Follow-up of mild hypothyroidism in a nursing home

Hypothyroidism and subclinical hypothyroidism in the older patient

OBJECTIVE

To review the etiology, precipitating factors, clinical findings, screening recommendations, and treatment for primary hypothyroidism and subclinical hypothyroidism in the older patient.

DATA SOURCES

A PubMed search of English language articles using a combination of words: elderly, thyroid, hypothyroid,* subclinical hypothyroid,* etiology, screening, diagnosis, and treatment to identify original studies, guidelines, and reviews on primary hypothyroidism and subclinical hypothyroidism published between 1979 and present.

STUDY SELECTION AND DATA EXTRACTION

Overall, 51 clinical reviews, original studies, references, and guidelines were obtained and evaluated on their clinical relevance to the older patient population.

DATA SYNTHESIS

The literature included guidelines and considerations for the diagnosis, screening, and management of subclinical and overt primary hypothyroidism in the older patient.

CONCLUSION

Females and individuals 60 years of age or older have a higher prevalence of primary hypothyroidism and subclinical hypothyroidism. While screening recommendations exist, the need or suggested age to initiate screening varies among organizations. TSH and free T4 values are used for diagnosing and monitoring. Levothyroxine remains the drug of choice for replacing endogenous thyroid hormone. Despite evidence to suggest its need, the treatment of subclinical hypothyroidism remains controversial.

Subclinical hypothyroidism in the elderly

Grade 2,3 and 4 hypothyroidism in the elderly, globally defined as subclinical hypothyroidism, is the object of this minireview. Attention is focused on the prevalence, on the causes and particularly on the clinical features that, in spite of the definition, frequently occur: these are summarized in cognitive impairment, mood disorders, lipid dysmetabolism, cardiovascular abnormalities. Finally a diagnostic algorithm is proposed for the selection of patients to be treated. The authors are of the opinion that a general screening with serum TSH assay for elderly hospitalized patients is worthwhile.

Diagnosing and managing thyroid disease in the nursing home

Thyroid disorders occur at any age, but hypothyroidism is more common in older than in younger adults. In fact, the prevalence of thyroid disorders increases with age, and it is higher in old-old frail residents in nursing homes. Since thyroid diseases in older age, both overt reduced and increased function, may manifest as disorders of other organs, physicians need a high index of suspicion to detect thyroid dysfunction in an older person with multiple comorbidities and chronic polypharmacy. This is particularly true for residents of long-term facilities, where multiple chronic diseases may make it less attractive to direct attention to thyroid function. Subclinical hyperthyroidism and hypothyroidism, more frequently seen in older populations, have been linked to increased total and cardiovascular mortality. Since chronic diseases are more prevalent in old age, nonthyroidal illness is also seen frequently in this age group. Although, there is still debate on the decision to treat or not to treat subclinical thyroid disorders, current recommendations state the necessity of considering treatment on an individual basis according to symptomatology and to the possible benefit that the older person may obtain with treatment, discouraging extended screening and treatment in the community population of subjects older than 65. However, in the long-term setting, the possibility of thyroid dysfunction can be more often investigated, and the consideration of treatment and follow-up is needed to improve quality of life of affected older people.

Does age play a role in clinical presentation of hypothyroidism?

OBJECTIVE

To determine if aging modifies the clinical presentation of hypothyroidism.

DESIGN

Comparison of 24 clinical signs of hypothyroidism between elderly patients (> or = 70 years of age) and younger patients (< or = 55 years of age).

SETTING

Prospective study of patients with chemically confirmed overt hypothyroidism.

PATIENTS

Sixty seven elderly patients (79.3 +/- 6.7 years) and 54 younger patients (40.8 +/- 9 years) were included in the study.

RESULTS

Neither mean duration of evolution nor mean thyroid-stimulating hormone (TSH) level were different between the 2 groups. Two signs were found in more than 50% of the elderly patients (fatigue and weakness). Four signs were significantly less frequent in elderly patients (chilliness, paresthesiae, weight gain, and cramps). Mean number of clinical signs in the elderly (6.6 +/- 4) was significantly smaller than in young patients (9.3 +/- 4.7) (P < 0.01).

CONCLUSIONS

Our results suggest that the presentation of hypothyroidism is altered in the elderly in comparison with young patients in that there are (1) fewer signs or symptoms and (2) diminished frequency of some classical signs. Our results underline the importance of TSH measurement in the elderly.