From the Guidelines
The workup for edema in an 80-year-old should begin with a thorough history and physical examination to determine the cause, focusing on cardiac, renal, hepatic, venous, or medication-related etiologies, as recommended by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. The initial evaluation should include basic laboratory tests such as:
- Complete blood count
- Comprehensive metabolic panel (including albumin, liver and kidney function tests)
- Urinalysis
- Thyroid function tests Cardiac assessment with BNP/NT-proBNP, ECG, and echocardiography is important to evaluate for heart failure, as suggested by the 1995 ACC/AHA guidelines for the evaluation and management of heart failure 1. Lower extremity ultrasound may be necessary if deep vein thrombosis is suspected. Chest X-ray can help identify pulmonary edema or pleural effusions. Medication review is crucial as many drugs commonly prescribed in the elderly (calcium channel blockers, NSAIDs, thiazolidinediones, and gabapentin) can cause edema. Management depends on the underlying cause but often includes sodium restriction (2-3g daily), elevation of affected limbs, compression stockings, and diuretics like furosemide (starting at 20-40mg daily) if appropriate. For elderly patients, special consideration should be given to potential medication side effects, fall risk with diuretics, and the possibility of multiple contributing factors to their edema, as highlighted in the 2005 ACC/AHA guideline update for the diagnosis and management of chronic heart failure in the adult 1. It is essential to consider the high prevalence of heart failure in the elderly and the potential for age-related changes in ventricular function, as well as the cumulative effects of hypertension and other chronic risk factors. A multidisciplinary approach to managing heart failure in elderly patients may be beneficial in decreasing the rate of readmission and associated morbidity.
From the Research
Edema Workup in an 80-Year-Old
To approach edema in an 80-year-old, consider the following steps:
- Evaluate the patient's medical history, including any previous conditions that could contribute to edema, such as heart failure, kidney disease, or liver disease 2
- Assess for signs of systemic disease, such as dependent edema and hemosiderin deposition, which could indicate venous insufficiency 2
- Consider the patient's medication list, including calcium channel blockers, which are known to cause peripheral edema 3, 4, 5, 6
- Perform a physical examination to distinguish between pitting and non-pitting edema, as this can help guide further evaluation and management 2
Potential Causes of Edema
Some potential causes of edema in an 80-year-old include:
- Venous insufficiency, which can cause chronic accumulation of edema in one or both lower extremities 2
- Calcium channel blocker-induced peripheral edema, which is a common side effect of these medications 3, 4, 5, 6
- Lymphedema, which can present in one or both lower extremities and is characterized by brawny, non-pitting skin with edema 2
- Obstructive sleep apnea, which can cause bilateral leg edema even in the absence of pulmonary hypertension 2
Diagnostic Evaluation
The diagnostic evaluation for edema in an 80-year-old may include:
- Duplex ultrasonography to rule out deep venous thrombosis 2
- Magnetic resonance venography to evaluate for pelvic or thigh proximal venous thrombosis or compression 2
- Laboratory tests to evaluate for underlying conditions such as kidney disease or liver disease
- Assessment of the patient's medication list and potential interactions or side effects that could contribute to edema 3, 4, 5, 6