Everyone knows that vitamins and nutrition are important for health, and many older adults take a multivitamin.

But did you know that even among older persons who do this, many still end up developing a serious deficiency in one particular vitamin?

It’s Vitamin B12.

If there’s one vitamin that I’d like all older adults and family caregivers to know more about, it would be vitamin B12.

(Second on my list would be vitamin D, but it’s much harder to develop low vitamin D levels if you take a daily supplement, as I explain in this post. Whereas vitamin B12 deficiency does develop in many older adults who are getting their recommended daily allowance.)

A deficiency in any vitamin can be catastrophic for health. But vitamin B12 deficiency stands out because a) it’s very common — experts have estimated that up to 20% of older adults may be low in this vitamin — and b) it’s often missed by doctors.

Geriatricians also like to pay attention to vitamin B12 because a deficiency can cause — or usually worsen — cognitive impairment or walking problems.

But if you know the symptoms and risk factors, you can help ensure that you get a vitamin B12 deficiency detected. Treatment is safe and effective, as long as you catch the problem before permanent damage occurs. Here’s what to know.

How Vitamin B12 Deficiency Harms Health

In the body, vitamin B12 – also known as cobalamin — is especially vital to making red blood cells, and maintaining proper function of nerve cells. When vitamin B12 levels are low, a person can develop health problems related to red blood cells and nerve cells malfunctioning. 

The most common problems related to low vitamin B12 levels include:

• Anemia. This means the red blood cell count is low. Red blood cells carry oxygen in the blood, so anemia can cause fatigue or shortness of breath. The breakdown of faulty red blood cells can also cause jaundice. (Learn more about anemia here: Anemia in the Older Adult: 10 Common Causes & What to Ask.)
• Neuropathy. This means that nerves in the body are not working well. This can cause a variety of symptoms, including tingling, numbness, burning, poor balance, and walking difficulties.
• Cognitive impairment. This means that nerve cells in the brain are not working well. This can cause memory problems, irritability, and even dementia.

You may have heard that vitamin B12 deficiency can cause pernicious anemia. But in fact, the term “pernicious anemia” means a specific vitamin B12 deficiency caused by the loss of the body’s ability to make “intrinsic factor.” Intrinsic factor is in the lining of the stomach, so a weakened stomach lining (which is called “atrophic gastritis” can cause pernicious anemia. The body needs intrinsic factor to absorb vitamin B12; without it, vitamin B12 levels eventually drop. This often causes anemia, but sometimes symptoms of nerve and brain problems occur first.

Why Low Vitamin B12 Levels Are Common in Older Adults

To understand how low vitamin B12 levels happen in aging adults, it’s good to start by learning how the body usually obtains and processes this vitamin.

In nature, vitamin B12 is available to humans only in meat and dairy products. However, in modern times, you can easily get it via a supplement or multivitamin. The recommended daily allowance for vitamin B12 for adults is 2.4 micrograms. Experts have estimated that a Western diet contains 5-7 micrograms of vitamin B12, and a multivitamin often contains 12-25 micrograms. 

Once you ingest vitamin B12, it is processed by acids and enzymes in the stomach and small intestine. The processed vitamin is then absorbed by the small intestine and stored in the body, especially in the liver. 

This stash can actually meet the body’s needs for a few years; although vitamin B12 is essential, only a tiny bit is needed every day. So if a healthy person stops taking in vitamin B12, it often takes a few years before the body runs out of it and develops symptoms.

So why does vitamin B12 deficiency particularly affect older adults?

As people get older, their ability to absorb vitamin B12 decreases. This is because aging adults often develop problems with the acids and stomach enzymes needed to process the vitamin. 

Common risk factors for low vitamin B12 levels in older adults include:

• Low levels of stomach acid. This can be due to weakening of the stomach lining (also known as “atrophic gastritis”), or to medications that reduce stomach acid. 
• Medications such as metformin (used for diabetes), which interferes with vitamin B12 absorption.
• Alcoholism, which irritates the stomach and sometimes is linked to a poor diet.
• Surgeries to remove parts (or all) of the stomach or small intestine.
• Any problem that causes poor absorption in the stomach or small intestine, such as Crohn’s disease.

Why Vitamin B12 Deficiency Is Often Missed in Aging Adults

Vitamin B12 deficiency is often missed because the symptoms – fatigue, anemia, neuropathy, memory problems, or walking difficulties – are quite common in older adults, and can easily be caused by something else.

Also, vitamin B12 deficiency tends to come on very slowly, so people often go through a long period of being mildly deficient. During this time, an older person might have barely noticeable symptoms, or the symptoms might be attributed to another chronic health condition. 

Still, a mild deficiency will almost always get worse over time. And even when an older adult has many other causes for fatigue or problems with mobility, it’s good to fix whatever aggravating factors – such as a vitamin deficiency — can be fixed.

Unlike many problems that affect aging adults, vitamin B12 deficiency is quite treatable. Detection is the key;  then make sure the treatment plan has raised the vitamin B12 levels and kept them steady.

Who Should Be Checked for Vitamin B12 Deficiency

An older person should probably be checked for Vitamin B12 deficiency if he or she is experiencing any of the health problems that can be caused by low levels of this vitamin. 

I especially recommend checking vitamin B12 levels if you’re concerned about memory, brain function, neuropathy, walking, or anemia. 

To make sure you aren’t missing a mild vitamin B12 deficiency, you can also proactively check for low vitamin B12 levels if you or your older relative is suffering from any of the common risk factors associated with this condition.

For instance, you can request a vitamin B12 check if you’re vegetarian, or if you’ve suffered from problems related to the stomach, pancreas, or intestine. It’s also reasonable to check the level if you’ve been on medication to reduce stomach acid for a long time.

How Vitamin B12 Deficiency is Diagnosed

The first step in checking for deficiency is a blood test to check the serum level of vitamin B12.

Because folate deficiency can cause a similar type of anemia (megaloblastic anemia, which means a low red blood cell count with overly-large cells), doctors often test the blood for both folate and vitamin B12. However, folate deficiency is much less common. 

You should know that it’s quite possible to have clinically low vitamin B12 levels without having anemia. If a clinician pooh-poohs a request for a vitamin B12 check because an older person had a recent normal blood count, you can share this research article with the clinician.

Although MedlinePlus says that “Normal values are 160 to 950 picograms per milliliter (pg/mL)”, the clinical reference UptoDate says that a normal serum vitamin B12 level is above 300 pg/mL.

Normal vitamin B12 levels do not change with age, so there’s no need to look for a different cutoff as people get older.

If the vitamin B12 level is borderline, a confirmatory blood test can be ordered. It involves testing for methylmalonic acid, which is higher than normal when people have vitamin B12 deficiency.

In my own practice, especially if an older person has risk factors for vitamin B12 deficiency, I consider a vitamin B12 level of 200-400 pg/mL borderline, and I usually order a methylmalonic acid level as a follow-up.

How to Treat Vitamin B12 Deficiency in Older Adults

If the blood tests confirm a vitamin B12 deficiency, the doctors will prescribe supplements to get the body’s levels back up. The doctor may also recommend additional tests or investigation to find out just why an older person has developed low vitamin B12. 

The usual dosage for initially treating vitamin B12 deficiency in older adults is 1000 micrograms, which can be given as a weekly intramuscular injection, or as a daily oral B12 supplement.

It’s common to start treatment for a significant vitamin B12 deficiency with weekly intramuscular shots (1000 micrograms of vitamin B12). This bypasses any absorption problems in the stomach or intestine, and is a good way to get an older person’s vitamin B12 level back to normal quickly.

High-dose oral vitamin B12 supplements (1000-2000 micrograms per day) have also been shown to raise levels, because high doses can usually compensate for the body’s poor absorption. However, oral treatments probably take longer to work than intramuscular shots. So they’re not ideal for initially correcting a deficiency, although they’re sometimes used to maintain vitamin B12 levels. 

I’ve found that most older patients prefer oral supplements over regular vitamin B12 injections, which is understandable; shots aren’t fun. However, this requires the older person to consistently take their supplement every single day. If you (or your older relative) has difficulty taking medications regularly, scheduled vitamin B12 shots are often the better option.

And the good thing about vitamin B12 treatment is that it’s basically impossible to overdose. Unlike some other vitamins, vitamin B12 doesn’t cause toxicity when levels are high. 

So if you’re being treated for vitamin B12 deficiency, you don’t need to worry that the doctors will overshoot. You just need to make sure a follow-up test has confirmed better vitamin B12 levels, and then you can work with the doctors to find the right maintenance dose to prevent future vitamin B12 deficiency. 

For an older person on vitamin B12 injections, once the blood level of vitamin B12 has normalized, the injections can be given once a month.

Are There Other Benefits To Taking Vitamin B12 Supplements?

Since we know vitamin B12 is necessary for the proper function of red blood cells and brain cells, you might be wondering if it’s good to take higher doses of vitamin B12 as part of a healthy aging approach.

It certainly won’t hurt, since vitamin B12 doesn’t cause problems at higher blood levels the way some vitamins do.

But once an older person has a good level of vitamin B12 in the body, it’s not clear that additional vitamin B12 will reduce the risk of problems like cancer or dementia. To date, much of the research on the benefits of extra vitamin B12 has been inconclusive. 

However, research has definitely confirmed that a deficiency in this essential vitamin is harmful to the body and the brain, with worse deficiencies generally causing greater harm.

So to help yourself or a loved one make the most of this vitamin, focus on detecting and treating vitamin B12 deficiency. Remember, this common problem is frequently overlooked.

You can help yourself by asking the doctor to check vitamin B12 if you’ve noticed any related symptoms, or by asking for a proactive check if you have any risk factors.

Older adults often have enough health problems to deal with. Let’s make sure to notice the ones that are easily detectable and treatable.

 

Q: My 88-year old mother often complains of various aches and pains. What is the safest over-the-counter painkiller for her to take? Aren’t some of them bad for your liver and kidneys?

A: Frequent aches and pains are a common problem for older adults.

If your mother has been complaining, you’ll want to make sure she gets a careful evaluation from her doctor. After all, frequent pain can be a sign of an important underlying health problem that needs attention. You’re also more likely to help your mom reduce her pain if you can help her doctors identify the underlying causes of her pain.

That said, it’s a good idea to ask what over-the-counter (OTC) pain relievers are safest for older people.

That’s because improper use of OTC painkiller tablets is actually a major cause of harm to older adults.

So let me tell you what OTC pain relievers geriatricians usually consider the safest, and which very common group of painkillers can cause serious side-effects in aging adults.

What’s the safest OTC painkiller for an aging parent?

For most older adults, the safest oral OTC painkiller for daily or frequent use is acetaminophen (brand name Tylenol), provided you are careful to not exceed a total dose of 3,000mg per day.

Acetaminophen is usually called paracetamol outside the U.S.

It is processed by the liver and in high doses can cause serious — sometimes even life-threatening — liver injury. So if an older person has a history of alcohol abuse or chronic liver disease, then an even lower daily limit will be needed, and I would strongly advise you to talk to a doctor about what daily limit might be suitable.

The tricky thing with acetaminophen is that it’s actually included in lots of different over-the-counter medications (e.g. Nyquil, Theraflu) and prescription medications (e.g. Percocet). So people can easily end up taking more daily acetaminophen than they realize. This can indeed be dangerous; research suggests that 40% of acetaminophen overdose cases are accidental.

But when taken at recommended doses, acetaminophen has surprisingly few serious side effects and rarely harms older adults. Unlike non-steroidal anti-inflammatory drugs (NSAIDs, see below), it does not put older adults at risk of internal bleeding, and it seems to have minimal impacts on kidney function and cardiovascular risk.

Be careful or avoid this common class of painkillers

At the drugstore, the most common alternatives to acetaminophen are painkiller tablets such as ibuprofen (brand names Advil and Motrin) and naproxen (brand names Aleve, Naprosyn, and Anaprox).

Both of these are part of a class of drugs known as non-steroidal anti-inflammatory drugs (NSAIDs). Many people are familiar with these medications. But in fact, older adults should be very careful before using NSAIDs often or regularly.

Unlike acetaminophen, which usually doesn’t become much riskier as people get older, NSAIDs cause side effects that are especially likely to become dangerous as people get older. These include:

• Increased risk of bleeding in the stomach, small bowel, or colon. Seniors who take a daily aspirin or a blood thinner are at especially high risk.
• Problems with the stomach lining, which can cause stomach pain or even peptic ulcer disease.
• Decreased kidney function. This can be especially problematic for those many older adults who have already experienced a chronic decline in kidney function.
• Interference with high blood pressure medications.
• Fluid retention and increased risk of heart failure.

Experts have estimated that NSAIDs cause 41,00 hospitalizations and 3,300 deaths among older adults every year.

Recent research has also suggested that NSAIDs cause a small but real increase in the risk of cardiovascular events (e.g. heart attacks and strokes).

Because of these well-known serious side effects of NSAIDs in older adults, in 2009 the American Geriatrics Society recommended that older adults avoid using NSAIDS for the treatment of chronic persistent pain. Today, oral NSAIDs remain on the Beer’s List of medications that older adults should avoid or use with caution. (For more on the Beer’s list, see this article: Medications Older Adults Should Avoid or Use with Caution: The American Geriatrics Society Beers Criteria 2019 Update.)

Now, it’s important to know NSAIDs can also be prescribed as creams or gels. These topical forms are much safer, and can be effective for pain relief.

Despite this fact, NSAID painkiller tablets are often bought by seniors at the drugstore. Perhaps even worse, NSAIDs are often prescribed to older adults by physicians, because the anti-inflammatory effect can provide relief from arthritis pain, gout, and other common health ailments.

(Commonly prescribed NSAIDs include indomethacin, diclofenac, sulindac, meloxicam, and celecoxib. These tend to be stronger than the NSAIDs available without a prescription. However, stronger NSAIDs are associated with higher risks of serious side effects, unless they are used as a cream or gel, in which case the risks are much less.)

Now let me share a true story. Many years ago, a man in his 70s transferred to my patient panel. He had been taking a daily NSAID for several months, prescribed by the previous doctor, to treat his chronic shoulder arthritis.

I cautioned him about continuing this medication, explaining that it could cause serious internal bleeding. He seemed dubious, and said his previous doctor had never mentioned bleeding. He wanted to continue it. I decided to let it slide for the time being.

A few weeks later, he was hospitalized for internal bleeding from his stomach. Naturally, I felt terrible about it.

This is not to say that older adults should never use NSAIDs. They are often more effective pain relievers than acetaminophen, especially for conditions such as arthritis. So even in geriatrics, we sometimes conclude that the likely benefits seem to outweigh the likely risks.

But this conclusion really should be reached in partnership with the patient and family; only they can tell us how much that pain relief means to them, and how concerned they are about the risk of bleeding and other dangerous side effects. (It’s also possible to reduce the risk of bleeding by having a patient take a medication to reduce stomach acid.)

Unfortunately, far too many older adults are never informed of the risks associated with NSAIDs. And in the drugstore, they sometimes choose ibuprofen over acetaminophen, because they’ve heard that Tylenol can cause liver failure.

Yes, acetaminophen has risks as well. But every year, NSAIDs cause far more hospitalizations among older adults than acetaminophen does.

Aspirin: a special NSAID we no longer use for pain

Aspirin is another analgesic available over-the-counter.

It’s technically also an NSAID, but its chemical structure is a bit different from the other NSAIDs. This is what allows it to be effective in reducing strokes and heart attacks. It is also less likely to affect the kidneys than other NSAIDs are.

(For more on the risks and benefits of aspirin, see this MayoClinic.com article.)

Aspirin is no longer used as an analgesic by the medical community. But many older adults still reach for aspirin to treat their aches and pains, because they are used to thinking of it as a painkiller. Aspirin is also included in certain over-the-counter medications, such as Excedrin.

Taking a very occasional aspirin for a headache or other pain is not terribly risky for most aging adults. But using aspirin more often increases the risk of internal bleeding. So, I discourage my older patients from using aspirin for pain.

Tips on safer use of OTC painkillers

In short, the safest oral OTC painkiller for older adults is usually acetaminophen, provided you don’t exceed 3,000 mg per day.

If you have any concerns about liver function or alcohol use, plan to use the medication daily on an ongoing basis, or otherwise want to err on the safer side, try to not exceed 2,000 mg per day, and seek medical input as soon as possible.

You should also be sure to bring up any chronic pain with your parent’s doctor. It’s important to get help identifying the underlying causes of the pain. The doctor can then help you develop a plan to manage the pain.

And don’t forget to ask about non-drug treatments for pain; they are often safer for older adults, but busy doctors may not bring them up unless you ask. For example, chronic pain self-management programs can be very helpful to some people. Physical therapy, massage, and certain forms of exercise can play an important role in pain relief, especially when it comes to chronic pain.

Now if your older parent is taking acetaminophen often or every day, you’ll want to be sure you’ve accounted for all acetaminophen she might be taking. Remember, acetaminophen is often included in medications for cough and cold, and in prescription painkillers. So you need to look at the ingredients list for all medications of this type. Experts believe that half of acetaminophen overdoses are unintentional, and result from people either making mistakes with their doses or not realizing they are taking other medications containing acetaminophen.

Last but not least: be sure to avoid the “PM” version of any OTC painkiller. The “PM” part means a mild sedative has been included, and such drugs — usually diphenhydramine, which is the main ingredient in Benadryl — are anticholinergic and known to be bad for brain health. (See 7 Common Brain-Toxic Drugs Older Adults Should Use With Caution for more about the risks of anticholinergic drugs.)

My own approach, when I do house calls, is to check the older person’s medicine cabinet. If I find any NSAIDs or over-the-counter anticholinergic medications (e.g. antihistamines, sleep aids, etc), I discuss them with my older patient and usually remove them from the house unless there’s a good reason to leave them.

If acetaminophen isn’t providing enough pain relief

If acetaminophen doesn’t provide enough relief for your mom’s pains, then it may be reasonable to consider over-the-counter (or sometimes prescription) NSAIDs, preferably for a limited period of time. But be sure to discuss the risks and alternatives with the doctor first, and be sure to discuss possible non-drug approaches to lessen pain.

You may also want to ask about topical painkillers, such as gels, creams, and patches. These are generally safer than oral medications, because less of the body is exposed to side effects.

For severe pain, it may also be reasonable to discuss other prescription drug options. Depending on the type of pain, in some cases it can be reasonable to consider using very small doses of opioids, or other types of painkillers. That said, bear in mind that all prescription pain relievers come with risks and can cause serious side effects. In older adults, most will affect brain function and balance.

The truth is that it’s often not possible to treat pain effectively and 100% safely, when it comes to using oral painkiller tablets. But by being informed and proactive, your family can help your mom get better care for her pain, while minimizing the risk of harm from pain relievers.

Good luck!

It’s annoying but unfortunately true: most parts of the body work less well as one gets older and older.

This is even true of the brain, which is part of why it becomes more common to experience a “tip of the tongue” moment as one gets older.

Such age-related changes in how the brain manages memory, thinking, and other mental processes are called “cognitive aging.”

Understanding how aging changes cognition is important. It can help you understand what to anticipate when it comes to your own aging. It can also help families better understand the changes they’re noticing in an older person, and whether those are out of the ordinary or not.

Since I’ve often written about changes in thinking that are abnormal and concerning in older adults, I thought it might be helpful for me to write an article outlining what is normal and to be expected.

Specifically, I’ll cover:

• How cognitive aging differs from other diseases and conditions that affect memory and thinking
• 6 ways that memory and thinking change with aging
• The difference between crystallized and fluid intelligence
• How to tell cognitive aging apart from more worrisome changes
• Practical takeaways and what you can do

Now, I’ll be frank. As you’ll see, most mental processes become less nimble with time. Just as your 75-year-old self can’t run as fast as your 30-year old self, your 75-year-old brain will, for the most part, not think as quickly either.

This can be discouraging news to many people. Which means they might feel reluctant to learn more about this.

But the news is not all bad. Yes, things tend to work a little slower and less well, but on the other hand older adults can often compensate by drawing on their experience. Cognitive aging also helps older adults become more optimistic and emotionally resilient, as I explain later in the article.

By better understanding cognitive aging, you’ll be better equipped to understand the older adults in your life, whether that is yourself or an older loved one.

How does cognitive aging differ from a disease or more concerning changes in mental function?

People sometimes have trouble understanding how cognitive aging is different from something more concerning, such as mild cognitive impairment, early Alzheimer’s disease, or other memory-related conditions they may have heard about.

A good explanation of the difference is available here, in the Cognitive Aging Action Guide published by the National Academy of Medicine (formerly the Institute of Medicine), which issued a fantastic report on cognitive aging in 2015.

Basically, cognitive aging is the brain’s version of your body parts working less efficiently due to age, rather than due to disease or serious damage.

This loss of efficiency is gradual. And like many other age-associated changes in the body, cognitive aging tends to happen a little differently for every person, in part due to things like genetics, lifestyle and environmental factors.

But it’s not a disease. Very importantly: cognitive aging doesn’t involve neurodegeneration or significant damage to the brain’s neurons.

So whereas Alzheimer’s disease and other conditions cause neurons to become badly damaged and eventually die, in a normal older person with cognitive aging, the brain’s neurons are basically ok, they’re just working less quickly and less well than earlier in life.

Although cognitive aging does cause certain mental processes to happen less quickly, normal cognitive aging should not impair an older person’s abilities to the point that they are visibly struggling with life tasks or no longer able to live independently.

6 Ways that Memory and Thinking Change With Aging

People often think of memory when they think of cognition or “brain function.” But there’s actually much more to thinking and the brain’s work.

Here are six key ways that cognition changes with aging.

Processing speed

What it is: This refers to how quickly the brain can process information and then provide a response, such as making a movement or providing an answer. Processing speed affects just about every function in the brain. Processing speed in of itself is not a specific mental task, it’s about how quickly you can manage a mental task.

How it changes with aging: 

• Processing speed decreases with age, with one expert describing it as a nearly linear decline.
• This decrease starts in early adulthood, so by the time people are in their 70s or 80s, processing speed is significantly down compared to the speed one had in one’s 20s.

Practical implications: 

• Older adults need more time to take in information and to formulate an appropriate response, compared to their younger selves.
• Some older adults may struggle with complex tasks that require a lot of quick information processing.
  • Driving, in particular, can be affected by slower processing, because driving requires the brain to keep noticing and processing a lot of information while quickly formulating appropriate responses.

Memory 

What it is: This is a broad category covering the ability to remember information. Key sub-types include:

• Working memory
  • This refers to the ability to temporarily hold information in mind and manipulate it mentally, like remembering a new phone number and then dialing it.
  • Working memory is involved in a variety of mental tasks, including problem-solving, making decisions, and processing language.
• Semantic long-term memory
  • This refers to factual information that you acquire over time, such as the name of a state capital.
• Episodic memory
  • This refers to one’s memory for personally experienced events that have happened at a particular place or time.
• Prospective memory
  • This refers to the ability to remember to do things in the future.
• Procedural memory
  • This is also known as skill learning. It refers to the learning and remembering how to do certain activities.
  • It usually requires time and practice to build up.

Memory is actually a complicated topic. There are many other subtypes of memory, and experts are also still debating just how to categorize and explain the many different ways that people remember information or how to do things.

It’s also technically a different task for the brain to create a memory (this is sometimes called encoding) versus to retrieve it. So a person may have trouble remembering something either because they had difficulty encoding it in the first place, or because they are having difficulty promptly retrieving it.

How memory changes with aging: Many aspects of memory do decline with age, but not all:

• Types of memory that decline:
  • Working memory
  • Episodic memory (especially for more recent events)
  • Prospective memory
• Types of memory that stay stable
  • Procedural memory
  • Semantic long-term memory (may decline after the seventh decade)

Practical implications: 

• Normal older adults are generally good at retaining information and memories that they’ve previously acquired, but they can take longer to retrieve them.
• The ability to perform well-learned procedures (e.g. typing) remains stable. However, older adults often need more time and practice to learn a new procedure and create the procedural memory.
• Declines in working memory mean that older adults may take longer or have more difficulty solving complex problems or weighing complicated decisions.
• Declines in episodic memory may cause older adults to be a little more forgetful, especially for recent events.
• Declines in prospective memory can make older adults more likely to forget something they were supposed to do.
• It can help to give older adults more time and support to actually encode information into their memories. This requires processing time and also adequate attention (see below).

Attention

What it is: Attention is the ability to concentrate and focus on something specific, so that the related information can be processed. Key sub-types include:

• Selective attention
  • This is the ability to focus on something specific despite the presence of other distracting and “irrelevant” information or stimuli.
  • Examples: spotting the relevant information on a cluttered website, following a conversation despite being in a busy environment.
• Divided attention
  • Also known as “multi-tasking,” this is the ability to manage multiple tasks or streams of information at the same time.
  • Examples: reading a recipe while listening to music, driving while talking to someone.
• Sustained attention
  • This is the ability to remain concentrated on something for an extended period of time.

How it changes with aging: Some aspects of attention do get worse with aging. Specifically:

• Selective attention gets worse with aging.
• Divided attention gets worse with aging.
• Sustained attention does not tend to get worse with aging.

Practical implications:

• As people get older, they are more easily distracted by noise, visual clutter, or a busy situation. It requires more effort for them to pay attention, especially when other things are going on.
• People will also get worse at multi-tasking or switching between tasks, as they get older.

Language Skills

What they are: Language skills cover a variety of abilities related to understanding and producing both verbal language and written language.

How they change with aging: 

• Vocabulary tends to remain stable with aging.
• The comprehension of written language tends to remain stable.
• Speech comprehension can decline with age, especially if the older person has any hearing difficulties or if the speech is rapid or distorted (because such speech requires more mental processing).
• Language production does decline with age. Examples include:
  • More time is needed to find a word, and it becomes more common to pause in the middle of a sentence.
  • Spelling familiar words may become more difficult.
  • The ability to name a common object tends to decline after age 70.

Practical implications:

• Normal older adults retain their vocabulary and ability to comprehend written language.
• They may struggle with understanding rapid speech or distorted speech (such as that broadcast by a loudspeaker or synthetic voice).
• Retrieving words often takes longer.

Executive Functioning

What it is: This refers to the mental skills that are needed for activities related to planning, organizing, problem-solving, abstract thinking, mental flexibility, and appropriate behavior. Executive function allows people to do things such as:

• Solve new problems
• Organize information and plan activities
• Think abstractly
• Use reason (especially when it comes to reasoning with unfamiliar material)
• Adapt to new situations
• Behave in socially appropriate ways
• Make complex decisions

How it changes with aging: Executive function generally declines with age, especially after age 70.

Practical implications:

• Normal older adults generally can perform the executive functioning tasks listed above, but they will not do them as well as when they were younger.
• Older adults may struggle or take more time for more demanding executive functioning tasks, especially if they are tired or otherwise cognitively feeling taxed.

Emotional Processing

What it is: This refers to the ways one processes and regulates emotions, especially the negative ones. Examples include:

• How quickly one moves out of a negative emotional state
• How physically or emotionally reactive one is to interpersonal stressors
• Mental strategies for minimizing negative stimuli, such as paying less attention to them

How it changes with aging: Older adults experience several changes that generally make them more positive and optimistic. These include:

• Paying less attention to or withdrawing from negatively-simulating situations.
• Paying more attention to positive things.
• Becoming better at remembering positive things.

Practical implications:

• Normal older adults develop a positivity bias, and will tend to pay more attention to situations that are emotionally positive.
• Older adults have more difficulty remembering or paying attention to situations or problems that generate negative emotions.
  • This may be part of why it’s difficult for them to engage in planning for unpleasant future eventualities.
• People tend to get happier and recover from negative emotions more quickly as they age.
• Older adults may seem to avoid or deny certain issues that they find unpleasant.

Crystallized versus fluid intelligence in aging

When experts discuss normal cognitive changes in aging, they sometimes refer to crystallized intelligence versus fluid intelligence.

Basically, crystallized intelligence refers to everything one has learned over time: skills, abilities, knowledge. This increases as people get older, because crystallized intelligence is a function of experience, practice, and familiarity. This can lead to what we might refer to as “wisdom.”

Crystallized intelligence gets better or stays stable as people get older. This experience and wisdom does enable older adults to compensate for some of the decline in processing speed and other ability. It also means that older adults may perform better than younger people at those mental tasks that require depth of experience or knowledge.

Fluid intelligence, on the other hand, refers to abilities related to processing power, taking in new information, problem-solving with new or less familiar information, and reacting quickly.

Fluid intelligence is at its peak when we are younger adults, and then declines over time.

How to tell cognitive aging apart from more worrisome changes

It’s true that some very common brain problems, such as very early Alzheimer’s disease, can be very hard to tell apart from changes due to cognitive aging.

If you’re concerned that certain symptoms might be early Alzheimer’s, I recommend taking a look at the Alzheimer’s Association’s handy list of “10 Early Signs and Symptoms of Alzheimer’s.”

What is nice about the Alzheimer’s Association’s resource is that for every early sign, they give an example of a normal change due to cognitive aging.

If you are wondering whether certain changes might qualify as “mild cognitive impairment” (MCI), then you’ll probably need to ask your health provider for more assistance in assessing memory and other cognitive domains.

In general, the diagnosis of MCI requires objective evidence of cognitive difficulties that is beyond what would be considered normal, but not bad enough to qualify as dementia. In other words, in MCI, cognitive testing should reveal that a person does worse than expected for his/her age and level of education. But the person should still be able to manage daily life tasks.

Otherwise, there are some signs and symptoms that are very unlikely to be due to cognitive aging alone. These include:

• Delusions
• Hallucinations
• Paranoia
• Personality changes
• Becoming irritable very easily, or emotionally much more volatile than before
• Depression
• Lack of interest in activities, and/or inability to enjoy activities one used to enjoy.

If you notice any such symptoms, it’s important to not assume this is “normal aging.” Instead, I recommend learning more about these symptoms and then bringing them up to your usual health providers. Such changes in behavior can be caused by a variety of different health conditions, none of which should be ignored.

You can learn more about what can cause paranoia and other forms of “late-life psychosis” here: 6 Causes of Paranoia in Aging & What to Do.

I also explain what should be done during a primary care evaluation for cognitive impairment here: Cognitive Impairment in Aging: 10 Common Causes & 10 Things the Doctor Should Check.

Last but not least, if you’ve gotten worried about an aging parent’s memory: my new book was written for you, and will walk you through what to do. You can learn more here.

Practical Takeaways & What You Can Do

In short, cognitive aging means that as we get older, our mental functions become less nimble and flexible, and many aspects of our memory get a little worse.

We also become more easily distracted by busy environments, and it takes more effort to work through complex problems and decisions.

Aging also tends to make people more positive, optimistic, trusting, emotionally resilient, and focused on good things. This often helps people feel happier as they get older.

But, this can make it harder for older adults to plan ahead to avoid problems, or to think through decisions that generate negative emotions. These changes to the aging brain can also make older adults more susceptible to deception and financial exploitation.

Can anything be done about cognitive aging?

It’s not really possible to prevent all cognitive aging. But there certainly are things that you can do! I would categorize them into two key categories:

1.Take steps to optimize and maintain your brain function.

These include a variety of sensible “brain-healthy” actions such as making sure to get enough sleep, exercising, not smoking, being careful about medications that affect brain function, and more. Here are some useful resources that provide a more detailed list of suggested actions:

• Cognitive Aging Action Guide for Individuals and Families (National Academy of Medicine)
• How to Promote Brain Health

2. Take sensible steps and precautions to compensate for cognitive aging changes. 

There’s no need to seriously limit oneself in later life, just because the brain isn’t quite as quick and nimble as it used to be.

That said, it’s probably a good idea to consider making a few sensible accommodations to the aging brain. These might include:

• Allow older adults more time to think through complicated decisions.
  • Writing down key points to consider can also help, as this reduces the need to use mental working memory.
• For more mentally demanding conversations and decisions, avoid noisy, busy, stimulating, or otherwise tiring environments.
  • An example of a mentally demanding conversation would be one in which adult children ask their aging parent to consider whether to move to a new living situation.
  • It’s also probably a good idea to avoid doing these late in the day, or when a person’s brain and body might be tired.
  • Use hearing aids or otherwise minimize hearing difficulties, for those many older adults who have some hearing loss. A good short-term solution can be to use a “PocketTalker”*, which is a simple hearing amplification device we often use in geriatrics.
• Remember that “negative” possibilities become harder for older adults to keep in mind. So it may take extra persistence and patience to discuss these.
  • Such “negative” possibilities include the possibility that one’s new romantic interest is after one’s money, that one might fall and break a hip at home, etc.
• Simplify finances and take steps to reduce the risk of financial exploitation in later life.

After researching this article, I found myself thinking that we should all consider making an effort to deal with big complicated mental tasks (e.g. estate planning, advance care planning) sooner rather than later.

Because the longer one waits, the harder it becomes for the brain to think through complicated decisions.

That said, the most important thing to take away is that even if your brain slows a little bit with aging, you should still be able to do all the things you want to in life. 

So, don’t fear aging. Chances are that you’ll become more emotionally settled and you’ll be more appreciative of relationships and other good things in life. And who wouldn’t want that?

 

Constipation is not a glamorous topic, but it’s certainly important, especially in older adults.

As anyone who has experienced occasional — or even chronic — constipation can tell you, it can really put a damper on quality of life and well-being.

Constipation can also cause more substantial problems, such as:

• Severe abdominal pain, which can lead to emergency room visits
• Hemorrhoids, which can bleed or be painful
• Increased irritability, agitation, or even aggression, in people with Alzheimer’s disease or other forms of dementia
• Stress and/or pain that can contribute to delirium (a state of new or worse confusion that often happens when older adults are hospitalized)
• Fecal incontinence, which can be caused or worsened by having a hard lump of stool lodged in the lower bowel
• Avoidance of needed pain medication, due to fear of constipation

Fortunately, it’s usually possible to help older adults effectively manage and prevent constipation. This helps maintain well-being and quality of life, and can also improve difficult behaviors related to dementia.

The trouble is that constipation is often either overlooked or sub-optimally managed by busy healthcare providers who aren’t trained in geriatrics. They are often focused on more “serious” health issues. Also, since many laxatives are available over-the-counter, some providers may assume that people will treat themselves if necessary.

Personally, I don’t like this hands-off approach to constipation. Although several useful laxatives are indeed available over-the-counter (OTC), I’ve found that the average person doesn’t know enough to correctly choose among them.

Also, although in geriatrics we often do end up recommending or prescribing laxatives, it’s vital to start by figuring out what is likely to be causing — or worsening — an older person’s constipation.

For instance, many medications can make constipation worse, so we usually make an attempt to identify and perhaps deprescribe those.

In short, if you’re an older adult, or if you’re helping an older loved one with health issues, it’s worthwhile to learn the basics of how constipation should be evaluated and managed. This way, you’ll be better equipped to get help from your health providers, and if it seems advisable, choose among OTC laxative options.

Here’s what I’ll cover in this article:

 

• Common signs and symptoms of constipation
• Common causes of constipation in older adults
• Medications that can cause or worsen constipation
• How constipation should be evaluated, and treated
• The laxative myth you shouldn’t believe
• 3 types of over-the-counter laxative that work (and one type that doesn’t)
• My approach to constipation in my older patients

I’ll end with a summary of key take-home points, to summarize what you should know if you’re concerned about constipation for yourself or another older person.

Common signs and symptoms

Constipation can generally be diagnosed when people experience two or more of the following signs, related to at least 25% of their bowel movements:

• straining
• hard or lumpy stools
• a sense of incomplete evacuation
• the need for “manual maneuvers” (some people find they need to help their stools come out)
• fewer than 3 bowel movements per week

People often want to know what is considered “normal” or “ideal,” when it comes to bowel movements. Although it’s probably ideal to have a bowel movement every day, it’s generally considered acceptable to have them every 2-3 days, provided they aren’t hard, painful, or difficult to pass.

The handy Bristol Stool Scale can be used to describe the consistency of a bowel movement, with Type 4 stool often being considered the “ideal” (formed but soft).

Constipation is pretty common in the general population and becomes even more so as people get older.  Experts estimate that over 65% of people over age 65 experience constipation, with straining being an especially common symptom.

Other symptoms that may be caused by constipation in older adults

Constipation may be associated with a feeling of fullness, bloating, or even pain in the belly. In some people, this may interfere with appetite.

Although most older adults will admit to symptoms of constipation when asked, a person with Alzheimer’s or a related dementia may be unable to remember or relay these symptoms. Instead, they might just act out or become more irritable when they are constipated.

Prolonged constipation can also lead to a more urgent problem called “fecal impaction.” This means having a hard mass of stool stuck in the rectum or colon. It happens because the longer stool remains in the colon, the dryer it tends to get (which makes it harder to pass).

Impaction tends to be very uncomfortable, and can even provoke a full-on crisis of belly pain. It can also be associated with diarrhea and fecal incontinence.

Clearing out impacted stool can be hard to do with oral laxatives; these can even make things worse by creating more pressure and movement upstream from the blockage.

Fecal impactions are usually dislodged using treatments “from below” to soften and break up the lump, such as suppositories and/or enemas. (I address what type of enema is safest below.) They sometimes require help from clinicians in urgent care or even the emergency room.

Common causes of constipation in older adults

Like many problems that affect older adults, constipation is often “multifactorial,” or due to multiple causes and risk factors.

To have a normal bowel movement, the body needs to do the following:

• Move fecal material through the colon without excess delay (stool gets dryer and harder, the longer it stays in the colon).
• Coordinate a defecation response when stool moves down to the rectum, which requires properly working nerves and pelvic muscles.

As people get older, it becomes increasingly common to develop difficulties with one or both of these physical processes. Such problems can be caused or worsened by:

• Medication side-effects (more on those below)
• Insufficient dietary fiber
• Insufficient water intake
• Electrolyte imbalances, including abnormal levels of blood calcium, potassium, or magnesium
• Endocrine disorders, including hypothyroidism
• Slow transit due to chronic nerve dysfunction, which can be due to neurological conditions (including Parkinson’s disease) or can be caused by long-standing conditions that eventually damage nerves, such as diabetes
• Irritable bowel syndrome
• Pelvic floor dysfunction
• Psychological factors, such as anxiety, depression, or even fear of pain during the bowel movement
• Very low levels of physical activity
• “Mechanical obstruction,” which means that the colon or rectum — or their proper function — is impaired by some kind of mass, lump, narrowing, or another physical factor
  • A tumor can cause this problem, but there are also non-cancerous reasons that a person can develop a mechanical obstruction affecting the bowels.

Medications associated with constipation

Several commonly used medications can cause or worsen constipation in older adults. They include:

• Anticholinergics, a broad class which includes sedating antihistamines, medications for overactive bladder, muscle relaxants, anti-nausea medications, and more. (This group of medications is also associated with worse brain function; they block acetylcholine, which is used by brain cells and by the nerves in the gut.)
• Opiate painkillers, such as codeine, morphine, oxycodone
• Diuretics
• Some forms of calcium supplementation
• Some forms of iron supplementation (often prescribed for anemia)

It’s not always possible or desirable to stop every medication associated with constipation. If a medication is otherwise providing an important health benefit and there’s no less constipating alternative, we can continue the medication and look for other ways to improve bowel function.

Still, it’s important to consider whether any current medications can be deprescribed, before deciding to use laxatives and other management approaches.

If opioids are absolutely necessary to manage pain (such as in someone with cancer, for instance), a special type of medication can be used, to counter the constipating effect of opioids in the bowel. This is generally better than depriving a person of much-needed pain medication.

How to evaluate constipation

How to treat constipation basically depends on what appears to be the main causes and contributors to a person’s symptoms.

An evaluation should start with the health provider asking for more information regarding the symptoms, including how long they’ve been going on, as well as the frequency and consistency of stools.

It’s also important for the clinician to ask about “red flags” that might indicate something more serious, such as colon cancer. These include:

• Blood in the stool (which can be red, or black and “tarry” in appearance)
• Weight loss
• New or rapidly worsening symptoms

The next steps of the evaluation will depend on a person’s medical history and symptoms. It’s generally reasonable for a healthcare provider to check for these common causes of constipation:

• Medication side-effects
• Low intake of dietary fiber
• Low fluid intake
• Common causes of painful defecation, such as hemorrhoids or anal fissures

Evaluation for possible mechanical obstruction will depend on what the clinician sees on physical examination, the presence of potential red flags, and other factors. Generally, a rectal exam is a good idea.

In a 2013 review, the American Society for Gastroenterology recommends that clinicians evaluate for possible pelvic floor dysfunction mainly in those people whose constipation doesn’t improve with lifestyle changes and over-the-counter (OTC) laxatives.

They also recommend diagnostic colonoscopy only for people with alarm symptoms, or who are overdue for colorectal cancer screening.

How to treat constipation

In most older adults with constipation, there are no red flags or signs of mechanical obstruction.

To treat these cases of “garden-variety” constipation, geriatricians usually use a step-wise approach:

• Identify and reduce constipating medications if possible.
  • This might mean checking to see if iron is really indicated for anemia treatment (it might no longer be needed)
• Increase dietary fiber intake and fluid intake, if indicated.
  • Prunes are often effective because they contain fiber and also sorbitol, a non-absorbable type of sugar that draws water into the bowel. A randomized study published in 2011 found that prunes were more effective than psyllium (brand name Metamucil), for the treatment of constipation.
  • Other forms of fiber should be slowly increased, to avoid bloating or discomfort. Adequate hydration is essential, because otherwise, fiber can become a hard mass in the colon that is difficult to move out.
  • For a detailed technical take on the effect of fiber in the bowel, see Understanding the Physics of Functional Fibers in the Gastrointestinal Tract: An Evidence-Based Approach to Resolving Enduring Misconceptions about Insoluble and Soluble Fiber.
• Encourage a regular toilet routine, with time on the toilet after meals and/or physical activity.
• If necessary — which it often is — use over-the-counter laxatives to establish and maintain regular bowel movements.

The American Society of Gastroenterology recommends more in-depth constipation evaluation for older adults who fail to improve from this type of first-round treatment. Some older adults do have pelvic floor disorders, which can be effectively treated through biofeedback.

The laxative myth you shouldn’t believe

People often have concerns about using laxatives more than occasionally, because they’ve heard this can be dangerous, or risky.

This is a myth that really should be dispelled. Although medical experts used to worry that chronic use of laxatives would result in a “lazy” bowel, there is no scientific evidence to support this concern.

In fact, in their technical review covering constipation, the American Society of Gastroenterology notes that “Contrary to earlier studies, stimulant laxatives (senna, bisacodyl) do not appear to damage the enteric nervous system.”

(FYI: the “enteric nervous system” means the system of nerves controlling the digestive tract.)

Lifestyle changes and over-the-counter oral laxatives are the approaches endorsed as the first-line of constipation therapy, by the American Gastroenterology Society and others. There are no evidence-based guidelines that caution clinicians to only use laxatives for a limited time period.

The four types of OTC laxatives that I’ll cover in the next section have been used by clinicians and older adults for decades, and when used correctly, are considered safe and do not seem to cause any long-term problems.

That’s not to say that they should be used willy-nilly, or in any which way. You absolutely should understand the basics of how each type works, so let’s cover that now.

Three types of laxative that work (and one that doesn’t)

There are basically four categories of oral over-the-counter (OTC) laxative available. Three of them are proven to work. A fourth type is commonly used but actually does not appear to be very effective. Each has a different main mechanism of action.

The three types of OTC laxative that work are:

• Osmotic agents: These include polyethylene glycol (brand name Miralax), sorbitol, and lactulose. Magnesium-based laxatives also mostly work through this mechanism.
  • These work by drawing extra water into the stool, which keeps it softer and easier to move through the bowel.
  • Studies have shown osmotic agents to be effective, even for 6-24 months. Research suggests that polyethylene glycol tends to be better tolerated than the other agents.
  • Magnesium-based agents should be used with caution in older adults, mainly because it’s possible to build up risky levels of magnesium if one has decreased kidney function, and mild-to-moderately decreased kidney function is quite common in older adults.
• Stimulant agents: These include senna (brand name Senakot) and bisacodyl (brand name Dulcolax).
  • These work by stimulating the colon to squeeze and move things along more quickly.
  • Studies have shown stimulant laxatives to be effective. They can be used as “rescue agents” (e.g. to prompt a bowel movement if there has been none for two days) or daily, if needed.
  • Bisacodyl is also available in suppository form, and can be used this way as a “rescue agent.”
• Bulking agents: These include soluble fiber supplements such as psyllium (brand name Metamucil) and methylcellulose (brand name Citrucel).
  • These work by making the stool bigger. Provided the stool doesn’t get too dried out and stiff, a bulkier stool is easier for the colon to move along.
  • Bulking agents have been shown to improve constipation symptoms, but they must be taken with lots of water. Older adults who take bulking agents without enough hydration — or who otherwise have very slow bowels — can become impacted by the extra fiber.
  • People with drug-induced constipation or slow transit are not likely to benefit from bulking agents.

(For more details regarding the scientific evidence on these laxatives, see this 2013 technical review.)

And now, let’s address the type of OTC laxative that is least likely to work.

The type of OTC laxative that isn’t really effective is a “stool softener”, such as docusate sodium (brand name Colace).

These create some extra lubrication and slipperiness around the stool. They actually have often been prescribed by doctors; when I was a medical student, almost all of our hospitalized patients were put on some Colace.

But, the scientific evidence just isn’t there! Because this type of laxative is so commonly prescribed, despite a weak evidence base, the Canadian Agency for Drugs and Technologies in Health completed a comprehensive review in 2014. Their conclusion was:

“Docusate appears to be no more effective than placebo for increasing stool frequency or softening stool consistency.”

So, save your money and your time. Don’t bother buying docusate or taking it. And if a clinician suggests it or prescribes it, politely speak up and say you’ve heard that the scientific evidence indicates this type of laxative is less effective than other types.

Laxatives do work and are often appropriate to use, but you need to use one of the ones that has been shown to work.

About prescription laxatives

Newer prescription laxatives are also available, and may be an option for those who remain constipated despite implementing lifestyle changes and correctly used over-the-counter laxatives. These include lubiprostone (brand name Amitiza) and linaclotide (brand name Linzess).

But, it’s not clear, from the scientific research, that they are more effective than older over-the-counter laxatives. In its technical review, the American Society of Gastroenterology noted that “meta-analyses, systematic reviews, and the only head-to-head comparative study suggested that some traditional approaches are as effective as newer agents for treating patients with chronic constipation.”

Since these newer medications have a more limited safety record and are also expensive, they probably should only be used after an older person has undergone careful evaluation, including evaluation for possible pelvic floor disorders.

About enemas

Enemas are another form of “constipation treatment” available over-the-counter in the U.S.

The main thing to know is that the most commonly available form, saline enemas (Fleet is a common brand name), have been associated with serious electrolyte disturbances and even kidney damage. Because of this, the FDA issued a warning in 2014, urging caution when saline enemas are used in older adults.

Enemas certainly can be helpful as “rescue therapy,” to prevent a painful fecal impaction if an older person hasn’t had a bowel movement for a few days. But they should not be used every day.

Frequent use of enemas is really a sign that a person needs a better bowel maintenance regimen. This often means some form of regular laxative use, plus a plan to use a little extra oral laxative as needed, before things reach the point of requiring an enema.

If an enema appears necessary, experts recommend that older adults avoid saline enemas, and instead use a warm tap water enema, or a mineral oil enema.

My approach to constipation in my older patients

Generally, to help my older patients with garden-variety constipation, I start by checking for medications that are constipating, and then recommending prunes and encouraging more fiber-rich foods. As noted above, a randomized trial found that 50 grams of prunes twice daily (about 12 prunes) was more effective in treating constipation than psyllium (brand name Metamucil).

Then we usually add a daily osmotic laxative, such as polyethylene glycol (Miralax). If needed, we might then add a stimulant agent, such as senna.

We do sometimes try a bulking agent, but I find that many frailer older adults tend to get stoppered up by the extra bulk. Again, if you use a supplement (such as Metamucil) to put extra fiber in the colon but can’t keep things moving along fast enough, that extra fiber might dry out and become very difficult to pass as a bowel movement.

It usually takes a little trial and error to figure out the right approach for each person, so it’s essential for an older person — or their family — to keep a log of the bowel movements and the laxatives that are taken. If a person has loose stools or too many bowel movements, in response to a given laxative regimen, we dial back the laxatives a bit.

It’s also important to have a plan for “rescue,” which means adding some extra “as-needed” laxative (usually either senna or a suppository), if a person hasn’t had a bowel movement for 2-3 days. The goal of rescue is to avoid the beginnings of fecal impaction.

Last but not least, we also try to make sure an older person is getting enough physical activity, and to establish a routine of having the person sit on the toilet after meals.

With a little time and effort, we usually find a way to help an older person have a comfortable bowel movement every 1-2 days.  This does often require taking a daily oral laxative indefinitely, but this is quite common in geriatrics. And as best we can tell, daily laxatives are unlikely to cause harm, provided one doesn’t use a magnesium laxative daily.

The most important take-home points on constipation in older adults

Here’s what I hope you’ll take away from this article:

1.Know that constipation is common but shouldn’t be considered a “normal” part of aging. It deserves to be evaluated and managed by your healthcare providers.

• Be sure to ask for help, if you’ve noticed any difficulties having a comfortable bowel movement every 1-2 days.
• A log of bowel movements and related symptoms will be very helpful to your health providers.

2. If an older person with Alzheimer’s or another dementia is acting out, consider the possibility of constipation.

3. Be sure to speak up if you’ve noticed any “alarm symptoms.”

• The main ones to look for are red blood in the stool, black or tarry stools, unintended weight loss, and new or worsening symptoms.

4. An initial evaluation of constipation should include the following:

• A review of concerning symptoms
• A review of diet, fiber, and fluid intake
• Checking for medications that cause or aggravate constipation (especially anticholinergics) and making sure that any prescribed iron is really necessary
• A rectal exam

5. Most garden-variety constipation can be effectively managed through a combination of lifestyle changes, deprescribing constipating medications, and using over-the-counter (OTC) laxatives.

• Lifestyle changes to consider include avoiding mild dehydration, eating fiber-rich foods, getting enough physical activity, and encouraging a regular toilet routine (e.g. sitting on the toilet after meals).
• Anticholinergics and other constipating medications should be deprescribed whenever possible.
• Daily prunes are especially effective as a “natural” laxative, since they contain soluble fiber and exert an “osmotic laxative” effect.

6. It is often ok to use OTC oral laxatives daily or regularly.

• Many older adults will need to use OTC laxatives to maintain regular bowel movements.
• There is no credible evidence that it’s harmful to use OTC oral laxatives long-term.

7. Three types of OTC laxative have proven efficacy: bulk-forming fiber supplements, osmotic laxatives, and stimulant laxatives. It often takes some trial and error to find the right regimen for a person.

• Osmotic laxatives such as polyethylene glycol (brand name Miralax) are well-tolerated by most older adults, and can be used daily.
• Fiber supplements such as psyllium (brand name Metamucil) are usually effective, provided an older adult drinks enough fluid and doesn’t suffer from a condition causing slow colonic transit. Fiber supplements that get dried out in a slow colon can worsen blockage.
• Stimulant laxatives such as senna are often helpful, and can be used in combination with an osmotic laxative. They can be used daily or as needed, for “rescue therapy.”

8. “Stool softeners” such as docusate sodium (brand name Colace) do not appear to be effective. Don’t bother taking them.

9. It’s best to have a bowel maintenance plan and also a “rescue plan.”

• Your health providers can help you determine which additional laxatives to use “as-needed,” if a person hasn’t had a bowel movement for a few days.
• Frequent use of “rescue” laxatives usually means the regular regimen should be adjusted.

10. Be prepared to do some trial and error, to figure out the best way to manage chronic constipation in any particular person.

• Be sure to keep track of bowel movements and what laxatives you — or your older relative — are taking.
• Your clinicians will need this information in order to advise you on how to further adjust your laxative use.

I hope you now feel better equipped to address this important issue for yourself, or on behalf of an older loved one. Good luck!

In this article, I’ll address a real mainstay of modern medicine: laboratory tests that require drawing blood.

This is sometimes referred to as “checking labs,” “doing bloodwork,” or even “checking blood.”

Most older adults have been through this. For instance, it’s pretty much impossible to be hospitalized without having bloodwork done, and it’s part of most emergency room care. Such testing is also often done as part of an annual exam, or “complete physical.”

Last but not least, blood testing is usually — although not always — very helpful when it comes to evaluating many common complaints that affect aging adults.

Fatigued and experiencing low energy? We should perhaps check for anemia and thyroid problems, among other things.

Confused and delirious? Bloodwork can help us check on an older person’s electrolytes (they can be thrown off by a medication side-effect, as well as by other causes). Blood tests can also provide us with information related to infection, kidney function, and much more.

Like much of medical care, blood testing is probably overused. But often, it’s an appropriate and an important part of evaluating an older person’s health care concerns. So as a geriatrician, I routinely order or recommend blood tests for older adults.

Historically, laboratory results were reviewed by the doctors and were only minimally discussed with patients and families. But today, it’s becoming more common for patients to ask questions about their results, and otherwise become more knowledgeable about this aspect of their health.

In fact, one of my top recommendations to older adults and family caregivers is to always request a copy of your laboratory results. (And then, keep it in your personal health record!)

This way, if you ever have questions about your health, or need to see a different doctor, you’ll be able to quickly access this useful information about yourself.

In this article, I’m going to list and briefly explain the blood tests that are most commonly used, for the primary medical care of older adults.

Specifically, I’ll cover four “panels” which are commonly ordered, and then I’ll list six more blood tests that I find especially useful.

In other words, we’re going to cover my top ten blood tests for the healthcare of aging adults.

I’ll finish with some practical tips for you to keep in mind, when it comes to blood tests.

4 common “panels” in laboratory blood testing

1. Complete Blood Count (CBC)

What it measures: A CBC is a collection of tests related to the cells in your blood.  It usually includes the following results:

• White blood cell count (WBCs): the number of white blood cells per microliter of blood
• Red blood cell count (RBCs): the number of red blood cells per microliter of blood
• Hemoglobin (Hgb): how many grams of this oxygen-carrying protein per deciliter of blood
• Hematocrit (Hct): the fraction of blood that is made up of red blood cells
• Mean corpuscular volume (MCV): the average size of red blood cells
• Platelet count (Plts): how many platelets (a smaller cell involved in clotting blood) per microliter of blood

The CBC can also be ordered “with differential.” This means that the white blood cells are classified into their subtypes. For more information on the CBC test, see Medline: CBC blood test. For details on the white blood cell count differential, and what the results might signify, see Medline: Blood differential test.

What the CBC is often used for:

• Anemia may be diagnosed if the red blood cell count, hemoglobin, and hematocrit are lower than normal.
  • I explain anemia in more depth here: Anemia in the Older Adult: 10 Common Causes & What to Ask.
• The white blood cell count usually goes up if a person is fighting an infection. Some medications, such as corticosteroids, can also cause an increase in the white blood cell count.
• If several types of blood cells (i.e. red blood cells, white blood cells, and platelets) are low, this can be a sign of a problem with the bone marrow.
• Occasionally an older person’s platelet count may be lower than normal (or even higher than normal). This usually requires further evaluation.

2. Basic metabolic panel (basic electrolyte panel)

What it measures: Although it’s possible to request a measurement of a single electrolyte, it’s far more common for electrolytes to be ordered as part of a panel of seven or eight measurements. This is often referred to as a “chem-7,”  and usually includes:

• Sodium 
• Potassium 
• Chloride
• Carbon dioxide (CO2) (sometimes referred to as “bicarbonate,” as this is the chemical form of carbon dioxide which is more common in the bloodstream)
• Blood urea nitrogen (BUN)
• Creatinine (often accompanied by an estimated “glomerular filtration rate,” or “eGFR”result)
• Glucose

What the basic metabolic panel is often used for:

• Medication side-effects can cause electrolytes such as sodium or potassium to be either too high or too low.
  • These electrolytes are often monitored when people take certain types of medications, such as certain blood pressure medications, or diuretics.
• Carbon dioxide levels reflect the acidity of the blood.
  • This can be affected by kidney function and by lung function. Severe infection can also change acid levels in the blood.
• Creatinine and BUN levels are most commonly used to monitor kidney function. Both of these measurements can go up if kidney function is temporarily impaired (e.g. by dehydration or a medication side-effect) or chronically impaired.
  • It is common for older adults to have at least mild decreases in kidney function.
  • Many medications must be dosed differently, if a person has decreased kidney function.
  • Laboratories now routinely use the patient’s age and creatinine level to calculate an “estimated glomerular filtration rate,” which represents the filtering power of the kidneys. This is considered a better measure of kidney function than simply relying on creatinine and BUN levels.
• Glucose levels represent the amount of sugar in the blood.
  • If they are higher than normal, this could be due to undiagnosed diabetes or inadequately controlled diabetes.
  • If the glucose levels are on the low side, this is called hypoglycemia. It is often caused by diabetes medications, and may indicate a need to reduce the dosage of these drugs.

For more details on these tests, see Medline: Basic Metabolic Panel. From this page, you can find links to additional pages which explain each of the above electrolytes and metabolic components in detail, including common causes of the result being abnormally high or low.

3. Comprehensive metabolic panel 

What it measures: This panel includes the items above in the basic metabolic panel, and then usually includes an additional seven items. For this reason, it’s sometimes referred to as a “chem-14” panel. Beyond the seven tests included the basic panel (see above), the comprehensive panel also adds:

• Calcium
• Total protein
• Albumin
• Bilirubin (total)
• Alkaline phosphatase
• AST (aspartate aminotransferase)
• ALT (alanine aminotransferase)

What the comprehensive metabolic panel is often used for:

• Calcium levels are usually regulated by the kidneys and by certain hormones.
  • Blood calcium levels are not usually a good way to assess calcium intake or total calcium stores in the bones and body.
  • High or low blood calcium levels can cause symptoms, including cognitive dysfunction, and usually indicate an underlying health problem. They can also be caused by certain types of medication.
• Albumin is one of the key proteins in the bloodstream. It is synthesized by the liver.
  • Low albumin levels may indicate a problem with the liver or a problem maintaining albumin in the bloodstream.
  • Malnutrition may cause low albumin levels.
• AST and ALT are enzymes contained in liver cells.
  • An elevation in these enzymes often indicates a problem affecting the liver. This can be caused by medications or by a variety of other health conditions.
• Bilirubin is produced by the liver, and usually drains down the bile ducts and into the small intestine. Some bilirubin is also related to the breakdown of red blood cells.
  • An increase in bilirubin can be caused by gallstones or another issue blocking the bile ducts.
• Alkaline phosphatase is found throughout the body, but especially in bile ducts and also in bone.
  • Higher levels are often caused by either a blockage in the liver or by a problem affecting bone metabolism.

For more details on these tests, and the possible causes of abnormal results, see Medline: Comprehensive Metabolic Panel.

4. Lipid (cholesterol) panel

What it measures: These tests measure the different types of cholesterol and related fats in the bloodstream. The panel usually includes:

• Total cholesterol
• High-density lipoprotein (HDL) cholesterol, sometimes known as “good” cholesterol
• Triglycerides
• Low-density lipoprotein (LDL) cholesterol, sometimes known as “bad” cholesterol
  • LDL results are usually calculated, based on the other three results

People are often asked to fast before having their cholesterol checked. This is because triglycerides can increase after eating, and this can cause a falsely low LDL to be calculated. However, research suggests that in most cases, it’s not necessary for people to fast; it’s inconvenient and only makes a small difference in test results.

What the lipid panel is often used for:

• These tests are usually used to evaluate cardiovascular risk in older adults.
• Higher than normal total or LDL cholesterol levels are sometimes treated with a medication, such as a statin. They can also be reduced by dietary changes (see Your Guide to Lowering Cholesterol with Therapeutic Lifestyle Changes, from the NIH).
• For more on these tests, see Medline:  Cholesterol testing and results.

6 more blood tests that I order often

Here are six other types of tests that I often order on my older patients:

1. Tests related to thyroid function

What these measure: These tests can be used to screen for thyroid disorders, or to help calibrate the dosage of thyroid replacement medications.  The most commonly used tests are:

• Thyroid stimulating hormone (TSH)
• Free thyroxine (“free T4” or FT4)

In more complicated situations, other tests related to thyroid function may also be ordered.

What these tests are often used for:

• Thyroid problems are common in older adults (especially older women), and are associated with symptoms such as fatigue and cognitive difficulties.
• If an older person is having symptoms that could be related to a thyroid problem, the first step is to check the TSH level.
• TSH usually reflects the body’s determination of whether the available thyroid hormone is sufficient or not.
  • If the thyroid gland is not making enough thyroid hormone, TSH should be higher than normal.
• Free T4 is often used to confirm a thyroid hormone problem, if the TSH is abnormal.

For more information about thyroid problems in older adults, see HealthinAging.org: Thyroid Problems. You can also read a more in-depth scholarly article here: Approach to and Treatment of Thyroid Disorders in the Elderly.

2.  Tests related to vitamin B12 levels

What these measure: These measure the serum levels of vitamin B12 and provide information as to whether the level is adequate for the body’s needs.  The two tests involved are:

• Vitamin B12
• Methylmalonic acid

Depending on the situation, if an older adult is found to have low vitamin B12 levels, additional testing may be pursued, to determine the underlying cause of this vitamin deficiency.

What these tests are often used for:

• Vitamin B12 deficiency is quite common in older adults, and can be related to common problems such as fatigue, memory problems, and walking difficulties.
• Methylmalonic acid levels in the body are related to vitamin B12 levels, and can help confirm a vitamin B12 deficiency.
  • It is especially important to check this, if an older person has vitamin B12 levels that are on the low side of normal.
  • Low vitamin B12 levels are associated with higher-than-normal methylmalonic acid levels
• For more information, see: How to Avoid Harm from Vitamin B12 Deficiency.

3. Glycated hemoglobin (Hemoglobin A1C)

What it measures: Glycated hemoglobin is formed in the body when blood glucose (blood sugar) attaches to the hemoglobin in red blood cells.  It is normal for glucose to do this, but if you have more glucose in the blood than normal, your percentage of glycated hemoglobin will be higher than normal. The higher one’s average blood sugar level, the greater percentage of glycated hemoglobin one will have. A result of 6.5% or above is suggestive of diabetes. For more information:

• Hemoglobin A1C test

What this test is usually used for:

• This test is most often ordered to monitor the blood sugar control of people with diabetes.
  • Whereas a blood glucose level (which can be checked by fingerstick or as part of a basic metabolic panel) reports the blood glucose level at a specific moment in time, a hemoglobin A1C reflects how high a person’s blood sugar has been, on average, over the prior three months.
• A hemoglobin A1C test can also be used as part of an evaluation for possible diabetes or pre-diabetes.
• Older adults should work with their doctors to determine what A1C goal is right for them. It is often appropriate to aim for a slightly higher goal in older adults than in younger adults. For more on this, see HealthinAging.org: Diabetes Care & Treatment.

4. Prothrombin time (PT) and International Normalized Ratio (INR)

What it measures: These two tests are used as a measure of how quickly a person’s blood clots. People taking the blood-thinner warfarin (brand name Coumadin) must have this regularly monitored. For more information:

• Prothrombin time (PT)

What this test is usually used for:

• The INR is calculated by the laboratory, based on the prothrombin time. In people taking warfarin, the usual goal is for the INR to be between 2.0 and 3.0.
  • The most common reason older adults take warfarin is to prevent strokes related to atrial fibrillation.
  • Warfarin may also be prescribed after a person has experienced a blood clot in the legs, lungs, or elsewhere.
• The prothrombin time is also sometimes checked if there are concerns about unexplained bleeding, severe infection, or the ability of the liver to synthesize clotting factors.

5. Brain natriuretic peptide (BNP) test

What it measures: Despite the name, BNP levels are mainly checked because they relate to heart function (not brain function!). BNP levels go up when a person’s heart cannot pump blood as effectively as it should, a problem known as “heart failure.” For more information on this test:

• Brain natriuretic peptide (BNP) test

A related, but less commonly used, test is the “N-terminal pro-B-type natriuretic peptide” (NT-proBNP) test.

What this test is used for:

• Checking a BNP level is mainly used to evaluate for new or worsening heart failure. This is a common chronic condition among older adults, which can occasionally get worse.
• The BNP test can be especially useful in evaluating a person who is complaining of shortness of breath.
  • Shortness of breath can be caused by several different problems, including pneumonia, chronic obstructive pulmonary disease, pulmonary edema, angina, and much more.
  • A low BNP level means that at that moment, the shortness of breath is unlikely to be due to heart failure.
• Checking BNP levels over time is also sometimes used to monitor a person’s heart failure and response to treatment.
• For more about heart failure, see MayoClinic.org: Heart failure tests and diagnosis and also HealthinAging.org: Heart failure.

6. Ferritin

What it measures: The body’s serum ferritin level is related to iron stores in the body. For more about this test:

• Ferritin

Depending on the situation, if an older person’s iron levels need further evaluation, additional tests can be ordered.

What this test is used for:

• Ferritin levels are most commonly used as part of an evaluation for anemia (low red blood cell count). A low ferritin level is suggestive of iron-deficiency, which is a common cause of anemia.
  • Studies estimate that only a third of anemias in older adults are due to deficiencies in iron or other essential elements.
  • It’s important to confirm iron deficiency by checking ferritin or other tests, before relying on iron to treat an older person’s anemia.
• Ferritin levels are also influenced by inflammation, which tends to make ferritin levels rise.
• If the ferritin levels are borderline, or if there are other reasons to be concerned about an older person’s ability to manage iron, additional blood tests related to iron may be ordered.
• For more on evaluating and treating anemia in older adults, see Anemia in the Older Adult: 10 Common Causes & What to Ask.

Obviously, there are many more tests that can be ordered as part of the medical care of older adults. But the tests I cover above are, by far, the ones I order the most often.

Tips to help you benefit from your blood tests and results

Here are my top tips:

1. Be sure you understand why a given test is being ordered. Is it meant to help evaluate a symptom? Monitor a chronic condition? Assess whether a treatment is working?

You will understand your own health issues better, if you ask questions about the purpose of the blood tests your doctors are proposing.

In general, blood tests should only be ordered for a reason, such as to evaluate a concerning symptom, to monitor a chronic disease, or to check for certain types of medication side-effect.

Keep in mind that it’s only occasionally appropriate to order blood tests for “screening.” A screening test means a person doesn’t have any symptoms. Such screening blood tests are only recommended for a handful of conditions.

For more on preventive health care and screening tests that may be appropriate for older adults, see 26 Recommended Preventive Health Services for Older Adults.

2. Ask your doctor to review the results and explain what they mean for your health. Try to look at the report with your doctor. It’s especially important to ask about any result that is flagged as abnormal by the laboratory system.

For instance, I have found that many older adults are unaware of the fact that they have mild or moderate kidney dysfunction, even though this has been evident in prior laboratory tests. This happens when people do not review reports and ask enough questions.

Wondering why the doctor wouldn’t tell an older person that the kidney function is abnormal?

Well, if it’s been going on for a while, the doctor might think the older person already knows about this issue. Or perhaps the doctor mentioned it before, but the older person didn’t quite hear it. It’s also not uncommon for doctors to just not get around to mentioning a mild abnormality that is pretty common in older people, such as mild anemia or mild kidney dysfunction.

3. Ask your doctor to explain how your results compare with your prior results. Laboratory reports will always provide a “normal” reference range. But what’s usually more useful is to see how a given result compares to your previous results.

For instance, if an older person’s complete blood count (CBC) shows signs of anemia, it’s very important to look at prior CBC results. This helps us determine what the “trajectory” of the blood count is. A blood count that is drifting down — or worse yet, dropping fairly suddenly — is much more concerning than one that has been lower-than-normal, but stable for the past year. Ditto test results suggesting diminished kidney function, and for many other abnormal blood test results.

Of course, you’ll want to understand what might be the cause of an abnormal result regardless of the trajectory. But a worsening blood test result usually means the issue is more urgent to sort out.

4. Request copies of your results, and keep them in your own record system. Past laboratory results provide incredibly useful information to health providers, and can be very useful to you as well.

If you keep your own copies of results, you’ll be better able to:

• Share them with new doctors, if you change health providers, move to a new city, or have to go to the emergency room.
• Research your health condition, in order to better understand it and know what questions to ask your doctor.

For instance, one of my family members recently had a “routine” cholesterol panel done. He takes no medications, is quite fit, and is in good health, so he was surprised when some of his results came back higher than normal. We promptly reviewed his previous results, from three years ago, and found that those results were within normal range. So this family member is now in the process of reconsidering his diet.

If he hadn’t had copies of his previous labs, he could have asked his doctor. But it’s much faster and more convenient to be able to look in your own records!

And don’t just rely on looking up past results through a patient portal. Clinics will often remove your access, if you are deemed to have left the practice.  So it is very important to keep your own copies of results.

Now that you understand bloodwork better, you can be more proactive about your health.

 

Have you ever been told that an older relative has anemia?

Or perhaps you noticed the red blood cell count flagged as “low” in the bloodwork report? Or noticed “low hemoglobin” in a doctor’s report?

Anemia means having a red blood cell count that is lower than normal, and it’s very common in older adults. About 10% of independently living people over age 65 have anemia. And anemia becomes even more common as people get older.

But many older adults and families hardly understand anemia.

This isn’t surprising: anemia is associated with a dizzying array of underlying health conditions, and can represent anything from a life-threatening emergency to a mild chronic problem that barely makes the primary care doctor blink.

Still, it worries me that older adults and families don’t know more about anemia. If you or your relative has this condition, it’s important to understand what’s going on and what the follow-up plan is. (I’ve so often discovered that a patient didn’t know he or she had had anemia!) Misunderstanding anemia can also lead to unnecessary worrying, or perhaps even inappropriate treatment with iron supplements.

And since anemia is often caused by some other problem in the body, not understanding anemia often means that people don’t understand something else that is important regarding their health.

Fortunately, you don’t have to be a doctor to have a decent understanding of the basics of anemia.

This post will help you understand:

• How anemia is detected and diagnosed in aging adults.
• Symptoms of anemia.
• The most common causes of anemia, and tests often used to check for them.
• What to ask the doctor.
• How to get better follow-up, if you or your relative is diagnosed with anemia.

Defining and detecting anemia

Anemia means having a lower-than-normal count of red blood cells circulating in the blood.

Red blood cells are always counted as part of a “Complete Blood Count” (CBC) test, which is a very commonly ordered blood test.

A CBC test usually includes the following results:

• White blood cell count (WBCs): the number of white blood cells per microliter of blood
• Red blood cell count (RBCs): the number of red blood cells per microliter of blood
• Hemoglobin (Hgb): how many grams of this oxygen-carrying protein per deciliter of blood
• Hematocrit (Hct): the fraction of blood that is made up of red blood cells
• Mean corpuscular volume (MCV): the average size of red blood cells
• Platelet count (Plts): how many platelets (a smaller cell involved in clotting blood) per microliter of blood

(For more information on the CBC test, see this Medline page. For more on common blood tests, see Understanding Laboratory Tests: 10 Commonly Used Blood Tests for Older Adults.)

By convention, to detect anemia clinicians rely on the hemoglobin level and the hematocrit, rather than on the red blood cell count.

A “normal” level of hemoglobin is usually in the range of 14-17gm/dL for men, and 12-15gm/dL for women. However, different laboratories may define the normal range slightly differently.

A low hemoglobin level — meaning, it’s below normal — can be used to detect anemia.  Clinicians often confirm the lower hemoglobin level by repeating the CBC test.

If clinicians detect anemia, they usually will review the mean corpuscular volume measurement (included in the CBC) to see if the red cells are smaller or bigger than normal. We do this because the size of the red blood cells can help point doctors towards the underlying cause of anemia.

Hence anemia is often described as:

• Microcytic: red cells smaller than normal
• Normocytic: red cells of a normal size
• Macrocytic: red cells larger than normal

Symptoms of anemia

The red blood cells in your blood use hemoglobin to carry oxygen from your lungs to every cell in your body. So when a person doesn’t have enough properly functioning red blood cells, the body begins to experience symptoms related to not having enough oxygen.

Common symptoms of anemia are:

• fatigue
• weakness
• shortness of breath
• high heartrate
• headaches
• becoming paler, which is often first seen by checking inside the lower lids
• lower blood pressure (especially if the anemia is caused by bleeding)

However, it’s very common for people to have mild anemia — meaning a hemoglobin level that’s not way below normal — and in this case, symptoms may be barely noticeable or non-existent.

That’s because the severity of symptoms depends on two crucial factors:

• How far below normal is the hemoglobin level?
• How quickly did the hemoglobin drop to this level?

This second factor is very important to keep in mind. The human body does somewhat adapt to lower hemoglobin levels, but only if it’s given weeks or months to do so.

So this means that if someone’s hemoglobin drops from 12.5gm/dL to 10gm/dL (which we’d generally consider a moderate level of anemia), they are likely to feel pretty crummy if this drop happened over two days, but much less so if it developed slowly over two months.

People sometimes want to know how low the hemoglobin has to be for anemia to be “severe.” This really depends on the past medical history of the person and on how fast the hemoglobin dropped, but generally, a hemoglobin of 6.5 to 7.9 gm/dL is often considered “severe” anemia.

People also sometimes want to know how low can hemoglobin go before causing death. In general, a hemoglobin less than 6.5 gm/dL is considered life-threatening. But again, how long the body can tolerate a low hemoglobin depends on many factors, and including whether the hemoglobin is continuing to drop quickly (due an internal bleed, for instance) or is slowly drifting down.  A study of Jehovah’s Witnesses who died after refusing transfusions found that those with hemoglobins between 4.1 to 5 gm/dL died, on average, about 11 days later.

The most common causes of anemia in aging adults

Whenever anemia is detected, it’s essential to figure out what is causing the low red blood cell count.

Compared to most cells in the body, normal red blood cells have a short lifespan: about 100-120 days. So a healthy body must always be producing red blood cells. This is done in the bone marrow and takes about seven days, then the new red blood cells work in the blood for 3-4 months. Once the red blood cell dies, the body recovers the iron and reuses it to create new red blood cells.

Anemia happens when something goes wrong with these normal processes. In kids and younger adults, there is usually one cause for anemia. But in older adults, it’s quite common for there to be several co-existing causes of anemia.

A useful way to think about anemia is by considering two categories of causes:

• A problem producing the red blood cells, and/or
• A problem losing red blood cells

Here are the most common causes of low hemoglobin for each category:

Problems producing red blood cells. These includes problems related to the bone marrow (where red blood cells are made) and deficiencies in vitamins and other substances used to make red blood cells. Common specific causes include:

• Chemotherapy or other medications affecting the bone marrow cells responsible for making red blood cells.
• Iron deficiency. This occasionally happens to vegetarians and others who don’t eat much meat. But it’s more commonly due to chronic blood loss, such as heavy periods in younger women, or a slowly bleeding ulcer in the stomach or small intestine, or even a chronic bleeding spot in the colon.
• Lack of vitamins needed for red blood cells. Vitamin B12 and folate are both essential to red blood cell formation.
• Low levels of erythropoietin. Erythropoietin is usually produced by the kidneys, and helps stimulate the bone marrow to make red blood cells. (This is the “epo” substance used in “blood doping” by unethical athletes.) People with kidney disease often have low levels of erythropoietin, which can cause a related anemia.
• Chronic inflammation. Many chronic illnesses are associated with a low or moderate level of chronic inflammation. Cancers and chronic infections can also cause inflammation. Inflammation seems to interfere with making red blood cells, a phenomenon known as “anemia of chronic disease.”
• Bone marrow disorders. Any disorder affecting the bone marrow or blood cells can interfere with red blood cell production and hence cause anemia.

Problems losing red blood cells. Blood loss causes anemia because red blood cells are leaving the blood stream. This can happen quickly and obviously, but also can happen slowly and subtly. Slow bleeds can worsen anemia by causing an iron-deficiency, as noted above. Some examples of how people lose blood include:

• Injury and trauma. This can cause visibly obvious bleeding, but also sometimes causes people to bleed into a space inside the body, which can be harder to detect.
• Chronic bleeding in the stomach, small intestine, or large bowel. This can be due to many reasons, some common ones include:
  • taking a daily aspirin or non-steroidal anti-inflammatory drug
  • peptic ulcer disease
  • cancer in the stomach or bowel
• Frequent blood draws. This is mainly a problem for people who are hospitalized and getting daily blood draws.
• Menstrual bleeding. This is usually an issue for younger women but occasionally affects older women.

There is also a third category of anemias, related to red blood cells being abnormally destroyed in the body before they live their usual lifespan. These are called hemolytic anemias and they are much less common.

A major study of causes of anemia in non-institutionalized older Americans found the following:

• One-third of the anemias were due to deficiency of iron, vitamin B12, and/or folate.
• One-third were due to chronic kidney disease or anemia of chronic disease.
• One-third of the anemias were “unexplained.”

How doctors evaluate anemia

Once anemia is detected, it’s important for health professionals to do some additional evaluation and follow-up, to figure out what might be causing the anemia.

Understanding the timeline of the anemia — did it come on quickly or slowly? Is the red blood count stable or still trending down with time? — helps doctors figure out what’s going on, and how urgent the situation is.

Common follow-up tests include:

• Checking the stool for signs of microscopic blood loss
• Checking a ferritin level (which reflects iron stores in the body)
• Checking vitamin B12 and folate levels
• Checking kidney function, which is initially done by reviewing the estimated glomerular filtration rate (included in most basic bloodwork results)
• Checking the reticulocyte count, which reflects whether the bone marrow trying to produce extra red blood cells to compensate for anemia
• Checking levels of an “inflammation marker” in the blood, such as the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
• Evaluation of the peripheral smear, which means the cells in the blood are examined via microscope
• Urine tests, to check for proteins associated with certain blood cell disorders

If the anemia is bad enough, or if the person is suffering significant symptoms, doctors might also consider a blood transfusion. However, although even mild anemia has been associated with worse health outcomes, research suggests that transfusing mild to moderate anemia generally isn’t beneficial. (This issue especially comes up when people are hospitalized or acutely ill.)

What to ask the doctor about anemia

If you are told that you or your older relative has anemia, be sure you understand how severe it seems to be, and what the doctors think might be causing it. This will help you understand the plan for follow-up and treatment.

Some specific questions that can be handy include:

• How bad is this anemia? Does it seem to be mild, moderate, or severe?
• What do you think is causing it? Could there be multiple causes or factors involved?
• How long do you think I’ve had this anemia? Does it seem to be stable or is it getting worse?
• Is this the cause of my symptoms or do you think something else is causing my symptoms?
• Could any of my medications be involved?
• What is our plan for further evaluation?
• What is our plan for treating this anemia?
• When do you recommend we check the CBC again? What is our plan for monitoring the anemia?

Be sure to request and keep copies of your lab results. It will help you and your doctors in the future to be able to review your past labs related to anemia and any related testing.

Avoiding common pitfalls related to anemia and iron

A very common diagnosis in older adults is iron-deficiency anemia. If you are diagnosed with this type of anemia, be sure the doctors have checked a ferritin level or otherwise confirmed you are low on iron.

I have actually reviewed medical charts in which a patient was prescribed iron for anemia, but no actual low iron level was documented. This suggests that the clinician may have presumed the anemia was due to low iron.

However, although iron deficiency is common, it’s important that clinicians and patients confirm this is the cause, before moving on to treatment with iron supplements. Doctors should also assess for other causes of anemia, since it’s very common for older adults to simultaneously experience multiple causes of anemia (e.g. iron deficiency and vitamin B12 deficiency).

If an iron deficiency is confirmed, be sure the doctors have tried to check for any causes of slow blood loss.

It is common for older adults to develop microscopic bleeds in their stomach or colon, especially if they take a daily aspirin or a non-steroidal anti-inflammatory drug (NSAIDs) such as ibuprofen. (For this reason — and others — NSAIDs are on the Beer’s list of medications that older adults should use with caution.)

Bear in mind that iron supplements are often quite constipating for older adults. So you only want to take them if an iron-deficiency anemia has been confirmed, and you want to make sure any causes of ongoing blood loss (which causes iron loss) have been addressed.

The most important take home points on anemia in older adults

Here’s what I hope you’ll take away from this article:

1.Anemia is a very common condition for older adults, and often has multiple underlying causes.

2. Anemia is often mild-to-moderate and chronic; don’t let the follow-up fall through the cracks.

3. If you are diagnosed with anemia or if you notice a lower than normal hemoglobin on your lab report, be sure to ask questions to understand your anemia. You’ll want to know:

• Is the anemia chronic or new?
• Is it mild, moderate, or severe?
• What is thought to be the cause? Have you been checked for common problems such as low iron or low vitamin B12?

4. If you are diagnosed with low iron levels: could it be from a small internal bleed and could that be associated with aspirin, a non-steroidal anti-inflammatory medication such as ibuprofen, or another medication?

5. Keep copies of your lab reports.

6. Make sure you know what the plan is, for following your blood count and for evaluating the cause of your anemia.

This article is about the most common aging brain problem that you may have never heard of.

While leading a fall prevention workshop a few years ago, I mentioned that an older person’s walking and balance problems might well be related to the presence of “small vessel ischemic changes” in the brain, which are very common in aging adults.

This led to an immediate flurry of follow-up questions. What exactly are these changes, people wanted to know. Do they happen to every older adult? And how they can best help their parents with cognitive decline?

Well, they don’t happen to every older person, but they do happen to the vast majority of them.  In fact, one study of older adults aged 60-90 found that 95% of them showed signs of these changes on brain MRI.

In other words, if your older parent ever gets an MRI of the head, he or she will probably show some signs of these changes.

So this is a condition that older adults and families should know about. Furthermore, these changes have been associated with problems of consequence to older adults, including:

• Cognitive decline,
• Problems with walking or balance,
• Strokes,
• Vascular dementia.

Now, perhaps the best technical term for what I’m referring to is “cerebral small vessel disease.” But many other synonyms are used by the medical community — especially in radiology reports. They include:

• Small vessel ischemic disease
• White matter disease
• Periventricular white matter changes
• Perivascular chronic ischemic white matter disease of aging
• Chronic microvascular changes, chronic microvascular ischemic changes
• White matter hyperintensities
• Age-related white matter changes
• Leukoaraiosis

In this post, I will explain what all older adults and their families should know about this extremely common condition related to the brain health of older adults.

In particular, I’ll address the following frequently asked questions:

• What is cerebral small vessel disease (SVD)?
• What are the symptoms of cerebral SVD?
• What causes cerebral SVD?
• How can cerebral SVD be treated or prevented?
• Should you request an MRI if you’re concerned about cerebral SVD?

I will also address what you can do, if you are concerned about cerebral SVD for yourself or an older loved one.

What is cerebral small vessel disease?

Cerebral small vessel disease (SVD) is an umbrella term covering a variety of abnormalities related to small blood vessels in the brain. Because most brain tissue appears white on MRIs, these abnormalities were historically referred to as “white matter changes.”

Per a recent medical review article, specific examples of cerebral SVD include “lacunar infarcts” (which are a type of small stroke), “white matter hyperintensities” (which are a radiological finding), and “cerebral microbleeds” (which means bleeding in the brain from a very small blood vessel).

In many cases, cerebral SVD seems to be a consequence of atherosclerosis affecting the smaller blood vessels that nourish brain tissue. Just as one’s larger blood vessels in the heart or elsewhere can accumulate plaque, inflammation, and chronic damage over the years, so can the smaller blood vessels.

Such chronic damage can lead the small blood vessels in the brain to become blocked (which starves brain cells of oxygen, and which we technically call ischemia), or to leak (which causes bleeding, which we call hemorrhage and can damage nearby brain cells).

When little bits of brain get damaged in these ways, they can change appearance on radiological scans. So when an MRI report says “white matter changes,” this means the radiologist is seeing signs that probably indicate cerebral SVD.

(Note: In this podcast episode, a UCSF brain health expert explains that although cerebral small vessel disease is probably the most common cause of white matter changes in older adults, it’s not the only condition that can cause such changes. )

Such signs of SVD may be described as “mild”, “moderate,” or “severe/extensive,” depending on how widespread they are.

Here is an enlargement of a good image, from the BMJ article “Changes in white matter as determinant of global functional decline in older independent outpatients.”

What are the symptoms of cerebral small vessel disease?

The severity of symptoms tends to correspond to whether radiological imaging shows the cerebral SVD to be mild, moderate, or severe.

Many older adults with cerebral SVD will have no noticeable symptoms. This is sometimes called “silent” SVD.

But many problems have been associated with cerebral SVD, especially when it is moderate or severe. These include:

• Cognitive impairment. Several studies, such as this one, have found that cerebral SVD is correlated with worse scores on the Mini-Mental State Exam. When problems with thinking skills are associated with SVD, this can be called “vascular cognitive impairment.”
• Problems with walking and balance. White matter lesions have been repeatedly associated with gait disturbances and mobility difficulties. A 2013 study found that moderate or severe cerebral SVD was associated with a decline in gait and balance function.
• Strokes. A 2010 meta-analysis concluded that white matter hyperintensities are associated with a more than two-fold increase in the risk of stroke.
• Depression. White matter changes have been associated with a higher risk of depression in older people, and may represent a contributor to depression that is particular to having first-time depression in later life.
• Vascular dementia. Signs of cerebral SVD are associated with both having vascular dementia, and eventually developing vascular dementia.
• Other dementias. Research suggests that cerebral SVD is also associated with an increased risk — or increased severity — of other forms of dementia, such as Alzheimer’s disease. Autopsy studies have confirmed that many older adults with dementia show signs of both Alzheimer’s pathology and cerebral small vessel disease.
• Transition to disability or death. In a 2009 study of 639 non-disabled older persons (mean age 74), over a three-year follow-up period, 29.5% of participants with severe white matter changes and 15.1% of participants with moderate white matter changes developed disabilities or died. In comparison, only 10.5% of participants with mild white matter changes transitioned to disability or death over three years. The researchers concluded that severity of cerebral SVD is an important risk factor for overall decline in older adults.

So what does this all mean, in terms of symptoms and cerebral SVD? Here’s how I would boil it down:

1.Overall, older adults with any of the problems listed above have a high probability of having cerebral SVD.

2. But, many older adults with cerebral SVD on MRI are asymptomatic, and do not notice any difficulties. This is especially true of aging adults with mild cerebral SVD.

3. Older adults with cerebral SVD are at increased risk of developing the problems above, often within a few years time. This is especially true of people with moderate or severe cerebral SVD.

What causes cerebral small vessel disease?

This is a topic of intense research, and the experts in this area tend to really nerd out when discussing it. (Read the scholarly papers listed below to see what I mean.) One reason it’s difficult to give an exact answer is that cerebral SVD is a broad umbrella term that encompasses many different types of problems with the brain’s small blood vessels.

Still, certain risk factors for developing cerebral SVD have been identified. Many overlap with risk factors for stroke. They include:

• Hypertension
• Dyslipidemia (e.g. high cholesterol)
• Atrial fibrillation
• Cerebral amyloid angiopathy
• Diabetes
• Smoking
• Age
• Inflammation

How can cerebral small vessel disease be treated or prevented?

Experts are still trying to figure out the answers to this question, and research into the prevention of cerebral SVD is ongoing.

Since progression of cerebral SVD seems often associated with clinical problems, experts are also trying to determine how we might prevent, or delay, the progression of SVD in older adults.

Generally, experts recommend that clinicians consider treating any underlying risk factors. In most cases, this means detecting and treating any traditional risk factors for stroke.

(For more on identifying and addressing stroke risk factors, see How to Address Cardiovascular Risk Factors for Better Brain Health: 12 Risks to Know & 5 Things to Do.)

To date, studies of hypertension treatment to prevent the progression of white matter changes have shown mixed results. It appears that treating high blood pressure can slow the progression of brain changes in some people. But such treatment may be less effective in people who are older than 80, or who already have severe cerebral SVD.

In other words, your best bet for preventing or slowing down cerebral SVD may be to properly treat high blood pressure and other risk factors before you are 80, or otherwise have significant SVD.

Furthermore, experts don’t yet agree on how low to go, when it comes to optimal blood pressure for an older person with cerebral small vessel disease. (This article explains why this has been difficult to determine.)

For now, to prevent the occurrence or progression of cerebral small vessel disease, it’s reasonable to start by observing the hypertension guidelines considered reasonable for most older adults: treat to a target of systolic blood pressure less than 150mm/Hg.

Whether to treat high blood pressure — and other cardiovascular risk factors — more aggressively should depend on an older person’s particular health circumstances. I explain a step-by-step process you can use (with links to related research) here: 6 Steps to Better High Blood Pressure Treatment for Older Adults.

You can also learn more about the research on CSVD and the effect of treating blood pressure here: The relation between antihypertensive treatment and progression of cerebral small vessel disease.

Should you request an MRI if you’re concerned about cerebral SVD?

Not necessarily. In my opinion, older adults should only get MRIs of the brain if the following two things are true:

1. They are experiencing worrisome clinical symptoms, and
2. The results of the MRI are needed to decide on how to treat the person.

For most older adults, an MRI showing signs of cerebral SVD will not, in of itself, change the management of medical problems.

If you have high blood pressure, you should consider treatment. If you are having difficulties with walking or balance, signs of cerebral SVD do not rule out the possibility of other common causes of walking problems, such as medication side-effects, foot pain, neuropathy, and so forth.

What if you’re concerned about memory or thinking problems? Well, you probably will find signs of cerebral SVD on an MRI, just because this is a common finding in all older adults, and it’s especially common in people who are experiencing cognitive changes.

However, the MRI cannot tell you whether the cognitive changes you are noticing are only due to cerebral SVD, versus due to developing Alzheimer’s disease, versus due one of the many other dementia mimics. You will still need to pursue a careful evaluation for cognitive impairment. And no matter what the MRI shows, you will likely need to consider optimizing cardiovascular risk factors.

So in most cases, a brain MRI just to check for cerebral SVD is probably not a good idea.

However, if an MRI is indicated for other reasons, you may find out that an older person has mild, moderate, or severe signs of cerebral SVD. In this case, especially if the cerebral SVD is moderate or severe, you’ll want to consider taking steps to reduce stroke risk, and also to monitor for cognitive changes and increased disability.

What to do if you’re worried about cerebral small vessel disease

If you are worried about cerebral SVD, for yourself or for an older relative, here are a few things you can do:

• Talk to your doctor about your concerns. You may want to discuss your options for optimizing vascular risk factors, including high blood pressure, high cholesterol, high blood sugar, smoking, and others. For more on identifying and addressing stroke risk factors, see How to Address Cardiovascular Risk Factors for Better Brain Health: 12 Risks to Know & 5 Things to Do.
• Remember that exercise, a healthy diet (such as the Mediterranean diet), good sleep, stress reduction, and many other non-pharmacological approaches can help manage vascular risk factors. Lifestyle approaches are safe and usually benefit your health in lots of ways. Medications to treat high blood pressure and cholesterol should be used judiciously.
• If an MRI of the brain is clinically indicated — or if one has recently been done — ask the doctor to help you understand how the findings may correspond to any worrisome symptoms you’ve noticed. But if you’ve been worried about cognitive impairment or falls, remember that such problems are usually multi-factorial (i.e. they have multiple causes). So it’s best to make sure the doctors have checked for all other common contributors to thinking problems and/or falls.
   

 

Swelling in the lower legs – known as “lower extremity edema” in medical terms – is a problem that often affects older adults.

The good news is that most of the time, it’s annoying, but not terribly dangerous. However, in other cases, swelling in the feet, ankles, or lower legs can be the sign of a new health problem, or a worsening chronic condition.

And, even if it’s “benign” and not related to a dangerous health condition, edema can be a major risk factor for skin breakdown and reduced mobility in aging adults.

Since leg swelling becomes so common as people get older, in this article we’ll demystify leg edema and cover the most important things that older adults and families should know about this condition. In particular, we’ll  cover:

• How does edema happen?
• Common causes of swollen ankles or legs in aging adults
• Medications that can cause leg swelling as a side-effect
• How leg swelling should be medically evaluated
• How to prevent and treat leg swelling
• What to know BEFORE going on a “water pill”

How does edema happen?

We notice edema when our shoes are too tight, or we get marks on our ankles from our socks.  But what’s really going on inside the body?

Edema happens when fluid moves outside of blood vessels and into what’s called the interstitial spaces of the body. These spaces are  also sometimes called the extra-vascular space (which literally just means “outside of blood vessels”), and is basically the moist space between cells, organs, and body parts.

Although you make think of blood vessels as being “waterproof”, physically they are more like a semi-permeable membrane, made of blood vessel cells that usually stay close together, and it’s normal for small quantities of fluid to pass back and forth.

If more fluid than usual passes out of the blood vessels, and this happens in the legs or near the surface of the body, it looks like a swollen or puffy area under the skin.

Fluid can move into the interstitial spaces and cause edema for a few different reasons. The most common causes are

1. “Leaky” blood vessels: Sometimes the blood vessel cells don’t stick together as tightly as they should. This can allow fluid molecules to slip through the connections between the blood vessel cells (like gaps between the bricks in a wall).
   1. This can happen due to severe infection or inflammation, among other things.
2. Low levels of protein in the blood: Proteins, such as albumin, help keep fluid inside blood vessels. This is because protein molecules in the blood exert an “osmotic” pressure (also called “oncotic pressure”) that helps retain fluid inside a blood vessel. If protein levels fall in the blood vessel, even if the membrane of the blood vessel is intact, fluid moves outside of the vein or artery to equalize the osmotic pressure across the membrane, and this creates edema.
   1. Some causes of low albumin levels in the blood include certain types of kidney disease, liver disease, and malnutrition.
3. Fluid overload: If there’s more fluid than usual in the blood vessel, it becomes “overloaded.” The extra fluid will be then end up pushed across the blood vessel wall because of high hydrostatic pressures.

Normally, our kidneys regulate body fluid levels by adjusting the amount of water and salt that is excreted or retained. But if those mechanisms fail or are overwhelmed, edema is often the result.

When we look at common causes of edema, keep these different mechanisms in mind.  The cause of the edema will play a major role in deciding on the best course of treatment.

What are the most common causes of leg edema

By far, the most common cause of leg edema is chronic venous insufficiency, but some other causes 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.

How Leg Swelling is Medically Evaluated

What to Tell Your Doctor About Leg Swelling

If you’ve noticed new or worsening leg swelling, it’s important to let your health provider know, so that you can be evaluated.

The doctor should check to make sure that you aren’t suffering from a potentially serious problem (such as one involving the heart, kidney, or liver), and will generally try to determine what is causing the leg swelling.

Questions the doctor will probably ask include:

• How long has the edema been there?
• Is it affecting both legs equally, or one more than the other?
• Is it painful? (Venous edema can cause aches, lymphedema is painless)
• What medications are being taken? Any recent changes?
• Does it get better overnight? Or with elevation of the legs?
• Any shortness of breath? Any difficulty lying flat?

Of course, they will also want to take a complete health history, to know whether you’ve ever had cancer, radiation or surgery to your pelvis or legs, and any known heart, liver or kidney problems.

Signs that more urgent evaluation of leg swelling may be needed

Certain signs and symptoms should prompt a more urgent evaluation. They include:

1. Breathing symptoms: Shortness of breath, cough, and trouble breathing when lying flat might be indicators of pulmonary edema, from CHF or another cause. If a person has these symptoms along with leg swelling, they should seek medical attention right away.
2. Swelling on one side only: Most of the causes of swelling described above will cause both legs to be affected, so if only one leg is swollen, it might be caused by:
   • A blood clot, which usually does limited harm in the leg but could break off and travel to the lung causing severe illness or even death,
   • Infection
   • Blockage related to a tumor

(Of course, if a person has previously had a blood clot or injury to one leg, it may appear quite different from the other leg and the swelling might be chronically asymmetric, so that needs to be considered as well.)

3. Pain: Most of the time, edema due to CVI is painless, although some people experience discomfort similar to an achy tiredness.  Severe or significant pain should not be ignored. In particular, a sudden severe pain in the legs or the chest is a reason to seek help without hesitation.

What Your Doctor Will Do

Your doctor will check for “pitting,” by gently pressing on the swollen area. Pitting occurs when pressure to the swollen area leaves a little depression behind for a few seconds to minutes.  Most causes of edema are pitting, but if there’s no pitting we would think about lymphedema or a fat deposit (lipedema).

A close examination of the legs is vital, to check for any varicose veins, discoloration of the skin, ulcers or breaks in the skin, and skin dryness.  If the legs seem to be different from each other in size, your doctor might measure both limbs to see if there’s true asymmetry.

It’s also important to do an examination of the heart and lungs. Expect your doctor to listen to the breath sounds and heart sounds, and to check your pulse and blood pressure. Doctors will also often examine the belly, to feel the liver and also make sure they don’t see signs of edema outside the legs.

Potential Tests and Additional Evaluation

Based on what you tell the doctor, your past medical history, and what the doctor observes through the physical examination, the doctor will then determine whether additional testing is needed.

Tests that may be ordered include urinalysis (to look for protein in the urine), creatinine (a test of kidney function), TSH (some thyroid conditions lead to edema), glucose,  albumin (a major protein found in the blood) and liver function tests may be ordered. (For more on blood tests, see Understanding Laboratory Tests: 10 Commonly Used Blood Tests for Older Adults.)

Tests of cardiac function may be a part of the work-up as well, such as a chest x-ray to look for an enlarged heart or fluid in the lungs, or an echocardiogram, which is an ultrasound study to look at the heart chambers and muscle contractility.

D-dimer is a blood test that can help detect a blood clot, and a doppler ultrasound of the leg can usually find a deep vein thrombosis – a common cause of swelling in one leg only.

If your doctor is looking for deeper causes to explain leg swelling, they may refer you for a sleep study.  Sleep apnea, if left untreated, can lead to the right-sided heart failure that we mentioned earlier.

It’s also possible that your doctor might not feel the need to order additional testing. Especially if bloodwork has been done in the past few months and if the symptoms and examination fit with chronic venous insufficiency, it can be reasonable for the doctor to proceed with treatment for this condition.

How Leg Swelling is Treated

As I noted above: most of the time, leg swelling in an older adult is caused by chronic venous insufficiency (CVI), an issue with the leg veins not doing an adequate job to return blood to the heart.

What to know BEFORE starting a “water pill” for leg or ankle swelling

You might think that a diuretic (a “water pill”) will help, and they certainly are often prescribed for this purpose. However, research has shown that they often don’t help much, probably because they don’t really address the underlying issue, which is weak valves in the veins and local fluid overload.

Furthermore, diuretics in older adults can easily cause side effects like dehydration low blood pressure, low potassium levels, and constipation.  They also increase urination, which can cause or worsen urinary continence issues. (For more on these issues, see How to Prevent and Treat Dehydration in Aging Adults and Urinary Incontinence in Aging.)

How to treat chronic venous insufficiency in aging adults

So before starting a water pill, be sure to ask your doctor about the cause of your leg swelling and consider trying these strategies first:

• Elevate the legs: raise your legs to at least the level of your heart for 30 minutes 3 or four times a day – this habit uses gravity to help the veins drain the blood from the lower limbs to return to the heart for circulation.
• Wear stockings: compression stockings with a low pressure (15-20 mmHg of pressure) are readily available at many drug stores and are not too difficult to put on and wear.  The stockings have higher pressure at the ankle which gradually reduces the higher up the leg it goes. Those with more moderate to severe edema may need to be specially measured and fitted for compression socks, which may require a prescription.
• Reduce salt intake: salt (aka sodium) can worsen edema by promoting fluid retention. Lowering salt intake can also reduce the risk of high blood pressure.  Hide the saltshaker and avoid processed food and takeout.
• Exercise the calf muscles: walking and pumping your calves is recommended to reduce the symptoms of CVI and speed the healing of ulcers if present.

Other treatment options for chronic venous insufficiency

• Venoactive agents: these are compounds that act in a variety of ways to relieve CVI symptoms. They improve venous tone, improve lymphatic drainage, fight inflammation, and increase blood viscosity. Examples are horse chestnut seed extract, micronized purified flavonoid fraction (MPFF)and pycnogenol.  A large review of scientific studies of venoactive agents showed that they can reduce swelling.
• Skin care: This may not help with edema but is a critical step to prevent ulcers (skin sores), which can occur as a complication of CVI.
• Ulcer care: ulcers on the legs and feet from CVI can be chronic and hard to treat. A specialized wound care team is often consulted to advise about any topical treatments or surgical procedures that can help with healing.  All of the measures to reduce edema described above will help with ulcer prevention and healing.

Again, the goal of treatment is to manage symptoms and prevent other problems, like ulcers and discomfort.  Most older adults can treat their leg swelling with some of the strategies described above and maintain their usual activities and quality of life.

Treatment of Leg Edema from Other Causes

If edema is not due to CVI, the treatment plan will target the underlying problem, whether it’s heart failure, a medication side effect, a kidney issue, or liver disease.

The Take-Home Messages about Leg Swelling:

Edema (or swelling) of the lower limbs is common in older adults.  The most common cause (about 70%) of leg edema is due to Chronic Venous Insufficiency (CVI).

Other serious causes of edema include congestive heart failure, kidney disease, and liver disease. Always be sure to get evaluated for new or worsened leg swelling, to make sure one of these more serious medical problems isn’t at hand.

If the leg swelling is present in one leg only, or if there’s a lot of pain, or if you notice other serious symptoms along with the leg swelling (shortness of breath, chest pain, cough or trouble breathing when lying flat), this could be a sign of an urgent problem which needs medical attention right away.

But again, most leg swelling in aging adults is chronic venous insufficiency. The ideal management of this chronic condition includes “lifestyle” measures such as elevating the legs regularly, using compression stockings, reducing salt intake,  and doing exercises which improve fluid movement in the legs.

It’s important to get help from your health providers to manage CVI, because without treatment, it can cause complications such as ulcers (skin sores), infections, and reductions in quality of life.

Diuretic medications (“water pills”) can sometimes help  to reduce edema from CVI, but the side effects can be serious: dehydration, potassium depletion, urinary incontinence and low blood pressure.

So, geriatricians recommend using diuretics with caution in older adults. They are also not a substitute for the lifestyle measures listed above.

In closing: if you have swollen legs, you’re not alone. Be sure to bring this condition to the attention to your health providers, to make sure your leg swelling isn’t due to something serious.

In most cases, it will be garden variety chronic venous insufficiency. Chances are good that you can use the strategies in this article to reduce the symptoms of edema, without resorting to medications.  Good luck!