C A S E ST U DY

A case study of an older adult with severe anemia refusing

blood transfusion
C. Michelle Thomas, BSN, RNC (Family Nurse Practitioner Student, Program Manager)1,
Harriet R. Coleman, BSN, RN, ACRN, NCSN, BC (Family Nurse Practitioner Student, School Nurse)2, &
Leslie-Faith Morritt Taub, ANP-C, GNP-BC, CDE, DNSc (Assistant Professor)3
1 The University Center for Bloodless Surgery and Medicine at University Hospital, The University of Medicine and Dentistry of New Jersey,
Newark, New Jersey
2 Rahway Board of Education–Franklin Elementary School, Rahway, New Jersey
3 School of Nursing, University of Medicine and Dentistry of New Jersey, Newark, New Jersey

Keywords
Anemia; iron deficiency; Jehovah’s Witness;
blood management.
Correspondence
C. Michelle Thomas, BSN, RNC,
150 Bergen St. C-450, Newark, NJ 07103.
Tel: 973-972-3836 (office); Fax: 973-972-0459;
E-mail: thomasmc@umdnj.edu
Received: January 2006; accepted: May 2006
doi:10.1111/j.1745-7599.2006.00188.x
Abstract
Purpose: To discuss the diagnosis and treatment of severe anemia in an older
adult who presents the challenge of declining blood transfusion in a real-world
scenario where critical thinking, evidence-based care, and collaboration with
other providers must come together to serve this patient’s unique needs.
Data sources: Extensive review of the scientific literature on anemia and the
situation in which a patient refuses blood transfusion presented in a case study
format.
Conclusions: A thorough physical assessment, complete health history, and
appropriate diagnostic workup should be used to distinguish the normal effects of
senescence from the signs and symptoms of anemia. Common conditions that
cause anemia in the elderly include chronic disease, iron deficiency, and gastro-
intestinal bleeding. These conditions may result in profound anemia. The chal-
lenge can be compounded when, because of religious tenets, a patient does not
accept a blood transfusion. This case study challenges nurse practitioners to apply
knowledge, seek guidance, and make appropriate referrals to care for a patient
in order to render care within the parameters of the patient’s belief system.
Implications for practice: The astute primary care provider recognizes that
anemia is not an expected physiological change associated with aging but
a manifestation of an underlying disease process. Fatigue, weakness, and
dyspnea are all symptoms of anemia that may be overlooked and attributed
to the aging process. Further, in keeping with the principles of autonomy and
self-determination, it is the clinician’s duty to work with all patients to restore
them to a state of optimal health while respecting deeply held spiritual beliefs.

Case study
Mrs. H. is a 65-year-old African American woman who
was in her normal state of health until she presented at her
nurse practitioner’s (NP) office with the complaints of
‘‘feeling cold and tired’’ for about a week. Mrs. H.’s medical
history contains several chronic medical conditions. All of
her known medical conditions are currently well con-
trolled and are as follows: hypothyroidism (controlled
with 175 mcg of levothyroxine sodium every day), diet-
controlled diabetes mellitus (HgbA1C normal at 5.5%),
hyperlipidemia (total cholesterol level 155 mg/dL), gas-
troesophageal reflux disease, and an overactive bladder.
Mrs. H. has always been conscientious about keeping her
healthcare appointments and is current with her gyneco-
logic, ophthalmologic, and podiatric care. This patient was
hospitalized for the surgical repair of a ventral hernia in

Journal of the American Academy of Nurse Practitioners 19 (2007) 43–48 ª 2007 The Author(s) 43
Journal compilation ª 2007 American Academy of Nurse Practitioners
Severe anemia in older adults
2001 and of renal calculi in 2003. Her last screening
colonoscopy was in 1998, and the findings were within
normal limits. Differential diagnoses to be considered for
this patient included the following: nutrient deficiencies,
mood disorders, infectious processes, metabolic disorders,
hematologic disorders, and rheumatologic disease.
Review of systems
Mrs. H. has no paresthesias in her extremities, and she
denies having noticed ecchymoses, or petechiae on her
skin or mucosa. Her appetite is unchanged, and she denies
pica. She denies feeling sad or depressed. She has neither
noticed any glossal changes nor experienced any type of
pain. She has not had any frank loss of blood (hematuria,
black tarry stools, and hematochezia), and her last men-
strual period was more than 15 years ago; she has expe-
rienced no vaginal bleeding since.
Family history
Mrs. H.’s family history is remarkable in that her father
died of colon cancer at 56 years of age. Her maternal aunt
died of breast cancer (age of death unknown). She has two
siblings, one sibling with both hypothyroidism and type 2
diabetes and another sibling with hypothyroidism. Mrs. H.
has four children in good health and one with systemic
lupus erythematosis. She denies a family history of ane-
mia, jaundice, bleeding disorders, or hemoglobinopathies.
Social history
Mrs. H retired from her housekeeping job several years
ago. She lives with her husband who is in good health. She
denies alcohol or tobacco use. She denies use of any over-
the-counter medications or herbal remedies and states that
she uses only the medications that her healthcare pro-
viders prescribe. Medicare covers Mrs. H.’s healthcare
costs, and she also has a supplementary plan that covers
her prescription drugs. She is a Jehovah’s Witness, her
religion gives her core values that she lives by, and she is
active within her congregation.
The physical exam
Upon physical examination, Mrs. H. is an overweight
(body mass index 28.7), alert, and oriented African Amer-
ican woman in no acute distress. Her vital signs are all
within normal range and present no variations from nor-
mal. Her skin is warm without edema, lesions, or excessive
dryness. Her nail beds are pale; however, her nails do not
show signs of splinter hemorrhages, clubbing, koilony-
chia, or cyanosis. Her head is normocephalic and atrau-
matic. Her eyes are anicteric, and her pupils are equal,
44
C.M. Thomas et al.
round, and reactive to light bilaterally. No petechiae of the
skin or oral mucosa, or comma signs are noted in the
conjunctival vessels. Her conjunctivas are shiny and pale
as is the nasal and oral mucosa. There is neither thyro-
megaly nor palpable lymph nodes in her neck. Respira-
tions are unlabored, and lungs fields are clear. The heart
rhythm is regular, and a new finding of a systolic ejection
murmur II/VI in intensity is noted. Symmetric +1 ulnar,
femoral, posterior tibial, and dorsal pedis pulses are pal-
pated. The abdomen is soft, nontender, and without orga-
nomegaly. A rectal exam revealed no masses and good
sphincter tone. Her stool tested negative for occult blood.
Sensation in her feet is intact to touch and vibration
bilaterally. Her gait is unencumbered. Cranial nerves II–VII
are grossly intact.
Laboratory data
Mrs. H.’s lab work reveals the following: blood urea
nitrogen and serum creatinine are within the normal
range, her peripheral blood smear shows no abnormal
cells, and her urinalysis reveals no red blood cells. Her
laboratory results reveal a microcytic hypochromic ane-
mia. The mean corpuscular volume (MCV) is 63.5 fL
(normal range 80–95 fL), and the mean corpuscular hemo-
globin concentration (MCHC) is 28.7 g/dL (normal range
32–36 g/dL). Mrs. H.’s hemoglobin is 4.5 g/dL (normal
range for a woman is 11.5–15.0 g/dL), and her platelets are
within normal range at 273.
The diagnosis
Anemia of chronic disease (AOCD) and iron deficiency
anemia (IDA) are the first and second most common
causes of anemia in the elderly, respectively (Eisenstaedt,
Penninx, & Woodman, 2006; Guralnik, Eisenstaedt,
Ferrucci, Klein, & Woodman, 2004). AOCD and IDA
may at times coexist especially in older adults (Montoya,
Wind, & Sole, 2002). The cause of anemia in the elderly
(see Table 2) is often multifactorial and may include blood
loss, malnutrition, and physiological changes such as
diminished bone marrow function (Carmel, 2001). Based
on the low MCV and MCHC, the NP concludes that Mrs. H.
has a microcytic hypochromic anemia caused by iron
deficiency based on a ferritin level of 4 ng/mL. Smith
(2000) supports this diagnosis stating that when the serum
ferritin is less than 15 ng/mL, iron deficiency is virtually
certain. A diagnosis of IDA is also supported by the fact that
the total iron-binding capacity is high normal; this would
be low in AOCD. Additionally, AOCD rarely progresses to
a hemoglobin level below 10 g/dL (Smith). Other types
of microcytic hypochromic anemias are thalassemia, side-
roblastic anemia, and anemia related to lead poisoning
C.M. Thomas et al. Severe anemia in older adults

most commonly found in children. These were ruled out as
the cause of Mrs. H.’s anemia because these disease pro-
cesses leave the patient with normal to high serum iron
levels. This patient’s serum iron level was markedly low
(see Table 1).
The treatment plan
The next step in this process is to determine the cause of
this patient’s IDA. Chronic gastrointestinal (GI) blood loss
should be suspected as an etiology of IDA in postmeno-
pausal women, and older patients with suspected IDA
should be thoroughly evaluated for GI cancers (Buttaro,
Trybulski, Bailey, & Sandberg-Cook, 2003). Also of con-
cern is the fact that this patient’s father died of colon cancer
at the age of 56. A family history of colorectal cancer
increases the patient’s own risk for colorectal cancer. In
general, the closer the familial relationship is to the
affected relative and the younger the age of the affected
relative, the greater is the individual’s risk for colorectal
cancer (Read & Kodner, 1999).
Mrs. H. was admitted to the hospital due to the severity
of her anemia (Hgb = 4.5 g/dL). The plan for Mrs. H.’s
hospitalization was to monitor her complete blood count
using micro blood sampling with specialized laboratory
equipment to test very tiny blood samples to conserve as
much of her circulating blood as possible and to treat the
anemia. Typically, a symptomatic patient with a hemoglo-
bin level this low would receive a blood transfusion;
however, blood transfusion was not an option for this
patient because of her religious beliefs. Mrs. H. was, how-
ever, informed that her blood count is low enough that a
blood transfusion would generally be the treatment of
choice. She continued to decline blood transfusion, con-
firmed that she understood the risks, and signed a release
of liability form stating the same.
Working within the patient’s belief system
In order to understand the reasons for Mrs. H.’s refusal of
generally recommended treatment and to make appropri-
ate alternative plans, the NP searched for information on
this religion. Jehovah’s Witnesses are Christians who be-
lieve that blood transfusion is forbidden. There are approx-
imately 6,613,829 Jehovah’s Witnesses in the world and
1,035,802 in the United States. That is approximately one
Jehovah’s Witness per 282 people in the United States.
Refusal of blood transfusions is based primarily on two
statements in the Bible. These are as follows: (a) God told
Noah and his family that blood represents the soul (or life)
and forbade them to eat it. (‘‘Every moving animal that is
alive may serve as food for you. As in the case of green
vegetation, I do give it all to you. Only flesh with its
soul—its blood—you must not eat.’’ Genesis 9:3, 4) and
(b) the command given in the New Testament to abstain
from blood (‘‘Hence my decision is not to trouble those
from the nations who are turning to God but to write them
to abstain from things polluted by idols and from fornica-
tion and from what is strangled and from blood.’’ Acts
15:19, 20). In respect for the sanctity of blood, Jehovah’s
Witnesses do not accept blood transfusions in whole or in
components even if such a procedure would be lifesaving.
Medical alternatives acceptable to Jehovah’s Witnesses
have proved to be very effective. The world headquarters
of Jehovah’s Witnesses is located in Brooklyn, New York,
where they have a department dedicated to the education
of healthcare providers in non–blood management (for

Table 1 Laboratory results for Mrs. H

11 days 18 days 25 days 37 days

Blood test result (normal range) Ha day 1 H day 4 H day 5 H day 6 post D/C post D/C post D/C post D/C

WBC (4.0–10.5 ! 103/lL 6.6 4.7 5.1 5.7 7.9 4.8 5.0 4.8
RBC (3.8–5.1 ! 103/lL) 2.49Y 2.19Y 2.32Y 2.42Y 3.26Y 3.51Y 4.13Y 4.44Y
Hgb (11.5–15.0 g/dL) 4.5Y 4.1Y 4.5Y 4.7Y 6.7Y 7.8Y 9.3Y 11.1Y
HCT (34%–44%) 15.8Y 14.3Y 15.4Y 16.4Y 24.7Y 27.8Y 33.5Y 37.9
MCV (80–98 fL) 63.5Y 65.4Y 66.3Y 67.7Y 76Y 79Y 81 85
MCH (27–34 pg) 18.2Y 18.8Y 19.2Y 28.6 26.9Y 28 22.5Y 29.2
MCHC (32–36 g/dL) 28.7Y 28.7Y 29Y 28.6Y 26.9Y 28Y 27.7Y 29.2Y
RDW (11.7%–15%) 21.8[ 21.9[ 21.4[ 22[ 34.3[ 34[ 33.6[ 28.6[
Platelets (140–415) 273 140 188 219 245 197 152 160
Reticulocyte (0.5–3.0) 2.5 3.9[ 3.8[ 6.7[ 4.3[ 4.7[ 3.1[
Serum iron (35–150 lg/dL) 8Y
TIBC (250–400 lg/dL) 384
Ferritin (30–150 ng/mL) 4Y

Note. RBC, red blood cells; WBC, white blood cells; TIBC, total iron-binding capacity; [, abnormal high result; Y, abnormal low result.
a
H (hospital) D/C, discharge from hospital; HCT, hematocrit; MCH, mean corpuscular hemoglobin; RDW, RBC distribution width.

45
Severe anemia in older adults C.M. Thomas et al.

Table 2 Most common types of anemia ANEMIA DOCUMENTED in postmenopausal female

Type of
anemia MCV Differential diagnoses
Thorough PHYSICAL EXAM (evaluate for frank GI blood loss)
IDA Microcytic hypochromic Blood loss
Inadequate iron intake
AOCD Normocytic normochromic Chronic renal failure
Chronic inflammation No acute blood loss identified
Hepatic disease
Endocrine failure
Macrocytic Macrocytic normochromic Pernicious anemia
Check CBC with indices, reticulocyte count, & Iron studies.
anemia Folic acid deficiency
Hemolytic Normocytic normochromic Autoimmune hemolysis
anemia Lymphoproliferative
disorders LAB RESULTS:
Drug induced
Microcytic, hypochromic anemia

Low reticulocyte count

more information on Jehovah’s Witnesses’ blood man-
agement beliefs, go to http://www.watchtower.org). In Low serum iron and ferritin
line with the beliefs of this religious group, Mrs. H. did
not consent to a blood transfusion, and she had an advance
medical directive documenting this refusal and her end-of- Iron deficiency Anemia
life choices in the event that she is unable to express them
for herself (see Figure 1). (blood transfusion declined by patient)

Acceptable treatment alternatives Treat with oral iron if tolerated

Manufactured erythropoietin (EPO; available as Epo- Supplement with EPO injections

gen, Procrit, and Aranesp) is a genetically engineered form
of a hormone produced by the kidneys that regulates the
production of red blood cells (see Table 3). While it is
commonly used to treat anemic patients with end-stage
renal disease, cancer, acquired immunodeficiency syn-
drome, inflammatory conditions of rheumatoid arthritis,
and inflammatory bowel disease, prior to elective surgery,
experts disagree on administering this drug to treat IDA.
This is because of the high cost and insufficient evidence of
benefit in IDA (Montoya et al., 2002). However, in the case
of a patient declining blood transfusion because of reli-
gious beliefs, it is a reasonable choice to stimulate eryth-
ropoiesis. Treatment for Mrs. H. includes iron sulfate 325
mg tablets (see Table 4) given by mouth three times a day
(with a stool softener to prevent constipation) along with
EPO 20,000 units subcutaneously every other day. She
was able to tolerate the oral iron preparation. If she had not
been able to tolerate oral supplementation or had a history
of a GI disease that would limit absorption of oral prepa-
rations, parenteral preparations would have been pre-
scribed. Parenteral therapy should be reserved until every
reasonable attempt at oral therapy has failed, because
resolution of IDA is not more rapid when using injectable
iron and the potential for anaphylactic reaction is
greater in parenteral forms (Fitzgerald, 2005; Montoya
et al.).
Follow CBC, iron studies and reticulocyte count
until anemia is resolved
Refer for evaluation of the cause on the anemia
by a gastroenterologist
Figure 1 Algorithm for evaluation of anemia used for Mrs. H.’s case
study.
The recommended dose of EPO for preoperative anemia
is 150–300 units/kg of body weight 3 weeks, 2 weeks, and
1 week prior to the surgery/procedure (Kelly, 2002).
Therefore, the appropriate dose for Mrs. H. in preparation
for her endoscopic procedures would be between 12,000
and 24,000 units for at least 3 weeks before the procedure;
however, in consultation with the hematologist she was
given much higher doses. Kelly notes that although a max-
imum safe dose has not been established for epoetin alfa,
doses of up to 1500 units/kg have been administered three
times a week for up to 3 weeks without toxic effects.
Adequate iron supplementation is imperative with EPO
therapy to maintain adequate iron stores to form red blood
cells. Specific to this case, Mrs. H. is educated that she
should leave 2 h between her levothyroxine sodium and

46
C.M. Thomas et al. Severe anemia in older adults

Table 3 Dosing for synthetic EPO preparations

Medication Indication Dosing (intravenous or subcutaneous)

Procrit/Epogen (epoetin alfa)
Aranesp (darbepoetin alfa)
Anemia of chronic renal failure
Anemia in patients with human
immunodeficiency virus treated
with AZT (zidovudine)
Chemotherapy-induced anemia
Reduction of allogeneic blood
transfusions in surgical patients
Anemia of chronic renal failure
50–100 units/kg tiw
100–300 units/kg tiw
150–300 units/kg tiw
300 units/kg ! 10 days pre-op, on the day of
surgery, and 4 days post-op or 600 units/kg
once weekly starting 21 days pre-op and
ending on the day of surgery (4 doses)
0.45 mcg/kg weekly

iron because iron salts may decrease the bioavailability of
levothyroxine sodium (Kelly).
Monitoring the treatment plan
Once EPO injections and iron supplementation began,
the patient’s reticulocyte count increased and the hemo-
globin and hematocrit levels followed (see Table 1). This
confirms that there was adequate iron absorption, mini-
mal if any continued blood loss, and functioning bone
marrow (Smith, 2000).
Mrs. H. was discharged from the hospital after 6 days
with a stable hemoglobin level of 4.7 g/dL to continue on
her oral iron therapy and a visiting nurse was to give her
EPO injections every other day. She was also instructed to
avoid aspirin and all nonsteroidal antiinflammatory med-
ications and to test every stool for occult blood (all have
been negative thus far). An appointment was made for her
to return to the NP’s office several times over the next few
weeks to monitor her anemia. All this information was
communicated to the patient and her daughter, who is
very involved and reliable in coordinating her mother’s
care.
Initiating appropriate referrals
The evaluation of this patient’s potential GI bleeding was
to be initiated once she had achieved a hemoglobin level of
at least 7 g/dL. A referral to a gastroenterologist was made
and a workup scheduled. On the 37th day after her
discharge from the hospital, Mrs. H.’s hemoglobin level
Table 4 Oral iron preparation dosing
Preparation Typical dose
Ferrous sulfate 325 mg tid
Ferrous gluconate 325 mg tid
Ferrous fumerate 325 mg tid
Polysaccharide–iron complex 1–2 capsules qd
reached 11.1 g/dL; at this time her EPO dose was decreased
to 20,000 units subcutaneously once every week and the
iron regimen was continued. Treatment for IDA is consid-
ered successful if the hemoglobin level increases more that
1 g/dL in 1 month, and this patient exceeded that (Montoya
et al., 2002). The patient had an esophagogastroduodeno-
scopy (EGD) and a colonoscopy, and neither revealed any
lesions, polyps, erosions, microangiodysplasia, or any other
explanation for her anemia. The American Gastroentero-
logical Association guidelines (2000) state that colonoscopy
and upper endoscopy are the cornerstones for investiga-
tion of occult blood loss; however, the origins of IDA and
positive fecal occult blood test (FOBT) results remain
unexplained in as many as 52% of cases and typically
require no further evaluation once the anemia is corrected.
Carmel (2001) recommends that a consideration for IDA
of unknown cause would be unrecognized celiac disease
(present in approximately 10% of unexplained IDA cases).
Celiac disease is a chronic nutritional disturbance caused
by the inability to metabolize gluten, which results in
malnutrition, a distended abdomen, muscle wasting,
and the passage of stools having a high fat content. This
workup includes serological testing for IgG and IgA anti-
bodies and a biopsy of the intestinal mucosa that is typ-
ically performed by a gastroenterologist. A biopsy of
the duodenum at the time of Mrs. H.’s EGD showed no
evidence of celiac disease.
Care of the patient is ongoing; prevention of anemia and
patient education are now the goals. Mrs. H.’s hemoglobin
has been maintained above 12 g/dL for several weeks after
discontinuing the EPO injections. Her systolic murmur has
resolved, and she continues her daily iron supplementa-
tion. It is important for NPs to know that Medicare will pay
for a colonoscopy in persons at high risk for colorectal
cancer every 2 years. Mrs. H. should be encouraged to
continue to have these colonoscopies routinely and to
contact her NP if she has any symptoms of anemia or no-
tices any changes in her stool indicating bleeding (Read &
Kodner, 1999). This patient requires diligent monitoring to

47
Severe anemia in older adults
avoid a recurrence of such a profound level of anemia.
Long-term follow-up of elderly patients in whom a source
or iron loss is not identified reveals that most often the
anemia resolves or remains stable with iron replacement
(Smith, 2000).
Importance of timely detection of anemia
in the aged population
As demonstrated in the case of Mrs. H., the elderly
patient may present in the primary care setting with
a severe anemia that exhibits minimal observable signs.
The astute clinician will not attribute mild symptoms to
normal senescence but will perform a reasonable metic-
ulous workup of the older patient with anemia to avoid
missing the underlying cause. Carefully executing a thor-
ough assessment helps avoid the potential hazards of
unchecked anemia in the aged patient that can result in
a decreased level of function. This diligent evaluation of
the older patient contributes to reaching the shared goal of
healthy aging. Although it is a typical malady of the
elderly, anemia is not a normal consequence of aging. It
is a fact that the prevalence of anemia increases with age
(Cohen, 2003). Anemia, however, is a sign of an under-
lying disease, not a disease in itself (Montoya et al., 2002).
A root cause of anemia can usually be found in approxi-
mately 80% of anemic elderly patients (Smith, 2000).
The most common cause of anemia in the elderly is
chronic disease, followed by iron deficiency (Smith, 2000).
AOCD is a normochromic normocytic anemia that is
characteristically mild (hemoglobin level 9.5 g/dL) to
moderate (hemoglobin level 8 g/dL). Patients with AOCD
have a low reticulocyte count, which indicates underpro-
duction of red blood cells (Weiss & Goodnough, 2005). IDA
occurs when iron deficiency is sufficiently severe to dimin-
ish erythropoiesis and cause the development of anemia.
Posthemorrhagic anemia is a frequent cause of iron defi-
ciency. Often patients present with severe IDA from slow
but persistent GI bleeding; these patients can even have
repeatedly negative FOBT (Conrad, 2005). In chronic
blood loss like this, the patient frequently cannot absorb
enough iron from the intestines to form hemoglobin as
rapidly as it is lost. Red blood cells are then produced that
are much smaller than normal and with little hemoglobin
inside. Discovering and treating anemia in the older
patient is important because anemia has been found to
be associated with a 150% increase in hospitalization risk
48
C.M. Thomas et al.
and a 200% increased risk of being admitted to a nursing
home (Penninx et al., 2003).
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Conflict of interest disclosure
The authors report no conflicts of interest and no induce-
ments to submit this article.