hemoglobin drop to this level?
This second factor is very important to keep in mind. The human body does somewhat adapt to lower hemoglobin levels, but only if it’s given weeks or months to do so.
So this means that if someone’s hemoglobin drops from 12.5gm/dL to 10gm/dL (which we’d generally consider a moderate level of anemia), they are likely to feel pretty crummy if this drop happened over two days, but much less so if it developed slowly over two months.
People sometimes want to know how low the hemoglobin has to be for anemia to be “severe.” This really depends on the past medical history of the person and on how fast the hemoglobin dropped, but generally, a hemoglobin of 6.5 to 7.9 gm/dL is often considered “severe” anemia.
People also sometimes want to know how low can hemoglobin go before causing death. In general, a hemoglobin less than 6.5 gm/dL is considered life-threatening. But again, how long the body can tolerate a low hemoglobin depends on many factors, including whether the hemoglobin is continuing to drop quickly (due an internal bleed, for instance) or is slowly drifting down. A study of Jehovah’s Witnesses who died after refusing transfusions found that those with hemoglobins between 4.1 to 5 gm/dL died, on average, about 11 days later.
The most common causes of anemia in aging adults
Whenever anemia is detected, it’s essential to figure out what is causing the low red blood cell count.
Compared to most cells in the body, normal red blood cells have a short lifespan: about 100-120 days. So a healthy body must always be producing red blood cells. This is done in the bone marrow and takes about seven days, then the new red blood cells work in the blood for 3-4 months. Once the red blood cell dies, the body recovers the iron and reuses it to create new red blood cells.
Anemia happens when something goes wrong with these normal processes. In kids and younger adults, there is usually one cause for anemia. But in older adults, it’s quite common for there to be several co-existing causes of anemia.
A useful way to think about anemia is by considering two categories of causes:
- A problem producing the red blood cells, and/or
- A problem losing red blood cells
Here are the most common causes of low hemoglobin for each category:
Problems producing red blood cells. These includes problems related to the bone marrow (where red blood cells are made) and deficiencies in vitamins and other substances used to make red blood cells. Common specific causes include:
- Chemotherapy or other medications affecting the bone marrow cells responsible for making red blood cells.
- Iron deficiency. This occasionally happens to vegetarians and others who don’t eat much meat. But it’s more commonly due to chronic blood loss, such as heavy periods in younger women, or a slowly bleeding ulcer in the stomach or small intestine, or even a chronic bleeding spot in the colon.
- Lack of vitamins needed for red blood cells. Vitamin B12 and folate are both essential to red blood cell formation.
- Low levels of erythropoietin. Erythropoietin is usually produced by the kidneys, and helps stimulate the bone marrow to make red blood cells. (This is the “epo” substance used in “blood doping” by unethical athletes.) People with kidney disease often have low levels of erythropoietin, which can cause a related anemia.
- Chronic inflammation. Many chronic illnesses are associated with a low or moderate level of chronic inflammation. Cancers and chronic infections can also cause inflammation. Inflammation seems to interfere with making red blood cells, a phenomenon known as “anemia of chronic disease.”
- Bone marrow disorders. Any disorder affecting the bone marrow or blood cells can interfere with red blood cell production and hence cause anemia.
Problems losing red blood cells. Blood loss causes anemia because red blood cells are leaving the blood stream. This can happen quickly and obviously, but also can happen slowly and subtly. Slow bleeds can worsen anemia by causing an iron deficiency, as noted above. Some examples of how people lose blood include:
- Injury and trauma. This can cause visibly obvious bleeding, but also sometimes causes people to bleed into a space inside the body, which can be harder to detect.
- Chronic bleeding in the stomach, small intestine, or large bowel. This can be due to many reasons, some common ones include:
- taking a daily aspirin or non-steroidal anti-inflammatory drug
- peptic ulcer disease
- cancer in the stomach or bowel
- Frequent blood draws. This is mainly a problem for people who are hospitalized and getting daily blood draws.
- Menstrual bleeding. This is usually an issue for younger women but occasionally affects older women.
There is also a third category of anemias, related to red blood cells being abnormally destroyed in the body before they live their usual lifespan. These are called hemolytic anemias and they are much less common.
A major study of causes of anemia in non-institutionalized older Americans found the following:
- One-third of the anemias were due to deficiency of iron, vitamin B12, and/or folate.
- One-third were due to chronic kidney disease or anemia of chronic disease.
- One-third of the anemias were “unexplained.”
How doctors evaluate and diagnose anemia
Once anemia is detected, it’s important for health professionals to do some additional evaluation and follow-up, to figure out what might be causing the anemia.
Understanding the timeline of the anemia — did it come on quickly or slowly? Is the red blood count stable or still trending down with time? — helps doctors figure out what’s going on, and how urgent the situation is.
Common follow-up tests include:
- Checking the stool for signs of microscopic blood loss
- Checking a ferritin level (which reflects iron stores in the body)
- Checking vitamin B12 and folate levels
- Checking kidney function, which is initially done by reviewing the estimated glomerular filtration rate (included in most basic bloodwork results)
- Checking the reticulocyte count, which reflects whether the bone marrow trying to produce extra red blood cells to compensate for anemia
- Checking levels of an “inflammation marker” in the blood, such as the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
- Evaluation of the peripheral smear, which means the cells in the blood are examined via microscope
- Urine tests, to check for proteins associated with certain blood cell disorders
If the anemia is bad enough, or if the person is suffering significant symptoms, doctors might also consider a blood transfusion. However, although even mild anemia has been associated with worse health outcomes, research suggests that transfusing mild to moderate anemia generally isn’t beneficial. (This issue especially comes up when people are hospitalized or acutely ill.)
What to ask the doctor about anemia
If you are told that you or your older relative has anemia, be sure you understand how severe it seems to be, and what the doctors think might be causing it. This will help you understand the plan for follow-up and treatment.
Some specific questions that can be handy include:
- How bad is this anemia? Does it seem to be mild, moderate, or severe?
- What do you think is causing it? Could there be multiple causes or factors involved?
- How long do you think I’ve had this anemia? Does it seem to be stable or is it getting worse?
- Is this the cause of my symptoms or do you think something else is causing my symptoms?
- Could any of my medications be involved?
- What is our plan for further evaluation?
- What is our plan for treating this anemia?
- When do you recommend we check the CBC again? What is our plan for monitoring the anemia?
Be sure to request and keep copies of your lab results. It will help you and your doctors in the future to be able to review your past labs related to anemia and any related testing.
Avoiding common pitfalls related to anemia and iron
A very common diagnosis in older adults is iron-deficiency anemia. If you are diagnosed with this type of anemia, be sure the doctors have checked a ferritin level or otherwise confirmed you are low on iron.
I have actually reviewed medical charts in which a patient was prescribed iron for anemia, but no actual low iron level was documented. This suggests that the clinician may have presumed the anemia was due to low iron.
However, although iron deficiency is common, it’s important that clinicians and patients confirm this is the cause, before moving on to treatment with iron supplements. Doctors should also assess for other causes of anemia, since it’s very common for older adults to simultaneously experience multiple causes of anemia (e.g. iron deficiency and vitamin B12 deficiency).
If an iron deficiency is confirmed, be sure the doctors have tried to check for any causes of slow blood loss.
It is common for older adults to develop microscopic bleeds in their stomach or colon, especially if they take a daily aspirin or a non-steroidal anti-inflammatory drug (NSAIDs) such as ibuprofen. (For this reason — and others — NSAIDs are on the Beer’s list of medications that older adults should use with caution.)
Bear in mind that iron supplements are often quite constipating for older adults. So you only want to take them if an iron-deficiency anemia has been confirmed, and you want to make sure any causes of ongoing blood loss (which causes iron loss) have been addressed.
Key points on anemia in older adults
Here’s what I hope you’ll take away from this article:
1.Anemia is a very common condition for older adults, and often has multiple underlying causes.
2. Anemia is often mild-to-moderate and chronic; don’t let the follow-up fall through the cracks.
3. If you are diagnosed with anemia or if you notice a lower than normal hemoglobin on your lab report, be sure to ask questions to understand your anemia. You’ll want to know:
- Is the anemia chronic or new?
- Is it mild, moderate, or severe?
- What is thought to be the cause? Have you been checked for common problems such as low iron or low vitamin B12?
4. If you are diagnosed with low iron levels: could it be from a small internal bleed and could that be associated with aspirin, a non-steroidal anti-inflammatory medication such as ibuprofen, or another medication?
5. Keep copies of your lab reports.
6. Make sure you know what the plan is, for following your blood count and for evaluating the cause of your anemia.
Note: We have reached over 200 comments on this post, so comments will now be closed. If you have a question, chances are it’s already been asked and answered. Thank you!
You may also find it helpful to read these related articles:
Understanding Laboratory Tests: 10 Commonly Used Blood Tests for Older Adults
How to Avoid Harm from Vitamin B12 Deficiency
This article was first published in 2016 & minor updates were made in November 2025. (The fundamentals of anemia in older adults don’t change much over time.)
Charu Baldwa says
Hi,
My father is 56. He has hemoglobin level of 10.2 and is low on iron levels. His RBC count is a bit higher than normal range. Doctor gave him 1100mg iron drip 2 weeks back. His Hemoglobin level is still 10.2. what is the normal time after which we should take test again. what can be futher course of action.
Regards,
Charu
Leslie Kernisan, MD MPH says
I don’t have any personal experience administering IV iron, but according to the related topic in Uptodate:
“There is no evidence that total doses above 1000 mg of elemental iron are clinically useful. We often give a fixed dose of approximately 1000 mg, which is generally sufficient to treat anemia (typical red blood cell iron deficit between 500 and 1000 mg) and provide additional storage iron without causing iron overload.”
Also, apparently IV iron interferes with most tests related to iron studies, so iron levels are not repeated during the month after administration of IV iron.
Usually, the hemoglobin level starts to slowly improve after 1-2 weeks, and one should see substantial improvement after one month.
I would encourage you to ask your father’s doctors to clarify what testing should be done, to make sure that his anemia has been sufficiently diagnosed and treated.
Sonja says
Hi. Your website very helpful. 1 weeks ago, my internist told me I have anemia. Score was
10. I am 72 and in good health otherwise. He started me on iron – 2 per day. This past week has been very very difficult. I have weakness and fatigue. I have 2 questions. First, how long does it take to start feeling better after taking iron. Second, since my CBC was taken about 2 weeks ago, should I get another CBC to see how I’m doing.
Thank you for your kind help
Leslie Kernisan, MD MPH says
I would encourage you to contact your doctors as soon as possible, and let them know you are feeling weak and doing worse than before.
When a person feels worse after being diagnosed with anemia, it’s usually reasonable to repeat the CBC within 1-2 weeks, to make sure the red blood cell count hasn’t dropped further.
Also be sure that your doctors explain to you why they think you have lost blood or otherwise become iron deficient. Don’t forget that it’s common for older adult to experience more than one cause of anemia at the same time.
Once the cause of blood loss has been fixed, then if anemia is due to iron-deficiency, the blood count should improve within 1-2 months. Good luck!
Susan George says
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chris says
Hi, my mother is 74 and has marginal zone lymphoma(she’s currently on watch and wait and has been for a number of years). Her Hematologist has said she is iron deficient(her level was 10) and has given her an iron infusion, but has also referred her to a Gastroenterologist. She has had 2 ct scans and an ultrasound and aside from a Splenomegaly,they were clear. My concerns are for colorectal cancer, although she feels fine ,has no blood in her faeces or stomach pains etc. My mother has also been on Warfarn for 30 years and self tests her own inr. Could the warfarin be responsible for a slow bleed that she would be unaware of? Thanks in advance:)
Leslie Kernisan, MD MPH says
Warfarin requires careful monitoring of a blood thinning metric called “INR.” Usually the goal is to dose warfarin so that a person’s INR remains between 2 and 3.
If your mom’s INR has usually been in the right range, it would be unusual for this by itself to cause a slow bleed.
Your mother is currently seeing the right specialists to address your concerns. I would encourage you to ask them to clarify why they think she is anemic and iron-deficient. The gastroenterologist should also be able to address your concern about whether she might have colo-rectal cancer, despite her so-far reassuring test results.
chris says
Hi,
My mother’s inr has been above 2 /3. It has been as high as 6, but mostly around the 4 range. So I’m guessing this puts her at greater risk of a bleed then?
Her inr has become more unstable this year and she seen an increase in bleeds into her eye and bruising.
Thank you for your help
Leslie Kernisan, MD MPH says
Yes, the higher the INR, the greater the risk of bleeding.
An unstable or frequently high INR sounds concerning. I would encourage you to bring it up with her doctors, especially the one who prescribes her warfarin or who initially recommended she be on it. (Many people take warfarin related to a heart condition, but the prescription is often written by the PCP.)
Warfarin is one of the top drugs for causing ER visits, hospitalizations, and complications, mainly because it can be a challenge to keep people within the safe range.
You might want to ask whether it might be possible to switch her to one of the newer blood thinning agents, such as dabigatran or apixaban (Pradaxa or Eliquis). These newer medications do not fluctuate in the body the way warfarin can, so these can be a safer choice for some older people. So far their safety track record seems acceptable, and recently an “antidote” to dabigatran was approved by the FDA.
If your mom is having bleeds in her eye and bruising, then I think it’s definitely important to discuss her anticoagulation with her doctors. It should be possible to reduce her bleeding risk, either by helping her better manage her INR levels or by switching to a different anticoagulant. Good luck!
Anu says
Hi
My mother in law who is 79 years old was diagnosed with atrial fibrillation 4 months ago. Since then her iron levels have dropped and she is anemic. is there a correlation between AF and anemia?
Leslie Kernisan, MD MPH says
Atrial fibrillation on its own does not cause anemia. However, atrial fibrillation does cause a significant risk of stroke, because when the heart fibrillates it’s much easier for the blood to create a clot; if that clot then travels to the brain, you can have a stroke.
To reduce this risk of stroke, most people with atrial fibrillation are put on a blood thinning medication. Those ARE associated with a risk of internal bleeding, which can cause anemia.
Karen K Gruis says
My 97 year old Mother was just hospitalized this past weekend with a hemoglobin count of 6.3 . . .in February of this year her count was 10.7 . . .they did a routine blood check and found the low count . . .they gave her 2 units of blood that brought her count to 11.2 . . .and sent her back to the home . . .they also used Protonix for the bleeding . . .they talked colonoscopy and scoping her throat but the gastronenterologist said both were too risky for her at her age and we agreed. Her blood pressure was very high 198/90 so they put her back on her blood pressure medicine which she has been off for almost a year because her pressure was so low . . they are going to monitor her BP each month and said if the count drops again to bring her back to the Hospital and they will give her blood and fluids again and continue to treat her that way and any invasive tests are out per her Health Care Directive . . .Even though they don’t know what’s causing the bleed is using Protonix good for her . . .it is a pph and that worries me . . .
Leslie Kernisan, MD MPH says
The proton pump inhibitor Protonix is routinely used to reduce the chance of rebleeding, but that only works if the bleeding is coming from the upper part of the gastrointestinal tract (e.g. the stomach or the beginning of the small intestine). A PPI does not help if one suspects bleeding from the colon.
Normally the doctors have some idea of whether the bleeding is more likely to be from the upper part of the GI tract versus the lower part. I would encourage you to ask them which one they suspect. It’s not ideal for an older adult to be on a PPI long-term unless it’s really necessary, but it’s also unlikely to harm her over the next 6-12 months, the recent concerns over PPIs are more about people taking them for years and years.
It’s probably most useful for you to focus on helping the doctors monitor her BP and her blood count. After a significant drop, it’s often a good idea to check the count again after a week or so, to make sure it is holding steady. It should also be possible to check her blood pressure at least every few days in the beginning, to make sure she is not too high or too low with the current dose of BP meds. Good luck!
Janet Hill says
My dad is 71 years old Afican American with Renal Failure, HBP, Diabetes(insulin), high cholesterol and he has anemia. He just had a heart attack and a bad stroke in June 2017. His hemoglobin levels dropped from 10 to 7 about 2 weeks ago. They did a cult and found small amounts of blood. I called today his levels were 11.3 on 8/17/17. He has an appointment tomorrow to see if he need a colonoscopy. He is very weak, not eating a lot, he has a knots popping up in his head and in his lower back. In May he just had a cyst that kept filling up with fluid removed off his back in which it healed slowly. My dad is getting light in skin color or a pale look, he is also somewhat disoriented. I am very concerned.
Leslie Kernisan, MD MPH says
Wow, sounds like your poor dad has had a rough time with his health these past few months.
His confusion might be delirium, you can learn more here: Hospital Delirium: What to Know and Do
I assume you are referring to a “hemoccult” test, which is when they put a smear of poop on a special card, which allows them to check for microscopic blood in the stool.
If he had a heart attack and a stroke, then he may have been put on medication to prevent further blood clots, such as Plavix and/or aspirin. Such medications do reduce the risk of another cardiovascular event, but they also come with a risk of bleeding; that type of medicine could contribute to or cause a bleeding episode such as what you describe. But at his age, it’s also possible to have all kinds of problems in the stomach or bowel that can cause bleeding; a colonoscopy would check for some of those.
I would encourage you to keep asking a lot of questions, as his situation does sound concerning. You may want to ask what is his hemoglobin level now; normally someone would not look very pale with a hemoglobin of 11.3. Good luck!
Laraine White says
My mother is 90 yrs old, she lives in a residential care home. She neglected her diabetes for many years without dealing with it, eating and drinking anything she liked. Now she is on insulin and has chronic kidney disease, She has had many blood transfusions and still the blood is very low – 5. with anemia. She has been in hospital every month for transfusions after blood analysis showed it low can you tell me why the blood is so low and for a long period of time now. Kind regards Laraine White
Leslie Kernisan, MD MPH says
A hemoglobin level of 5 is indeed quite low, probably too low to be caused just by chronic kidney disease and/or anemia of chronic disease.
It’s impossible for me to say why it’s so low. You will need to keep asking her doctors questions. Why do they think it’s so low? What is their plan for figuring out the cause, or at least helping her sustain a better hemoglobin level? What do they think you and your mother should expect over the next few months?
Good luck!
Linda S vazquez says
My aunt will 88 next month. Over the past year she has had episode of blacking out and falling. The latest incident happened at the top of her basement stairs. She blavked out and tumbled to the bottom. She then made her way upstairs. Het son took her to emergency. They said her blood level was low and 2 liters. It is still low. We need help. They also diagnosed a bladder infection
Leslie Kernisan, MD MPH says
Sorry to hear about your aunt’s difficulties.
Yes, I agree that you need more help. You will need to keep asking a lot of questions of the doctors. How low is her red blood cell level? How fast did it drop? What do they think caused it? What are they planning to do to investigate further, or to treat this?
You don’t say how low her blood count was, but if it’s low enough, it can certainly lead to passing out, and falls. However there are many other problems that can lead to this. So, you may want to ask more questions to make sure those symptoms have been properly investigated. In particular, low blood pressure can also cause blacking out and falling.
Good luck!
Wendy says
My 94 year old father is a nursing home resident with not much quality of life left. He has advance directives in place to prevent unnecessary procedures to prolong his life. I was told today by one of his nurses that they did some blood work and detected a hemoglobin level of 5.1. He has been tired and not eating well. What can I expect as his levels continue to drop without treatment? Currently he has no pain. Will this change?
Leslie Kernisan, MD MPH says
A hemoglobin of 5.1 is pretty low. I would expect him to get increasingly tired, and also perhaps start experiencing some shortness of breath. A low hemoglobin level also puts some strain on the heart and other organs. He could start experiencing some angina, and he could at some point experience a cardiac arrest. With low oxygen levels in the brain, he might also be drowsy or confused.
If he is 94 and the goal is to keep him comfortable and not prolong his life, then you may want to consider hospice care. A hospice team may be better able to manage any symptoms, and will also be equipped to answer your questions and provide you with support, as you help your father navigate this last stage of life. Good luck!