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10 - Endocrine Disorders |
277
adrenergic excess, or if contraindicated a nondi-
hydropyridine calcium channel blocker such as
verapamil. In addition, supersaturated potas-
sium iodine and glucocorticoids can be used in
preparation for thyroid surgery.
63
The goals of treatment for hypothy-
roidism are to control symptoms and prevent
myxedema, which is rare but occurs more
commonly in patients older than 75 years. The
recommended first-line treatment for hypothy-
roidism is levothyroxine. Although other prepa-
rations such as dessicated thyroid, triiodothyro-
nine, and combination products containing T4
and T3 are available, these formulations do not
offer clinical advantages over levothyroxine for
most patients. Dessicated thyroid is an inappro-
priate drug to use in older adults because of its
potential cardiac effects; this drug is on the list
of Beers criteria drugs.
72
A meta-analysis of 11
studies consisting of 1,216 patients evaluated
the combination of T4 and T3 versus T4 mono-
therapy in clinical hypothyroidism. Bodily pain,
quality of life, depression, fatigue, and anxiety
were similar between the two treatments. In addi-
tion, cognitive functioning, lipids and lipopro-
teins, and adverse effects were similar. Based
on this evidence, a combination product of T3
and T4 does not offer compelling advantages in
clinical hypothyroidism.
73
Treatment Recommendations for
Older Adults
Hyperthyroidism
The treatment of hyperthyroidism in older adults
usually involves the use of I-131 and antithyroid
drugs. I-131 is preferred in older adults because
the treatment is effective and the long-term risks
are of less concern. In addition, if hyperthyroidism
recurs (such as following the use of antithyroid
drugs), older adults may have an increased risk
of atrial fibrillation.
63
Patients generally become
euthyroid within 6–12 weeks after receiving
I-131, and many individuals eventually become
hypothyroid.
64
The use of I-131 in older adults
with underlying ischemic heart disease may
increase the risk of radiation-induced thyroiditis
due to the release of preformed thyroid hormone
from the gland. To prevent this effect, antithyroid
drugs may be administered for 1–2 months and
then discontinued for 3–5 days before adminis-
tering the I-131.
71
Another approach to the treatment of hyper-
thyroidism is to use antithyroid drugs as the
first-line treatment. Propylthiouracil is dosed 50–
100 mg every 8 hours and methimazole 15–
30 mg once daily. Antithyroid drugs are adminis-
tered for 6–18 months, and thyroid function tests
are monitored every 2 months at least early in
therapy. Adverse effects include skin rashes,
arthralgias, and myalgias. Although rare, agran-
ulocytosis may be more common in older adults,
primarily occurring in the first 90 days.
74
Hypothyroidism
The treatment of hypothyroidism should begin
with 12.5–25 mcg of levothyroxine daily, espe-
cially in older adults with underlying ischemic
heart disease or heart failure.
57
Although older
adults may be less likely to absorb T4 as well
as young individuals, they may require a smaller
starting dose because of decreased lean body
mass.
57
Serum TSH concentrations should be
monitored after 4–6 weeks and after any subse-
quent dosage adjustment.
64
Dosage adjust-
ments should be between 12.5 and 25 mcg, and
symptoms should be carefully assessed. The
goal is to have the TSH within the normal refer-
ence range and to prevent overreplacement,
which might increase the risk of precipitating
cardiac symptoms and of worsening osteopenia
or osteoporosis.
Levothyroxine should be dosed once daily
on an empty stomach. In addition to foods,
such as fiber, decreasing the absorption of levo-
thyroxine, many drugs and minerals may also
prevent its absorption. Bile acid sequestrants
such as colestipol and minerals such as calcium
and iron may decrease levothyroxine absorption.
Other drugs such as phenobarbital, phenytoin,
carbamazepine, and rifampin may increase the
hepatic metabolism of levothyroxine. A thorough
medication history is essential for older adults
taking levothyroxine.
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| Fundamentals of Geriatric Pharmacotherapy
KEY POINT:
As patients become
euthyroid after treatment of hyperthyroidism
or hypothyroidism, their entire drug
regimen should be carefully reviewed. e
clearance of some medications may have
been increased or decreased, and dosage
adjustments may be indicated to maintain
the safety and ecacy of the drug regimen.
P G
D
The pituitary gland is responsible for the secre-
tion of hormones such as adrenocorticotropic
hormone and growth hormone (GH). Although
little data exist on the prevalence of pituitary
gland disorders in older adults, GH deficiency
may occur in some older adults. One study
demonstrated that GH replacement can increase
lean muscle mass, reduce adipose tissue, and
increase markers for bone metabolism in older
adults with pituitary disease.
75
GH has been
promoted extensively as an anti-aging therapy,
although the evidence of its safety and efficacy
in older adults is limited.
76
A 26-week study of 131
healthy community-dwelling adults between 65
and 88 demonstrated increased lean body mass
and decreased fat mass, while muscle strength
was unchanged.
76
The long-term safety of GH
remains unknown; potential concerns include
diabetes and glucose intolerance,
77
periph-
eral edema, joint pain, carpal tunnel syndrome,
gynecomastia, and potentially an increased risk
of cancer.
78
C S H
O A
Menopause
Most women will experience menopause
between the ages of 45 and 55, as a normal part
of aging. With this “change of life,” women may
experience vasomotor symptoms such as hot
flashes as well as vaginal atrophy and dryness.
During this time, the risk of developing coronary
heart disease (CHD), osteoporosis, breast and
colorectal cancer, and cognitive impairment
increase significantly.
Over the past 40 years, many observational
studies and small clinical trials suggested that
hormone therapy (HT) with either estrogen
alone or in combination with a progestin had
health benefits in older women. Although find-
ings from observational studies were consistent,
they were flawed. Women who were using HT in
cohort studies were different from women who
chose not to use hormones, in that they were
healthier and more adherent. In addition, these
women typically had begun using HT soon after
menopause.
79
The findings of the Women’s Health Initia-
tive (WHI) challenged traditional beliefs about
the risks and benefits with HT.
80,81
Over 162,000
postmenopausal women between the ages of 50
and 79 were enrolled in three clinical trials and an
observational study. One clinical trial evaluated
the risks and benefits of HT in 16,608 women
without CHD.
80
The active treatment included conju-
gated equine estrogens 0.625 mg plus medroxy-
progesterone 2.5 mg daily in women who had
an intact uterus. A second WHI study of 10,739
women used conjugated equine estrogens
0.625 mg daily in women who had undergone
a hysterectomy.
81
Nonfatal MI and death due to
CHD were the primary outcome measures, and
the development of invasive breast cancer was
the primary adverse outcome. The outcomes
are summarized in Table 10-3. A recent analysis
indicated that most risks and benefits declined
following discontinuation of HT, although the
increased breast cancer risk continued during
the follow-up period.
82
Attention has focused recently on the timing
hypothesis, in which the benefits of HT may
outweigh the risks when used either in the first
10 years after the onset of menopause or up
to age 60. For example, with cardiovascular
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279
disease, the use of HT in older women may
result in plaque destabilization if atherosclerosis
is present, potentially resulting in stroke and
MI. Similarly, benefits from HT on cognition and
the risk of Alzheimer disease were apparent in
observational studies, while the WHI substudy
on memory demonstrated an increased risk of
dementia among older women given HT.
79,83
The
International Menopause Society has stated that
the benefits likely outweigh the risks of HT for
vasomotor symptoms and osteoporosis preven-
tion when used in women <60 years of age or
<10 years from the onset of menopause.
84
Use
in older women must be carefully individualized,
with specific recognition of the limited role of
HT.
82-84
Andropause
The term andropause has been used to describe
a syndrome in some middle-aged and older men
that includes decreased energy, impaired libido
and erectile dysfunction, muscle weakness, and
depression. Over the past 10 years, the use of
different testosterone products has been exten-
sively promoted to improve these symptoms.
One report evaluating androgen prescribing
between 2001 and 2011 demonstrated a three-
fold increase in their use in all age groups,
including men 70 and older. Prescriptions for
testosterone gel formulations increased fivefold
during this time period. Although almost three-
quarters of men taking these products had a
testosterone level, the prevalence of low values
is unknown.
85
Similar to the use of HT in women before
the findings of WHI were published, evidence
supporting the safe and effective use of different
testosterone products from randomized clinical
trials has been limited. Low testosterone concen-
trations have been associated with obesity,
diabetes, incident and severity of coronary
artery disease, as well as cardiovascular and
all-cause mortality in observational studies.
86
Effects of testosterone replacement on lipids
have been mixed, and a lowered total choles-
terol reported in some studies. Although obser-
vational studies and some clinical trials have
suggested other potential benefits, the clinical
studies have enrolled small numbers of patients
and were typically of short duration.
86
However,
in a randomized, placebo-controlled study of 209
men with a mean age of 74 years and limitations
in mobility, daily use of a 1% testosterone gel
resulted in improvements in leg press and chest
press strength, as well as in climbing stairs.
87
Although effective in raising testosterone
concentrations, concerns have increased about
testosterone’s cardiovascular safety. A retro-
spective cohort study used data from 8,709
men in the Veterans Affairs health system who
had undergone coronary angiography. The
men had testosterone concentrations below
300 ng/dL and 1,223 received a testosterone
product. The primary outcome measure was a
composite of MI, ischemic stroke, and all-cause
mortality. Men receiving hormone therapy had
an absolute increase in the risk of the primary
outcome measure of 5.8% over men who were
not receiving the drug therapy at 3 years after
Table 10-3. Selected Potential Risks
and Benefits of Oral Hormone Therapy
(Estrogen plus Progestin) in Older Women
Risks
• Increased risk of thromboembolic disease in the
first year.
• Increased risk of coronary heart disease and stroke
within the first several years, highest among older
postmenopausal women.
•
Increased risk of breast cancer with longer
duration, which rapidly decreases with cessation of
therapy.
• Potentially increased risk of ovarian cancer.
•
Potentially increased risk of dementia possibly
due to silent small strokes, and no benefit in mild
cognitive impairment.
Benefits
• Decreased risk of hip and related fractures.
• Decreased risk of invasive colorectal cancer,
although it is diagnosed at a more advanced stage.
• Decreased moderate-to-severe vasomotor
symptoms, although no overall benefit on health-
related quality of life.
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| Fundamentals of Geriatric Pharmacotherapy
coronary angiography.
88
Another cohort study
from a large healthcare database assessed the
risk of nonfatal MI in men in the first 90 days after
receiving their first prescription for testosterone
therapy. The comparator group included men
from the same database who received their first
prescription for either sildenafil or tadalafil. The
rate ratio for MI was 2.19 (95% CI 1.27, 3.77) for
men over 65 that increased to 3.43 (95% CI 1.54,
7.66) for those men 75 and older. A similar trend
was not reported with sildenafil and tadalafil.
89
Based on the findings of these two studies and
ongoing monitoring, the Food and Drug Admin-
istration has decided to reassess the safety of
testosterone products.
90
S D
Sexual intimacy and activity remain important
even into late life. A nationally representative
survey reported the prevalence of sexual activity
among 3,005 community-dwelling older Ameri-
cans between the ages of 57 and 85. Sexual
activity was defined as a mutually voluntary
activity with another person that involved sexual
contact regardless of whether or not intercourse
or orgasm occurred. Among respondents ages
57 to 64, the prevalence of sexual activity was
73%, while among those 65 to 74 years and 75
to 85 years the prevalence was 53% and 26%,
respectively.
91
Among sexually active adults
between the ages of 75 and 85, 54% reported
sexual activity at least two to three times per
month and 23% indicated sex at least once a
week. Although a lack of a partner or the pres-
ence of a partner with serious health-related
issues may limit the frequency of sexual function,
older adults, similar to younger individuals, value
sexual activity as a part of maintaining close
personal relationships.
Etiology, Epidemiology, and
Clinical Presentation in Older
Adults
Erectile problems are the most commonly
reported sexual dysfunction, with an estimated
prevalence of 37% of older men.
91
The annual
incidence of erectile dysfunction was 12.4 per
1,000 person-years among men 40–49, 29.8
among men 50–59, and 46.4 among men 60–69
years old. After adjusting for age, the risk of
erectile dysfunction was higher among men with
hypertension, diabetes, and heart disease.
92
Normal erectile functioning is the result of a
complex interplay between endocrine, vascular,
neurologic, and psychosocial factors. Erectile
dysfunction, defined as the inability to attain
or maintain an erection sufficient for satisfac-
tory sexual intercourse, may be due to many
factors. Vascular causes such as atherosclerosis
from diabetes, as well as neurological problems
following a stroke may result in erectile dysfunc-
tion. Many drugs may also contribute to it.
KEY POINT:
Erectile dysfunction in
older men is a multifactorial condition.
Attention should be focused on optimal
treatment of underlying diseases such as
hypertension and diabetes, rather than
considering it solely an adverse eect of drugs.
Sexual dysfunction in men may also include
changes in libido, ejaculation, and orgasm, and
commonly occurs with advancing age. Testos-
terone concentrations may decline by 1% to 2%
per year, and levels of free testosterone decrease
by up to 30% in men in their seventh decade of
life. Luteinizing hormone is reported to be higher
than among younger men.
93
Women have reported less sexual activity
across all age groups compared to men. Among
women ages 75–85, only 16.7% reported sex
with a partner in the prior 12 months, while
38.5% of men had engaged in sexual activity.
91
In a recent survey, decreased libido, difficulty
with vaginal lubrication, and the inability to
climax was reported by 43%, 39%, and 34%,
respectively.
91
Female sexual dysfunction has
been classified as disorders of desire, arousal,
orgasm, and sexual pain or dyspareunia. Sexual
dysfunction among women may be caused
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281
by many factors, including physiological and
hormonal changes resulting from menopause as
well as relationship, physical, and mental health
problems. In addition, older women frequently
may lack a partner or have a partner with serious
health-related issues, which limits their sexual
activity.
Summary of Standard Treatment
The first-line pharmacotherapy of erectile
dysfunction in men consists of the oral phospho-
diesterase type 5 (PDE-5) inhibitors including
sildenafil, tadalafil, vardenafil, and avanafil.
The transurethral or intracavernosal adminis-
tration of alprostadil also enhances the smooth
muscle relaxation needed to attain an erection.
Testosterone therapy, especially in a transdermal
formulation, is reserved for men with documented
hypogonadism. Penile devices, including a
vacuum pump and a surgically-implanted penile
prosthetic, have been used in men who either
do not respond or who have contraindications
to drug therapy. Psychotherapy may be used
when the erectile dysfunction is believed to have
a psychogenic etiology.
94
The treatment of sexual dysfunction in
women depends on the underlying cause and
the specific sexual disorder. For example, symp-
toms of vaginal dryness can be treated with
topical lubricants. The treatment of hypoactive
sexual desire disorder has included nonphar-
macologic and educational approaches as
well as drug therapy. Transdermal testosterone
in a dosage of 300 mcg daily has been used,
although not commercially available for arousal
disorders. A 6-month study of 814 postmeno-
pausal women ages 20 to 70 with hypoactive
sexual desire disorder evaluated the effective-
ness of 150-mcg and 300-mcg testosterone
patches compared to a placebo patch. Although
the higher dose patch demonstrated some
benefit, the effects were modest.
95
PDE-5 inhibitors have been studied for disor-
ders in desire, arousal, and orgasm in women
with inconsistent results. Sexual pain disorders
have been treated with psychotherapy and other
nonpharmacologic approaches. Dyspareunia
due to vaginal atrophy has been managed
primarily with oral and topical estrogens. Ospe-
mifene, an oral estrogen agonist/antagonist, was
recently approved for the treatment of moderate
to severe dyspareunia.
Treatment Recommendations for
Older Adults
The treatment of sexual dysfunction in older
men and women involves first identifying and
appropriately managing the potentially contrib-
uting factors. Many diseases and drugs may
adversely affect sexual functioning; however, the
cause of sexual dysfunction is frequently due to
multiple factors.
Contraindications to the use of PDE-5 inhibi-
tors may be more likely to be present in older
men due to the presence of underlying cardio-
vascular disease. Although generally safe,
their use in older men raises several potential
concerns. All PDE-5 inhibitors are contraindi-
cated in individuals taking nitrates because of
the risk of severe hypotension, as vasodilation
from the anti-ischemic therapy may be signifi-
cantly increased because both drugs are nitric
oxide donors.
96
In general, nitrates should be
avoided for at least 24 and 48 hours following the
use of sildenafil (and vardenafil) and tadalafil,
respectively.
Older men should also be carefully evalu-
ated with regard to underlying coronary artery
disease (CAD) because of concern that
increased sexual activity theoretically might
increase the risk of coronary ischemia. Patients
who are considered to be at intermediate risk
include those who have CAD and at least three
other risk factors, such as a recent MI or stroke.
Individuals at high risk include those men with
unstable angina and uncontrolled risk factors
such as class III or IV heart failure or an MI in the
past 2 weeks.
97
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| Fundamentals of Geriatric Pharmacotherapy
KEY POINT:
Older men should be
carefully evaluated for a history of CAD
and concomitant drug therapy such as
nitrates before a PDE-5 inhibitor is tried.
Older men with documented hypogonadism
as the cause of their erectile dysfunction may be
candidates for testosterone therapy, although
the testosterone concentration should be <200–
300 ng/mL.
98
Multiple testosterone products are
available, including depot injectable formula-
tions, patches, gels, and buccal tablets. Testos-
terone enanthate or cypionate is started at a
dosage of 75–100 mg intramuscularly weekly
or 150–200 mg every 2 weeks. Testosterone
patches may be started at one to two 5-mg
patches applied to the back, neck, or upper
arm every night. The testosterone gel (Androgel,
Testim) is applied in the morning to clean, dry
nonscrotal skin in a starting dosage of 5 g,
which delivers 5 mg of testosterone daily. A self-
adherent buccal tablet of 30 mg of testosterone
is also available and dosed twice daily. The tablet
is placed between the inner check and the gums
above the incisor tooth and held firmly in place
for 30 seconds using a finger. The rounded side
of the tablet should be against the gums. The
tablet remains in place until the epithelial cells
are shed in 12–15 hours. The dosage of these
testosterone products is increased based on the
serum testosterone concentrations obtained 2–3
months after starting the products.
In addition to the previously discussed
cardiovascular concerns, adverse effects
include the development of polycythemia vera;
therapy should be stopped if the hematocrit
exceeds 55%. Sleep apnea may worsen if risk
factors such as obesity and chronic lung disease
are present. Gynecomastia may also occur
with testosterone therapy. Older men receiving
testosterone should be carefully monitored
for worsening benign prostatic hyperplasia (if
present). The prostate specific antigen concen-
trations should also be carefully monitored and
a digital rectal exam performed at least yearly.
98
Other monitoring of testosterone therapy is
product specific.
98
In men receiving the buccal
formulation, potential changes in taste and irri-
tation of oral mucosa should be evaluated. For
the injectable products, men should be asked
about any fluctuations in mood and libido in the
interval between injections. The development of
skin irritation should be carefully monitored with
the use of testosterone patches. Although testos-
terone gels may also cause skin irritation, the
most important education issue is to ensure that
the skin-to-skin transmission of the testosterone
to women and children is avoided to minimize
potential exposure to the hormone.
98
Sexual dysfunction in women is also multi-
factorial, and concomitant drug therapy such as
selective serotonin reuptake inhibitors (SSRIs)
and aromatase inhibitors potentially contribute
to symptoms.
99
A woman may present with
symptoms of painful intercourse or dyspareunia,
decreased sexual desire, reduced arousal, or
orgasmic dysfunction. The appropriate treat-
ment depends on the presenting symptoms.
For dyspareunia due to vulvovaginal atrophy, a
nonprescription vaginal lubricant or long-acting
moisturizer can be tried initially. Vaginal lubri-
cants can be classified as water-based, silicone-
based, or oil-based. In general, iso-osmolar
water-based products, as well as silicone-based
products, are preferred, although compara-
tive studies in older women are not available.
99
Vaginal, transdermal, and oral estrogens are
also options. Vaginal estrogen products include
creams, rings, and tablets and are effective
without disrupting vaginal flora. Ospemifene is
a newly approved selective estrogen receptor
modulator (SERM) that is an oral treatment for
moderate to severe dyspareunia. Similar to
other SERMs, the drug may increase meno-
pausal symptoms such as hot flashes, and the
risk of uterine cancer and venous thromboem-
bolism is unclear.
100
The use of drug therapies
such as testosterone and other androgens for
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283
reduced sexual desire and PDE-5 inhibitors for
decreased sexual arousal and orgasm in older
women remain controversial and are not gener-
ally recommended. For the woman who has
developed sexual dysfunction from an SSRI, a
switch to bupropion may relieve her symptoms
if contraindications to the latter antidepressant
do not exist. Finally, both older men and women
should be counseled to avoid use of natural
products for sexual functioning, especially prod-
ucts bought online, without first discussing their
potential use with a healthcare provider.
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| Fundamentals of Geriatric Pharmacotherapy
C 1: D M
Setting:
Outpatient geriatric clinic.
Subjective:
LR is an 84-year-old man who presents for follow-up with his primary care physician after an
emergency department visit for elevated blood pressure.
Past Medical History:
Hypertension ×18 years, diabetes mellitus type 2, GERD, osteoarthritis (OA), anxiety, history of
pneumonia, history of falls.
Medications:
Lisinopril 20 mg once daily, amlodipine 5 mg once daily, aspirin 81 mg once daily, Lantus
30 units subcutaneously every morning, omeprazole 20 mg once daily, acetaminophen 325 mg
1–2 tablets ever
y 6 hours as needed, tramadol 50 mg every 6 hours as needed, zolpidem 5 mg
at bedtime, One Touch Ultra test strips 3–4 times daily and when sick.
Allergies:
Ibuprofen (upset stomach), penicillin (rash).
Family History:
Father passed away at age 75 and had type 2 diabetes, mother passed away at age 81, brother
is alive and also has type 2 diabetes.
Social History:
Denies use of tobacco or alcohol. Does not exercise consistently but goes for a walk every now
and then “when the weather is nice,” using a walker to ambulate. Lives in an assisted living
facility and has Medicare Part D.
Objective:
Ht 61˝, Wt 125 lb, BP 154/92 BPM, HR 72. Recent blood glucose readings (11 a.m.): 161, 110.
HbA
1c
today: 7.8%. Serum creatinine: 0.9 mg/dL. GDS score 3/15 (3 months ago), 6/15 (today).
Assessment:
LR is an 84-year-old man with type 2 diabetes, uncontrolled blood pressure, and possible
depression. He is at risk for future falls.
Plan:
1.
An appropriate target HbA
1c
for LR is <8 %, given his age and risk for falls due to
medications, pain, and use of walker. His HbA
1c
can be checked every 12 months, or
sooner if changes are made to his Lantus. It would be reasonable to reduce his blood
glucose monitoring to once daily in the morning and when he is sick.
2. Discuss with LR whether he has been adherent with his lisinopril and whether or not he is
able to afford his medications in order to take them consistently. A dosage increase would
be appropriate if he is adherent. Assess his diet for sources of sodium. Monitor his blood
pressure and target <140/90 mmHg, although a higher systolic BP may be acceptable
(<150).
3. Review LR’s responses on the Geriatric Depression Scale and discuss any precipitating
events that may have increased his score. Assess whether the depression may be
short-term or related to his chronic disease, and whether he may benefit from a trial of
medication.
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4. LR should be assessed for ability to transfer on his own with and without a walker. LR
should engage in moderate-intensity aerobic and resistance exercises to build strength.
Rationale:
A less stringent target HbA
1c
may be appropriate for older adults with poor health, frailty,
multiple comorbidities, or risk of falls. Self-monitoring of blood glucose should be individualized
for older adults based on benefit, cost, and convenience. Older adults with type 2 diabetes
should be screened for depression at the time of diagnosis and if a decline in function is
observed. Moderate-intensity exercise has been shown to increase strength, decrease the loss
of lean body mass, and improve cardiorespiratory function.
Case Summary:
This case illustrates the appropriate goals for an older adult with controlled type 2 diabetes and
uncontrolled hypertension. It also highlights the potential for depression in older adults with
type 2 diabetes and the benefits of regular exercise.
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C 2: H
Setting:
Family medicine clinic.
Subjective:
ST is an 81-year-old woman presenting to the family medicine clinic for review of her
medications and for annual influenza vaccination. She reports that she missed just one or two
doses of medication in the past month. She denies any adverse effects from her medications.
She mentions that she has been feeling more tired than usual and is having a little difficulty
participating in activities because of this. She has also been eating more sweets recently.
Past Medical History:
Hypertension, osteoporosis, mild cognitive impairment, obesity, GERD, and dry eyes.
Medications:
Hydrochlorothiazide 25 mg once daily, calcium/vitamin D 600 mg/400 International Units
twice daily, omeprazole 20 mg once daily, multivitamin once daily, docusate twice daily,
acetaminophen as needed.
Allergies:
Morphine (nausea).
Family History:
Noncontributory.
Social History:
Quit smoking 50 years ago, has a few glasses of wine during the holidays, lives by herself in
the community.
Objective:
Ht 61˝, Wt 184 lb, BP 142/90 BPM, HR 76, T4 within normal range, TSH 5.8 milliunits/L,
MMSE 24.
Assessment:
ST is an 81-year-old woman with possible subclinical hypothyroidism and obesity. Potential
symptoms of hypothyroidism include fatigue and constipation.
Plan:
•
Assess ST’s current diet and activity level to determine whether her symptoms may be
relieved through lifestyle interventions. If ST’s condition does not improve, re-evaluate
TSH and compare to usual levels to determine whether or not her level has increased
significantly. If a diagnosis of subclinical hypothyroidism is made, levothyroxine
12.5–25 mcg once daily in the morning would be appropriate.
• Counsel ST regarding the overall health benefits of exercise. If her weight does not
decrease after adjustments are made to her levothyroxine, her TSH becomes stable,
and weight loss is still desired, consider dietary counseling and energy restriction if
nutritionally appropriate.
• Counsel ST regarding potential for drug interaction if calcium is taken within 4 hours of
levothyroxine.
• Complaints of constipation can be addressed with symptomatic interventions such as
laxatives on a short-term, as-needed basis, with or without the stool softener she already
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