Endocrine Considerations in the Elderly Lecture Powerpoint Flashcards
Recall the hypothalamic pituitary thyroid axis
Hypothalamus secretes TRH, pituitary releases TSH, thyroid releases T4 mostly and a little T3
Aging and the thyroid gland (4)
- thyroid gland becomes smaller and denser
- pituitary TSH doesn’t change
- T3 and T4 production declines
- thyroid hormone action decreases
Most common thyroid disease in the elderly
Subclinical hypothyroid disease (elevated TSH with normal serum T4)
Hypothyroidism common presentation in elderly (4)
- peaks in the 7th decade
- women 3-10x more than men
- cold intolerance
- mild symptoms that can take years
Most common cause of hypothyroidism in the dlerly
Hashimoto’s disease (autoimmune destruction of thyroid tissue)
Drugs that can cause hypothyroidism (5)
- amiodarone
- lithium
- phenytoin
- carbamezapine
- gleevac
Myxedema coma in the elderly
Initial presentation of hypothyroidism more often in elderly populations but still relatively rare (sees frank psychosis, drop in mental status and associated CO2 retention following depressed respriatory drive, and coma) - is life threatening and rare
Hypothyroidism sees a link with ___ and ___ in the elderly
dementia, carpal tunnel syndrome
Overt hypothyoridism
Elevated TSH with low T4
Thyroid replacement therapy
For overt hypothyroidism, 25 mcg initially of levothyroxine starting at a low dose (already at increased risk for cardiac complication) and increase in increments of 25 mcg
When should subclinical hypothyroidism be treated?
If it becomes overt, or if TSH is consistently elevated above 10 uU per mL, or at provider discretion
Most common causes (2) of hyperthyroidism in the elderly
Multinodular goiter and graves disease
Most common hyperthyroidism in the elderly
Subclinical hyperthyroidism (low TSH with normal T4)
Hyperthyroidism signs and symptoms (5)
- anxiety/depression
- tremors
- weight loss
- lid lag
- heat intolerance
2 evals for hyperthyroidism
- Anti TSH receptor antibodies (rule out graves disease)
- radioactive iodine uptake
Hyperthyroidism treatment options (3)
- medications (methimazole or propylthiouracil)
- radioactive iodine
- surgery as back up
Thyroid storm
Acute hyperthyroidism, occurs after operation, trauma, infection or radiaoactive idoine therapy that causes fever, confusion, agitation and potentially coma or death, life threatening but low death rate compared to myxedema (not as common as myxedema either)
3 most common presenting symptoms in elderly with diabetes
Incontinence and confusion, up to 50% may be asymptomatic
Diabetes types and geriatric populations
Majority are type 2, but CAN see type 1 typically in thinner lean active geriatric patients
Medication causes of diabetes (4)
- high dose or long term steroid use
- thiazide diuretics
- statins
- furosemide
Most common 3 presenting symptoms in young with diabetes
Polyuria, polydipsia, polyphagia
Renal threshold and the elderly
Value at which glucose is spilled into urine, typically 160-180 but is higher in the elderly therefore urinalysis not a good measure to check
Why are elderly more susceptible to hypoglycemia
Glucose regulatory mechanisms are altered with age, such as glucagon and epinephrine, and might not present symptoms (diaphoresis, fatigue, etc) until exceptionally lower
Complications of untreated hypoglycemia in elderly (3)
- may precipitate stroke
- MI
- injury from trauma during syncope
Large and small vessel complications of untreated diabetes in the elderly (4)
- peripheral vascular dz
- retinopathy (cataracts)
- nephropathy
- neuropathy
Hyperglycemic hyperosmolar nonketoic syndrome in geriatrics
More often seen in elderly (kids see diabetic ketoacidosis more often, has no ketones present and patient is NOT acidotic), associated with severe dehydration and severe electrolyte disturbances often due to underlying kidney problems, decreased sensation of thirst or access to water
Diabetes screening guidelines USPTF
At risk adults 45 (obese or overweight) and repeat every 3 years
Diagnosis made on basis of fasting glucose >126, random value >200, or A1C >6.5%
What HbA1C are geriatric patients treated at?
8% ( a little wiggle room)
Sulfonyurea mechanism of action vs biguanides (metformin)
Sulfonyureas lower blood sugar by stimulating release of insulin, biguanides (metformin) decreases glucose release from the liver
