Graves’ (Thyroid) Disease in Older Adults
What do the following patients over the age of 60 years have in common?
- A 72 year old woman with “fluttering of the heart” and unclear chest discomfort on climbing stairs
- An 80 years of age man with severe constipation who drops off to sleep typically
- A 65 years of age female who has actually lost strength in her legs, triggering difficulty in climbing stairs; she has actually just recently lost 15 lbs in spite of an excellent cravings
- A 75 year old lady who has developed problem swallowing and a dry cough, accompanied by hoarseness, weight gain, and dry, itchy skin
- A 78 year old man with hearing loss
- An 84 years of age female in whom a hand tremor has actually caused her to give up favorite activities. She is so depressed that she will not eat, and she has lost 12 pounds in the last 4 months.
All of these patients have abnormal function of their thyroid glands. Patients 1, 3 and 6 have hyperthyroidism, that is, extreme production of thyroid hormonal agent by their thyroid glands. Patients 2, 4 and 5 have hypothyroidism, or reduced production of thyroid hormonal agent. While some of the symptoms of hyperthyroidism and hypothyroidism resemble those in younger patients, it is not unusual for both hyperthyroidism and hypothyroidism to be manifest in subtle ways in older patients, often masquerading as diseases of the bowel or heart or a disorder of the nervous system. An important hint to the existence of thyroid disease in a senior patient is a history of thyroid disease in another close relative such as a brother, sister or child of the patient.
Graves’ (Thyroid) Disease in Older Adults
HYPERTHYROIDISM IN THE OLDER PATIENT
As in all hyperthyroid patients, if there is too much thyroid hormone, every function of the body tends to speed up (see Hyperthyroidism brochure). However, while the younger patient frequently has several symptoms associated with the overactive thyroid, the senior patient may just have a couple of symptoms. For instance, patient number 1, above, experienced only an experience of her heart fluttering, and some chest discomfort on climbing up stairs. Other patients might likewise have couple of symptoms, such as patient number 6, whose main symptoms are anxiety and tremor. Such a patient may withdraw from interactions with family and friends.
Also read: Parathyroid Hormone (PTH) Blood Test
TREATMENT OF THE OLDER PATIENT WITH HYPERTHYROIDISM
Just like younger patients, treatment of hyperthyroidism in the older patient consists of antithyroid drugs and radioactive iodine (see Hyperthyroidism sales brochure). Surgery is hardly ever advised due to increased operative risks in the older patient. While Graves’ disease is still a common cause of hyperthyroidism, harmful nodular goiter is seen more often in the older patient. During therapy, the results of modification in thyroid function on other body systems should be carefully kept track of, due to an increased probability of co-existing cardiac, central nerve system and thyroid disease in older patients. Frequently, thyroid function is brought under control first with antithyroid drugs (propylthiouracil or methimazole (Tapazole ®) )prior to conclusive treatment with radioactive iodine.
During the initial phase of treatment, doctors will observe cardiac function closely due to the impact of changing thyroid hormone levels on the heart. Symptoms of hyperthyroidism might be brought under control with adjunctive medications, such as beta-adrenergic blockers (propranolol [Inderal ®], metoprolol [Lopressor ®], which are typically provided to slow a fast heart rate, although they need to be given with care in the patient with co-existing congestive heart failure and the dose should be minimized when thyroid function is controlled in the normal variety. Symptoms and signs of angina pectoris and heart failure must be dealt with in tandem with the treatment to bring thyroid function under control.
As soon as thyroid function is kept in the normal variety with oral medication, the doctor and patient can decide on conclusive treatment with radioactive iodine together. There is some controversy about what the normal level of TSH is for senior patients. In general, an effort is made to render thyroid function either normal or low in a senior patient treated with radioactive iodine. Treatment of an underactive thyroid condition (hypothyroidism) is typically more straightforward than the problem of persistent hyperthyroidism in the older patient, because of the effect hyperthyroidism can have on the heart, as suggested above. A frequent scientific concern is the treatment of patients with normal T4 and T3 with suppressed TSH. An isolated low TSH is particularly typical in older patients. A lot of clinicians will follow these patients, without treatment unless they are symptomatic.
Also read: Thyroid Cancer (Papillary Carcinoma)
HYPOTHYROIDISM IN THE OLDER PATIENT
Hypothyroidism is typical in patients over 60 years of age and steadily increases with age (see Hypothyroidism sales brochure). Approximately 1 in 4 patients in assisted living home might have undiagnosed hypothyroidism. Unlike symptoms of hyperthyroidism, the symptoms of hypothyroidism are extremely non-specific in all patients, even more so in the older patient. Just like hyperthyroidism, the frequency of several symptoms reduces in the older patient. For instance, amnesia or a decline in cognitive performance, frequently attributed to advancing age, might be the only symptoms of hypothyroidism present. Symptoms and signs of hypothyroidism might consist of weight gain, drowsiness, dry skin, and constipation, however lack of these symptoms does not rule out the medical diagnosis. To make this diagnosis in the elderly patient, a doctor often requires a high index of suspicion. Clues to the possibility of hypothyroidism consist of a positive family history of thyroid disease, previous treatment for hyperthyroidism, or a history of extensive surgery and/or radiotherapy to the neck.
A choice to treat the patient with a new medical diagnosis of hypothyroidism will rest on numerous elements, 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 physicians will repeat the test in 3-4 months and choose to begin thyroid hormone replacement when the TSH level remains above the normal range. The presence or lack, and severity, of thyroid-related symptoms and co-existing diseases such as coronary artery disease or heart failure will identify the dose of thyroid hormone replacement that is provided.
Also read: Complications of Hypothyroidism
TREATMENT OF THE OLDER PATIENT WITH HYPOTHYROIDISM
As with the younger patient, pure artificial thyroxine (L-T4), taken daily by mouth, completely replaces the function of the thyroid gland and effectively treats the symptoms of hypothyroidism in many patients (see Thyroid Hormone Treatment brochure). In particular, treatment of the older hypothyroid patient should take into consideration that complete thyroid hormone replacement need not happen quickly, and in fact may put stress on the heart and main nerve system if accomplished too quickly. Rather, hormonal agent treatment is normally begun slowly with a partial daily dosage, in order to allow the heart and central nervous system to adjust to increasing levels of thyroid hormone. The patient and member of the family need to be aware of a possible increase in angina, shortness of breath, confusion and modification in sleep practices, and inform the recommending doctor if these happen.
Treatment might therefore begin with L-T4 in a dose of 25 to 50 micrograms daily, and the dose increased in steps every 4-6 weeks till the lab tests reveal a gradual return of blood thyroid hormonal agent and thyroid-stimulating hormone (TSH) levels to the normal range. Older patients without any evidence of heart disease, stroke or dementia may be started on larger doses (for example, half of the prepared for full replacement dose) and continue to complete hormonal agent replacement more quickly. In patients who experience increased angina pectoris, symptoms of congestive heart failure, or psychological modifications such as confusion will have to have their dose of L-T4 decreased, then more slowly increased over a number of months’ time.
Also read: Herbal Treatment for Hypothyroidism
Thyroid conditions have no age limits; certainly, hypothyroidism is clearly more common in older than in more youthful adults. Despite the increased frequency of thyroid issues in older individuals, doctors need a high index of suspicion to make the diagnosis given that thyroid disorders typically manifest as a condition of another system in the body. Older patients with thyroid conditions require unique attention to gradual and mindful treatment, and, as always, require long-lasting follow-up.