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DownloadHypothyroidism in Gerontology
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Hypothyroidism in a Geriatric Patient
Hypothyroidism affects approximately 5% of individuals above 60 years of age. It may be due to different causes such as resection of the thyroid gland or gland failure. Failure or damage to the pituitary gland may also cause hypothyroidism due to absent or decreased secretion of thyroid stimulating hormone (TSH). Hypothyroidism affects multiple organ systems thus disrupting their standard functions. However, the severity of the condition varies considerably from unrecognized disease to striking myxedema. This paper discusses various aspects of the illness and pertinent points regarding its occurrence within the geriatric population. Though a potentially fatal condition, hypothyroidism can be managed efficiently.
Presentation
The clinical presentation of hypothyroidism differs remarkably among patients. Mild hypothyroidism may not be readily detected due to gentle presentations and requires screening of the serum TSH for diagnosis (Fitzgerald, 2017). Patients with hypothyroidism usually have nonspecific symptoms such as weight gain, depression, weakness, fatigue, arthralgia, dyspnea on exertion, constipation, dry skin, Raynaud syndrome among others. Less common manifestations of hypothyroidism include poor appetite, decreased auditory acuity, diminished sense of smell and taste, neck discomfort, dysphagia, and amenorrhea. Findings during the physical examination include thin, brittle nails, diastolic hypertension, peripheral edema, pallor, carotenemia, bradycardia, and delayed tendon reflexes.
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Although elderly patients may present with the classic symptoms of hypothyroidism, their complaints are less specific than those of younger patients. Medical professionals often falsely attribute mild presentation of the illness to the aging process which includes symptoms such as dry skin, fatigue, and lack of concentration. Fatigue is the most common manifestation among elderly patients, with more than 50% of patients reporting with this symptom (Bensenor, Olmos, & Lotufo, 2012). Patients suffering from Hashimoto thyroiditis often indicate dyspnea and wheezing. Common neurologic manifestations of hypothyroidism among the elderly population are hypogeusia, dysgeusia, diminished auditory acuity, and ataxia (Bensenor, Olmos, & Lotufo, 2012). The least common manifestation of this population is muscle cramps, weight gain, cold intolerance, and paresthesias (Bensenor, Olmos, & Lotufo, 2012). It is essential to appreciate the unique indications of hypothyroidism among the elderly to facilitate early diagnosis and treatment. Recognition of these signs and symptoms also simplifies distinguishing the condition from other differential diagnoses including anemia and depressive disorder.
Pathological Basis
Physical and functional changes in the thyroid gland that accompany aging facilitate the high occurrence of hypothyroidism among the geriatric population. Foremost, the thyroid gland undergoes progressive atrophy and fibrosis leading to a decreased in its volume. This decrease is mostly attributed to the increase in the prevalence of autoantibodies with age, stretching to about 20% in women over 60 years old – the most common cause of hypothyroidism in the elderly is autoimmune thyroid failure (Kim, 2017). Iatrogenic hypothyroidism is another important cause; prescription of drugs which may cause hypothyroidism such as lithium, radioactive iodine, and amiodarone is higher among the elderly (Kim, 2017). Iodine uptake by the thyroid decreases with age, leading to a decrease in the secretion of T3. Despite extensive research, it is yet to be affirmed why the disease presents variably among individuals of different age groups.
Comorbidities Affecting Treatment
Coronary artery disease (CAD) is the most pertinent comorbidity considered while managing an elderly patient with hypothyroidism. CAD arises due to the deposition of cholesterol-containing plaques in the coronary arteries – which supply blood to the heart muscles. Decreased blood flow to the myocardium results in angina pectoris and complete blockage may cause a myocardial infarction. The incidence of coronary artery disease increases with age. Hypothyroidism aggravates this condition because a deficiency in thyroid hormones causes a decrease in the uptake of lipids by different body tissues (Ajish & Jayakumar, 2012). Hypothyroidism is managed by giving replacement therapy to the thyroid hormones. Presence of significant cardiac disease should prompt rationing of the replacement therapy because their vigorous administration would increase the myocardial oxygen demand substantially and may result in angina pectoris, myocardial infarction, and cardiac arrhythmias. Moreover, the medical practitioner should investigate the patient for osteoporosis. This condition refers to the progressive degeneration of the bone matrix which additionally worsens with age (Kim, 2017). Replacement therapy should be blunted in such patients since it may inadvertently accelerate bone degeneration.
Important Considerations for the Nurse Practitioner
It is crucial for the nurse practitioner to distinguish between primary and secondary hypothyroidism before initiating a treatment and care plan. This differentiation is usually realized during diagnosis. In both conditions, there are low levels of thyroid hormones in serum. However, the TSH levels in serum are elevated in primary hypothyroidism and low in secondary hypothyroidism. The nurse should interpret thyroid function tests carefully particularly in patients with underlying illnesses – critical illness may mimic secondary hypothyroidism and readings from patients in the recovery phase may resemble primary hypothyroidism (Papaleontiou & Haymart, 2012).
In both states, the nurse should begin courses of replacement therapy for thyroid hormones. Nonetheless, one should always remember that elderly patients are more sensitive to the administration of exogenous thyroid hormones. Therefore, the administration should be started at lower doses and adjusted appropriately based on patient response. The recommended starting dose for patients without cardiac disease is 25 mg/day and 12.5 mg/day in patients with cardiac comorbidity (Papaleontiou & Haymart, 2012). After the evaluation of the cardiovascular tolerance, the daily dose may be increased by 12.5-25 mcg every four weeks until an adequate replacement is achieved and confirmed by serum analysis. It is important to remember that TSH may take longer to normalize in the geriatric population with primary hypothyroidism. Therefore, slight elevation of the TSH with normal levels of T3 and T4 should not warrant an increase in the replacement therapy.
A vigorous course of replacement therapy is allowed in patients with myxedema coma. This is a life-threatening condition which occurs commonly among elderly women and is induced by various factors in the hypothyroid patient such as stroke, heart failure, and trauma. The nurse should administer more massive doses of levothyroxine intravenously beginning with a 500mcg loading dose followed by 50-100mcg daily. The nurse should also manage other associated symptoms such as administration of 5% dextrose for hypoglycemia, 0.9% saline for mild hyponatremia, and a blanket for hypothermia. Patients with secondary hypothyroidism usually have cortisol and gonadotropin deficiency (Kim, 2017). If the patient is suspected to have cortisol deficiency, the nurse should begin with a course of cortisol replacement before initiating thyroid hormone replacement to prevent an adrenal crisis.
Patient Education
Patients should be taught about the nature of their condition – notably that it is mostly due to unpreventable causes such as Hashimoto thyroiditis and gland resection. However, patients can be informed about the classic presentation of the illness and the necessity of seeing a medical professional earliest when the symptoms appear. They should be instructed to take their medication as directed and the need to attend all the appointments scheduled by their careers. I would deliver this information personally to the patient in a one-on-one session. I will simplify the information and write significant and important points on a piece of paper to facilitate quicker comprehension and recollection.
Summary
As seen, hypothyroidism affects approximately 5% of individuals above 60 years of age. It may be due to different causes such as resection of the thyroid gland or gland failure. Failure or damage to the pituitary gland may also cause hypothyroidism due to absent or decreased secretion of thyroid stimulating hormone (TSH). The paper identifies that patients with hypothyroidism usually have nonspecific symptoms such as weight gain, depression, weakness, fatigue, arthralgia, dyspnea on exertion, constipation, dry skin, Raynaud syndrome among others. Of special concern for this paper was to note that although elderly patients may present with the classic symptoms of hypothyroidism, complaints are less specific than those of younger patients. Medical professionals often falsely attribute mild presentation of the illness to aging process which includes symptoms such as dry skin, fatigue, and lack of concentration. The paper is concluding by recommending that patients should be taught of the nature of their condition which is notably due to unpreventable causes such as Hashimoto thyroiditis and gland resection. However, patients can be informed about the classic presentation of the illness and the necessity of seeing a medical professional earliest when the symptoms appear.
References
Ajish, T. P., & Jayakumar, R. V. (2012). Geriatric Thyroidology: An update. Indian Journal of Endocrinology and Metabolism, 16(4), 542–547.
Bensenor, I. M., Olmos, R. D., & Lotufo, P. A. (2012). Hypothyroidism in the elderly: diagnosis and management. Clinical Interventions in Aging, 7, 97–111.
Fitzgerald, P. A. (2017). Endocrine disorders. In: Papadakis, M. A., McPhee, S. J., & Rabow, M. W., editors. Current Medical Diagnosis and Treatment. New York: McGraw Hill.
Kim, M. I. (2017). Hypothyroidism in the elderly. In: De Groot, L. J., Chrousos, G., Dungan, K., et al., editors. Endotext. South Dartmouth (MA): MDText.com, Inc.
Papaleontiou, M., & Haymart, M. R. (2012). Approach to and treatment of thyroid disorders in the elderly. Medical Clinics of North America, 96(2), 297-310.
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