Long-Term Care Survey Alert

This mistake is one you definitely don't want to make.

Automatically ordering iron for residents with low hemoglobin might sound like the prudent thing to do. But that strategy skips an assessment step that can put residents in harm's way.

The problem: Say a resident has anemia due to a slow gastrointestinal bleed caused by medication or an underlying GI condition. Giving him iron will lessen or even halt the slow decline in hemoglobin, says Richard Marasco, a pharmacist consultant in Valdosta, GA, specializing in geriatric anemia. But it won't "affect the cause of the bleeding." The iron can also mask many clinical conditions, Marasco cautions.

The solution: The clinical team needs to evaluate the cause of a hemoglobin under 12 grams/liter in residents of either sex, says Marasco. As part of that evaluation, look for occult blood in the stool, he advises.

Free resource: For a handy algorithm that walks you through assessing the cause of anemia in the elderly, see the chart entitled, "Evaluation of Anemia in the Elderly" in the article "Anemia in the Elderly" in the American Family Physician at www.aafp.org/afp/20001001/1565.html.

Did you know? Iron deficiency anemia "usually results from chronic gastrointestinal blood loss caused by nonsteroidal anti-inflammatory drug­induced gastritis, ulcer, colon cancer, diverticula or angiodysplasia," according to Douglas Smith, MD, in the article, "Anemia in the Elderly" (see the previous citation). Smith notes that elderly people can also develop iron deficiency anemia due to inadequate intake or poor absorption. But "without blood loss, anemia takes several years to develop," he states.

Watch out for this drug combination: Elderly people "in general who are taking even low-dose aspirin -- and most certainly aspirin plus Plavix -- are at risk for blood loss causing anemia," cautions consultant pharmacist James Cooper, PhD, at the University of Georgia in Athens.

Important warning sign: "For a patient taking NSAIDs, a one-gram drop in hemoglobin in two weeks to three months can signal that the person is at risk for a major GI bleed in the near future," says Cooper. "As-  pirin plus Plavix is the most likely cause of such a drop, according to a recent unpublished study of GI bleeds in long-term care facilities."

Tip: To prevent GI bleeding, Tylenol up to 3 grams a day is safer than NSAIDs, says Cooper.

Risk management strategies: Make sure the resident has a hemoglobin of at least 12 grams/liter before starting him on aspirin, NSAIDs and other drugs known to cause potential GI bleeding, advises Cooper. Look for a history of GI conditions known to cause bleeding in order to give the physician a heads up. And document "baseline assessment measures of the patient's physiologic symptoms," such as shortness of breath, fatigue, irritability, low blood pressure or tachycardia, advises Allison Burfield, MSN, RN, in Orlando, FL. That way you can more easily detect a change from baseline.