Thyroid and elderly sameer aggarwal

How common are thyroid problems in older people?

If thyroid gland is hyperfunctioning it is called as Hyperthyroidism and if thyroid gland is underfunctioning it is called as state of Hypothyroidism. Thyroid underfunction is about twice as common as overfunction. Thyroid problems are more common in older women than in men. Thyroid gland enlargement can be diffuse or nodular. Occasionally thyroid enlargements are calcified thyroid nodules. Although these calcified nodules may in fact be benign, it is generally advisable to biopsy them to determine their exact cause.

 

Symptoms of thyroid gland dysfunction

Symptoms of hyperthyroidism and hypothyroidism are similar to those in younger patients. It is not uncommon for both hyperthyroidism  to  manifest in subtle ways in older patients, often masquerading as diseases of the bowel or heart or a disorder of the nervous system like history of  tremors,weight loss, palpitations, osteoporosis, depression and psychiatric manifestations. Unlike symptoms of hyperthyroidism, the symptoms of hypothyroidism are very non-specific in all patients, even more so in the older patient. Memory loss or a decrease in cognitive functioning, often attributed to advancing age, may be the only symptoms of hypothyroidism present.  Hypothyroidism usually presents with history of lethargy, change in voice, weight gain, cold intolerance, constipation.

Clues to the possibility of hypothyroidism include a positive family history of thyroid disease, past treatment for hyperthyroidism, or a history of extensive surgery and/or radiotherapy to the neck

 

 

Tests Required:

 

T3/T4/ TSH
TSH comes from the base of the brain and stimulates the production of thyroid hormone (T3/T4). When there are low levels of thyroid hormone (T3/T4) in the body, more TSH is produced by the brain to stimulate the thyroid to produce more thyroid hormone.
When there are high levels of thyroid hormones( T3/T4 ) in the system, less TSH is produced to signal the thyroid to produce less.

 

Imaging

If thyroid gland enlargement is nodular patient may require Ultrasound of thyroid and thyroid scanning followed by FNAC (Needle aspiration of nodule)

 

Treatment

 

Hyperthyroidism

Treatment of the older patient with hyperthyroidism includes antithyroid drugs and/or radioactive iodine. Surgery is less preferred because of old age and increased operative risks in the older patient. While Graves’ disease is still a common cause of hyperthyroidism, toxic nodular goiter is seen more frequently in the older patient. However, for many toxic nodular goiters, surgery is the only preferred option as they are huge. During therapy, the effects of change in thyroid function on other body systems must be monitored, due to an increased likelihood of co-existing cardiac, central nervous system and thyroid disease in elderly patients. Most often, thyroid function is brought under control first with antithyroid drugs (carbimazole or methimazole) before definitive treatment with radioactive iodine or surgery. During the initial phase of treatment, doctors will observe cardiac function closely due to the effect of changing thyroid hormone levels on the heart. Symptoms of hyperthyroidism may be brought under control with adjunct medications, such as beta blockers (propranolol, metoprolol) which are often given to slow down a rapid heart rate, although they must be given with caution in the patient with co-existing congestive heart failure and the dose should be reduced once thyroid function is controlled in the normal range.

Once thyroid function is maintained in the normal range with oral medication, the doctor and patient can make a decision on definitive treatment with radioactive iodine or surgery.

A frequent concern is the treatment of patients with reports of normal T4 and T3 with suppressed TSH. An isolated low TSH is particularly common in older patients. Most clinicians will follow these patients, without treatment unless they are symptomatic or if they are having irregular heart rate or osteoporosis.

 

Hypothyroidism

A decision to treat the patient with a new diagnosis of hypothyroidism will depend on several factors, including whether the patient is symptomatic from hypothyroidism, or just has an elevated thyroid-stimulating hormone (TSH) level. In the case of the latter finding, many doctors will repeat the test in 3-4 months and elect to begin thyroid hormone replacement when the TSH level stays is more than equal to 10 mIu/ML. The presence or absence, and severity, of thyroid-related symptoms and co-existing diseases such as coronary artery disease or heart failure will determine the dose of thyroid hormone replacement that is given.

Treatment of the older patient with hypothyroidism is as with the younger patient. Thyroxine (LT4) tablets, taken once daily by mouth in fasting state, fully replaces the function of the thyroid gland and successfully treats the symptoms of hypothyroidism in most patients. Thyroid hormone treatment is usually begun slowly with a partial daily dose, in order to allow the heart and central nervous system to adjust to increasing levels of thyroid hormone. The patient and family members must be aware of a possible increase in angina, shortness of breath, confusion and change in sleep habits, and notify the prescribing physician if these occur. Treatment may therefore begin with LT4 in a dose of 25 to 50 micrograms daily, and the dose increased in steps every 4-6 weeks until the laboratory tests show a gradual return of blood thyroid hormone and thyroid-stimulating hormone (TSH) levels to the normal range. Older patients with no evidence of heart disease, stroke or dementia may be started on larger doses (for example, half of the anticipated full replacement dose) and proceed to full hormone replacement more quickly. In patients who experience increased angina pectoris, symptoms of congestive heart failure, or mental changes such as confusion will need to have their dose of LT4 decreased, then more gradually increased over several months’ time.

Summary

Thyroid disease have no age limits.

Definitive treatment of thyroid disorders is available.

Prevalence of Hypothyroidism is clearly more common in older than in younger adults. Physicians need a high index of suspicion to make the diagnosis since thyroid disorders often manifest as a disorder of another system in the body. Older patients with thyroid disorders require special attention to gradual and careful treatment, and require lifelong follow-up. Patients will have a normal life span if given proper treatment and care.

 

This webpage is edited by Dr. Sameer Aggarwal.

Dr. Sameer is an expert Endocrinologist and is currently working as Consultant Endocrinology at PGIMS, Rohtak (Haryana) India.