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Mims Magazine - Geriatrics July 2017

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Published by tasch, 2017-07-06 09:48:37

Geriatrics - July 2017

Mims Magazine - Geriatrics July 2017

Keywords: Mims Magazine,Mims,Medical magazine,online magazine,Mims Geriatrics,Geriatrics

Acute lung infections in the elderly 141

antimicrobials is prohibitively high, with old man’s friend and considered it as almost TREATMENT APPROACHES
limited promise of return on investment, a natural form of death. The diagnosis of
therefore most life-science companies pneumonia must only be applied to infec-
now focus on other areas for drug devel- tion of the distal respiratory bronchioles and
opment. Antibiotics should not be used in alveoli. Not all respiratory infections should
patients with viral infections and should be be labelled pneumonia as their manage-
used with great circumspection when indi- ment and prognoses may differ.
cated; prescribing the correct product for
the correct patient. (Comorbid conditions, A community study from Nottingham in
age, demographics and season should the UK showed that the average general
influence choice when prescribing empiri- practitioner will see eight to 10 cases of
cally or when culture results are available.) pneumonia a year. 75 % of them can be
managed at home. HIV infection has,
The use of vaccination must be however, changed the picture in South
promoted. Fortunately, we can now Africa in that younger adults now form
predict the expected viral causes of influ- part of the pneumonia group. For
enza and therefore should have the example, Johannesburg-based pulmo-
correct vaccine ready. Antibacterial nologist Prof Charles Feldman, in the major
vaccination is also available to reduce academic hospital where he practises,
pneumococcal respiratory infections. now cares mostly for HIV-infected patients
with pneumonia. The scenario would vary,
In the meantime, diagnostic tools such as depending on where a doctor works and
the fibre-optic bronchoscope, CT-scan if there are old age homes in the catch-
and improved lung function-testing ment area of the practice.
methods have also been developed, as
well as microbiological testing methods, to DIAGNOSIS
give medical professionals quicker answers.
The onset of pneumonia is usually fairly
This then is the scenario that has devel- sudden, with the hallmark features of
oped during the lifetime of the elderly infection, such as fever, a faster respiratory
patient to whom we now attend. We should rate and a raised pulse rate which in the
also keep in mind that the ethical considera- elderly may be masked by medication
tions of our profession have developed to a such as β-blockers. If the signs are bilateral
point where they are not adequately and in the lower lobes of the lung,
covered by the Hippocratic Oath. The concomitant cardiac failure should be
family doctor doing house calls at all hours is ruled out. Stony dullness on percussion
an increasingly rare occurrence. Medical may indicate a complication or cardiac
schemes often determine funded therapy failure. If wheezing is present, the bronchi
and doctors have to, for example, explain are also affected and the emphasis
the reasons for a patient being admitted to should be on bronchopneumonia or
hospital. Cost control is stressed and the bronchitis. Beware of the silent lung in a
measurement of patient-reported short-of-breath patient with a fever when
outcomes, as well as of doctor- and bronchiolitis may be present.
hospital-specific clinical outcomes, has
become increasingly important. If possible, an X-ray of the chest should
be done to confirm the diagnosis and the
In considering the elderly patient with extent of the consolidation, the presence
lung disease, we must remember that it is of cavitations, pleural effusion and an
not only the lungs that have aged but the enlarged cardiac shadow. If the patient is
entire body – however, not all organs lose severely ill and already in respiratory
their functional reserve at the same rate. failure, it must be remembered that earlier
antibiotic use will improve the prognosis:
COMMUNITY-ACQUIRED Do not wait for an X-ray to be done; start
PNEUMONIA definitive treatment in the severely ill
elderly. In order to evaluate the severity of
The Canadian physician, Sir William Osler
(1849-1920) described pneumonia as the HANDBOOK OF GERIATRIC MEDICINE

142 PULMONARY CONDITIONS

the illness, the patient must have his or her breaths/min, B – blood pressure systolic
blood urea done. The white cell count as <90 mm Hg and/or diastolic <60 mm Hg,
well as the serum albumin can be taken at 65 – age over 65 years.
the same time. Oximetry should be widely
available and gives a good idea of blood Score one point for each parameter.
oxygenation and whether there is respira- Patients with 0 or 1 can be managed at
tory failure (<90 %). The clinical sign of home. A score of 2 warrants admission to a
cyanosis is known to be difficult to assess hospital for observation. A patient with
and the accuracy varies amongst scores of 3 and higher should be admitted
doctors. Arterial blood gasses will also to high care; those with scores of 4-5 may
support the diagnosis of respiratory failure need intensive care with possible ventilator
(PaO2 <60 mm Hg or <8 kPa) and of support. Mortality prediction: score 0 =
exhaustion/hypoventilation (CO2 rising). 0.7 %; score 1 = 3.2 %; score 2 = 3 %; score
Use the CURB-65 scoring system to assess 3 = 17 %; score 4 = 41.5 % and score
prognosis (mortality). 5 = 57 %. Patients with a comorbid diagnosis,
such as ischaemic heart disease, diabetes,
DIAGNOSING SPECIFIC previous stroke disease and Parkinson’s
AETIOLOGICAL ORGANISMS disease, may need earlier admission.

In the past, the clinical picture was unreli- TREATMENT
able for a specific aetiological diagnosis.
The use of sputum cultures, even with Caring for the patient with pneumonia
criteria such as sputum cell-type and does not mean that we should stop all
-count with oropharyngeal swabs, gave a other treatment for conditions such as
diagnosis in only 38 % of cases: viruses in diabetes, cardiac failure, ischaemic heart
23 %, bacteria in 11 % and a combination disease, Parkinson’s disease and rheu-
in 3 %; tuberculosis or fungus infections in matic conditions.
1 %.3 We know that in the 1918 flu epide-
mic, a secondary bacterial infection The majority of bacterial community-
complicated the initial viral infection. With acquired pneumonias would be Strep-
modern methods, such as polymerase tococcus pneumoniae and Haemophilus
chain reaction, early specific diagnosis influenzae. Since elderly patients often
can be made even in the prodromal reside in care facilities, a health care-
phase of the infection. This is, however, still related pneumonia should be consi-
very expensive. dered.4 In those living in old-age homes,
Staphylococcus aureus, Klebsiella pneu-
HOSPITALISATION moniae and Enterobacter should be
suspected. Viral infections are also easily
In order to improve the prognosis of seri- spread in old age homes. In the younger
ously ill patients, it is important to carefully patient, HIV may be the underlying cause,
select those who must be admitted to but it should be remembered that elderly
hospital. In frail, elderly patients, however, patients on modern biological treatment
there may be considerations other than for, e.g., rheumatic disease, are also at
the pneumonia itself that warrant atten- greater risk for infections.5 With the above
tion, such as their social support system. in mind, patients with bacterial CAP
Giving a prescription to a frail, elderly should be started on an antibiotic such as
patient who lives on his or her own is unac- ampicillin 0.5 g every 6 hours or amoxicillin
ceptable. For example, elderly people 1-2 g 8-hourly, orally. In rural areas where
living alone often have pets, which may resistance may be less of a problem,
be the reason why some resist admission. penicillin G 1.2 g 6-hourly IM can be used.
In hospital, the antibiotics can be given
To assist in making an informed decision parenterally. It must be kept in mind that
as to whether to admit or not, the CURB-65 Staphylococcus aureus and particularly
severity score is helpful: C - confusion, U – methicillin-resistant (MRSA) bacteria
urea >7 mmol/l, R – respiratory rate >30 seldom cause community-acquired

HANDBOOK OF GERIATRIC MEDICINE

Acute lung infections in the elderly 143

pneumonia. In the study by Self in the USA immobility. This causes prolonged rehabili- TREATMENT APPROACHES
(n = 2259), 1.6 % patients had staphylo- tation in the elderly.
coccal community-acquired pneumonia;
of these 0.7 % was MRSA. The almost In the past, corticosteroid therapy in CAP
routine use of anti-MRSA antibiotics in was frowned upon, but several recent
hospital is not indicated.6 studies have shown that prednisone at a
dosage of between 20 and 60 mg a day
Where atypical infections are consid- for seven days reduces morbidity and
ered, aminopenicillin should be combined complications in patients admitted to
with erythromycin 500 mg 6-hourly or hospital. This may be because of the
clarithromycin 500 mg 12-hourly or azithro- reduction of the cytokine and inflamma-
mycin 500 mg daily. tory responses even in viral infections.8

Patients should respond to the above Discharge arrangements should start on
therapy within 24 to 72 hours, but resolu- admission of the patient to hospital.
tion of the clinical signs in the elderly may Patients are now discharged earlier
be slower. Antibiotic therapy must be because of the high cost of hospitalisa-
continued for at least five days in the usual tion. Supportive care, including meals,
infections.7 Should the patient not respond should be arranged during the recupera-
to treatment, hospital admission should be tion phase. Social workers and
reconsidered. The reason for the lack of home-based carers are strongly advised
improvement could be bacterial resist- for selected patients.
ance, such as in a S. aureus infection;
infection with an unusual pathogen such Prevention is better than cure. Although
as Legionella, Mycoplasma pneumoniae, elderly people who are well-nourished
Chlamydia pneumoniae, or Pneumocystis and fit may have a better chance of
jirovecii; or tuberculosis. In patients with a survival, they will still be exposed to
neuromuscular disease such as Parkinson’s epidemic viral infections. The only mean-
disease, or who have suffered a stroke, ingful preventive measure will be
aspiration with anaerobic organisms vaccination against the expected influ-
should be considered and treatment with enza virus infections and the pneu-
amoxycillin-clavulanate (co-amoxyclav), mococcal bacterial infections. The annual
with or without metronidazole, started. A uptake of influenza vaccination is still very
non-infective illness, such as pulmonary low, even in the USA.9 Work done in China
embolism, sarcoidosis or underlying carci- with extremely high numbers of patients
noma, may be causally related. Com- and controls has shown that side effects
plications such as empyema would also were minimal. In those elderly people with
not respond as expected. a decreased and slower immune
response, a booster vaccination should
(The above advice is as per the article be considered. Older patients are to be
entitled “The management of community given a polyvalent pneumococcal
acquired pneumonia in adults”, published vaccine, PPSV23, when started on biolog-
in the SAMJ of December 2007 [under ical treatment for auto-immune diseases.10
revision]. It is also consistent with the British The 13 valent pneumococcal vaccine is
guidelines published in the BNF, number given on a separate occasion. This should
70, in September 2015 to March 2016. The be repeated every four years. In spite of
Pocket Guide to Antibiotic Prescribing for the promises of the vitamin industry in the
Adults in South Africa, published on behalf lay press, it is hard to substantiate them
of the South African Antibiotic Stewardship with well-controlled double-blind studies.
Programme in 2015, can be most helpful.)
Coughing bouts in the patient with
Bed rest should be kept to a minimum as pneumonia can be very tiring and prevent
the patient’s recovery may be compli- night-time sleep. Codeine containing
cated not only by pressure ulcers, but also cough mixture given at night may help the
by muscle atrophy which starts within patient to rest better, however, constipa-
hours and causes weakness and tion must be prevented.

HANDBOOK OF GERIATRIC MEDICINE

144 PULMONARY CONDITIONS

During the acute phase, physiotherapy ACUTE BRONCHITIS
may only prolong this phase, as was AND INFLUENZA
shown in a Swedish paper. When the
acute phase has passed, the temperature Wintertime is the season for acute bron-
is normalising and the crackles are chitis. It is usually caused by viral infections
subsiding, physiotherapy will benefit the such influenza A or B viruses, adenoviruses
patient and aid in his or her mobility. or rhinoviruses in adults. In the elderly,
respiratory syncytial and parainfluenza
Routine, empathetic nursing care is viruses should also be added. Secondary
expected and insisted upon for elderly bacterial infections may occur. Vac-
patients. Initially, they may need assis- cination is only against the influenza A and
tance with the eating of small, regular B infections seen in epidemics; other
meals and drinking of sufficient fluids. In respiratory viruses may still be the cause of
the severely demented patient, tube- the same symptoms.
feeding should be resisted.
In view of the viral aetiology, antibiotics
Special care to prevent pressure ulcers should not be given in the otherwise
must be given and the caring doctor will healthy elderly patient. Yellow, purulent
inspect pressure areas daily: heels and toes, sputum does not signify a bacterial
the sacral region and the occipital scalp. infection.13

PROGNOSIS The American College of Physicians,
amongst others, has been educating
Pneumonia is still among the more doctors for the past 15 years in the correct
common causes of death in the elderly. use of antibiotic therapy. In a study of
Between 6 and 24 % of hospitalised 3  153 visits to physicians’ offices and
patients may still die. hospital outpatients for acute bronchitis
without underlying lung diseases, the use of
A study of three million Medicare benefi- antibiotic-prescribing for adults with acute
ciaries in the USA demonstrated that in the bronchitis actually increased to 40 %.14
year following hospital admission for
pneumonia, 31 % of these patients died. When antibiotics are not prescribed, we
They are also at a six- to 11-time greater must not ignore the patient. Cough
risk for readmission than the elderly in the suppressants, such as a codeine-
general population.11 containing cough mixture or pholcodine,
is indicated at night. It is amazing how well
CARING FOR THE CARE-GIVERS the capsaicin-containing lozenges
Fisherman’s Friend work during the day. A
We tend to forget the care-givers for the β-receptor stimulant inhaler not only
frail elderly. This may be a family member relieves bronchospasm, but also stimulates
or spouse who has been carrying the cilial function.15 The patient must be
burden for years. warned that the cough may last for as
long as six weeks.
In a Canadian study on care-givers,
partly based on a questionnaire given out Exercise such as jogging may increase
seven days after the discharge of patients the respiratory rate and depth of
who had been admitted to hospital for breathing. The increase of airflow leads to
intensive care and ventilator therapy, evaporation of fluid in the bronchi and
70 % of care-givers were female, 61 % a therefore has a cooling effect. This may
spouse, and 66 % had depression. cause bronchospasm in the asthmatic
and stimulate the coughing reflex. The
After one year, 55 % were still consid- elderly may find that staying in a tempera-
ered depressive. It was the younger ture-controlled atmosphere will reduce
care-givers with the least social support the tendency to cough.
who suffered the most.12
The use of antiviral medication such
Burnout in the care-giver is a reason for as oseltamivir in patients with influenza
abuse of the elderly. Attention to this has been shown to be effective in
common problem should help to improve
long-term care for the elderly.

HANDBOOK OF GERIATRIC MEDICINE





















































Photo-ageing lesions including solar keratosis/actinic keratosis 171

(“actinic keratosis”). J Am Acad Dermatol. cancerization. A randomized placebo- TREATMENT APPROACHES
2000;42(1, pt 2):11-17. controlled study. Br J Dermatol. 2010; 162:
5. Marks  R, Jolley  D, Dorevitch  AP, et al.  The
incidence of non-melanocytic skin cancers 171-175.
in an Australian population: results of a 17. Bagazgoitia L, Cuevas Santos J, Juarranz A,
five-year prospective study. Med J Aust.
1989;150(9):475-478. et al. Photodynamic therapy reduces the
6. Marks  R, Rennie  G, Selwood  TS.  Malignant
transformation of solar keratoses to squa- histologic features of actinic damage and
mous cell carcinoma. Lancet. 1988;1(8589):
795-797. the
expression of early oncogenic markers.
7. Patel G, Armstrong A, Eisen D. Efficacy of Br J Dermatol. 2011;165:144-145.
photodynamic therapy vs other interven- 18. Szeimies RM, Torezan L, Niwa A, et al.
tions in randomized clinical trials for the Clinical, histopathological and immunohis-
treatment of actinic keratoses. A system- tochemical assessment of human skin field
atic review and meta-analysis. JAMA cancerization before and after photody-
Dermatol. 2014;150(12):1281-1288. namic therapy. Br J Dermatol. 2012;167:
8. Redaelli A, Braccini F. Facial Ageing. 150-159.
Oeofirenze. 2012. P44- 60. 19. Weiss RA, Weiss MA, Geronimus RG, et al. A
9. Puizina Ivic N. Skin Ageing. Acta Derma- novel non thermal non-ablative full panel
tovan APA 2008; 17:2:47-54. LED photomodulation device for reversal of
10. Dohil MA. Efficacy, safety, and tolerability photo-ageing: digital and clinical results in
of 4 % 5-fluorouracil cream in a novel various skin types. J Drugs Dermatol. 2004,
patented aqueous cream containing 3(6):605-10.
peanut oil once daily compared with 5 % 20. Geronimus R, Weiss RA, Weiss MA, et al.
5-fluorouracil cream twice daily: meeting Non-ablative LED photomodulation-light
the challenge in the treatment of actinic activated fibroblast clinical trial. Lasers Surg
keratosis. J Drugs Dermatol. 2016 Oct Med. 2003, 25:22.
1;15(10)1218-1224, MA Dohil. 21. Boehncke WH, Sterry W, Kaufmann R.
11. Rossi, S, ed. (2013). Australian Medicines Treatment of psoriasis by topical photody-
Handbook (2013 ed.). Adelaide: The namic therapy with polychromatic light.
Australian Medicines Handbook Unit Trust. Lancet. Mar 26 1994;343(8900):801.
12. Krawtchenko N, et al. Br J Dermatol. 22. Bissonnette R, Lui H. Current status of photo-
2007;157(Suppl.2):34-40. dynamic therapy in dermatology.
13. Kalka K, Merk H, Mukhtar H. Photodynamic Dermatol Clin. Jul 1997;15(3):507-19.
therapy in dermatology. J Am Acad 23. Uebelhoer NS, Dover JS. Photodynamic
Dermatol. 2000 Mar;42(3):389-413; quiz 414-6. therapy for cosmetic applications.
14. Morton CA, McKenna KE, Rhodes LE. Dermatol Ther. May-Jun 2005;18(3):242-52.
Guidelines for topical photodynamic 24. Glogau RG. Chemical peeling and ageing
therapy: update. Br J Dermatol. Dec skin. J Geriatr Dematol. 1994;2:30-35.
2008;159(6):1245-66. 25. Kokoska MS, Thomas JR. Anatomy and
15. Braathen L, Morton C, Basset-Seguin N, et pathophysiology of facial ageing. Facial
al. Photodynamic therapy for skin field Plast Surg Clin North Am. 2001;9:179-187.
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International Society for Photodynamic tion. ASAPS information website. Updated
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Derma. 2012; 26: 1063-1066. 27. Manstein D, Herron GS, Sink RK, et al.
16. Apalla Z, Sotiriou E, Chovarda E, et al. Skin Fractional photothermolysis: a new
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HANDBOOK OF GERIATRIC MEDICINE

172 DERMATOLOGICAL AND AESTHETIC CONDITIONS

Varicose veins

Dr N le Grange External to the fascia and muscles, superfi-
MBChB (Stell) cial veins serve primarily as reservoirs with
 Aesthetics Centre, Tyger Waterfront, limited transport ability.
Bellville
ANATOMY
The World Health Organization defines
varicose veins as "saccular dilatation of The superficial veins of the lower limbs
veins which are often tortuous".1 terminate in the two saphenous veins,
which drain most of the blood from the
The tortuous appearance is termed superficial fascia. The great (also referred
"varicose", derived from the Greek term for to as the long) saphenous vein (GSV) is the
"grape-like". longest vein in the body. The GSV begins
at the medial end of the dorsal venous
Varicose veins are part of the spectrum arch on the foot and passes anterior to
of chronic venous diseases and include the medial maleolus of the tibia. It then
spider telangiectasias, reticular veins, and ascends obliquely across the inferior-third
true varicosities. Varicose veins alone, of the tibia towards the medial aspect of
without more advanced signs of chronic the knee. Here it lies superficial to the
venous insufficiency, may also result in medial epicondyle, approximately 10 cm
important reductions in quality of life.2 posterior to the medial border of the
patella. From here, it runs to the anterior
Patients tend to seek therapy for telangi- midline of the thigh and the saphenous
ectasias or varicose veins principally opening in the deep fascia. The GSV
because of their unsightly appearance. perforates the sieve-like cribiform-fascia
and femoral-sheath forming part of the
EPIDEMIOLOGY deep fascia of the thigh and ends in the
femoral vein. The GSV anastomoses freely
It has generally been estimated that vari- with the small saphenous vein.
cose veins affect 25 to 33 % of people in
Western countries, with an increase in PERFORATING VEINS
frequency with age.3 A study conducted in Perforating veins connect the deep veins
London of people aged 35 to 70 years4 to the superficial veins. Incompetent perfo-
concluded that the prevalence of varicose rators transmit high intravascular pressure
veins in men and women was 17 % and 31 % directly to their tributaries. The average
respectively. Over 80 % of the total popula- number of perforating veins per leg is
tion had reticular varicosities or found to be between 155 and 64. They
telangiectasia. There are few studies on the usually contain one to three one-way
incidence of varicose veins; however, the valves, depending on their length.
Framingham5 study found that the two-year Normally perforating veins have thin walls
incidence of varicose veins was 39.4/1 000 varying in diameter from approximately
for men and 51.9/1 000 for women. 1-2 mm. When incompetent though, perfo-
rating veins become thick-walled and may
PATHOPHYSIOLOGY reach a diameter of 5 mm or more.6

Although all veins have a similar structure, There are one or two relatively constant
the particular functions of the venous perforating veins in the thigh associated
system of the leg are imposed by their with the medial intramuscular septum
surroundings. When covered by muscles known as Hunterian or Dods' perforating
and fascia, the deep veins serve as a veins. These connect the GSV to the
transport system. Depending on the femoral vein in the mid-medial thigh and
tension of peri-venous tissues, deep veins
may either draw blood from the superficial
veins or pump blood towards the heart.

HANDBOOK OF GERIATRIC MEDICINE

Varicose veins 173

the mid-lower third of the thigh. n L eg heaviness TREATMENT APPROACHES
Incompetence of the Hunterian perforator n Exercise intolerance
is a common cause for medial thigh vari- n P ain or tenderness along the course of
cose veins, especially in places with
competent sapheno-femoral junctions. a vein
n P ruritus
Another common perforator is Boyd's n Burning sensations
perforating vein, also called a Boyd's n Restless legs
perforator. This usually appears 10 cm n N ight cramps
below the knee joint on the medial aspect n O edema
of the lower limbs. n S kin changes
n Paraesthesias
Another group of perforating veins is
located on the medial border of the lower The symptoms of varicose veins are often
leg. They usually occur in approximately disproportionate to the amount of factual
6 cm-10 cm, 13 cm-15 cm, 18 cm-20 cm pathological change. Often, most
and 24 cm-25 cm above the sole of the patients do not realise how good their legs
foot. This group is referred to as the can feel until after treatment of these
Cockett's perforators. They connect the affected veins by either compression
posterior arch vein with the posterior tibial sclerotherapy or by wearing lightweight,
veins, but do not drain directly into the graduated compression stockings.
small saphenous vein.6
SIGNS OF VARICOSE VEIN DISEASE
LESSER SAPHENOUS VEINS
The small saphenous vein is also known as It is estimated that between 17-50 % of
the lesser saphenous vein (LSV). It is people with varicose veins have cuta-
formed by the union of veins rising from neous findings. There is a strong association
the lateral part of the dorsal venous arch. between the severity of clinical signs and
The LSV passes along the lateral side of the superficial venous incompetence. Signs of
foot with the sural nerve posterior to the venous stasis disease include:
lateral maleolus and ascends along the n A nkle oedema
lateral side of the Achilles tendon. The n Dilated veins and venules
small saphenous vein passes through the n T elangiectasias
popliteal-fossa where it perforates the n Corona phlebectasia
deep popliteal-fascia and ends in the n Pigmentation
popliteal vein. The LSV has a thick wall and n Venous dermatitis
usually measures approximately 3 mm in n Atrophie blanche
diameter when normal.6 The small saphe-
nous vein often receives substantial CLINICAL MANAGEMENT
tributaries from the medial aspect of the
ankle, thereby communicating with the As with any medical procedure, a thor-
medial ankle perforators. ough examination and treatment
planning is essential to achieve success.
OTHER SUPERFICIAL VEINS
The superficial collateral or communi- The presence of bulging varicosities and
cating venous network consists of many chronic venous insufficiency are usually
longitudinally-, transversally- and readily apparent. In patients with only
obliquely-oriented veins. These veins are telangiectasias of the legs and no
normally of low diameter, but when vari- dilated veins, most doctors would agree
cose can dilate to more than one cm. that further non-invasive testing is
unnecessary.
SYMPTOMATOLOGY
MEDICAL HISTORY
Common chronic symptoms of varicose As with most other patients, it is important to
veins include the following:7 start by taking a good medical history,
including a family history of varicose vein

HANDBOOK OF GERIATRIC MEDICINE

174 DERMATOLOGICAL AND AESTHETIC CONDITIONS

disease. One particular gene, FOXC2, an incompetent deep and perforator
located on chromosome 16, has been linked system is present. Superficial venous incom-
to lower-extremity venous valve failure.8 petence is present if superficial varicose
veins fill rapidly on tourniquet release.9
Take note of the time and age of onset. If
symptoms of varicose vein disease NON-INVASIVE DIAGNOSTIC
become worse after a period of immobili- TECHNIQUES
sation such as when travelling or after an The two most popular instruments used
operation, it may be indicative of an will be the Doppler ultrasound and the
underlying deep venous thrombosis. The duplex scanner. If the cause of varicose
rapid onset or a progressive increase in the veins is not clear from the clinical exami-
size or recent onset of oedema may show nation or if an intervention is being
an abdominal or pelvic tumor, for example. considered, colour duplex scanning to
determine superficial and deep venous
Any prior treatment for varicose vein reflux should be performed. Venous reflux
disease as well as the patient's response to is defined as retrograde flow of >0.5
the different treatment modalities should seconds in duration after distal manual
be noted. Any complications experienced augmentation. Venous ultrasonography
should be discussed, a history of prior can also detect deep or superficial
hyperpigmentation, or poor response to a venous thrombosis. If obstruction or
particular sclerosing agent may support a extrinsic compression of iliac venous
variety of changes in treatment protocol. segments or the inferior vena cava is
suspected, additional imaging such as
Symptoms and the severity thereof computed tomography, magnetic reso-
should also be discussed; however, it is nance, or invasive venography may
important to note that the symptoms do be indicated.
not necessarily correlate with the size or
severity of varicose veins present. TREATMENT

Complications such as ulceration and Selection of therapy for varicose veins
haemorrhaging should also be discussed. should take into account symptoms, loca-
tion, severity, and cause. In addition to
PHYSICAL EXAMINATION symptoms refractory to non-invasive
Using no special equipment, one can measures and cosmetic concerns, recur-
obtain a degree of information regarding rent varicose vein haemorrhage and
overall venous flow from the leg, signs of superficial thrombophlebitis are indica-
valvular insufficiency, the presence of tions for invasive vein therapy. Invasive
primary vs secondary varicose veins and vein therapies such as sclerotherapy,
the presence of possible deep vein throm- surgery, or endovenous ablation are
bosis. It is important to view the entire leg contra-indicated in pregnancy, acute
and not to confine examination simply to venous thrombo-embolism, and periph-
the area the patient feels is abnormal. For eral artery disease (ankle:brachial
the same reason, ensure that both legs index <0.9).
are examined.
LIFESTYLE MODIFICATION
Examination techniques include the Lifestyle modification is crucial to ensure a
cough test, the percussion test with the treatment response that is as complete
Brody-Trendelenburg test the most helpful and durable as possible. Because vari-
and important. The Brody-Trendelenburg cose veins are associated with obesity,
test can help distinguish between superfi- weight loss is an important step in reducing
cial venous and deep venous insufficiency progression and preventing recurrence.
and is performed with the patient recum- Regular physical activity such as walking
bent, the leg elevated to 45º, and a and foot flexion exercises may improve
tourniquet applied to the mid-thigh after
the veins have been completely drained.
On standing, if venous refill distal to the
tourniquet occurs in less than 30 seconds,

HANDBOOK OF GERIATRIC MEDICINE

Varicose veins 175

calf-muscle pump function. Elevation of chestnut extract had a greater reduction TREATMENT APPROACHES
the feet to at least heart level for 30 in their lower leg volume compared with
minutes at least four times a day and placebo after 12 weeks of therapy. The
avoidance of prolonged standing and horse chestnut extract was well tolerated
sitting, decompress lower extremity veins and no adverse events were noted,
and improve symptoms. Smoking cessa- although gastro-intestinal irritation has
tion should be emphasised in patients with been reported.
varicose veins.
SURGICAL TREATMENT
COMPRESSION THERAPY Varicosities in branches of the major
Compression stockings are frequently superficial veins can be treated using stab
prescribed as the first step in varicose vein or micro-incision phlebectomy, which
management and are effective for treat- requires only local tumescent anaesthesia
ment of discomfort and oedema.1 and leaves minimal scars. These microsur-
Compression stockings improve venous gical techniques have replaced more
haemodynamics by decreasing venous traditional large-incision phlebectomy. For
reflux and reducing ambulatory venous varicosities in the greater and lesser
hypertension. Because of limited, saphenous veins, endovenous techniques
randomised, controlled trial evidence, the have largely replaced traditional large-
impact of compression stockings on incision surgical stripping and vein ligation.
progression or recurrence of varicose Surgical stripping is associated with vari-
veins remains unclear.10 A multicentre cose vein recurrence in up to 50 % of
randomised, controlled trial of active patients by five years, most often as a
versus placebo compression stockings result of incomplete phlebectomy, persis-
suggested that routine use of compression tent venous reflux, or neovascularisation.
stockings may not prevent post-throm- Complications of surgical stripping include
botic syndrome in patients with first extensive ecchymosis and scarring,
proximal deep vein thrombosis.11 Patients haematoma, lymphocele, infection,
should be instructed to don compression nerve injury, and deep vein thrombosis.
stockings in the morning and can remove
them at night before going to bed. ENDOVENOUS THERAPY
Graduated compression strength is Endovenous therapy with either radiofre-
prescribed to treat larger varicosities and quency or laser ablation relies on thermal
greater severity of symptoms and chronic injury to cause thrombotic and fibrotic
venous insufficiency. Unfortunately, the closure of the saphenous veins in patients
rate of nonadherence to compression with documented superficial venous
stocking regimens approaches 60 % in reflux. Local tumescent anaesthesia is
patients with chronic venous disease, required for patient comfort, to separate
including varicose veins.9 the vein from the skin surface, and to
protect surrounding tissue from heat injury.
PHARMACOTHERAPY A systematic review demonstrated that
Very few drugs help to treat varicose three-year estimated pooled success
veins. Diuretics are commonly prescribed rates of endovenous therapies for saphe-
for oedema, but generally do little to nous varicosities were 84 % for radio-
relieve the pain or discomfort. Horse frequency ablation and 94 % for
chestnut extract has been shown to endovenous laser ablation, compared
decrease oedema by increasing venous with 78 % for surgical stripping.9 Long-term
tone and venous flow. In a randomised, randomised, controlled trial data have
placebo-controlled study,12 horse established endovenous therapy as an
chestnut extract was compared to effective and durable alternative to
compression stockings. Patients wearing surgical stripping. In a randomised,
compression hose or taking the horse controlled trial comparing endovenous

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