Adherence to and efficacy of different compression methods for treating chronic venous insufficiency in the elderly

Abstract

Objectives

To investigate the adherence to and efficacy of different compression methods in elderly patients.

Methods

A retrospective review of compression therapy in 120 elderly patients (≥65 years) with chronic venous insufficiency was performed to study the initially preferred compression method, adherence to each method, and its efficacy.

Results

Initially, an oversize strong stocking (24%), an appropriate size moderate stocking (19%), and bandages (37%) were equally preferred. Adherence at 1 month was 69%, 96%, and 91%, respectively, and they reduced ankle circumferences in C3 patients by 1.8 ± 1.9 cm, 0.3 ± 1.7 cm, and 2.9 ± 1.7 cm, respectively. The improvement rates of C4 symptoms were 79%, 60%, and 91%, respectively. Only three patients (2%) preferred an appropriate size strong stocking.

Conclusions

In elderly patients, an appropriate size strong stocking was not preferred. The best adherence was achieved by using a moderate stocking, while the best efficacy was achieved by using bandages.

Keywords

Chronic venous insufficiency compression stocking compression bandage

Introduction

Compression therapy providing interface pressure (IP) of 30 mmHg or greater appears to be effective in improving pain, swelling, and skin pigmentation due to chronic venous insufficiency (CVI).¹ However, such stockings are too tight and resistant for elderly patients, particularly the weak elderly, to apply by themselves. As a result, it is common practice to prescribe stockings of either a lower pressure or larger size. These alternative stockings are, in fact, not totally useless, and can be reasonably effective in a certain number of patients. Another alternative is the use of compression bandages, which may be even more effective in managing CVI symptoms. Although some standards regarding the prescription of proper compression methods to manage CVI symptoms have been described² it is not clear what should be done when the patients cannot tolerate the recommended compression methods. In the current study, we reviewed our elderly patients’ adherence to different compression methods and their efficacy, and discussed practical and feasible alternatives.

Patients and methods

This retrospective study was approved by the Institutional Review Board of Yamaguchi University Hospital (Center for Clinical Research, Ube, Yamaguchi, Japan), and the need for individual patient consent was waived. The subjects included in the current retrospective study were 120 patients who were 65 years or older, who visited our clinic between April 2009 and December 2014 because of CVI, and were indicated for conservative therapy. The patient characteristics are summarized in Table 1. In this study, functional venous insufficiency was defined as below:

Table 1.

Patient characteristics.

Age		65–69	70–74	75–79	>80	Total	P
Age		(N = 17)	(N = 29)	(N = 33)	(N = 41)	(N = 120)	P
CEAP	C3	7 (41%)	10 (34%)	19 (58%)	16 (39%)	52 (43%)	N.S.
	C4,5	7 (41%)	17 (59%)	8 (24%)	16 (39%)	48 (40%)
	C6	3 (18%)	2 (7%)	6 (18%)	9 (22%)	20 (17%)
Gender	male:female	1:16	8:21	8:25	10:31	27:93	N.S.
Pathology	Functional venous insufficiency	4 (24%)	17 (59%)	17 (52%)	34 (83%)	72 (60%)	P < 0.01
	Primary venous insufficiency	13 (76%)	11 (38%)	13 (39%)	6 (15%)	43 (36%)
	Post-thrombotic syndrome	0 (0%)	1 (3%)	3 (9%)	1 (2%)	5 (4%)

P-value indicates difference among the age groups.

C: clinical class in CEAP classification,^3,4 NS: not significant among the age groups.

No reflux or occlusion in the deep veins, saphenous veins, accessary saphenous veins, or perforators on duplex venous ultrasound.

Confirmed severe gait disturbance and/or prolonged sitting due to joint problems, general weakness, obesity, etc.

No other edemagenic conditions e.g., cardiac/hepatic/renal failure, etc.

Dependent edema, which we considered as a part of functional venous insufficiency, may not be totally derived from venous insufficiency, but could also be due to reduced lymphatic pumping,⁵ skin viscoelasticity,⁶ etc. in the elderly. However, since calf muscle pump failure can result in ambulatory venous hypertension,^7,8 and since this group of patients often develops the symptoms seen in advanced CVI,⁹ we included these patients in this study. CVI that was considered to be mainly due to severe obesity (BMI > 35 kg/m²) was regarded as functional CVI. CVI due to primary superficial and/or deep venous insufficiency, including varicose veins, was regarded as primary venous insufficiency. When the patient had different symptoms in each leg, the patient was regarded as suffering from the more severe symptom.

For the patients with only C3 symptoms according to the CEAP classification,^3,4 an appropriate size moderate stocking that generates an IP of 20–30 mmHg (Medical Support class I Knee-high stockings®, Medics Corporation, Tokushima, Japan) or oversize (2–4 sizes too large) strong stocking that was originally designed to generate an IP of 30–40 mmHg (Medical Support class II Knee-high stockings®, Medics Corporation, Tokushima, Japan) was recommended first. When the patient was unable to or refused to apply the stocking, bandages were recommended next. We instructed patients to use our original bandage technique in order to stabilize the IP and stiffness, as we previously reported.¹⁰ Briefly, the two key points of this technique are:

Place the bandage softly around the leg and smooth out the wrinkles in an advancing direction to fit the leg and to avoid intentional stretch on bandages

Use three rolls of the provided bandage (Getto elastic bandage®, Kawamoto Corporation, Osaka, Japan, extensibility 108%, width 10 cm, length 4.5 m/roll) between the ankle and the popliteal fossa.

This technique provides a stable IP of around 40–50 mmHg and in most Japanese people independent of the bandagers’ skill.¹¹ If the patient’s condition was complicated by pedal edema, another bandage was applied to the foot. For the patients with C4 and C5 symptoms, an appropriate size strong stocking or bandages were recommended first, followed by an appropriate size moderate stocking or an oversize strong stocking. For the patients with C6 symptoms, only bandages were prescribed.

For each patient, adherence to each compression method was assessed 1 month after the first visit. When the patient applied his/her compression method more than 5 days per week, it was regarded as being adherent. In patients with C3 symptoms only, the circumferences at the calf and ankle before and after 1 month of compression therapy were measured. In patients with C4 symptom, the changes in skin manifestations were evaluated at 3 months. Since we did not have objective measures, we regarded them improved when the below signs and/or findings were confirmed:

Hyperpigmentation was regarded as improved, when skin discoloration was confirmed both by the physician and patient.

Stasis dermatitis was regarded as improved, when skin redness, itching, scaling were all resolved.

For lipodermatosclosis, we could not find any subjective/objective measures to properly evaluate its improvement, so we did not evaluate it in this study. For C6 patients, the change in ulcer size was evaluated at 3 months.

Statistical analysis

Results are expressed as the mean ± standard deviation or count, unless otherwise indicated. The χ² test was used to test the differences of symptoms, pathology, patients’ preferences, and adherence to different compression methods among the age groups, and improvement of C4 symptom by different compression methods. The Wilcoxon signed-rank sum test was used to test the changes in calf/ankle circumferences and ulcer sizes. Statistical analyses were performed using JMP 11.0 (SAS Institute, Cary, NC, USA). A P value < 0.05 was considered statistically significant.

Results

As shown in Table 1, the proportion of clinical severity was not significantly different among the age groups, but functional venous insufficiency was less in subjects aged 65–69 (24%) and more in subjects aged over 80 (83%), compared to the other age groups. Table 2 demonstrates the preferred compression methods at the patients’ first visit and their adherence to them after 1 month. Interface pressures obtained by stockings or bandages at the beginning were roughly the same with those we previously measured in normal subjects.^10,12 An appropriate size strong stocking was not preferred in any of the age groups. An oversize strong stocking, an appropriate size moderate stocking, and bandages were evenly preferred at the start of the study. Rejection of any type of compression was consistently found (∼20%) in all age groups. Since these patients did not appear in our clinic again, we could not follow their course. Differences among the age groups were not found. The rate of donning stockings or applying bandages by the patient him/herself was significantly lower in the patients of 75 years or older. After 1 month, the best adherence was achieved with an appropriate size moderate stocking, followed by bandages. Adherence to the oversize strong stocking was worse than the appropriate size moderate stocking and bandages. Again, differences among age groups were not found. The number of subjects who used an appropriate size strong stocking was too small to analyze adherence. Since we routinely recommend bandages for the patients with severe joint problems and/or palsy, incompliance to stockings were considered to be caused by patients’ weakness and/or intolerance to discomfort.

Table 2.

Initial compression methods and adherence at 1 month.

Age	65–69	70–74	75–79	>80	Total	P
Age	(N = 17)	(N = 29)	(N = 33)	(N = 41)	(N = 120)
Initial compression method						NS
(% in each age group)
Appropriate size strong stocking	1 (2%)	1 (3%)	0 (0%)	1 (2%)	3 (2%)
Oversize strong stocking	3 (17%)	9 (31%)	6 (18%)	11 (27%)	29 (24%)
Appropriate size moderate stocking	4 (22%)	6 (21%)	9 (27%)	4 (10%)	23 (19%)
Bandages	4 (22%)	9 (31%)	11 (33%)	20 (49%)	44 (37%)
Rejected	5 (18%)	4 (18%)	7 (22%)	5 (12%)	21 (18%)
Stocking donning/Bandage application						P < 0.01
(% in each age group)
Self	12 (100%)	22 (88%)	15 (58%)	15 (42%)	64 (65%)
Caregiver	0 (0%)	3 (12%)	11 (42%)	21 (58%)	35 (35%)
Adherence at 1 month						NS
(% vs. initial visit)
Appropriate size strong stocking	1 (100%)	0 (0%)	–	1 (100%)	2 (67%)
Oversize strong stocking	3 (100%)	7 (78%)	4 (67%)	6 (55%)	20 (69%)
Appropriate size moderate stocking	4 (100%)	6 (100%)	8 (89%)	4 (100%)	22 (96%)
Bandages	4 (100%)	9 (100%)	9 (82%)	18 (90%)	40 (91%)

Note: P value indicates difference among the age groups.

NS: not significant among the age groups.

Changes in the calf and ankle diameter of the patients with only C3 symptoms using different compression methods are reported in Table 3. At the beginning, no significant differences in diameters were noticed. In both the calf and ankle, significant reductions of the circumferences were achieved with either an oversize strong stocking (calf: −1.5 ± 2.1 cm, ankle: −1.8 ± 1.9 cm) or bandages (calf: −2.2 ± 2.3 cm, ankle: −2.9 ± 1.7 cm). With an appropriate size moderate stocking, a small but significant reduction of circumference was achieved at the calf (−0.6 ± 1.7 cm). However, at the ankle, the reduction was achieved in only half of the patients and the overall change was insignificant (−0.3 ± 2.2 cm).

Table 3.

Changes in calf and ankle circumference after 1 month in C3 patients.

	Legs/patients	Calf (cm)			Ankle (cm)
	Legs/patients	Pre	1 M		Pre	1 M
Oversize strong stocking	6-Dec	36.2 ± 4.0	34.7 ± 4.3	*	24.1 ± 3.3	22.4 ± 3.1	**
Appropriate size moderate stocking	33/17	34.2 ± 2.6	33.6 ± 3.3	*	23.6 ± 1.8	23.3 ± 2.2	N.S.
Bandages	18/9	34.8 ± 3.8	32.6 ± 3.1	**	25.2 ± 2.1	22.3 ± 1.7	**

C: clinical class in CEAP classification; Pre: at initial visit; 1 M: after 1 month of compression therapy; NS: not significant.

P < 0.05, **P < 0.01.

Among the patients with C4 symptoms (Table 4), the greatest rate of improvement was achieved by using an appropriate size strong stocking (100%), and bandages (91%), followed by an oversize strong stocking (79%). With an appropriate size moderate stocking, improvement of the symptoms were achieved in only 60% of the patients, although the differences among the groups did not reach statistical significance.

Table 4.

Changes in symptoms after 3 months in C4 patients.

	N	Improved
Appropriate size strong stocking	2	2 (100%)
Oversize strong stocking	14	11 (79%)
Appropriate size moderate stocking	5	3 (60%)
Bandages	11	10 (91%)

In 20 patients with C6 symptom, the ulcer size (long axis × short axis) was significantly reduced from 4.8 ± 2.2 × 3.6 ± 1.8 cm to 1.7 ± 2.5 × 1.1 ± 1.8 cm during 3 months of compression therapy using bandages (P < 0.0001). As long as bandages were regularly and properly applied, which was confirmed in 90% of this study group, ulcer sizes reduced without exception, independent of pathology, and they later healed.

Discussion

The major findings in this study were as follows: first, as age increased, the rate of functional venous insufficiency increased; second, only a few elderly patients preferred applying appropriate size strong stockings, but rather they preferred oversize strong stockings, appropriate size moderate stockings, and bandages equally; and third, the efficacy of a moderate stocking seemed inferior to that of other compression methods.

In Japan, the number of patients with severe motion disabilities has been increasing over the past 50 years, particularly among people over 60 years of age. Those who are burdened with gait disturbance generally become immobile and need to sit on chairs, beds, or wheelchairs for prolonged periods, resulting in functional CVI.⁹ This also seems to be true in Western countries.¹³ From our results, it appeared that the rate of functional CVI increased as age increased. Indeed, the management of functional CVI is certainly a developing worldwide problem. So far, this unavoidable and growing condition can be managed only by proper compression, and not by medication and/or surgery.

It is generally accepted that compression stockings which exert an IP > 40 mmHg are not only difficult to apply, but are also not well tolerated during rest.² However, most of our patients > 65 years old felt this way even with an IP > 30 mmHg, which made us realize that practical alternatives were essential. Therefore, in addition to lower pressure stockings, we also recommend oversize stockings in this situation. This is because the IP obtained by a 3-size too large strong stocking was between that achieved by appropriate size strong and moderate stockings, and the impacts of these stockings on venous hemodynamics were similar.^12,14 Also, for using bandages, we employed an original technique created particularly for the elderly to apply the bandages easily and stably. Since variable tension causes unpredictable IP under bandages, which results in an uncontrollable compression therapy, we instructed the patients not to stretch the bandages. Using this technique, the IP increases linearly according to the number of bandages,^10,11 which makes them easier to control. Moreover, since this technique can be practiced with only one hand, even patients with a paralyzed hand or fixed fingers can apply bandages by themselves. Our results revealed that patients’ preferences were almost equal among using an appropriate size moderate stocking, an oversize strong stocking, and bandages.

However, the efficacy of these compression methods did not seem equal. Bandages provided promising results in C3-6 patients. On the other hand, the efficacy of a moderate stocking seemed to be less than the other compression methods. Namely, the amount of edema reduction and the rate of improvement of C4 symptoms tended to be lower than the other methods. However, with the oversize strong stocking, the clinical results were somewhat between those achieved by bandages and moderate stockings in terms of adherence to and improvements of C3, 4 symptoms. It has been reported that leg edema may be controlled by an IP of 20–30 mmHg,¹⁵ but 30–40 mmHg is necessary to manage the symptoms of C4b or greater.² This may be confirmed in our current study. Namely, although the adherence to moderate stockings was best, its improvement rate of C4 symptoms tended to be lower compared to the other compression methods. Additionally, its amount of edema reduction was also smaller. However, we should note that elderly patients with CVI often prefer to tolerate incomplete resolution of symptoms rather than applying intolerably strong compression. Namely, many patients only hope for reasonable improvements in the sensation of heaviness, tightness, pain, or prevention of ulcer formation and/or weeping vesicles, rather than complete resolution. Therefore, cautious dictation of patients’ complaints and accurate recognition of their current disease status and prognosis are necessary to prescribe reasonable compression material and IP/stiffness.

In the current study, roughly 20% of patients in all age groups rejected compression therapy, which was consistent with the results reported by Raju et al.¹⁶ Therefore, an effort should be made to reduce the number of these rejections by being attentive and providing repeated explanation and guidance. A treatment option other than compression may be required, but this seems unrealistic as long as people live under gravity.

Limitations

Since this study was a single-center, retrospective study that included a limited number of subjects, reaching a definite conclusion was difficult. The patients’ preferences for different compression methods naturally vary depending on treatment policy and options available in each clinic. For instance, our patients’ adherence to an appropriate size strong stocking might be extremely low. This may be due to our recommendation of using oversize or lower-pressure stockings. Thus, this may not be true in other clinics. When the combination of different methods, such as bandages on stockings, was included, the results could be entirely different. Therefore, the validity of using various alternative compression methods should be tested in a larger multicenter study.

Conclusion

In the current study, we found that only a few elderly patients preferred an appropriate size strong stocking. As alternatives, an oversize strong stocking, an appropriate size moderate stocking, and bandages were equally preferred. However, the best adherence was achieved by using an appropriate size moderate stocking, but its efficacy seemed to be the poorest. The best treatment effect was achieved by using bandages and maintaining reasonable adherence, although bandages are bulky in nature. An oversize strong stocking showed reasonably good efficacy and adherence but was not best in either respect. Therefore, it seems necessary for us to prescribe compression methods based on both medical and practical points of view.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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