Peripheral arterial disease (PAD) in older adults: leg pain, risks and treatment

The NHS describes PAD as a common condition in which a build-up of fatty deposits (atheroma, made up of cholesterol and other waste) in the artery walls narrows them and restricts blood supply to the leg muscles, a process called atherosclerosis. It is a form of cardiovascular disease. The BHF adds that the same atherosclerosis causes coronary heart disease and angina, and that the two share risk factors.

The NHS lists smoking as the most significant risk factor, along with type 1 and type 2 diabetes, high blood pressure, high cholesterol and growing older.

Intermittent claudication is the main symptom: a cramp or pain in the leg muscles on walking, relieved by rest. The BHF says it can range from mild to severe, is relieved within 10 minutes, most often affects the calves, and can be in both legs or worse in one. Some people describe aching or burning. The NHS lists other possible signs: hair loss on the legs and feet, numbness or weakness, brittle slow-growing toenails, ulcers that do not heal, changing skin colour (paler or blue, which may be harder to see on brown and black skin), shiny skin, erectile dysfunction in men, and wasting of the leg muscles. The BHF adds burning or aching pain in the feet and toes at rest or during sleep.

Symptoms usually develop slowly. The NHS and BHF both say that symptoms developing quickly or suddenly worsening could need emergency treatment. For an older person who walks less, claudication may not be noticed because the legs are not pushed hard enough to bring it on, which is one reason foot ulcers or cold, pale feet are worth reporting.

The NHS says PAD is usually diagnosed by physical examination by a GP and by comparing the blood pressure in your arm and your ankle, a measure called the ankle brachial pressure index (ABPI). The BHF says some surgeries also use a Doppler scan to check how well blood flows in the legs, and that the GP will assess your risk of heart attack and stroke by checking blood pressure and cholesterol and asking about smoking and lifestyle. If diagnosis is difficult or circulation is very poor with ulcers or gangrene, referral to hospital for an MRI of the legs may follow.

The NHS says PAD is largely treated by lifestyle changes and medication. Regular exercise and not smoking are the main measures; also eating healthily, losing weight if overweight and moderating alcohol. The underlying high blood pressure, high cholesterol and diabetes should be treated too. The BHF explains that treatment aims to improve blood flow so enough oxygen reaches leg muscles on walking, and describes a supervised exercise programme encouraging you to walk to the point of feeling the pain, with the aim of increasing walking distance; if a supervised programme is not available, a healthcare professional supports home exercise.

If exercise and lifestyle do not help, the BHF says an angioplasty to open a blocked artery or a bypass operation may be considered, and if you do not want surgery you can discuss other options with the specialist team. With treatment, the NHS says most people's symptoms remain stable and some improve. For frailer older adults, the decision about procedures is made with the vascular team, balancing benefit against surgical risk.

The NHS says PAD is not immediately life-threatening, but atherosclerosis can cause serious and potentially fatal problems; blockages can affect arteries to the heart and brain, so PAD makes coronary heart disease, stroke, heart attack and angina more likely. Critical limb ischaemia (CLI) develops if blood flow becomes severely restricted. Its symptoms include severe burning pain in the legs and feet even at rest, pale, shiny, smooth, dry skin, wounds and ulcers that do not heal, loss of muscle mass, and cold, numb toes or lower limbs that turn red then black, swell or produce smelly pus (gangrene).

The NHS says to contact a GP immediately if you think you are developing CLI, or call 111 or use 111 online if that is not possible. An angioplasty or bypass graft is usually recommended, though may not always succeed or be possible, and in a few cases amputation may be needed. The BHF calls chronic limb-threatening ischaemia the end stage of PAD.

Stopping smoking is the single most useful step, according to the NHS ranking of risk factors. Walking regularly, even when it brings on discomfort, is the heart of the supervised programme described by the BHF. Checking your feet each day for sores, colour changes or coldness, wearing well-fitting shoes, and telling the GP or practice nurse about any wound that is not healing are sensible habits, particularly for people with diabetes, where numbness can hide injury. Taking prescribed blood pressure, cholesterol and antiplatelet or similar medicines as advised helps protect the heart and brain as well as the legs.