From the Guidelines
A comprehensive work-up for an 89-year-old with bilateral lower extremity edema should prioritize a thorough history and physical examination, including vascular examination, to identify the underlying cause, with a focus on assessing for peripheral artery disease (PAD) and other potential causes of edema. The evaluation should include assessment of cardiac function, renal function, and medication review, as certain conditions and medications can contribute to edema.
Key Components of the Work-up
- History and physical examination to identify symptoms and signs suggestive of PAD, such as claudication, and to assess for other potential causes of edema, including heart failure and venous insufficiency 1
- Vascular examination, including pulse palpation, auscultation for femoral bruits, and inspection of the legs and feet, to assess for PAD 1
- Laboratory tests, including comprehensive metabolic panel, complete blood count, thyroid function tests, and urinalysis, to evaluate kidney and liver function, and to check for anemia and proteinuria
- Imaging studies, such as chest X-ray and venous Doppler ultrasound of the lower extremities, to evaluate for pulmonary congestion, pleural effusions, and deep vein thrombosis
- Medication review to identify potential contributors to edema, such as calcium channel blockers, NSAIDs, and steroids
Diagnostic Testing for PAD
- Ankle-brachial index (ABI) as the initial test to confirm the diagnosis of PAD, with abnormal results prompting further evaluation 1
- Consideration of other diagnostic tests, such as toe-brachial index (TBI) and skin perfusion pressure, to assess for significant arterial occlusive disease
Management of Edema
- Initial management often includes elevation of the legs, compression stockings, and possibly diuretics, such as furosemide 20-40mg daily, though dosing should be cautious in the elderly
- Salt restriction to less than 2g sodium daily is also recommended to help reduce edema
- Consideration of supervised exercise program or structured community- or home-based exercise program to improve functional status and reduce symptoms of PAD, if present 1
From the Research
Evaluation of Bilateral Lower Extremity Edema
- The evaluation of bilateral lower extremity edema in an 89-year-old patient should begin with obtaining a basic metabolic panel, liver function tests, thyroid function testing, brain natriuretic peptide levels, and a urine protein/creatinine ratio 2.
- Validated decision rules, such as the Wells and STOP-Bang criteria, can guide decision-making regarding the possibility of venous thromboembolic disease and obstructive sleep apnea, respectively 2.
- For patients with chronic bilateral lower-extremity edema, duplex ultrasonography with reflux can help diagnose chronic venous insufficiency 2.
Diagnostic Considerations
- Patients with pulmonary edema or elevated brain natriuretic peptide levels should undergo echocardiography to assess for heart failure 2.
- Lymphedema is often a clinical diagnosis; lymphoscintigraphy can be performed if the diagnosis is unclear 2.
- The possibility of iatrogenic pneumothorax secondary to thoracentesis should be considered in patients with a history of recent pleural violation, as it can cause isolated inferior vena cava syndrome and subsequent lower extremity swelling 3.
Treatment Options
- Treatment of edema is specific to the etiology, and diuretics are effective but should be used only for systemic causes of edema 2.
- Ruscus extract and horse chestnut seed demonstrate moderate-quality evidence to improve edema from chronic venous insufficiency 2.
- Compression therapy is effective for most causes of edema 2.
- Spironolactone can be used to treat heart failure, but serum electrolytes and renal function tests should be closely monitored, especially in patients with intact renal function 4.