How is edema (swelling caused by excess fluid) managed in aged individuals?

Management of Edema in Aged Individuals

For older adults with edema, treatment should focus on the underlying cause, with diuretics used cautiously due to risks of electrolyte imbalances, volume depletion, and falls in this population. 1

Diagnosis of Edema in Older Adults

• Determine the type of edema present, as treatment approaches differ significantly:

  • Low-intake dehydration (hyperosmolar state) with edema 2
  • Volume depletion (hypovolemic state) with edema 2
  • Venous insufficiency edema 1
  • Cardiac edema 1
  • Medication-induced edema 1
  • Lymphedema 3

• Assess for volume depletion following fluid and salt loss by checking for:

  • At least four of the following seven signs indicating moderate to severe volume depletion: confusion, non-fluent speech, extremity weakness, dry mucous membranes, dry tongue, furrowed tongue, sunken eyes 2
  • Postural pulse change (≥30 beats per minute) or severe postural dizziness when standing 2

• Laboratory assessment should include:

  • Serum or plasma osmolality (>300 mOsm/kg indicates dehydration) 2
  • Basic metabolic panel, liver function tests, and brain natriuretic peptide levels 4

Treatment Approach Based on Edema Type

For Low-Intake Dehydration with Edema:

• For patients who appear well with measured serum osmolality >300 mOsm/kg:

  • Encourage increased fluid intake with preferred beverages (tea, coffee, fruit juice, water) 2
  • Avoid oral rehydration therapy and sports drinks as they are not indicated 2

• For patients who appear unwell with measured serum osmolality >300 mOsm/kg:

  • Offer subcutaneous or intravenous fluids in parallel with encouraging oral fluid intake 2
  • Subcutaneous dextrose infusions (half-normal saline-glucose 5%, 40 g/L dextrose and 30 mmol/L NaCl, or similar solutions) can be as effective as intravenous infusion with similar adverse effect rates 2

• For patients unable to drink with measured serum osmolality >300 mOsm/kg:

  • Consider intravenous fluids as the method of choice, especially when greater fluid volumes are needed 2
  • Remember that parenteral hydration should be considered a medical treatment rather than basic care, with benefits and risks carefully balanced 2

For Volume Depletion with Edema:

• Administer isotonic fluids orally, nasogastrically, subcutaneously, or intravenously 2
• Use isotonic or slightly hypotonic fluids for replacement 2
• Monitor clinical signs and serum levels of phosphate, magnesium, potassium, and thiamine, particularly within the first 72 hours of nutritional support 2

For Venous Insufficiency Edema:

• Implement leg elevation to assist with venous drainage 5
• Consider compression therapy, which is effective for most causes of edema 4
• Raised-leg exercise is effective specifically for edema due to venous insufficiency 5
• Consider Ruscus extract and horse chestnut seed, which have moderate-quality evidence for improving edema from chronic venous insufficiency 4

For Cardiac Edema:

• For treatment of edema in heart failure, spironolactone may be used:

  • Initial dose of 25 mg once daily in patients with serum potassium ≤5.0 mEq/L and eGFR >50 mL/min 6
  • Consider 25 mg every other day in patients with eGFR between 30-50 mL/min due to hyperkalemia risk 6
  • In patients with NYHA class III and IV heart failure, spironolactone has been shown to reduce morbidity and mortality 3

• For diuretic treatment of edema in general:

  • Initial daily dosage of hydrochlorothiazide or other diuretics should be carefully considered in older adults 7
  • Monitor for electrolyte imbalances, volume depletion, and fall risk with long-term diuretic use 1

Special Considerations in Older Adults

• Encourage physical activity and exercise in older persons with edema to maintain or improve muscle mass and function 2
• During exercise interventions, provide adequate amounts of energy and protein to maintain body weight and muscle mass 2
• In overweight older persons, avoid weight-reducing diets to prevent loss of muscle mass and accompanying functional decline 2
• For patients with dysphagia, consider thickened fluids alongside access to free water to protect against aspiration while increasing fluid intake 2
• For bed-bound patients with severe edema who cannot tolerate diuretics, controlled subcutaneous fluid drainage at home may be an effective, safe, and feasible alternative 8

Monitoring and Follow-up

• Reassess hydration status regularly until corrected, then monitor periodically 2
• Watch for signs of refeeding syndrome in malnourished older patients, which can include volume overload and electrolyte disturbances 2
• Monitor for adverse effects of diuretic therapy, including electrolyte imbalances and volume depletion 1
• If diuretic withdrawal is attempted, monitor closely as the risk of edema recurrence may be significantly higher in the withdrawal group, though often temporary in nature 2