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ADDITIONAL PATIENT RESOURCES • WWW.THYROID.ORG
For further details on this and other thyroid-related topics,
please visit the patient resources section on the American
What do the following patients over the age of 60 years have incommon?
Hyperthyroidism in the older patient
1) A 72 year old grandmother with “fluttering of the heart” and vague
As in all hyperthyroid patients, if there is too much thyroid hormone, every
function of the body tends to speed up (see
2) An 80 year old man with severe constipation who falls asleep
However, while the younger patient often has multiple symptoms related
to the overactive thyroid, the elderly patient may only have one or twosymptoms. For example, patient number 1, above, experienced only a
3) A 63 year old retired grade school teacher who has lost strength
sensation of her heart fluttering, and some chest discomfort on climbing
in her legs, causing difficulty in climbing stairs and in carrying
stairs. Other patients may also have few symptoms, such as patient number
more than 3 books at a time; she has recently lost 15 lbs in spite
6, whose main symptoms are depression and tremor. Such a patient may
withdraw from interactions with friends and family.
4) A 75 year old grandmother who has developed difficulty
Treatment of the older patient with hyperthyroidism
swallowing and a dry cough, accompanied by hoarseness, weightgain, and dry, itchy skin;
As with younger patients, treatment of hyperthyroidism in the older patientincludes antithyroid drugs and radioactive iodine (see
5) A 78 year old retired musician whose family complains because
Surgery is rarely recommended due to increased operative risks
in the older patient. While Graves’ disease is still a common cause of
6) An 84 year old very energetic seamstress in whom a hand tremor
hyperthyroidism, toxic nodular goiter is seen more frequently in the older
has caused her to give up her favorite activity. She is so depressed
patient. During therapy, the effects of change in thyroid function on other
that she will not eat, and she has lost 12 lbs in the last 4 months.
body systems must be closely monitored, due to an increased likelihoodof co-existing cardiac, central nervous system and thyroid disease in older
All of these patients have abnormal function of their thyroid glands.
patients. Most often, thyroid function is brought under control first with
Patients 1, 3 and 6 have hyper
thyroidism, that is, excessive
antithyroid drugs (propylthiouracil or methimazole (Tapazole®)) before
of thyroid hormone by their thyroid glands. Patients 2, 4 and 5 have
definitive treatment with radioactive iodine.
thyroidism, or reduced
production of thyroid hormone. Whilesome of the symptoms of hyperthyroidism and hypothyroidism are
During the initial phase of treatment, doctors will observe cardiac function
similar to those in younger patients, it is not uncommon for both
closely due to the effect of changing thyroid hormone levels on the heart.
hyperthyroidism and hypothyroidism to be manifest in subtle ways
Symptoms of hyperthyroidism may be brought under control with
in older patients, often masquerading as diseases of the bowel or
adjunctive medications, such as beta-adrenergic blockers (propranolol
heart or a disorder of the nervous system. An important clue to the
[Inderal®], metoprolol [Lopressor®]), which are often given to slow a
presence of thyroid disease in an elderly patient is a history of
rapid heart rate, although they must be given with caution in the patient
thyroid disease in another close family member such as a brother,
with co-existing congestive heart failure and the dose should be reduced
This page and its contentsare Copyright 2005
once thyroid function is controlled in the normal range. Symptoms and
Treatment of the older patient with hypothyroidism
signs of angina pectoris and heart failure must be treated in tandem with
As with the younger patient, pure synthetic thyroxine (L-T ), taken
the treatment to bring thyroid function under control.
once daily by mouth, fully replaces the function of the thyroid gland
Once thyroid function is maintained in the normal range with oral
and successfully treats the symptoms of hypothyroidism in most
medication, the doctor and patient can make a decision on definitive
treatment with radioactive iodine together. In general, an attempt is made
treatment of the older hypothyroid patient must take into account that
to render thyroid function either normal or low in an elderly patient
full thyroid hormone replacement need not take place rapidly, and in
treated with radioactive iodine. Treatment of an underactive thyroid
fact may put stress on the heart and central nervous system if
condition (hypothyroidism) is usually more straightforward than the
accomplished too quickly. Rather, hormone treatment is usually
problem of recurrent hyperthyroidism in the older patient, because of
begun slowly with a partial daily dose, in order to allow the heart
the effect hyperthyroidism can have on the heart, as indicated above.
and central nervous system to adjust to increasing levels of thyroidhormone. The patient and family members must be aware of apossible 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 L-T in a dose of 25 to 50
micrograms daily, and the dose increased in steps every 4-6 weeks untilthe laboratory tests show a gradual return of blood thyroid hormoneand thyroid-stimulating hormone (TSH) levels to the normal range.
Hypothyroidism in the older patient
Older patients with no evidence of heart disease, stroke or dementiamay be started on larger doses (for example, half of the anticipated
Hypothyroidism is very common in patients over 60 years of age and
full replacement dose) and proceed to full hormone replacement
more quickly. In patients who experience increased angina pectoris,
patients in nursing homes may have undiagnosed hypothyroidism. Unlike
symptoms of congestive heart failure, or mental changes such as
symptoms of hyperthyroidism, the symptoms of hypothyroidism are very
confusion will need to have their dose of L-T decreased, then more
non-specific in all patients, even more so in the older patient. As with
gradually increased over several months’ time.
hyperthyroidism, the frequency of multiple symptoms decreases in theolder patient. For example, memory loss or a decrease in cognitive
functioning, often attributed to advancing age, may be the only symptoms
Thyroid disorders have no age limits; indeed, hypothyroidism is clearly
of hypothyroidism present. Symptoms and signs of hypothyroidism may
more common in older than in younger adults. Despite the increased
include weight gain, sleepiness, dry skin, and constipation, but lack of
frequency of thyroid problems in older individuals, physicians need
these symptoms does not rule out the diagnosis. To make this diagnosis
a high index of suspicion to make the diagnosis since thyroid
in the elderly patient, a doctor often needs a high index of suspicion.
disorders often manifest as a disorder of another system in the body.
Clues to the possibility of hypothyroidism include a positive family history
Older patients with thyroid disorders require special attention to
of thyroid disease, past treatment for hyperthyroidism, or a history of
gradual and careful treatment, and, as always, require lifelong follow-
extensive surgery and/or radiotherapy to the neck.
A decision to treat the patient with a new diagnosis of hypothyroidismwill rest on several factors, including whether the patient is symptomatic
ADDITIONAL PATIENT RESOURCES
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 above the normal range. 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.
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