Swelling of the legs, feet and ankles is a common problem in seniors. The medical term for this is edema. Edema is the trapping of excess fluid in any part of the body, but occurs most commonly in the ankles, legs and feet. One source estimates almost 4.4 million people in the U.S. suffer from edema.
Edema causes a puffiness of the tissue under the skin. The skin may appear stretched or shiny. Pressing on the swollen area may leave a dent when the pressure is relieved.
Usually swelling of the legs and feet comes on gradually and may not be noticed immediately. If edema is accompanied by shortness of breath, difficulty breathing, chest pain or one leg is swollen while the other one isn’t, the patient should seek immediate medical evaluation.
Many conditions can cause swelling or edema. The most common causes are:
• Lack of exercise or sitting or standing still for too long.
• Heat may cause or increase ankle and leg swelling.
• Burns can cause localized swelling around the area where they occur.
• Hormone fluctuations associated with menopause and the use of estrogens for menopausal symptoms.
• Some medications used to treat high blood pressure and heart problems such as amlodipine, nifedipine and diltiazem. Non-steroidal anti-inflammatory agents (NSAIDs) such as ibuprofen and naprosyn. Some drugs used for diabetes such as Avandia and Actos, which belong to the group of drugs called thiazolinedines.
• Excessive salt intake.
• Poor nutrition with inadequate intake of protein and B vitamins.
Diseases that can cause edema
Several diseases are associated with the development of swelling of the legs and feet and may also cause edema of the hands and around the eyes.
Kidney diseases may decrease the ability of the kidneys to remove salt and water from the body. Some kidney diseases cause loss of a protein called albumin in the urine. If this happens, edema may develop.
Heart failure, which can occur following a heart attack or other heart disease can cause swelling. In these situations the heart loses the ability to pump blood efficiently and fluid collects in the tissues.
Chronic lung disease can cause increased pressure in blood vessels in the lungs and right heart. This eventually causes swelling in the legs and feet.
Sleep apnea causes right heart failure that can cause the accumulation of fluid in the legs and feet.
Liver disease, especially cirrhosis, can cause blood to back up in the body’s main vein, the inferior vena cava, which results in swelling in the legs and feet.
Diabetes can contribute, because it can cause heart failure and kidney disease.
Allergies can cause generalized swelling in some people. This usually develops suddenly after exposure to something the patient is allergic to.
Arthritis, especially rheumatoid arthritis, can cause ankle swelling or swelling of any joint it affects.
Thyroid disease is another cause, usually low thyroid function or hypothyroidism.
Edema in only one leg may be caused by:
• A blood clot in a vein that prevents blood flow. This is a medical emergency.
• Varicose veins or venous insufficiency when the valves of the veins in one or both legs have been damaged and can’t pump blood back to the heart.
• A broken extremity that hasn’t been noticed by an elderly or disabled person who can’t report or doesn’t notice pain.
• Lymphedema, which occurs because the lymph system has been damaged by disease or tumor or this may be idiopathic or hereditary.
• Cysts or tumors that press on a vein and prevent normal blood flow.
Diagnosis, testing
Evaluation of a patient with edema includes a thorough history and physical examination. Other tests may be ordered such as a chest X-ray, blood tests to check kidney and liver function, urine tests to look for protein and kidney disease, and possibly an ultrasound of the heart or echocardiogram.
If sleep apnea is suspected, a sleep study may be indicated.
Medication and treatment
The treatment of swelling of the legs and feet depends on the cause of the edema. Things patients can do include:
• Decreasing the amount of salt in the diet. Avoid processed food, especially fast food and canned and frozen ready-to-eat meals.
• If overweight, losing weight, and getting regular exercise.
• Elevation of the legs as much as possible when seated, wearing support stockings and walking around regularly to avoid sitting or standing in one place too long.
• Avoiding heat.
• Massaging the legs if approved by a medical care provider.
Medical treatment for swelling of the legs and feet may include diuretics or “water pills” that cause increased urination and loss of fluid and salt; stopping or changing medications that can cause edema; treatment of a blood clot with appropriate medications; treatment of any other underlying condition causing the edema.
The onset of swelling of the legs, ankle or feet requires an initial evaluation by a medical care provider to determine the cause. Only then can effective treatment be prescribed.
Stephanie Jaeger is a retired internist, family practitioner and emergency room physician living in Anchorage.
