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it affects anxiety rather than mood and energy levels, and it is a response primarily
to transitional training and work experiences. Life imbalance occurs when one feels
compelled to focus on training or job tasks to the detriment of meeting personal
and family needs and responsibilities. It can lead to feelings of depression and anxiety as well as feelings of inadequacy and guilt. Life imbalance can be distinguished
from job burnout in that it involves feeling trapped in a job situation that does not
allow for adequate time for self and family, whereas burnout’s primary symptom is
emotional exhaustion.
A study published in 2018 in the Journal of Internal Medicine highlights the
importance for more investigation (especially longitudinal studies) in this area
to better understand the problem and focus on a multiprong solution of both
structural/organizational and individual physician interventions to correct this
current crisis.
COMPREHENSION QUESTIONS
8.1 A 26-year-old third-year medical student awakens each day with dread as she
contemplates her day on the clinical rotation. What she dreads the most are
attending rounds, where she is expected to answer difficult clinical questions in
front of everybody. She wonders why she ever thought she was smart enough
for medical school. Which of the following is most accurate?
A. She is suffering from imposter syndrome, a common syndrome among
learners.
B. She is definitely not suited for medical school and should drop out.
C. While clinical environments can be difficult, this is how students learn.
She should soldier on and tough out the rotation.
D. Awakening with dread is a normal part of medical school.
8.2 A 27-year-old medical student is nearing the end of his required clinical clerkship on internal medicine. Although he began medical school with enthusiasm
and eagerness to learn, now he only feels tired and wishes he could hurry up
and finish the day so he can go home and rest. His current rotation includes
numerous late-day admissions. He notices that at the end of a long day, he
rushes and only lets his patient respond in yes–no answers to his questions,
cutting off their rambling responses or added detail. He goes home exhausted
and feeling guilty about interacting with his patients in this way. Which of the
following statements is most accurate?
A. This is a normal response to a busy day and hectic medical school schedule.
B. This is a manifestation of depersonalization and may be a sign of burnout.
C. Students should expect that a loss of enthusiasm and idealism will occur
naturally through the process of medical school.
D. Patients do not mind being interrupted. They realize that student doctors
have time constraints.
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8.3 Dr. Jackson is a 55-year-old man who has been in medical practice for 25 years.
He used to enjoy his work greatly and feel a sense of satisfaction when he left
each day, knowing that he had contributed to the well-being of his patients
and staff. Recently, however, his practice was bought by a local hospital, and
productivity requirements have increased. He must rush through each visit,
and he finds that his work is no longer satisfying. He cannot give each patient
the proper time and attention. Which of the following individual interventions
would most likely be effective in this situation?
A. Spend the necessary time with patients and save charting for later.
B. Threaten to quit unless productivity targets are more reasonable.
C. Stress management and resiliency training.
D. Recommend a more efficient electronic health system.
ANSWERS
8.1 A. Although imposter syndrome is a normal response of a student to initial
clinical rotations, as a student gains experience the sense of dread is short-lived
and is replaced by a growing sense of mastery. Feeling dread does not mean
she is not suited for medical school (answer B). Sustained dread of clinical
work, however, is emotionally exhausting and unhealthy. Rather than soldiering through (answer C), a student is advised to seek help via formal or informal
student support groups or the student dean’s office. Awakening each day with
dread (answer D) is not normal and should be investigated.
8.2 B. This medical student is clearly burned out and experiencing depersonalization, leading to cynical attitudes toward patients and a lack of empathy. He
exhibits an age-old conflict: balancing good medical care with healthy self-care.
As productivity pressures have increased, this conflict has escalated. When clinicians are expected to see more patients in shorter times, the conflict becomes less
a situation of balancing self-care and more an institutional issue of quality care.
The solutions are best done at an institutional level. Enthusiasm and idealism
may be tempered and matured but are not lost during training (answer C), and
patients should never have to accept poor care (answer D) on the grounds of a
busy provider schedule.
8.3 C. Sadly, this situation of having a dramatic increase in productivity targets
is a very common scenario for today’s providers. There are organizational
interventions that may be helpful, such as answer D (more efficient electronic
health system). Threatening to quit (answer B) is not very positive. Answer A
(spending more time charting later) will likely impinge on personal time and
even cause more depression and burnout. The individual interventions that
have been shown to effectively reduce burnout include stress management
and resiliency training, positive coping strategies, and mindfulness.
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CLINICAL PEARLS
» The prevailing symptom of provider burnout is emotional exhaustion. It
sometimes also includes treating patients as objects rather than persons
and having a lowered sense of personal accomplishment.
» Multiple studies have documented the prevalence of physical burnout
symptoms at about 50% in both physicians in training and practicing
physicians.
» Clinician burnout is a public health crisis and affects clinicians, patients,
and the health care organization.
» It is important to address burnout so that we can more fully experience
the joy, meaning, and rewards inherent in this healing profession.
» Every day brings new opportunities to partner with patients for healing,
to be invited into their lives when help is most needed, to develop durable relationships over many years, and to be rewarded with our patients’
expressions of gratitude for our role in their lives.
» Physician suicide rates have steadily increased over the past 15 years.
» The solution to clinician burnout is both a structural/organizational and
an individual intervention and change.
REFERENCES
Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Burnout among health care professionals: a call to explore
and address this underrecognized threat to safe, high-quality care. NAM Perspectives. Discussion
paper, National Academy of Medicine, Washington, DC. July 5, 2017. Retrieved from NAM.edu/
Perspectives. https://doi.org/10.31478/201707b
Linzer M, Paplau S, Grossman E, et al. A cluster randomized trial of interventions to improve work
conditions and clinical burnout in primary care: results from the Health Work Place (HWP) Study.
J Gen Intern Med. 2015:30(8):1105-1111.
Maslach C, Leiter MP. The Truth about Burnout: How Organizations Cause Personal Stress and What to
Do About It. San Francisco, CA: Jossey-Bass; 1997.
Nedrow A, Steckler NA, Jardman J. Physician resilience and burnout: Can you make the switch?
Fam Pract Manag. 2013;20(1):25-30.
Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational
strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017:92(1):129-146.
http://dx.doi.org/10.1016/j.mayocp.2016.10.004
Sinksy CA, Willard-Grace E, Schutzbank AM, et al. In search of joy in practice: a report of 23 high-
functioning primary care practices. Ann Fam Med. 2013;11(3):272-278.
West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction,
and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.
West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions.
J Intern Med. 2018;283(6):516-529.
CASE 9
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A 65-year-old woman presents to the emergency department complaining of
worsening shortness of breath and palpitations for about 1 week. She reports
“feeling dizzy” on and off for the past year; the dizziness is associated with
weakness that has been worsening for the past month. She has been feeling “too
tired” to even walk to her backyard and water her flower bed, which she used to
do “all the time.” She has been so dyspneic walking up the stairs at her home that
she moved downstairs to the guest room about a week ago. Review of systems
is significant for knee pain, for which she frequently takes aspirin or ibuprofen;
otherwise, the review of systems is negative. She has no significant medical history
and has not been to a doctor in several years. She had a normal well-woman
examination and screening colonoscopy about 5 years ago. She occasionally
has an alcoholic drink and denies tobacco or drug use. She is married and is a
retired shopkeeper. On examination, her blood pressure is 150/85 mm Hg, pulse is
98 beats/min, respiratory rate is 20breaths/min, temperature is 98.7 °F (37.1 °C),
and oxygen saturation is 99% on room air. Significant findings on examination
include conjunctival pallor, mild tenderness with deep palpation in the epigastric
and left upper quadrant (LUQ) region of the abdomen, normal bowel sounds,
and no organomegaly but a positive stool guaiac test. The remainder of the
examination, including respiratory, cardiovascular, and nervous systems, is normal.
▶ What is the most likely diagnosis?
▶ What is your next diagnostic step?
▶ What is the next step in therapy?
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ANSWERS TO CASE 9:
Anemia in the Geriatric Patient
Summary: A 65-year-old woman presents with
Worsening dyspnea on exertion, fatigue, dizziness, and palpitations
Dyspnea that has caused her to alter her lifestyle (moving downstairs, not watering
plants)
Conjunctival pallor
Guaiac-positive stool
Mild tenderness with deep palpation in the epigastric and LUQ region
Most likely diagnosis: Anemia secondary to gastrointestinal (GI) bleeding; other
considerations should include new-onset angina, congestive heart failure, and atrial
fibrillation.
Next diagnostic step: A complete blood count (CBC) to evaluate for the anemia, an
electrocardiogram (ECG) and cardiac enzymes, and a prothrombin time (PT) and
partial thromboplastin time (PTT) to look for coagulation abnormalities.
Next step in therapy: Further workup, including blood transfusion (if needed),
completion of two more sets of cardiac enzymes, and ECGs. A gastroenterology
consult for esophagogastroduodenoscopy (EGD) and colonoscopy is appropriate
because of the positive guaiac findings.
ANALYSIS
Objectives
1. Know a diagnostic approach to anemia in geriatrics. (EPA 2, 3)
2. Be familiar with a rational workup for anemia of different origins. (EPA 1, 2)
3. Describe the treatment of anemia in older patients. (EPA 4)
Considerations
A 65-year-old woman who has developed worsening dyspnea and palpitations
over a 1-week period of time needs to be evaluated for cardiac and respiratory
problems despite the gradual onset of symptoms. Specifically, in a postmenopausal woman, signs and symptoms of angina or acute myocardial infarction
may not always have a typical presentation. That the patient has been feeling
weak and has conjunctival pallor warrants testing for anemia. Since evaluation
with serial cardiac enzymes and ECGs is part of the workup, admission into the
hospital is appropriate.
Assuming that the initial workup for cardiac and pulmonary causes is negative
and that the hemoglobin and hematocrit levels are low, a thorough evaluation for
the cause of the anemia is necessary. A CBC with peripheral smear, reticulocyte
count, iron studies, and vitamin B12 and folic acid levels would provide clues to
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the type of anemia that this patient has. A gastroenterology consult for possible
EGD and colonoscopy to further investigate the source of GI bleeding should be
considered. The presence of epigastric and LUQ pain, along with long-term use of
nonsteroidal anti-inflammatory drugs, should also raise a flag for testing to rule out
a bleeding ulcer.
The presence of other findings may direct your workup toward other diagnoses.
If this patient were from a developing country, the possibility of intestinal parasites would need to be considered. If the PT and PTT were abnormal, GI bleeding
from a coagulopathy or liver disease would be possibilities. Weight loss, lymphadenopathy, and coagulopathy may warrant evaluation for nongastrointestinal malignancies, such as leukemias or lymphomas. In younger patients, sickle cell disease,
thalassemias, glucose-6-phosphate dehydrogenase deficiency, and other inherited
causes of anemia would be on the differential diagnosis list. These are unlikely to
manifest as an initial diagnosis at the age of 65 years.
APPROACH TO:
Anemia in the Geriatric Population
DEFINITION
ANEMIA: According to the World Health Organization, a hemoglobin level of less
than 12 g/dL in women and less than 13 g/dL in men. In older populations, anemia
may be defined as a hemoglobin less than 12 g/dL for both men and women.
CLINICAL APPROACH
Epidemiology
The prevalence of anemia in Americans older than age 65 years is estimated at 9%
to 45%. There is a wide variation in the rates of anemia in different ethnic and racial
groups, with the National Health and Nutrition Examination Surveys data showing
the highest rates in non-Hispanic blacks and lowest rates in non-Hispanic whites.
These differences are reportedly a result of biologic, not socioeconomic, differences.
Most studies show the rate of anemia to be higher in men than women, and there is
increasing evidence for anemia as an independent risk factor for increased morbidity and mortality and decreased quality of life.
Pathophysiology
Microcytic Anemia. The most common cause of anemia with a low mean corpuscular volume (MCV), microcytic anemia, is iron deficiency. Iron deficiency could
be confirmed by subsequent testing that shows a low serum iron, low ferritin, and
high total iron-binding capacity (TIBC). Other causes of microcytic anemia include
thalassemias and anemia of chronic inflammation. In the elderly, iron deficiency is
frequently caused by chronic GI blood loss, poor nutritional intake, or a bleeding
disorder. A thorough evaluation of the GI tract for a source of blood loss, usually requiring a gastroenterology consultation for upper and lower GI endoscopy,
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should be undertaken, as iron-deficiency anemia may be the initial presentation of
a GI malignancy.
Macrocytic Anemia. Anemia with an elevated MCV, macrocytic anemia, is most
often a manifestation of folate or vitamin B12 deficiency; other causes include drug
effects, liver disease, and hypothyroidism. The presence of macrocytic anemia, with
or without the symptoms previously mentioned, should lead to further testing to
determine B12 and folate levels. An elevated methylmalonic acid (MMA) level can
be used to confirm a vitamin B12 deficiency; an elevated homocysteine level can be
used to confirm folate deficiency. Folate deficiency anemia is usually seen in alcoholics, whereas B12-deficiency anemia mostly occurs in people with pernicious anemia,
a history of gastrectomy, and diseases associated with malabsorption (eg, bacterial
infection, Crohn disease, celiac disease). The long-term use of certain medications,
including proton pump inhibitors and H2 blockers, can also result in the inhibition of B12 absorption. Under normal conditions, the body stores 50% of its
B12(2–5mg total in adults) in the liver for 3 to 5 years. A minimal amount of B12 is
lost daily through GI secretions. B12-deficiency anemia is rare but possible in longterm vegans and vegetarians. B12 deficiency can be distinguished clinically from folic
acid deficiency by the presence of neurological symptoms in B12 deficiency.
Normocytic Anemia. In the elderly, anemia of chronic inflammation (formerly
known as anemia of chronic disease) is the most common cause of a normocytic
anemia. Anemia of chronic inflammation is anemia that is secondary to some other
underlying condition that leads to increased inflammation and bone marrow suppression. Along with causing a normocytic anemia, anemia of chronic inflammation
can also present as a microcytic anemia. This type of anemia can easily be confused
with iron-deficiency anemia because of its similar initial laboratory picture. In ane-
mia of chronic inflammation, the body’s iron stores (measured by serum ferritin) are
normal, but the capability of using the stored iron in the reticuloendothelial system
becomes decreased. A lack of improvement in symptoms and hemoglobin level with
iron supplementation is an important clue indicating that the cause is chronic disease and not iron depletion, regardless of the laboratory picture. Another cause of
normocytic anemia is renal insufficiency due to decreased erythropoietin production. Although bone marrow iron store remains the gold standard to differentiate between iron-deficiency anemia and anemia of chronic inflammation, simple
serum testing is still used to diagnose and differentiate these two types of anemia
(Table 9–1).
Table 9–1 • LABORATORY VALUES DIFFERENTIATING IRON-DEFICIENCY
ANEMIA FROM ANEMIA OF CHRONIC INFLAMMATION
Test Iron Deficiency
Serum iron Low Low or normal
Total iron-binding capacity (TIBC) High Low
Transferrin saturation Low Low or normal
Serum ferritin Low Normal or high
Anemia of Chronic
Inflammation
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Clinical Presentation
Anemia that develops slowly may be asymptomatic and found incidentally on laboratory testing. Fatigue, weakness, and dyspnea are symptoms that are commonly
reported by elderly persons with anemia. These vague and nonspecific symptoms
are often ignored by both patients and clinicians as symptoms of “old age.” Anemia
may result in worsening of symptoms of other underlying conditions. For example,
the reduced oxygen-carrying capacity of the blood as a consequence of anemia may
exacerbate dyspnea associated with congestive heart failure.
Certain signs found on examination may prompt a workup for anemia. Conjunc-
tival pallor is recommended as a reliable sign of anemia in the elderly and commonly
noted in patients with hemoglobin < 9 g/dL. Other signs may suggest a specific
cause of anemia. Glossitis, decreased vibratory and positional senses, ataxia, paresthesia, confusion, dementia, and pearly gray hair at an early age are signs suggestive of vitamin B12-deficiency anemia. Folate deficiency can cause similar signs,
except for the neurologic deficits. Profound iron deficiency may produce koilonychias (spoon nails), glossitis, or dysphagia. Other clinical manifestations of anemia
include jaundice and splenomegaly. Jaundice can be a clue that hemolysis is a contributing factor to the anemia, while splenomegaly can indicate that a thalassemia
or neoplasm may be present.
Initial workup of anemia should include a CBC with measurement of red blood cell
(RBC) indices, a peripheral blood smear, and a reticulocyte count. Further laboratory
studies would be indicated based on the results of the initial tests and the presence
of symptoms or signs suggestive of other diseases.
Treatment
The treatment of anemia is determined based on the type and cause of the anemia.
Any cause of anemia that creates a hemodynamic instability can be treated with an
RBC transfusion.
Correcting Blood Loss. A hemoglobin less than 7 g/dL is a commonly used
threshold for transfusion; however, transfusion may be indicated at higher levels
if the patient is symptomatic or has a comorbid condition such as coronary artery
disease. Iron-deficiency anemia is treated first by identification and correction of
any source of blood loss.
Oral Iron Supplementation. Most iron deficiency can be corrected by oral iron
replacement. Oral iron is given as ferrous sulfate 325 mg (contains 65 mg of elemental iron) three times a day. In uncomplicated anemia, it is considered first-line therapy
because of its low cost and easy accessibility. Adherence to oral iron may be poor due
to GI side effects (dark stools, nausea, vomiting, and constipation) and the required
6 to 8 weeks of treatment needed to correct the anemia. New evidence suggests that
lower oral iron doses may be as effective as higher doses and have fewer side effects.
Intravenous Iron Supplementation. Individuals with malabsorptive conditions,
malignancy, chronic kidney disease, heart failure, or significant blood loss may not
benefit from oral iron replacement and therefore require parenteral iron preparations. It is recommended that patients requiring parenteral administration be given
iron intravenously and not intramuscularly. Given the high risk of side effects, only
trained clinicians should administer intravenous iron.
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Vitamin Therapy. Vitamin B12 deficiency traditionally has been treated by intra-
muscular B12 therapy with a regimen of 1000 µg IM daily for 7 days, then weekly
for 4 weeks, then monthly for the rest of the patient’s life. However, most patients
can be successfully treated with oral B12 therapy using 1000 to 2000 µg in a similar
regimen. Folate deficiency can be treated with oral therapy of 1 mg daily until the
deficiency is corrected.
Anemia of Chronic Inflammation Treatment. Anemia of chronic inflammation is
managed primarily by treatment of the underlying condition in order to decrease
inflammation and bone marrow suppression. When anemia of chronic inflammation is severe (hemoglobin < 10 g/dL), the risks and benefits of two modalities of
treatment, blood transfusion and erythropoiesis-stimulating agents, may be considered. Of note, the goals of treatment of anemia of chronic inflammation in patients
with chronic kidney disease undergoing dialysis are to maintain a hemoglobin level
between 10 and 12 g/dL; higher hemoglobin levels in this patient population are
associated with increased rates of death and cardiovascular events.
CASE CORRELATION
See also Case 14 (Hematuria) and Case 23 (Lower Gastrointestinal
Bleeding).
COMPREHENSION QUESTIONS
9.1 A 58-year-old woman comes to your office complaining of fatigue. She has
also noticed a burning sensation in her feet over the past 6 months. A CBC
shows anemia with an increased MCV. Which of the following is the most
likely cause of her anemia?
A. Lack of intrinsic factor
B. Inadequate dietary folate
C. Strict vegetarian diet for the past 6 months
D. Chronic GI blood loss
9.2 A 65-year-old man with a history of rheumatoid arthritis is found to have a
microcytic anemia. He had a colonoscopy 1 year ago that was normal, and a stool
guaiac is negative. Which of the following is the most likely cause of his anemia?
A. Iron deficiency
B. Chronic disease
C. Pernicious anemia
D. Folate deficiency
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9.3 A 68-year-old man is found to have an incidental finding of anemia while
hospitalized with pneumonia. His physical examination is normal except for
crackles in the left lower lobe. Serum laboratory examinations reveal a normal
MMA and a decreased serum folate level. Which of the following is the best
next step?
A. Administer CAGE questionnaire
B. Esophagogastroduodenoscopy
C. Serum iron assay
D. Neurology consultation
For questions 9.4 and 9.5, match the following laboratory pictures (A–D) of
patients with anemia:
A. Normal MMA; decreased serum folate level
B. Elevated MMA; decreased serum B12 level
C. Elevated ferritin; normal MCV; decreased serum iron level
D. Decreased ferritin; decreased MCV; decreased serum iron level
9.4 A 68-year-old man has an incidental finding of anemia while in the hospital for
alcohol abuse.
9.5 A 67-year-old man presents with dizziness and a positive stool guaiac test.
ANSWERS
9.1 A. The clinical presentation of paresthesia and CBC findings are consistent
with macrocytic anemia due to B12 deficiency. Pernicious anemia (lack of
intrinsic factor) is the most common cause; recall that intrinsic factor is critical to binding vitamin B12 and absorption by the terminal ileum. Also, B12
deficiency can rarely be seen in patients who follow a strict vegetarian diet
(answerC); however, the body’s B12 stores can last several years before they are
depleted. Answer B (inadequate folate) is another cause of macrocytic anemia,
but it usually does not have neurological symptoms. Answer D (chronic GI
blood loss) can lead to an iron-deficiency anemia, but it usually presents with
microcytic anemia and without neurological symptoms.
9.2 B. Anemia of chronic inflammation can cause normocytic or microcytic anemia
and may be secondary to rheumatoid arthritis in the patient. Iron-deficiency
anemia (answer A) is less likely to be the etiology with a normal colonoscopy
and negative stool guaiac, and serum iron studies could be used to help differentiate the two. Answer C (pernicious anemia) and answer D (folate deficiency) would lead to vitamin B12 deficiency and a macrocytic anemia.
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