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Leg Swelling in Aging: What to Know & What to Do - Part 2 of 5


What are the most common causes of leg edema?

By far, the most common cause of leg edema is chronic venous insufficiency, but there are some other causes that are critical to rule out.


Chronic venous insufficiency

This is the cause in about 70% of older adults with leg edema.  To understand chronic venous insufficiency (CVI), we first need to cover how veins work. Veins are the blood vessels that return blood to the heart so that it can be pumped to the lungs and get oxygenated. Veins don’t have muscles in their linings like arteries do; instead, they rely on a system of valves to keep blood from flowing backwards. Over time, these valves become less effective, and blood can hang around in the veins longer than it needs to – a phenomenon called venous insufficiency.


When venous insufficiency becomes chronic, this can cause varicose veins and/or edema, due to there being extra fluid in the veins. Venous insufficiency can also end up causing phlebitis (inflammation of the veins), ulceration of the skin (sores and wounds) and even sometimes cellulitis (skin infections). CVI is common, affecting an estimated 7 million people worldwide and causing 3 million to develop venous ulcers, the most common type of leg ulcers. The cost of venous ulcers  to the  US healthcare system is estimated at  2 to 3 billion dollars a year.


Risk factors for CVI include:

  • Advancing age

  • Family history

  • Prolonged standing

  • Obesity

  • Smoking

  • Sedentary lifestyle

  • Lower extremity trauma

  • Prior venous thrombosis (blood clots in the veins)

In the section on treatment, I’ll explain how to manage edema due to CVI and share tips on reducing the risk of complications. Keep in mind that leg swelling is something that people live with on a chronic basis and is rarely completely cured.  The goals of a treatment plan are to reduce the edema, prevent the discoloration and thinning of the skin, and prevent or heal skin sores.


Congestive Heart Failure (CHF)

Congestive heart failure (CHF) is the most common cause of generalized edema (affecting the legs, abdomen, and sometimes the lower back and even higher on the body), and a major cause of edema of the legs.


Heart failure is a term that we use when the heart muscle is weakened and not pumping blood as effectively as it should.  Heart failure is often described as being “right-sided” or “left-sided” depending on which chamber of the heart is most affected.  The “congestive” part refers to the backflow of blood into the veins in the lungs (if it’s “left-sided”) or the legs or lower part of the body (if right-sided”). Some people have right-and left-sided heart failure. 


In CHF, there’s fluid congestion in the veins, but that’s not the whole story.  When CHF is chronic, lasting more than a few weeks, it reduces blood flow to the kidneys, and they respond by causing the retention of salt and fluid in the body. This is an especially important factor when treating the edema associated with CHF. In CHF, the edema in the lungs, or pulmonary edema, can be much more difficult to live with; it usually causes shortness of breath, coughing, and breathlessness when lying flat to sleep.


CHF treatment frequently involves diuretic medications (also known as “water pills” to relieve symptoms. Some commonly used diuretics used for CHF include furosemide, spironolactone and metalazone. The dosing of diuretics often must be managed  carefully to minimize the potential side effects of low blood pressure, potassium depletion, dehydration, and kidney injury.

People living with CHF are usually advised to restrict their daily fluid and salt intake, weigh themselves frequently, and adjust the daily water pill dose depending on their weight, along with regular bloodwork. In this article, we won’t go into more detail about CHF, as it’s a complicated topic of its own. The main thing you should know is that if you’ve been concerned about leg swelling in an older person, it’s important to find out if they have a history of heart failure or heart problems, especially if they are also reporting symptoms of shortness of breath.


Medication-related leg edema

Some medications can cause or worsen swollen legs.  or make them worse.  In most cases, the drugs increase fluid and salt retention, causing edema, but for some drugs, such as dihydropyridine calcium channel blockers (like amlodipine) the capillaries become leakier, and in other cases, the exact mechanism for edema isn’t known.  Below is a list of medications that may cause edema.


  • Antihypertensive drugs

  • Calcium channel blockers

  • Beta blockers

  • Clonidine

  • Hydralazine

  • Minoxidil

  • Methyldopa

  • Hormones

  • Corticosteroids

  • Estrogen

  • Progesterone

  • Testosterone

  • Other

  • Nonsteroidal anti-inflammatory drugs (including over-the-counter painkillers)

  • Pioglitazone

  • Rosiglitazone

  • Monoamine oxidase inhibitors


New or worsened leg swelling should always prompt a medical evaluation, to make sure the swelling isn’t due to a medication side-effect. (To learn more about medications to avoid in aging adults, read this article: Medications Older Adults Should Avoid or Use with Caution).


Liver disease

In cirrhosis of the liver, edema may occur in the lower limbs or, more commonly,  localized to the belly (called ascites).  The liver is where the body makes albumin, a major component of protein in the blood, but in cirrhosis, the damaged liver can no longer maintain adequate production of albumin and other key proteins.  The resulting lower blood protein levels mean that fluid will leak out into the interstitial spaces, which can cause edema and also noticeable swelling of the belly. Diuretics can be used to help people with cirrhosis, and sometimes drainage of the abdominal ascites is performed, with careful management of blood pressure and electrolyte balance.


Kidney disease

A kidney condition called nephrotic syndrome is associated with protein leaking out into the urine.  This can cause edema in the legs and elsewhere in the body. A urine dipstick normally checks for protein in the urine, and a more precise check can be done through a urinalysis.


Lymphedema

Although most fluid in the body moves through blood vessels, the body also has a network of lymphatic vessels, which connect to lymph nodes and move fluid and immune system cells through the body. Lymphedema means edema caused by fluid overload in the lymphatic vessels, not the veins. When there’s too much fluid for the lymph system to drain, or not enough capacity in the lymphatic channels, swelling is the result. Lymphedema is most often associated with a history of cancer and/or lymph node surgery, and usually affects one limb, rather than both.  Seventy percent of prostate and breast cancer survivors experience lymphedema as do 80% of those with severe obesity. This type of edema is treated by elevating the limb as much as possible, the use of compression garments, a special kind of decongestive massage, or microsurgery to enhance the lymphatic system. Of note,  treatment with diuretics (“water pills”) is not usually effective.

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