Hyperthyroidism in the Elderly

Abstract

It is not uncommon for thyrotoxicosis to appear in an atypical manner in older patients. The classical symptoms are often absent. The disease is frequently characterized by cardiac, gastrointestinal, neuromuscular, and neuropsychiatric symptoms. As hyperthyroidism is readily amenable to effective treatment that can improve the quality of life, the clinical suspicion of this disease is always indicated and exclusion of this diagnosis should always be pursued. Recognizing the admittedly great difficulty in making, or even suspecting, the diagnosis of hyperthyroidism in the elderly, our rule is to test for hyperthyroidism in essentially all geriatric patients presenting chronic systemic symptoms or signs. On the other hand, we do not recommend community-wide screening of persons over 60 for hyperthyroidism. Community-wide screening falls far below the break-even point in cost-benefit analysis. The most sensible detector of hyperthyroidism now widely available is the serum free T3 index (FT3I), but it may be falsely normal because of the effect of systemic illness on extrathyroidal T4-to-T3 conversion. The advent of ultrasensitive methods for TSH may change these statements considerably. It may become the single screening procedure for both hyper- and hypothyroidism.

Longitudinal evidence of the impact of normal thyroid stimulating hormone variations on cognitive functioning in very old age

“…These cutoff scores were chosen according to clinical recommendations in order to exclude subjects with potential thyroid-related disease. Thus, the lower limit for TSH was set at 0.4 mU/liter, and the upper limit at 5.0 mU/liter (Griffin and Solomon, 1986). For these reasons, subjects with TSH values outside the normal range at either of the two follow up assessments were excluded.…”

Thyrotoxicosis in the Elderly

“…As pointed out by Griffin and Solomon, thyrotoxicosis may present in the elderly with symptoms suggesting cardiac, gastrointestinal, or neuromuscular/psychiatric disease 1 . In fact, whereas younger thyrotoxics have multiple symptoms when first seen, the elderly thyrotoxic may present with symptoms related to just one organ system 2 .…”

“…Because the elderly person with thyrotoxicosis may have, in addition, a serious systemic illness, his thyroid tests may be altered in the same manner as those associated with severe nonthyroidal illnesses 10 , 11 . The most common of those changes is a reduction in the serum T 3 concentration (low T 3 syndrome) as described by Griffin and Solomon 1 . The serum T 3 concentration, almost uniformly elevated in thyrotoxicosis in younger individuals, is quickly lowered during a serious illness so that any level over 100 ng/dl in such patients should be considered inappropriately high 12 .…”

“…In the patient whose thyrotoxicosis is due to a toxic nodular goiter, Griffin and Solomon 1 explain why surgery may be preferable to 131 I. However, because larger doses of 131 I can be used in such patients and medical therapy is effective if needed, this author prefers 131 I ablative therapy.…”

Hyperthyroidism in the Elderly

“…To the Editor: —We would like to make the following comments on the article by Griffin and Solomon 1 : 1) not only can thyrotoxicosis present with atrial fibrillation and heart failure, but atrial fibrillation and heart failure can lead to abnormalities of thyroid hormones 2 that are commonly noted in patients with hyperthyroidism; 2) thyroid stimulating hormone, as measured by a sensitive single radio‐immunometric assay, is suppressed by acute illness in the elderly 3 . Bhakri et al 3 studied 180 consecutive admissions to an acute geriatric unit.…”