Circulatory problems

Definition

Circulatory problems in older adults can be caused by disorders such as high blood pressure, high cholesterol and atherosclerosis , diabetes, peripheral artery disease, varicose veins, deep vein thrombosis and pulmonary embolism , Raynaud's phenomenon, and temporal arteritis. Left untreated or combined with mobility problems, circulatory disorders can lead to problems that include decreased mobility, vision loss, bedsores, and infection.

Description

As a person ages, the heart becomes larger and the walls of the arteries become stiffer and less elastic. As a result, the arteries cannot relax as quickly when the heart pumps, leading to higher blood pressure when the heart contracts. Older adults are at increased risk for a circulatory problem called hypertension (high blood pressure). High blood pressure makes the heart work harder, and over time can cause damage to the blood vessels throughout the body.

The risk of high cholesterol, a waxy substance made in the liver that is also found in meat, milk, and other dairy products, increases with age. The greater a person's cholesterol level, the greater the risk for heart disease . When a person has too much cholesterol in the blood, it begins to build up on the walls of the arteries, eventually causing these pathways to harden and narrow. This fatty buildup causes blood flow to the heart to slow down or become blocked altogether; an older person may experience chest pain or even a heart attack .

Diabetes is a disorder that interferes with the body's production of insulin and causes high levels of sugar in the blood. Diabetes also increases the risk for heart disease, high blood pressure, and stroke . A major complication of diabetes is compromised blood flow and blockage of blood vessels in the legs and feet.

Poor blood flow can lead to foot ulcers, infections, and in extreme cases, require amputation of the toes, feet, or lower extremities.

Another circulatory problem that typically afflicts older adults is peripheral arterial disease (PAD). PAD occurs when fatty buildup occurs on the walls of the arteries that carry blood from the heart to the head, internal organs, and extremities (typically the legs). This blocked blood flow leads to pain, numbness, and an increased risk of infection; in severe cases, PAD can cause tissue death only treatable with amputation. PAD can be extremely serious and increase the risk for other health problems. People with the disease have a six to seven times greater risk of heart disease and stroke than people without the disorder.

Veins, the blood vessels that transport blood from the body to the heart, have valves that work to keep blood moving from the heart. As a person ages, the valves can begin to work less efficiently, causing blood to back up and pool and the veins to swell and twist underneath the skin. This circulatory problem is known as varicose veins.

Another vein-related circulatory problem that may affect older adults is deep vein thrombosis (DVT). In DVT, a thickened clump of blood (called a clot) forms in a vein deep in the body, such as the lower leg or thigh. DVT is serious because if the clot breaks off and travels through the bloodstream to the lungs (a pulmonary embolism), it can damage the organs or even result in death .

People with the circulatory disorder Raynaud's phenomenon experience episodes of skin color changes, numbness, and throbbing in the body's extremities, typically the fingers and toes. These episodes occur when the blood vessels in the fingers and toes constrict too much, usually in response to cold temperatures or emotional stress . There are two types of Raynaud's phenomenon. Primary Raynaud's phenomenon is when the problem occurs on its own. When it occurs in conjunction with another health

condition, typically an autoimmune disorder such as scleroderma or lupus , it is known as secondary Raynaud's phenomenon.

Temporal arteritis (sometimes called giant cell arteritis) is an inflammatory circulatory problem that causes the blood vessels supplying the head, eyes, and optic nerves to swell. If the condition is not treated, it can cause blurred vision, double vision, and in severe cases, permanent vision loss, when the blood flow to the eyes and optic nerve is obstructed.

Demographics

High blood pressure is common, especially among older adults. According to the National Heart, Lung and Blood Institute (NHLBI), nearly one in three (65 million) American adults experience high blood pressure, and half of all adults 65 and older have the disorder. African Americans, men over age 45, and women over age 55 are at greater risk for developing high blood pressure.

Men 45 years and older and women 55 years and older have an increased risk of high cholesterol levels, which can compromise or block blood flow to vital organs.

Nearly 21% of adults 60 and older (about 10.3 million) have diabetes, which puts them at risk for circulatory problems. Minority populations are disproportionately affected by this disease. African Americans, Hispanics, American Indians, Alaska Natives, Asian Americans, and Pacific Islanders have an increased risk of diabetes, compared to Caucasians.

PAD affects 8–12 million people in the United States. Among adults 65 and older, 12% to 20% experience PAD. People with chronic illnesses such as diabetes are particularly at risk.

Varicose veins affect 25 million Americans and are most common in people 30 to 70, especially women.

Although DVT can occur in people of all ages, it is particularly common in people over age 60. People who have undergone surgery or have had limited mobility are also at greater risk for DVT.

Primary Raynaud's phenomenon tends to occur in younger teens and adults. Secondary Raynaud's phenomenon most often occurs in people older than 40 years of age. About 3% of the general population is affected by Raynaud's phenomenon. In people with connective tissue diseases this circulatory problem is much more common, affecting more than 90% of people with scleroderma and more than 30% of people with systemic lupus erythematosus and Sjögren's syndrome.

Temporal arteritis most often affects people 60 and older and is four times more likely to occur in women than men.

Causes and symptoms

High blood pressure is called the silent killer because most people with the condition have no symptoms. There are usually no symptoms of high cholesterol either. Annual tests to check cholesterol and high blood pressure can indicate to doctors that a patient has a problem.

Chest pain (angina ), heart attack, or stroke may be signs that a person's diabetes or atherosclerosis is causing circulatory complications. A person experiencing a heart attack may feel nauseated, sweaty, and extremely weak, in addition to having chest pain. A person having a stroke may have sudden weakness, confusion, dizziness , severe headaches , or trouble seeing out of one or both eyes.

In addition, people with diabetes can develop symptoms of PAD, such as pain in the legs during activity or exercise , numbness or tingling in the feet or legs, or sores on the lower extremities that take a long time to heal.

People with varicose veins may experience signs and symptoms such as visible enlarged veins and swelling of the ankles and feet; throbbing, cramps, or itching of the legs; or discolored skin around the varicose vein. Although a harmless type of blood clot (called superficial thrombophlebitis) can occur near the affected vein, varicose veins do not generally cause life-threatening clots that can occur with DVT.

Only about half of people with DVT experience symptoms of this circulatory disorder, including leg or vein swelling, tenderness or a feeling of warmth in the leg that may be aggravated by walking or standing, and discolored skin on the leg. If a blood clot caused by DVT breaks off and blocks blood flow, it can cause a pulmonary embolism (PE). Symptoms of PE include coughing up blood, unexplained shortness of breath, and pain when taking a deep breath.

During an episode of Raynaud's phenomenon, the blood vessels on the skin's surface overreact, causing the skin of the fingers and toes to turn white (pallor), blue (cyanosis), and then red (rubor). Initially, a person with Raynaud's may feel cold and numbness in the fingers and toes; the extremities may tingle and throb after blood flow returns.

People with temporal arteritis experience head-aches, scalp tenderness, and pain in the temple. They may also have blurred vision, droopy eyelids, poor appetite, fever, fatigue, and neck or jaw soreness.

Diagnosis

Having a health professional measure blood pressure with a blood pressure cuff can determine whether a person has high blood pressure. Blood pressure is considered normal if the top number (systolic) stays below 120 and if the bottom number (diastolic) stays below 80.

A blood test called a lipoprotein profile is used to diagnose high blood cholesterol. This test indicates how much total cholesterol, LDL cholesterol (the bad cholesterol), HDL cholesterol (the good cholesterol), and triglycerides (a type of fat) is in a person's blood.

In addition to conducting a physical examination and taking information about a patient's history, diabetes is diagnosed with glucose tests, which measure blood sugar levels after a person has gone a period of time without eating.

When diagnosing PAD, the doctor takes the patient's medical and family history, conducts a physical exam, and uses a 10- to 15-minute test called the ankle-brachial index (ABI). This test compares blood pressure in the ankle to blood pressure in the arm and determines how well blood is flowing throughout the person's body. Treadmill tests, ultrasounds, magnetic resonance angiograms (MRA), and arteriograms may also be used to check how well a patient's blood is flowing and whether there are any blockages.

Typically, varicose veins are visually evident, but Doppler ultrasounds and angiograms may be used to check a patient's blood flow and rule out the likelihood of dangerous blood clots .

In addition to taking a general medical history and conducting a physical examination to check for signs of DVT, ultrasounds and venography are used to check a person's blood flow and circulation. A D-dimer test, which measures a substance that is released when clots in the blood dissolve is also sometimes used.

Raynaud's phenomenon is usually diagnosed by taking a complete medical history and listening to a patient's description of symptoms. Tests can be performed to check for inflammation in the body or connective tissue disease, since Raynaud's phenomenon is often linked to these disorders.

If temporal arteritis is suspected, blood tests that check for inflammation in the body are performed.

Treatment

Treatment for circulatory problems in older adults often involves lifestyle changes, medication, or surgery.

If a person has high blood pressure, the initial recommendation is usually to lose weight, follow a low-sodium diet , get at least 30 minutes of exercise daily, quit smoking , and limit alcohol consumption. If those strategies do not work, blood pressure medicines (including diuretics, beta blockers, angiotensin-converting enzyme inhibitors, calcium channel blockers , and vasodilators) may be prescribed to control blood pressure.

Many of the same lifestyle changes used to control high blood pressure are also recommended for people with high cholesterol levels to prevent the de-velopment of atherosclerosis. If lifestyle changes are not effective, cholesterol-lowering drugs may be prescribed, such as statins, bile acid sequestrants, nicotinic acid, and fibrates.

People with diabetes need to make lifestyle changes to treat their disease. Taking insulin is usually required to control the disease (taking insulin is necessary with type 1 diabetes; sometimes people with type 2 diabetes can manage the condition with lifestyle changes alone). Learning how to monitor blood glucose levels and adjust insulin dosages is an important part of diabetes treatment. Some people use complementary and alternative medicine treatments such as acupuncture , biofeedback , chromium, ginseng, magnesium, and vanadium to treat diabetes. People who want to try these strategies should first discuss it with their primary care doctor.

Treatment for PAD involves many of the same lifestyle changes necessary for high blood pressure. People with PAD also work with their doctors to reduce their blood glucose levels if they have diabetes.

Medications may be prescribed to thin the blood and prevent blood clots or to reduce pain in the legs caused by this circulatory condition.

For varicose veins, it is recommended that patients elevate their legs when sitting or resting and avoid long periods of standing. Losing weight, getting regular exercise, and avoiding tight clothes can help alleviate this circulatory disorder. Compression stockings, which are available at drugstores and medical supply stores, may also help. Surgical procedures such as sclerotherapy, laser surgery, vein surgery, and other procedures can improve the cosmetic appearance of varicose veins in some cases.

People with DVT are often prescribed anticoagulant drugs , which decrease the blood's ability to clot. Other drugs, such as thrombin inhibitors (which interfere with blood clotting) and thrombolytics (which dissolve blood clots), may be used to treat DVT. People who cannot take blood thinners may be treated with a vena cava filter, which catches clots in veins before they move to the lungs, thereby preventing PE. Someone with DVT may benefit from wearing compression stockings to reduce leg swelling.

QUESTIONS TO ASK YOUR DOCTOR

• What is my risk for circulatory problems?
• What are my blood pressure and cholesterol measurements?
• Am I at a healthy weight, and could my weight contribute to circulatory problems?
• Do any existing health problems put me at greater risk for circulatory problems?
• What type and how much physical activity should I be doing to prevent circulatory problems as I age?
• Can you help me quit smoking?
• What do I need to know about caring for my feet and legs?

Medications are typically prescribed immediately for people with secondary Raynaud's phenomenon because they are more likely to experience ulcers or tissue damage than people with the primary form of the disorder. Calcium channel blockers, high blood pressure medications, and vasodilators are all used to prevent Raynaud's attacks and heal skin damage caused by the blood vessel constriction. It is recommended that people with Raynaud's employ self-care measures, such as avoiding smoking, temperature extremes, and stress, and exercising regularly to reduce the risk of attacks.

Oral steroid medications are typically prescribed to control the inflammation associated with temporal arteritis. In some cases this circulatory problem subsides within a few days; for other patients, long-term dosages of steroids are required.

Prevention

In most cases, preventing circulatory problems in older adults centers around the healthy habits used to manage circulatory disorders. People can prevent many circulatory problems by:

• Eating a diet low in saturated fat, cholesterol, and sodium and rich in fruits, vegetables, whole grains, and fiber. Doing so can reduce the risk of high blood pressure, high cholesterol, and diabetes, as well as their associated complications.
• Exercising at least 30 minutes daily. Not only does regular exercise help with weight management, it also raises good cholesterol and lowers bad cholesterol levels. Light activity after surgery, illness, or during long car trips can help prevent the risk of DVT.
• Maintaining a healthy weight or losing weight if overweight can reduce the risk of high blood pressure, high cholesterol levels, and diabetes. Being overweight puts added pressure on the veins, increasing the risk for varicose veins.
• Avoiding or quitting smoking because smoking constricts the blood vessels and increases the risk of circulatory problems, including atherosclerosis, Raynaud's phenomenon, and PAD.
• Reducing emotional stress, which can exacerbate circulatory problems including high blood pressure and Raynaud's phenomenon.
• Avoiding extreme temperatures, which can increase the likelihood of Raynaud's phenomenon episodes.
• Caring for their feet. Protecting the feet from injury is especially important to people with diabetes and PAD. Washing feet and checking for blisters, cuts, and sores daily is critical, as is wearing well-fitting shoes. A patient's doctor may recommend special foot care regimens or shoes to prevent diabetes-related foot problems.

Caregiver concerns

Circulatory problems and the medicines used to treat them can adversely affect balance, mobility, and gait, thereby increasing the risk of falls among the elderly. Caregivers can lend a hand by ensuring the person's home is well-lit; contains handrails, no-slip mats, grab bars, and other assistive devices; and that the senior has access to a phone or other call device in case of a fall or other emergency.

In addition, canes, walking sticks, or walkers may help someone with circulatory problems feel more steady when they walk. The patient's doctor may recommend other home modifications and devices to help prevent slips and falls.

Bedsores (sometimes called pressure ulcers) are a common complication that can arise due to circulatory problems. When steady pressure, such as from a bed or wheelchair, cuts off the blood flow to a certain area of the body, a warm, itchy, open sore that looks like a blister can develop. Bedsores often occur on the tailbone or buttocks, the spine or shoulders, or the backs of the arms and legs. Caregivers should ensure that the pressure is relieved and the wound is cleaned and treated; otherwise, life-threatening infection can develop. Changing positions often and using supportive surfaces such as air- or water-filled devices can prevent the development of bedsores.

KEY TERMS

Amputation —Surgical removal of a limb that is damaged beyond repair due to nerve problems or loss of blood supply.

Angina —A pressing or squeezing pain that usually occurs in the chest under the breast bone and is the result of the heart failing to receive adequate blood flow. It can also occur in the shoulders, neck, and back.

Atherosclerosis —Fatty buildup on the walls of the arteries. Over time, these arteries become narrower and blood flow is restricted.

Blood glucose —A sugar made by the body from food. It moves through the bloodstream to provide energy to the body's cells.

Blood pressure —The force of blood against the walls of the blood vessels.

Insulin —A hormone that the body requires to use glucose for energy.

Plaque —Fat, cholesterol, calcium, and other blood substances that may build up on the walls of the arteries and cause atherosclerosis.

Resources

OTHER

National Institute of Diabetes and Digestive and Kidney Diseases Clearinghouses Publications Catalog. http://www.catalog.niddk.nih.gov/materials.cfm?CH=NDIC.

ORGANIZATIONS

American Heart Association, 7272 Greenville Avenue, Dallas, TX, 75231, (800) 242-8721, http://www.americanheart.org.

National Heart, Lung and Blood Institute, P.O. Box 30105, Bethesda, MD, 20824-0105, (301) 592-8573, (301) 592-8563, nhlbiinfo@nhlbi.nih.gov, http://www.nhlbi.nih.gov.

National Institute of Arthritis and Musculoskeletal and Skin Diseases, 1 AMS Circle, Bethesda, MD, 20892-3675, (301) 495-4484, (877) 22-NIAMS (226-4267), (301) 718-6366, niamsinfo@mail.nih.gov, http://www.niams.nih.gov.

National Institute of Diabetes and Digestive and Kidney Diseases, 2 Information Way, Bethesda, MD, 20892-3570, (800) 891-5389, (703) 738-4929, nddic@info.niddk.nih.gov, http://www.niddk.nih.gov.

Amy L. Sutton