Cushing's syndrome in the elderly: data from the European Registry on Cushing's syndrome

Abstract

Objective To evaluate whether age-related differences exist in clinical characteristics, diagnostic approach and management strategies in patients with Cushing’s syndrome included in the European Registry on Cushing’s Syndrome (ERCUSYN). Design Cohort study. Methods We analyzed 1791 patients with CS, of whom 1234 (69%) had pituitary-dependent CS (PIT-CS), 450 (25%) adrenal-dependent CS (ADR-CS) and 107 (6%) had an ectopic source (ECT-CS). According to the WHO criteria, 1616 patients (90.2%) were classified as younger (<65 years) and 175 (9.8%) as older (>65 years). Results Older patients were more frequently males and had a lower BMI and waist circumference as compared with the younger. Older patients also had a lower prevalence of skin alterations, depression, hair loss, hirsutism and reduced libido, but a higher prevalence of muscle weakness, diabetes, hypertension, cardiovascular disease, venous thromboembolism and bone fractures than younger patients, regardless of sex (p<0.01 for all comparisons). Measurement of UFC supported the diagnosis of CS less frequently in older patients as compared with the younger (p<0.05). An extra-sellar macroadenoma (macrocorticotropinoma with extrasellar extension) was more common in older PIT-CS patients than in the younger (p<0.01). Older PIT-CS patients more frequently received cortisol-lowering medications and radiotherapy as a first-line treatment, whereas surgery was the preferred approach in the younger (p<0.01 for all comparisons). When transsphenoidal surgery was performed, the remission rate was lower in the elderly as compared with their younger counterpart (p<0.05). Conclusions Older CS patients lack several typical symptoms of hypercortisolism, present with more comorbidities regardless of sex, and are more often conservatively treated.

Cushing's Syndrome in the Elderly

“…However, other authors reported that, in acute stress conditions, older adults showed overall lower cortisol and a lower stress-induced cortisol increase in comparison to younger adults [47]. In the ERCUSYN cohort, UFC concentrations less frequently supported the diagnosis of hypercortisolism in the older patients with pituitary CS in comparison to the younger, whereas other hormonal tests did not differ according to age [9].…”

“…Finally, whereas older CS patients typically presented with a significantly higher burden of comorbidities, including hypertension, diabetes, cardiovascular disease, and VTE , as compared with the younger, the prevalence of depression was lower in the former [9]. This surprising finding may be due to underdiagnosing.…”

“…Although the available data do not show any age-related differences in terms of delay in diagnosis, recognition of hypercortisolism in older patients may be difficult due to lack of the typical stigmata of CS in them and attribution of comorbidities to aging rather than hypercortisolemia [3,9]. Clinical presentation of ECS is frequently different from that in pituitary and adrenal CS, in that symptoms are more severe and their onset is more rapid.…”

“…Similarly, in the European Registry on Cushing's Syndrome (ERCUSYN) cohort containing 1519 subjects, patients with adrenal-dependent CS were significantly older than patients with pituitary-dependent CS [1]. When analyzing only the latter, older patients had more commonly a pituitary macroadenoma in comparison to the younger group [9]. On the contrary, in a study by Qiao at al.…”

“…Older CS patients more often experience bone fractures than their younger counterparts, partly due to age-related frailty and muscle weakness, which increase the risk of falls [9].…”