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Leg Swelling or Oedema in Elderly

Introduction

  • Leg swelling can occur to any parts of the legs, including the feet, ankles, calves or thighs

  • The aetiology of chronic leg swelling may be complex and a number of different factors may predispose an individual to develop swelling

  • Patients with chronic leg oedema may experience increased psychological distress and have problems with mobility

  • Treatment strategies should aim to control the leg swelling, minimise associated problems and enhance the quality of life

  • The most likely cause of leg oedema  in patients over age 60 is venous insufficiency. Venous insufficiency affects up to 30% of the population. Time of onset :

    • Acute oedema  à less than 72hrs (3days)

    • Chronic oedema à more than 72hrs

  • Leg swelling / oedema can result either from:

    • Fluid build-up ( fluid retention or trapped fluid)

    • Inflammation in injured or  diseased  tissues or joint.

  1. Leg swelling caused by the build-up of fluids in leg tissues is known as peripheraloedema. Common causes related to trapped fluids are :

    • Acute / chronic  kidney failure

    • Cardiomyopathy (disease of heart tissue)

    • Chronic venous insufficiency

    • Heart failure

    • Lymphedema(blockage of lymph system)

    • Nephrotic syndrome

    • Non-steroidal anti-inflammatory drugs ( NSAIDs) e.g. ibuprofen

    • Prescription medications, including some drugs for depression, diabetes and high blood pressure

    • Prolonged sitting or standing

    • Thrombophlebitis ( blood clot, usually in the leg)

  1. Causes related to inflammation :

    • Leg swelling may be caused by an immune system response that leads to inflammation in leg tissues

    • Leg swelling related to inflammation is usually associated with pain

Factors that can contribute to inflammation in the leg include :

  • Achilles tendon rupture

  • Tearing of the anterior cruciate ligament/ACL  in your knee

  • Fracture /broken ankle, foot or leg

  • Gout (arthritis related to excess uric acid)

  • Infection or wound in the leg

  • Knee bursitis ( inflammation of fluid-filled sacs in the knee joint)

  • Osteoarthritis

  • Rheumatoid arthritis ( inflammatory joint disease)

  • Sprained ankle

Symptoms and Signs

History taking is important to know the causes of legs swelling. Key elements of the history include:

  • What is the duration of oedema?

    • Acute or chronic. If acute, deep vein thrombosis should be considered

  • Is the oedema painful?

    • Deep vein thrombosis and reflex sympathetic dystrophy are painful

    • Chronic venous insufficiency mild pain

    • Lymphedema is painless

  • What drugs are being taken?

    • Drugs  causes of leg oedema are: Calcium channel blockers, b-blocker, prednisone, anti-inflammatory, hormone progesterone ,estrogen,testosterone

  • Is there a history of systemic disease?

    • Heart, liver or kidney disease

  • Is there a history of pelvic / abdominal cancer or radiation?

    • Cancer uterus, cancer colon etc

  • Does the oedema improve overnight?

    • Venous oedema is more likely to improve overnight

  • Is there a history consistent with sleep apnea?

    • Sleep apnea can cause pulmonary hypertension – common cause of leg oedema

Physical Examination

Key elements of the physical examination include:

  • Body mass index (BMI) – o besity  is associated with sleep apnea and venous insufficiency

  • Distribution of oedema :

    • Unilateral leg oedema – local causes eg. d eep vein thrombosis, venous insufficiency

    • Bilateral oedema – local cause or systemic disease eg.heart failure or kidney disease

    • Generalised oedema – systemic disease

  • Tenderness – deep vein thrombosis, cellulitis

  • Pitting- deep vein thrombosis and venous insufficiency usually pit. Myxedema and advanced lymphedema do not pit

  • Varicose veins- leg varicosities are often present in patients with venous  insufficiency

  • Kaposi-Stemmer sign – inability to pinch a fold of skin on the dorsum of foot at the base of the second toe

  • Skin changes – brown hemosiderin deposits on the lower legs and ankles are consistent with venous insufficiency

  • Signs of systemic disease

    • Heart failure – jugular venous distension, lung crackles

    • Liver disease  – ascites, jaundice

Complication

  • Immobility due to leg swelling

  • Chronic leg swelling can cause skin and tissue changes, tendency to bacterial and fungal infection

  • Reduce quality of life

  • D eformity

Treatment

If the etiology is unclear, laboratory test should be done such as :

  • Complete  blood count

  • Urinalysis

  • Electrolytes and creatinine

  • Blood sugar

  • Thyroid – stimulating  hormone

  • Liver function test – albumin

Additional tests are indicated depending on the clinical presentation. Examples :

  • Cardiac etiology – Electrocardiogram, Echocardiogram, Chest X-ray

  • Acute oedema (< 72 hrs) – Doppler examination

  • Nephrotic syndrome – Serum lipid plus basic investigation

  • Lymphoscintigraphy (imaging studies) – to distinguish lymphedema from venous oedema and to determine the cause of lymphedema

Treatment depend on the underlying causes of leg swelling  or oedema i.e.

Acute or chronic, systemic disease or neoplasma.

For examples :

  1. Acute Deep Vein Thrombosis – treated with low – molecular weight heparin

  2. Venous Insufficiency – a chronic condition which is treated with leg elevation and knee-high compression stocking. The aims of support and compression therapy are to reduce swelling and maintain limb size and normal shape by preventing oedema from re-accumulating in the tissues and enhancing lymph and venous flow in the limb

  3. Lymphedema- non-specific treatment includes exercise, elevation, compressive garments, manual lymphatic drainage

Prevention

  • Treat the underlying cause appropriately before the complication of leg swelling occur

  • Education, information and advice to seek treatment early

  • The following tips can help to reduce the leg swelling :

    • Put a pillow under your legs when lying down, which may lessen swelling related to the build-up of fluid

    • If you need to stand or sit for long periods, give yourself frequent breaks and move around, unless the movement causes pain

    • Don’t stop taking a prescribed medication without talking to your doctor even if you suspect it may be causing leg swelling

Rehabilitation

  • The main aim of exercise in chronic oedema is to maximise mobility and flexibility to enhance lymph and venous flow

  • Physiotherapy and occupational therapy are required

  • Exercise programmes should be individualised

Last Review : 16 July 2013
Writer : Dr. Sanidah bt. Md. Ali