Slow and Not So Steady
Answer: D
Our patient comes to us with an increasingly common presentation: an elder with vague, subacute symptoms and significant family disruption.
Geriatrics in a nutshell is: function, function, function. When an older adult has a change in the ability to perform daily functions, the physician must actively search out disease that, if left unrecognized, could accelerate the patient’s decline.
Emergency physicians are rapidly becoming the “go-to” specialists to address these presentations, due to difficulty in access to care, either financial or logistic. Premature closure with a diagnosis of dementia (A, C) may delay or obstruct discovery of an underlying disorder.
Polypharmacy and high pill burden are a major problem in elder patients, with many medications added by various specialists who are not completely aware of the other medications prescribed by their colleagues. Often a new medication is prescribed to counteract the adverse effect of another medication on the list, adding
to the never-ending cycle of adverse effects. Patients rarely need to be admitted for observation after withdrawing a medication (B); this should be a gradual, planned process, often over weeks to months, coordinated by the primary medical doctor.
To reframe her presentation: this previously relatively well woman complains of generalized weakness, constipation, and easy fatigue; on examination you find a coarse voice, dry, flaky skin, and relative bradycardia.
Although any of these in various combinations generate a broad differential diagnosis, this woman was investigated further for hypothyroidism (advanced age can be a trigger for a variety of autoimmune conditions).
Hypothyroidism in the elderly is often under-recognized, because many symptoms overlap with age-related deconditioning or are ascribed to another cause with overlapping features. Other signs such as pleural effusions or lower extremity edema may be interpreted as heart failure. To complicate matters further, palpation of the neck and thyroid imaging in this population are often not helpful in the diagnosis, as the majority of elderly patients will have a normal sized thyroid.
Our patient was found to have a low free thyroid level and high TSH. She was admitted and started on levothyroxine therapy (D). Over the course of a week, her mental status was back to her high-functioning baseline, her energy level and appetite returned, and she was enthusiastically taken home by her family.
Other possible scenarios we may encounter that may be a cryptic presentation of hypothyroidism in the
elderly:
● Man on metoprolol, amlodipine, and digoxin for hypertension, CHF, and atrial fibrillation complains
of weakness, fatigue, constipation, weight gain
● Woman who complains only of weakness and decreased mobility, found to have normal neurologic exam
except for delayed contraction and relaxation phases in deep tendon reflexes
● Woman with history of high total cholesterol and triglycerides with carpal tunnel syndrome
● Man with depression and dementia with any of the above signs or symptoms
● Cerebellar findings or neuropathy with an otherwise normal work up
● Unexplained hyponatremia, macrocytic anemia, elevated creatinine phosphokinase (CK), and/or lactate
dehydrogenase (LDH) may be caused by a deficiency in thyroid hormone
Bottom line:
Before diagnosing an elderly patient with “just old age” or “worsening dementia”, consider alternative reasons, such as undiagnosed hypothyroidism. These patients can improve markedly if treated.
References
Fulton MM, Allen ER. Polypharmacy in the elderly: a literature review. J Am Acad Nurse Pract. 2005; Apr;17(4):123-32.
Maselli M, Inelmen EM, Giantin V, Manzato E. Hypothyroidism in the elderly: diagnostic pitfalls illustrated by a case report. Arch Gerontol Geriatr. 2012; Jul-Aug;55(1):82-4. doi: 10.1016/j.archger.2011.05.003. Epub 2011 Jun
2.
Shakaib U, Rehman MD, Dennis W et al. Thyroid Disorders in Elderly Patients. South Med J. 2005;98(5):543-549.
Valenti G, Fabbo A. Subclinical hypothyroidism in the elderly. Arch Gerontol Geriatr. 1996; 22(1): 585-592.
Our patient comes to us with an increasingly common presentation: an elder with vague, subacute symptoms and significant family disruption.
Geriatrics in a nutshell is: function, function, function. When an older adult has a change in the ability to perform daily functions, the physician must actively search out disease that, if left unrecognized, could accelerate the patient’s decline.
Emergency physicians are rapidly becoming the “go-to” specialists to address these presentations, due to difficulty in access to care, either financial or logistic. Premature closure with a diagnosis of dementia (A, C) may delay or obstruct discovery of an underlying disorder.
Polypharmacy and high pill burden are a major problem in elder patients, with many medications added by various specialists who are not completely aware of the other medications prescribed by their colleagues. Often a new medication is prescribed to counteract the adverse effect of another medication on the list, adding
to the never-ending cycle of adverse effects. Patients rarely need to be admitted for observation after withdrawing a medication (B); this should be a gradual, planned process, often over weeks to months, coordinated by the primary medical doctor.
To reframe her presentation: this previously relatively well woman complains of generalized weakness, constipation, and easy fatigue; on examination you find a coarse voice, dry, flaky skin, and relative bradycardia.
Although any of these in various combinations generate a broad differential diagnosis, this woman was investigated further for hypothyroidism (advanced age can be a trigger for a variety of autoimmune conditions).
Hypothyroidism in the elderly is often under-recognized, because many symptoms overlap with age-related deconditioning or are ascribed to another cause with overlapping features. Other signs such as pleural effusions or lower extremity edema may be interpreted as heart failure. To complicate matters further, palpation of the neck and thyroid imaging in this population are often not helpful in the diagnosis, as the majority of elderly patients will have a normal sized thyroid.
Our patient was found to have a low free thyroid level and high TSH. She was admitted and started on levothyroxine therapy (D). Over the course of a week, her mental status was back to her high-functioning baseline, her energy level and appetite returned, and she was enthusiastically taken home by her family.
Other possible scenarios we may encounter that may be a cryptic presentation of hypothyroidism in the
elderly:
● Man on metoprolol, amlodipine, and digoxin for hypertension, CHF, and atrial fibrillation complains
of weakness, fatigue, constipation, weight gain
● Woman who complains only of weakness and decreased mobility, found to have normal neurologic exam
except for delayed contraction and relaxation phases in deep tendon reflexes
● Woman with history of high total cholesterol and triglycerides with carpal tunnel syndrome
● Man with depression and dementia with any of the above signs or symptoms
● Cerebellar findings or neuropathy with an otherwise normal work up
● Unexplained hyponatremia, macrocytic anemia, elevated creatinine phosphokinase (CK), and/or lactate
dehydrogenase (LDH) may be caused by a deficiency in thyroid hormone
Bottom line:
Before diagnosing an elderly patient with “just old age” or “worsening dementia”, consider alternative reasons, such as undiagnosed hypothyroidism. These patients can improve markedly if treated.
References
Fulton MM, Allen ER. Polypharmacy in the elderly: a literature review. J Am Acad Nurse Pract. 2005; Apr;17(4):123-32.
Maselli M, Inelmen EM, Giantin V, Manzato E. Hypothyroidism in the elderly: diagnostic pitfalls illustrated by a case report. Arch Gerontol Geriatr. 2012; Jul-Aug;55(1):82-4. doi: 10.1016/j.archger.2011.05.003. Epub 2011 Jun
2.
Shakaib U, Rehman MD, Dennis W et al. Thyroid Disorders in Elderly Patients. South Med J. 2005;98(5):543-549.
Valenti G, Fabbo A. Subclinical hypothyroidism in the elderly. Arch Gerontol Geriatr. 1996; 22(1): 585-592.