How to manage leg oedema in aged care?

Management of Leg Oedema in Aged Care

Leg elevation exercises (20 minutes, three times daily) should be the first-line non-pharmacological intervention for elderly patients with leg oedema, particularly when caused by venous insufficiency, while diuretics should be avoided unless there is a clear indication such as heart failure or renal disease. 1, 2

Initial Assessment and Diagnosis

The cause of bilateral leg oedema in elderly patients is often multifactorial and requires systematic evaluation before initiating treatment 3:

• Chronic venous insufficiency is the most common cause (63.2% of cases) in elderly populations 1
• Heart failure accounts for approximately 15% of cases 1
• Drug-induced oedema represents 13.8% of cases, particularly from antihypertensive and anti-inflammatory medications 1, 3
• Less common causes include renal disease, liver disease, lymphedema, lipedema, and pelvic masses 1, 4

Key clinical features to assess:

• Duration (acute vs chronic) and distribution (unilateral vs bilateral) 4
• Accompanying symptoms: dyspnea suggesting heart failure, pain indicating thrombosis or infection, skin thickening and pigmentation suggesting venous insufficiency 4
• Medication review for causative agents 3, 1
• Basic laboratory tests, urinalysis, chest radiography, and echocardiogram when clinically indicated 3

Non-Pharmacological Management (First-Line)

Leg Elevation Protocol

For venous insufficiency-related oedema, implement raised-leg exercises:

• 20 minutes, three times daily (morning, afternoon, evening) 1, 5
• Legs should be elevated above heart level 1
• This intervention showed significant reduction in leg circumference at 4 weeks (P < 0.001) in compliant patients 1
• Important caveat: Leg elevation is only effective for oedema due to venous insufficiency and is not effective for lymphedema 5, 1

Compression Therapy Considerations

• Compression stockings have limited long-term effectiveness and may not be suitable for patients with disproportionately large thighs or those who are non-compliant 5
• Patient compliance is a significant barrier to compression therapy success 5

Positioning and Skin Care

• Elderly patients with fragile skin require careful monitoring to prevent pressure necrosis, particularly over bony prominences like the heel 2
• Regular repositioning during prolonged periods of leg elevation is essential 2
• For diabetic patients with peripheral neuropathy and oedema, daily foot inspection and proper footwear are crucial 6, 2

Pharmacological Management (Use Cautiously)

When to Consider Diuretics

Diuretics should only be prescribed when there is a clear systemic indication 2, 3:

• Heart failure with fluid overload 7
• Renal disease including nephrotic syndrome 7
• Cirrhosis of the liver 7

Diuretic Prescribing in Elderly

When diuretics are indicated 7:

• Start at the low end of the dosing range for geriatric patients 7
• Initial dose: 20-40 mg furosemide as a single dose 7
• Careful clinical observation and laboratory monitoring are essential, particularly when doses exceed 80 mg/day 7

Critical Warnings About Diuretic Use

Long-term diuretic use in elderly patients without clear indication leads to:

• Severe electrolyte imbalances 3
• Volume depletion 3
• Increased fall risk 3
• Very low certainty evidence supports diuretic deprescribing in patients using diuretics for peripheral oedema without heart failure or hypertension 2

Diuretic Deprescribing Evidence

For elderly patients on diuretics for peripheral oedema without heart failure or hypertension 2:

• 15% of patients required diuretic re-initiation after withdrawal 2
• Oedema recurrence after withdrawal was temporary in nature 2
• Most patients experienced only slight increases in oedema after withdrawal 2
• No effect on mortality was observed with diuretic deprescribing 2

Multidisciplinary Approach

A coordinated team approach is essential 6:

• General practitioner for overall coordination 6
• Podiatrist for foot care, particularly in diabetic patients 6
• Vascular assessment when peripheral artery disease is suspected 2
• Diabetologist for patients with diabetes-related complications 6

Common Pitfalls to Avoid

• Do not reflexively prescribe diuretics without determining the underlying cause of oedema 3, 2
• Do not overlook medication review as drug-induced oedema is common and reversible 3, 1
• Do not ignore vascular assessment in diabetic patients, as focusing solely on the neurological aspect can lead to complications 6
• Do not use leg elevation for lymphedema, as it is ineffective for this etiology 5
• Do not continue diuretics long-term in elderly patients with peripheral oedema without heart failure or renal disease due to adverse event risk 2, 3