Nearly half of all Indian adults over 60 are anaemic. A nationally representative study using the Longitudinal Aging Study in India found the overall anaemia prevalence among older adults to be 49.92%, higher among women at 53.9% than men at 45.8%. Among those found to be anaemic, 63.5% had nutritional anaemia, with isolated iron deficiency being the single most common cause at 51.8%. This is not a marginal health issue. It is a near-majority condition that is quietly reducing energy, cognition, and physical capacity in seniors across Gurgaon, often without a single person in the family realising it is happening.

Fatigue is not just old age

The story is almost always the same. A senior parent becomes increasingly tired. They sit more, walk less, lose interest in their usual activities. Their appetite drops. They seem mentally slower taking longer to respond, forgetting more than before. The family attributes it to age, to the heat, to retirement, to "tension." The doctor, if consulted, often focuses on the presenting complaint a cough, a blood pressure check without ordering a complete blood count.

Anaemia in elderly Indians is one of the most systematically under-diagnosed conditions in this age group, for a specific and correctable reason: its symptoms fatigue, reduced exertion tolerance, cognitive slowing, pallor, and low mood map almost precisely onto what families and clinicians expect old age to look like.

The consequences of this misidentification are serious. Low haemoglobin in older adults has been associated with increased risk of hospitalisation and death, decreased skeletal muscle strength, decreased mobility, and cognitive decline. A senior who is quietly anaemic is not just tired they are operating at reduced physiological capacity across every organ system, including the brain and heart, and they are at measurably higher risk of falling.

Three distinct mechanisms, each requiring a different response

Anaemia in elderly patients is not one condition with one cause. It is a clinical endpoint that can be reached by three substantially different biological pathways and treating the wrong one does not help.

Iron deficiency anaemia remains the most common cause even in elderly patients, accounting for over half of all anaemia in Indian seniors. In this age group, unlike younger adults, the cause is rarely inadequate dietary intake alone. In elderly patients, iron deficiency most commonly reflects chronic occult gastrointestinal blood loss from peptic ulcers, gastric erosions, colorectal polyps, or early gastrointestinal malignancy. This is the most clinically important reason not to dismiss iron deficiency anaemia in a senior as simply a dietary problem without investigating its source.

Anaemia of chronic disease (ACD), also called anaemia of inflammation, is the second major mechanism. This form is driven by the chronic low-grade inflammatory state that accompanies ageing a process now referred to as "inflammaging" and by the cytokine and peptide pathways it activates. The inflammatory cytokines IL-1β and IL-6 induce the secretion of hepcidin, a hepatic peptide that is the primary governing factor for both iron absorption and iron distribution across tissues. Elevated hepcidin driven by IL-6 inhibits the release of cellular iron into plasma by binding to ferroportin, the cellular iron export channel. The result is functional iron deficiency: the body has iron in storage (in macrophages and the liver) but cannot mobilise it for red blood cell production. Serum ferritin may appear normal or even elevated, while serum iron and transferrin saturation are low a pattern that traps clinicians who rely on ferritin alone to assess iron status.

B12 and folate deficiency anaemia produces a macrocytic picture red cells that are fewer in number but abnormally large. As discussed in our earlier piece on peripheral neuropathy, B12 deficiency in Indian elderly patients is common due to vegetarian diet patterns, age-related gastric acid decline reducing B12 absorption, and long-term metformin use depleting B12. Folate deficiency is less common but occurs in patients with very restricted diets or chronic alcohol use.

In clinical practice, these three mechanisms frequently overlap a senior with diabetes and chronic kidney disease may simultaneously have iron deficiency from GI blood loss, anaemia of inflammation from CKD-driven IL-6 elevation, and B12 deficiency from long-term metformin. This is why a single haemoglobin number, without a complete workup, tells only a fraction of the story.

The Clinical Reality for Indian Seniors in Gurgaon

Anaemia among elderly Indians has historically been studied predominantly in rural populations and in women of reproductive age. Urban elderly adults have been largely invisible in national surveys and yet the LASI-DAD data, which is nationally representative and includes urban seniors, reveals a prevalence approaching 50%. A systematic review and meta-analysis across 22 Indian studies found the pooled anaemia prevalence among the elderly to be 68.3%, a figure that should have prompted major policy attention and largely has not.

For seniors several risk factors converge. Elderly patients here are typically managing multiple chronic conditions diabetes, hypertension, chronic kidney disease, and arthritis all of which independently drive the IL-6/hepcidin pathway of anaemia of chronic disease. Many are on long-term non-steroidal anti-inflammatory drugs (NSAIDs) for joint pain, which cause occult GI blood loss. Many are vegetarian. Many are on metformin. Many are mildly dehydrated through the summer months, concentrating whatever haemoglobin they have but not adding to it.

A further clinical problem specific to this population: anaemia in elderly men is frequently missed because haemoglobin in men is compared against a normal range derived from younger males. The progressive physiological decline in haemoglobin that occurs in men after 40, combined with the accumulation of chronic disease burden, means a haemoglobin of 11.5 g/dL in a 72-year-old man with diabetes and CKD is not a mild finding it is a clinically significant anaemia with multiple likely contributors, each requiring individual attention.

Practical Steps: What Families Should Do

1. Request a complete blood count at every annual check not just haemoglobin
A full CBC with red cell indices (MCV, MCH, MCHC) gives essential information about the type of anaemia. Microcytic, hypochromic anaemia suggests iron deficiency. Macrocytic anaemia with elevated MCV suggests B12 or folate deficiency. Normocytic anaemia normal-sized cells, reduced in number often points to anaemia of chronic disease or kidney-related anaemia. Knowing which type guides the next step entirely.

2. Request a comprehensive iron panel and inflammatory markers together
For an elderly patient with anaemia, the workup should include serum iron, ferritin, transferrin saturation, and TIBC not ferritin alone. A high ferritin in the context of low serum iron and low transferrin saturation is the hallmark of anaemia of chronic disease. Request CRP alongside this panel: an elevated CRP in this context confirms the inflammatory driver and changes management from iron supplementation to treating the underlying inflammatory condition.

3. Always test B12 and folate do not assume cause from MCV alone
A normal or borderline MCV does not exclude B12 deficiency in elderly patients with concurrent iron deficiency, since the two conditions have opposing effects on cell size and can cancel each other out. In any elderly vegetarian patient, any patient on long-term metformin, or any patient with cognitive symptoms accompanying anaemia, B12 must be explicitly tested.

4. Do not dismiss iron deficiency anaemia as dietary without investigating the GI tract
In an elderly patient particularly a man new-onset iron deficiency anaemia must be assumed to reflect occult GI blood loss until proven otherwise. This requires at minimum a faecal occult blood test and, in most cases, referral for upper and lower GI endoscopy. A dietary explanation for iron deficiency anaemia in an elderly man is a diagnosis of exclusion, not a default.

5. Track haemoglobin serially not just at diagnosis
For a senior already known to have chronic kidney disease, diabetes, or rheumatoid arthritis, anaemia is a predictable complication. Serial haemoglobin monitoring every 3 to 6 months allows early detection of worsening before it becomes symptomatic. A drop of 1–2 g/dL over six months in an elderly patient warrants investigation regardless of the absolute value.