Approach to and treatment of thyroid disorders in the elderly

Epidemiologic changes in thyroid disease

PURPOSE OF REVIEW

To analyze the evolving epidemiologic trends in thyroid disease, focusing on risk factors, underlying drivers of these changes, and their implications on clinical practice and research priorities.

RECENT FINDINGS

Thyroid disease remains one of the most prevalent groups of disorders globally, and the shift in its frequency and distribution is multifactorial. The prevalence of hypothyroidism increases with age, although normal thyrotropin ranges appear to be age-dependent, raising concern for potentially inappropriate levothyroxine use. Hyperthyroidism and Graves' disease continue to be predominant in reproductive-age women but exhibit a milder phenotype at diagnosis. Thyroid nodules are increasingly found in asymptomatic patients, likely from more widespread use of neck and chest imaging. Thyroid cancer incidence has risen exponentially over the years, mostly driven by overdiagnosis of low-risk tumors; however, a small rise in incidence of higher risk tumors has been noted. Obesity appears to be a risk factor for thyroid cancer occurrence and more aggressive forms of the disease.

SUMMARY

Understanding epidemiologic trends in thyroid disease is crucial for guiding clinical practice and research efforts, aiming to optimize patient outcomes while preventing unnecessary and potentially harmful interventions.

Rare Presentation of Thyrotoxicosis Defying Methimazole Treatment: A Case Series

Thyrotoxicosis, also known as hyperthyroidism, is a condition characterized by the excessive production of thyroid hormones by the thyroid gland. Besides Graves' disease, other common causes of thyrotoxicosis include toxic multinodular goiter, toxic adenoma, and subacute thyroiditis. The treatment of thyrotoxicosis depends on the underlying cause and may include medications (e.g., antithyroid drugs, beta-blockers), radioactive iodine therapy, or surgical removal of the thyroid gland (thyroidectomy). In this report, we present two instances of thyrotoxicosis where conventional high doses of antithyroid treatment failed to control the condition effectively. This failure prompted the exploration of alternative therapeutic interventions. These cases highlight the intricacies involved in managing thyrotoxic crises that do not respond to methimazole (MMI), emphasizing the necessity for innovative approaches such as plasmapheresis and thyroidectomy. Understanding such scenarios is vital for enhancing the care provided to patients encountering resistance to standard treatments. The distinct clinical pathways and treatment strategies adopted in these cases offer valuable insights into this disease management, particularly concerning resistance to MMI.

Advances in Thyroid Function Tests: Precision Diagnostics and Clinical Implications

This narrative review explores the evolving field of thyroid function testing, explicitly highlighting the significance of precision diagnostics and their substantial impact on clinical practice. Commencing with a comprehensive examination of the historical progression of thyroid diagnostics, the discourse proceeds to explore recent developments, highlighting the paramount importance of accuracy in testing methods. The primary issue under consideration is the crucial requirement for accuracy in the field of therapeutic practice. The review critically examines the problems related to the interpretation, standardization, and ethical considerations in examining advanced laboratory techniques, novel biomarkers, and state-of-the-art technologies like immunoassays, molecular testing, and automation. The focus on the paradigm shift towards precision diagnostics brings attention to the complex connection between test results and their direct influence on patient care. This investigation expands upon the incorporation of imaging and molecular diagnostics, highlighting the rising significance of precision in customizing treatment strategies. In summary, the study provides a prospective viewpoint, recognizing the persistent obstacles and highlighting the want for dependable, uniform methodologies in thyroid diagnostics. This narrative's primary objective is to guide physicians, researchers, and stakeholders in effectively navigating the intricate nature of contemporary thyroid function tests, with a particular emphasis on resolving the fundamental issue of precision.

Management of thyroid dysfunction and thyroid nodules in the ageing patient

Thyroid dysfunction is a common endocrine disorder in the general population, with a reported prevalence of 10-15%. However, this rate is even higher in older adults, with an estimated prevalence of ≈25% in some populations. Since elderly patients usually present more comorbidities than younger individuals, thyroid dysfunction may carry a synergistic negative health impact, mainly due to increased cardiovascular disease risk. Moreover, thyroid dysfunction in the elderly can be more difficult to diagnose due to its subtle or even asymptomatic clinical presentation, and the interpretation of thyroid function tests may be affected by drugs that interfere with thyroid function or by the coexistence of several diseases. On the other hand, thyroid nodules are also a prevalent condition in older adults, and its incidence increases with age. The assessment and management of thyroid nodules in the ageing patient should take into account several factors, as risk stratification, thyroid cancer biology, patient´s overall health, comorbidities, treatment preferences, and goals of care. In this review article, we summarize the current knowledge on the pathophysiology, diagnosis, and therapeutic management of thyroid dysfunction in elderly patients and we also review how to identify and manage thyroid nodules in this population.

Consumption of health resources in older people with differentiated thyroid carcinoma: a multicenter analysis

OBJECTIVE

There is hardly any information on the consumption of healthcare resources by older people with differentiated thyroid cancer (DTC). We analyzed these consumptions in older patients with DTC and compared patients 75 years and older with subjects aged 60-74 years.

METHODS

A multicenter, retrospective analysis was designed. We recorded three groups of health resources consumption (visits, diagnostic procedures, and therapeutic procedures) and identified a subgroup of patients with high consumption of resources. We compared patients aged between 60-74 years (group 1) with patients aged 75 and over (group 2).

RESULTS

We included 1654 patients (women, 74.4%), of whom 1388 (83.9%) belonged to group 1 and 266 (16.1%) to group 2. In group 2, we found a higher proportion of patients requiring emergency department visits (7.9 vs. 4.3%, P = 0.019) and imaging studies (24.1 vs. 17.3%; P = 0.012) compared to group 1. However, we did not find any significant difference between both groups in the consumption of other visits, diagnostic procedures, or therapeutic procedures. Overall, 340 patients (20.6%) were identified as high consumers of health resources, 270 (19.5%) in group 1 and 70 (26.3%) in group 2 (P = 0.013). Multivariate logistic regression analysis showed that the risk of recurrence and mortality, radioiodine treatment, tumor size, and vascular invasion were significantly related to the high global consumption of resources. However, the age was not significantly related to it.

CONCLUSION

In patients with DTC over 60 years of age, advanced age is not an independent determining factor in the consumption of health resources.

Impact of thyroid hormone perturbations in adult mice: brain weight and blood vessel changes, gene expression variation, and neurobehavioral outcomes

Mouse models of hyper- and hypothyroidism were used to examine the effects of thyroid hormone (TH) dyshomeostasis on the aging mammalian brain. 13-14 month-old mice were treated for 4months with either levothyroxine (hyperthyroid) or a propylthiouracil and methimazole combination (PTU/Met; hypothyroid). Hyperthyroid mice performed better on Morris Water Maze than control mice, while hypothyroid mice performed worse. Brain weight was increased in thyroxine-treated, and decreased in PTU/Met-treated animals. The brain weight change was strongly correlated with circulating and tissue T4. Quantitative measurements of microvessels were compared using digital neuropathologic methods. There was an increase in microvessel area in hyperthyroid mice. Hypothyroid mice showed a trend for elevated glial fibrillary acidic protein-immunoreactive astrocytes, indicating an increase in neuroinflammation. Gene expression alterations were associated with TH perturbation and astrocyte-expressed transcripts were particularly affected. For example, expression of Gli2 and Gli3, mediators in the Sonic Hedgehog signaling pathway, were strongly impacted by both treatments. We conclude that TH perturbations produce robust neurobehavioral, pathological, and brain gene expression changes in aging mouse models.

Using Markov chains and temporal alignment to identify clinical patterns in Dementia

In the healthcare sector, resorting to big data and advanced analytics is a great advantage when dealing with complex groups of patients in terms of comorbidities, representing a significant step towards personalized targeting. In this work, we focus on understanding key features and clinical pathways of patients with multimorbidity suffering from Dementia. This disease can result from many heterogeneous factors, potentially becoming more prevalent as the population ages. We present a set of methods that allow us to identify medical appointment patterns within a cohort of 1924 patients followed from January 2007 to August 2021 in Hospital da Luz (Lisbon), and to stratify patients into subgroups that exhibit similar patterns of interaction. With Markov Chains, we are able to identify the most prevailing medical appointments attended by Dementia patients, as well as recurring transitions between these. To perform patient stratification, we applied AliClu, a temporal sequence alignment algorithm for clustering longitudinal clinical data, which allowed us to successfully identify patient subgroups with similar medical appointment activity. A feature analysis per cluster obtained allows the identification of distinct patterns and characteristics. This pipeline provides a tool to identify prevailing clinical pathways of medical appointments within the dataset, as well as the most common transitions between medical specialities within Dementia patients. This methodology, alongside demographic and clinical data, has the potential to provide early signalling of the most likely clinical pathways and serve as a support tool for health providers in deciding the best course of treatment, considering a patient as a whole.

Towards De-Implementation of low-value thyroid care in older adults

PURPOSE OF REVIEW

This review discusses the current literature regarding low-value thyroid care in older adults, summarizing recent findings pertaining to screening for thyroid dysfunction and management of hypothyroidism, thyroid nodules and low-risk differentiated thyroid cancer.

RECENT FINDINGS

Despite a shift to a "less is more" paradigm for clinical thyroid care in older adults in recent years, current studies demonstrate that low-value care practices are still prevalent. Ineffective and potentially harmful services, such as routine treatment of subclinical hypothyroidism which can lead to overtreatment with thyroid hormone, inappropriate use of thyroid ultrasound, blanket fine needle aspiration biopsies of thyroid nodules, and more aggressive approaches to low-risk differentiated thyroid cancers, have been shown to contribute to adverse effects, particularly in comorbid older adults.

SUMMARY

Low-value thyroid care is common in older adults and can trigger a cascade of overdiagnosis and overtreatment leading to patient harm and increased healthcare costs, highlighting the urgent need for de-implementation efforts.

Differentiated thyroid carcinoma in the elderly: influence of age on disease-free and overall survival

PURPOSE

We investigated whether age at diagnosis of differentiated thyroid carcinoma (DTC) may be a risk factor for structural disease and mortality after primary treatment in aging patients.

METHODS

A multicenter, retrospective analysis including patients older than 60 years at DCT diagnosis was designed. All subjects were treated by surgery with or without radioiodine adjuvant therapy and had a minimum follow-up of one year. We compared elderly patients (group 1, 60-74 years) with very old patients (group 2, ≥75 years).

RESULTS

The study involved 1668 patients (74.3% women, median age 67 years, 87.6% papillary thyroid cancer, 73.3% treated with radioiodine), including 1397 in group 1 and 271 in group 2. Patients in group 2 had larger tumor size (1.8 [0.8-3.0] vs 1.5 [0.7-2.8] cm; P = 0.005), higher proportions of tumors with vascular invasion (23.8 vs 16.4%; P = 0.006), and lower proportion of lymphocytic thyroiditis (18.6 vs 24.9%; P = 0.013) than subjects in group 1. Kaplan-Meier survival analysis showed that patients in group 2 had significantly lower structural disease-free survival (DFS) and overall survival (OS) than patients in group 1 (P = 0.035 and <0.001, respectively). In multivariate Cox regression analysis, age was a risk factor significantly associated with OS. However, age was significantly associated with DFS in unadjusted analysis and in analysis adjusted by gender and risk classification variables, but not when pathological and therapy-related variables were introduced in the model. On the other hand, patients who received radioiodine had worse DFS (P < 0.001) compared to those who did not.

CONCLUSION

Although age is a conditioning factor for OS, very old patients do not have a greater risk of developing structural disease throughout the follow-up than elderly patients with DTC.

Development and preliminary validation of a machine learning system for thyroid dysfunction diagnosis based on routine laboratory tests

Background

Approximately 2.4 million patients in Japan would benefit from treatment for thyroid disease, including Graves’ disease and Hashimoto’s disease. However, only 450,000 of them are receiving treatment, and many patients with thyroid dysfunction remain largely overlooked. In this retrospective study, we aimed to develop and conduct preliminary testing on a machine learning method for screening patients with hyperthyroidism and hypothyroidism who would benefit from prompt medical treatment.

Methods

We collected electronic medical records and medical checkup data from four hospitals in Japan. We applied four machine learning algorithms to construct classification models to distinguish patients with hyperthyroidism and hypothyroidism from control subjects using routine laboratory tests. Performance evaluation metrics such as sensitivity, specificity, and the area under receiver operating characteristic (AUROC) were obtained. Techniques such as feature importance were further applied to understand the contribution of each feature to the machine learning output.

Results

The results of cross-validation and external evaluation indicated that we achieved high classification accuracies (AUROC = 93.8% for hyperthyroidism model and AUROC = 90.9% for hypothyroidism model). Serum creatinine (S-Cr), mean corpuscular volume (MCV), and total cholesterol were the three features that were most strongly correlated with the hyperthyroidism model, and S-Cr, lactic acid dehydrogenase (LDH), and total cholesterol were correlated with the hypothyroidism model.

Conclusions

We demonstrated the potential of machine learning approaches for diagnosing the presence of thyroid dysfunction from routine laboratory tests. Further validation, including prospective clinical studies, is necessary prior to application of our method in the clinic.

The metabolomics approach revealed a distinctive metabolomics pattern associated with hyperthyroidism treatment

BACKGROUND

Hyperthyroidism is characterized by increased thyroid hormone production, which impacts various processes, including metabolism and energy expenditure. Yet, the underlying mechanism and subsequent influence of these changes are unknown. Metabolomics is a broad analytical method that enables qualitative and quantitative examination of metabolite level changes in biological systems in response to various stimuli, pathologies, or treatments.

OBJECTIVES

This study uses untargeted metabolomics to explore the potential pathways and metabolic patterns associated with hyperthyroidism treatment.

METHODS

The study consisted of 20 patients newly diagnosed with hyperthyroidism who were assessed at baseline and followed up after starting antithyroid treatment. Two blood samples were taken from each patient, pre (hyperthyroid state) and post-treatment (euthyroid state). Hyperthyroid and euthyroid states were identified based on thyroxine and thyroid-stimulating hormone levels. The metabolic alteration associated with antithyroid therapy was investigated using liquid chromatography- high-resolution mass spectrometry. The untargeted metabolomics data was analyzed using both univariate and multivariate analyses using MetaboAnalyst v5.0. The significant metabolic pattern was identified using the lab standard pipeline, which included molecular annotation in the Human Metabolome Database, LipidMap, LipidBlast, and METLIN. The identified metabolites were examined using pathway and network analyses and linked to cellular metabolism.

RESULTS

The results revealed a strong group separation between the pre- and post-hyperthyroidism treatment (Q2 = 0.573, R2 = 0.995), indicating significant differences in the plasma metabolome after treatment. Eighty-three mass ions were significantly dysregulated, of which 53 and 30 characteristics were up and down-regulated in the post-treatment compared to the pre-treatment group, respectively. The medium-chain acylcarnitines, octanoylcarnitine, and decanoylcarnitine, previously found to rise in hyperthyroid patients, were among the down-regulated metabolites, suggesting that their reduction could be a possible biomarker for monitoring euthyroid restoration. Kynurenine is a downregulated tryptophan metabolite, indicating that the enzyme kynurenine 3-hydroxylase, inhibited in hyperthyroidism, is back functioning. L-cystine, a cysteine dimer produced from cysteine oxidation, was among the down-regulated metabolites, and its accumulation is considered a sign of oxidative stress, which was reported to accompany hyperthyroidism; L-cystine levels dropped, this suggests that the plasma level of L-cystine can be used to monitor the progress of euthyroid state restoration.

CONCLUSION

The plasma metabolome of patients with hyperthyroidism before and after treatments revealed differences in the abundance of several small metabolites. Our findings add to our understanding of hyperthyroidism's altered metabolome and associated metabolic processes and shed light on acylcarnitines as a new biomarker for treatment monitoring in conjunction with thyroxine and thyroid-stimulating hormone.

Can Age at Diagnosis and Sex Improve the Performance of the American Thyroid Association Risk Stratification System for Prediction of Structural Persistent and Recurrent Disease in Patients With Differentiated Thyroid Carcinoma? A Multicenter Study

OBJECTIVE

Although the age at diagnosis has been suggested as a major determinant of disease-specific survival in the recent TNM staging system, it is not included in the recent American Thyroid Association (ATA) guidelines to estimate the risk of recurrence. Nevertheless, the effect of sex on differentiated thyroid carcinoma (DTC) recurrence is controversial. Therefore, this multicenter study was conducted to assess whether age at diagnosis and sex can improve the performance of the ATA 3-tiered risk stratification system in patients with DTC with at least 5 years of follow-up.

METHODS

In this study, the computer-recorded data of the patients diagnosed with DTC between January 1985 and January 2016 were analyzed. Only patients with proven structural persistent/recurrent disease were selected for comparisons.

RESULTS

This study consisted of 1691 patients (female, 1367) with DTC. In Kaplan-Meier analysis, disease-free survival (DFS) was markedly longer in females only in the ATA low-risk category (P = .045). Nevertheless, a markedly longer DFS was observed in patients aged <45 years in the ATA low- and intermediate-risk categories (P = .004 and P = .009, respectively), whereas in patients aged <55 years, DFS was markedly longer only in the ATA low-risk category (P < .001). In the Cox proportional hazards model, ages of ≥45 and ≥55 years at diagnosis and the ATA risk stratification system were all independent predictors of persistent/recurrent disease.

CONCLUSION

Applying the age cutoff of 45 years in the ATA intermediate- and low-risk categories may identify patients at a higher risk of persistence/recurrence and may improve the performance of the ATA risk stratification system, whereas sex may improve the performance of only the ATA low-risk category.

Competing Causes of Death in Older Adults with Thyroid Cancer

Background: Understanding the impact of comorbidities and competing risks of death when caring for older adults with thyroid cancer is key for personalized management. The objective of this study was to determine whether older adults with thyroid cancer are more likely to die from thyroid cancer or other etiologies, and determine patient factors associated with each. Methods: The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify patients aged ≥66 years diagnosed with thyroid cancer (papillary, follicular, Hürthle cell, medullary, anaplastic, and other) between 2000 and 2015 (median follow-up, 50 months). We analyzed time to event (i.e., death from other causes or death from thyroid cancer) using cumulative incidence functions. Competing risk hazards regression was used to determine the association between patient (e.g., age at diagnosis and specific comorbidities) and tumor characteristics (e.g., SEER stage) with two competing mortality outcomes: death from other causes and death from thyroid cancer. Results: Of 21,509 patients with a median age of 72 years (range 66-106), 4168 (19.4%) died of other causes and 2644 (12.3%) died of thyroid cancer during the study period. For differentiated thyroid cancer patients, likelihood of dying from other causes exceeds likelihood of dying from thyroid cancer, whereas the opposite is true for anaplastic thyroid cancer. For medullary thyroid cancer, after 6.25 years patients are more likely to die from other etiologies than thyroid cancer. Using competing risks hazards regression, male sex (hazards ratio [HR] 1.47; 95% confidence interval [CI 1.37-1.57]), black race (HR 1.30; CI [1.16-1.46]), and comorbidities (e.g., heart disease, HR 1.34; CI [1.25-1.44]; chronic lower respiratory disease, HR 1.25; CI [1.17-1.34]) were associated with death from other causes. Tumor characteristics such as histology, tumor size, and stage correlated with death from thyroid cancer (e.g., distant SEER stage compared with localized, HR 12.65; CI [10.91-14.66]). Conclusions: The clinical context, including patients' specific comorbidities, should be considered when diagnosing and managing thyroid cancer. Our findings can be used to develop decision models that account for competing causes of death, as an aid for clinical decision making.

Modulating Thyroid Hormone Levels in Adult Mice: Impact on Behavior and Compensatory Brain Changes

Thyroid hormone (TH) perturbation is a common medical problem. Because of substantial public health impact, prior researchers have studied hyper- and hypothyroidism in animal models. Although most prior research focused on in utero and/or developmental effects, changes in circulating TH levels are commonly seen in elderly individuals: approximately 20% of persons older than 80 years have clinically impactful hypothyroidism and up to 5% have clinical hyperthyroidism, with women being more often affected than men. TH disease model methodology in mice have varied but usually focus on a single sex, and the impact(s) of TH perturbation on the adult brain are not well understood. We administered thyroxine to middle-aged (13 to 14 months) male and female mice to model hyperthyroidism and TH-lowering drugs propylthiouracil (PTU) and methimazole, to induce hypothyroidism. These pharmacological agents are used commonly in adult humans. Circulating TH-level changes were observed when thyroxine was dosed at 20 µg/mL in drinking water for two weeks. By contrast, PTU and methimazole did not elicit a consistent reproducible effect until two months of treatment. No substantial changes in TH levels were detected in brain tissues of treated animals; however, pronounced changes in gene expression, specifically for TH-processing transcripts, were observed following the treatment with thyroxine. Our study indicated a robust compensatory mechanism by which the brain tissue/cells minimize the TH fluctuation in CNS by altering gene expression. Neurobehavioral changes were related to the TH perturbation and suggested potential associations between cognitive status and hyper- and hypothyroidism.

Thyroid disorders in elderly: A comprehensive review

The approach to management of thyroid disorders in the elderly differs from that for younger individuals: it considers frailty of the population, coexisting medical illness and medications, clearance rate of medications and drug-drug interactions along with target organ sensitivity to the treatment. We present a comprehensive review of literature for the clinical presentation, pathophysiology, diagnostic evaluation, and management of thyroid disorders in the elderly.

Predictor Analysis in Radiofrequency Ablation of Benign Thyroid Nodules: A Single Center Experience

Purpose

To confirm the efficacy of ultrasound (US) guided radiofrequency ablation (RFA) in the treatment of benign thyroid nodules, we evaluated as primary outcome the technical efficacy and clinical success in a single center dataset. The secondary outcome was to find a correlation between nodules' pre-treatment features and volume reduction rate (VRR) ≥75% at 12 months after RFA and during follow-up period.

Methods

This retrospective study included 119 consecutive patients (99 females, 20 males, 51.5 ± 14.4 years) with benign thyroid nodules treated in our hospital between October 2014 and December 2018 with a mean follow-up of 26.8 months (range 3-48). Clinical and US features before and after RFA were evaluated by a US examination at 1, 3, 6, 12 months and annually thereafter up to 48 months.

Results

The median pre-treatment volume was 22.4 ml; after RFA we observed a statistically significant volume reduction from the first month (11.7 ml) to the last follow-up (p < 0.001 for all follow-up times). The median VRR was 47.1, 55.3, 61.2, 67.6, 72.8, 71.3, and 62.9% at 1, 3, 6, 12, 24, 36, and 48 months of follow-up respectively, showing a progressive significant improvement up to 24 months (VRRs 1 vs 3 months, 3 vs 6 months and 6 vs 12 months p < 0.001, 12 vs 24 months p = 0.05) while no differences at 24 vs 36 and 36 vs 48 months were observed. Symptoms improved significantly (complete resolution 64.35%, partial resolution 35.65%), and neck circumference was reduced as compared to pre-treatment (p < 0.001). Lower pre-treatment neck circumference (37.5 vs 36.0 cm, p = 0.01) was a positive predictor of VRR ≥75% at 12 months. Macrocystic echostructure (HR 2.48, p 0.046) and pre-treatment volume >22.4 ml (HR 0.54, p 0.036) were found to be independent positive and negative predictors of VRR ≥75% respectively. One-month post RFA VRR ≥50% represented the best positive predictor of technical success.

Conclusions

This study confirmed the efficacy of RFA in the treatment of benign thyroid nodules. In particular we show that by selecting macrocystic nodules smaller than 22.4 ml better long-term response can be achieved, which is predicted by an early shrinkage of the nodule.

Thyroid Nodule Evaluation and Management in Older Adults: A Review of Practical Considerations for Clinical Endocrinologists

OBJECTIVE

Contextualizing the evaluation of older adults with thyroid nodules is necessary to fully understand which management strategy is the most appropriate. Our goal was to summarize available clinical evidence to provide guidance in the care of older adults with thyroid nodules and highlight special considerations for thyroid nodule evaluation and management in this population.

METHODS

We conducted a literature search of PubMed and Ovid MEDLINE from January 2000 to November 2020 to identify relevant peer-reviewed articles published in English. References from the included articles as well as articles identified by the authors were also reviewed.

RESULTS

The prevalence of thyroid nodules increases with age. Although thyroid nodules in older adults have a lower risk of malignancy, identified cancers are more likely to be of high-risk histology. The goals of thyroid nodule evaluation and the tools used for diagnosis are similar for older and younger patients with thyroid nodules. However, limited evidence exists regarding thyroid nodule evaluation and management to guide personalized decision making in the geriatric population.

CONCLUSION

Considering patient context is significant in the diagnosis and management of thyroid nodules in older adults. When making management decisions in this population, it is essential to carefully weigh the risks and benefits of thyroid nodule diagnosis and treatment, in view of older adults' higher prevalence of high-risk thyroid cancer as well as increased risk for multimorbidity, functional and cognitive decline, and treatment complications.

Association of Hypertension and Hyperthyroidism in a Subspecialty Clinic and a National Database

OBJECTIVE

Hypertension can cause significant morbidity and reduced life expectancy. Most patients with hypertension have primary hypertension; however, 10% to 15% have secondary hypertension. Endocrine disorders as a secondary cause occur in approximately 10% of patients with secondary hypertension, and thyroid disorders account for approximately 1% of all patients with hypertension. The identification of patients with hyperthyroidism has important benefits for these particular patients. The objective of this study was to examine the occurrence of high blood pressure in patients with hyperthyroidism.

METHODS

We reviewed the clinical information available from 414 new patients referred to an endocrinology clinic in west Texas for evaluation of hyperthyroidism. The final cohort included 96 patients who had both thyroid laboratory tests and blood pressure measurements at the time of their clinic visit. We also examined this relationship in a nationally representative sample of US adults (National Health and Nutrition Examination Survey 2007-2012), which included thyroid test results and at least one blood pressure measurement (N = 8837).

RESULTS

Sixty-five of these clinic patients had elevated blood pressure based on criteria suggested by the American College of Cardiology/American Heart Association. These patients had similar thyroid hormone levels as patients who did not have hypertension but tended to be older. Ordinary least squares regression analysis of the National Health and Nutrition Examination Survey 2007-2012 data demonstrated a significant positive association between free T3 levels and systolic blood pressure, adjusting for age, sex, and the use of levothyroxine.

CONCLUSIONS

These findings from a specialty clinic and a national sample suggest that clinicians should consider the possibility of hyperthyroidism in patients with hypertension, even in older patients.

Hypertension and Hyperthyroidism: Association and Pathogenesis

Hypertension can cause significant morbidity and reduced life expectancy. Most patients with hypertension have primary hypertension; however, 10 to 15% of patients have secondary hypertension. Endocrine disorders explain approximately 10% of hypertension in all patients, and thyroid disorders account for approximately 1% of cases with hypertension. Hyperthyroidism can cause increased cardiac output, increased systolic blood pressures, and increased levels of renin, angiotensin, and aldosterone. Treatment of hyperthyroidism can cure hypertension in some patients. Consequently, identification of patients with secondary hypertension potentially has important benefits, and understanding secondary hypertension provides a framework for investigating the pathophysiology of hypertension. Clinicians should consider the possibility of hyperthyroidism in patients with hypertension, even in those of more advanced age.

An Age-Specific Serum Thyrotropin Reference Range for the Diagnosis of Thyroid Diseases in Older Adults: A Cross-Sectional Survey in China

Background: The fact that serum thyrotropin (TSH) levels increase with age may influence the diagnosis of thyroid diseases in older adults. This study aimed to establish an age-specific serum TSH reference range, examine the prevalence of thyroid diseases in older adults ≥65 years, and analyze the risk factors. Methods: A cross-sectional study of adult populations in 10 cities in China was conducted from 2010 to 2011. A total of 15,008 subjects were randomly selected and completed the present study. Urinary iodine concentration, serum TSH, thyroid peroxidase antibody (TPOAb), and thyroglobulin antibody (TgAb) titers were measured. Thyroid ultrasonography and questionnaires were completed by all the subjects. When the TSH level was abnormal, free thyroxine and/or free triiodothyronine levels were measured. Results: When the reference range of the general population was used, the prevalence rates of overt hypothyroidism (Ohypo) and subclinical hypothyroidism (Shypo) in older adults ≥65 years were significantly higher than those in younger adults <65 years (2.09% vs. 0.80% and 19.87% vs. 16.23%, respectively; p < 0.001). Positive TPOAb and positive TgAb were associated with the prevalence of Shypo in older adults. An age-specific serum TSH reference range was formulated according to guidelines set forth by the National Academy of Clinical Biochemistry. Both the median and upper limit values of serum TSH in older adults were higher than those in younger adults (2.58 [0.75-8.86] mIU/L vs. 2.38 [0.76-6.57] mIU/L; p < 0.001). Using the age-specific serum TSH reference range, the prevalence of Shypo in older adults was 3.3%, which was significantly lower than the prevalence based on the reference range of the general population (3.3% vs. 19.87%). The prevalence rates of Ohypo, overt hyperthyroidism (Ohyper), and subclinical hyperthyroidism (Shyper) did not change much (Ohypo: 1.6% vs. 2.09%; Ohyper: 0.7% vs. 0.52%; and Shyper: 3.8% vs. 0.73%). Positive TPOAb, but not positive TgAb, was also associated with the prevalence of Shypo as diagnosed with the age-specific serum TSH reference range. Conclusion: The serum TSH level increases with age, which may represent a normal compensatory phenomenon in older adults ≥65 years. To prevent misdiagnosis and mistreatment, the use of an age-specific serum TSH reference range is recommended in older adults for the diagnosis of thyroid diseases.

Management of immunotherapy toxicities in older adults

Advanced age is a risk factor for cancer and is attributed to dysregulation of the immune system. Historically, treatment of advanced cancer has primarily involved systemic chemotherapy that is associated with high treatment related toxicity especially in older adults. Immune checkpoint inhibitors (ICIs) provide an exciting treatment option for older adults in terms of efficacy and safety as compared to systemic chemotherapy. Given the pace of approval of ICIs for multiple cancers, there is an increase in both the use of ICIs and the associated immune-related adverse events. In this article, we address how to approach immunotherapy related toxicities in older adults given the availability of limited data.

Thyroid disease in the perimenopause and postmenopause period

The interpretation of thyroid function tests should be cautiously made during the perimenopause and postmenopause period bearing in mind that physiologic changes do exist in this group of women in terms of secretion and metabolism of thyrotropin and thyroid hormones. Moreover the incidence of thyroid disorders increases in postmenopausal and elderly women. There is no consensus for screening postmenopausal women even though there is well-known evidence about the effect of thyroid status on cognitive function, cardiovascular risk, bone turnover, and longevity. The diagnosis of any thyroid disorder is challenging in these patients because the symptoms are more subtle and attributed to menopausal symptoms. Management requires more attention in this population than that of younger groups, because high doses of L-thyroxine can lead to cardiac complications and increased bone turnover. Furthermore radio-iodine is preferred in treatment of hyperthyroidism in older patients. The risk of nodular thyroid disease and thyroid cancers increases in this group. Although the diagnostic approach is the same as for young patients, the risk of surgery is high and disease prognosis is worse. Women with any form of thyroid disease should be treated according to the current guidelines. Decision for menopausal hormonal therapy should be individualized regardless of the concomitant presence of thyroid disorders.

An overview of the contribution of acupuncture to thyroid disorders

Thyroid dysfunction, affecting people of all ages, not only damages human growth and energy metabolism but is also comorbid with other illnesses such as cardiovascular disease, kidney disease and gastrointestinal disorders. With the increasing acceptance of alternative and complementary therapies, acupuncture, a traditional Chinese medical practice, has also been employed to address this problem. Analysing 29 clinical projects that were retrieved from 29 major digital databases and include 1757 patients aged 7-79 years from China, Italy, Korea, Macedonia and Russia, this narrative review offers an overview of the efficacy, and evaluated the safe and cost-effective use of acupuncture against hyperthyroidism, hypothyroidism and thyroid-relevant illnesses. Findings indicated reductions in patient symptoms and improvements in biomarkers where acupuncture was used alone or in combination therapy. In addition to showing the role of acupuncture as an alternative and complementary medicine or as an adjunctive therapy for curative and rehabilitative purposes, more well-designed researches are needed to achieve reliable data.

Dyslipidaemia in the elderly: to treat or not to treat?

INTRODUCTION

The elderly population (i.e. aged ≥ 65 years) is increasing worldwide. Ageing is associated with a higher incidence and prevalence of cardiovascular disease (CVD). Areas covered: The prevalence of CVD risk factors including type 2 diabetes mellitus, hypertension and dyslipidaemia also increases with advancing age, contributing to the higher absolute CVD risk observed in the elderly. The present narrative review comments on the associations of dyslipidaemia with CVD as well as the effects of lifestyle measures and lipid-lowering drugs on lipids and CVD risk with a special focus on the elderly population. Individual treatment goals and therapeutic options according to current guidelines are also reviewed. Finally, we discuss special characteristics of the elderly that may influence the efficacy and safety of drug therapy and should be considered before selection of hypolipidaemic pharmacotherapy. Expert commentary: There may be a greater CVD benefit in older patients following drug therapy compared with younger ones. Treatment goals and therapeutic options should be individualized according to current guidelines. Specific characteristics that may influence the efficacy and safety of drug therapy in the elderly should be considered in relation to dyslipidaemia treatment.

Diagnostics of Thyroid Malignancy and Indications for Surgery in the Elderly and Younger Counterparts: Comparison of 3,749 Patients

Background

It seems valuable for clinicians to know if diagnostics of thyroid malignancy (TM) and indications for surgery in the elderly patients differ from these in younger counterparts.

Materials and Methods

Retrospective analysis of the medical records of 3,749 patients surgically treated for thyroid tumor. Data of patients with histopathology confirmed TM (n = 309) were studied.

Results

The rate of cytological prediction to malignancy was more than three times higher in elderly women. Compression was a main reason for surgery in the elderly (p < 0.0001). The final diagnosis of malignancy was significantly higher in older women (p = 0.002). Clinical suspicion of malignancy was positively correlated with histopathological diagnosis in total group of women (r = 0.543, p < 0.001) and total group of men (r = 0.560, p < 0.001). The subgroup of the eldest TM patients included a significantly higher number of subjects with advanced cancer and primary tumor progression (p < 0.0001). Distant metastases were significantly more presented among the elderly patients (p = 0.032).

Conclusions

The rate of cytological prediction to malignancy in elderly women is high. Tracheal compression is a common surgical indication in the elderly patients. The final diagnoses of malignancy predominate in elderly women. The oldest TM patients present a higher number of advanced thyroid tumors and distant metastases.

MANAGEMENT OF ENDOCRINE DISEASE: l-Thyroxine replacement therapy in the frail elderly: a challenge in clinical practice

The number of elderly people, mostly aged over 85 years (the 'oldest old'), is increasing worldwide. As a consequence, accompanying morbidity and disability have been increasing, and frailty, defined as an age-related condition of decline of physiological reserves and vulnerability, represents an emerging problem. Caring for older frail people may represent a challenge, since the elderly differ significantly from younger adults in terms of comorbidity, polypharmacy, pharmacokinetics and greater vulnerability to adverse drug reactions. Specific criteria of therapeutic appropriateness and modified goals of care are needed in such patients, also in endocrine care settings. Indeed, thyroid dysfunctions are among the most common conditions in older, multimorbid populations. The prevalence of overt and subclinical hypothyroidism is as high as 20% and thyroid hormone prescription is common in the elderly, with a trend toward levothyroxine treatment of more marginal degrees of hypothyroidism. In addition, older patients have the highest rate of overtreatment during replacement therapy and are more susceptible to developing adverse effects from thyroid hormone excess. Recently, results of a multicentric randomized controlled trial, the TRUST-IEMO collaboration trial, added further insights to the debated question of whether and when levothyroxine treatment is required and if it is beneficial in the elderly. With this in mind, we revised the relevant literature on the impact of thyroid dysfunction and replacement therapy among older people, with the aim to better define indications, benefits and risks of l-T4 replacement therapy in the frail elderly.

Thyroid Function in Aging: A Discerning Approach

Thyroid disease, increasingly common among the general population, is also rising among the elderly, which, given that the global population is aging, constitutes a serious public health issue that needs to be urgently addressed. The most common thyroid disease in younger and older individuals alike is hypothyroidism, including subclinical (SCH) and overt disease. Since TSH tends to increase with age due to intrinsic changes of thyroid metabolism and the gradual resetting of the hypothalamic-pituitary-thyroid axis, the diagnosis of "true" hypothyroidism is challenging, another difficulty being distinguishing disease-specific from aging-associated clinical symptoms. Hypothyroidism in the elderly may cause or exacerbate macrocytic anemia, hypercholesterolemia and kidney dysfunction, therefore careful clinical and biochemical control is necessary. Meanwhile, as an increase of TSH in the old and very old has been associated with longevity, a resetting of the TSH normal range according to age is strongly required before any diagnosis is made and treatment is implemented. Levothyroxine, which remains the treatment of choice, should be initiated in the old at TSH>10 mIU/l, starting with 25 μg/daily followed by cautious upward titration. Recent data (the TRUST study) revealed that treatment of SCH in the elderly does not improve hypothyroid symptoms and the tiredness score when compared with a placebo group. Hyperthyroidism is associated with increased mortality in the aged, this dependent upon type and adequacy of treatment. Treatment should be seriously considered in older patients who have endogenous subclinical hyperthyroidism with a TSH between 0.1 and 0.4 mIU/L, with regular monitoring being strongly advised.

REFERRAL OF OLDER THYROID CANCER PATIENTS TO A HIGH-VOLUME SURGEON: RESULTS OF A MULTIDISCIPLINARY PHYSICIAN SURVEY

OBJECTIVE

Surgical outcomes of thyroid cancer patients are improved with high-volume surgeons. However, age disparities in referral to specialist surgical centers still exist. The factors that influence decision making regarding referral of older thyroid cancer patients to high-volume surgeons remain unknown.

METHODS

We surveyed members of the Endocrine Society, American College of Physicians, and American Academy of Family Practice.

RESULTS

Overall, 270 physicians completed the survey. Patient preference (69%), transportation barriers (62%), and confidence in local surgeon (54%) were the most cited factors decreasing likelihood of referral to a high-volume surgeon. In clinical scenarios, referral rates to a high-volume surgeon were similar for patients aged 40 and 65 years with a 1-cm thyroid nodule diagnostic of thyroid cancer (n = 137 [54%]; n = 132 [52%], respectively) as for an 85-year-old with a 4-cm nodule (n = 148 [59%]). When comorbidities were introduced, more physicians (n = 186 [74%]) would refer a 65-year-old with a 4-cm thyroid nodule and comorbidities, compared to an 85-year-old with the same nodule size without comorbidi-ties. In multivariable analysis, treating >10 thyroid cancer patients/year (P<.001; P<.005) and endocrinology specialty (P = .003; P = .003) were associated with referral to a high-volume surgeon for a 65-year-old with comorbidities and an 85-year-old without comorbidities, respectively.

CONCLUSION

Understanding surgical referral patterns of older thyroid cancer patients is vital in identifying obstacles in the referral process. We found that patient factors including comorbidities and physician factors including specialty and patient volume influence these patterns. This is the first step towards developing targeted interventions for these patients.

Comparative clinicopathological and outcome analysis of differentiated thyroid cancer in Saudi patients aged below 60 years and above 60 years

INTRODUCTION

The aim of this study was to evaluate the treatment outcomes of differentiated thyroid cancer in Saudi patients aged above 60 years.

MATERIALS AND METHODS

Comparative analysis was performed in 252 patients aged 46-60 years (Group A) and 118 patients aged above 60 years (Group B), who had thyroidectomy, radioactive iodine-131, and thyroid-stimulating hormone suppression therapy between July 2000 and December 2012. Different clinicopathological features, treatment, complications, disease-free survival, and overall survival rates were compared.

RESULTS

Mean age of patients in Group A was 51.9 years (range: 46-60), and mean age of those in Group B was 68.6 years (range: 62-97). Group B patients had higher positive lymph nodes (43.2%), P=0.011. The frequency of extrathyroidal extension, multifocality, and lymphovascular space invasion was seen more in Group B than in Group A. Postsurgical complications (permanent hypoparathyroidism, bleeding, and wound infections) were also seen more in Group B (P=0.043, P=0.011, and P=0.021, respectively). Group B patients experienced more locoregional recurrences (11.0%, P=0.025); similarly, more distant metastases were observed in Group B (15.3%, P=0.003). The 10-year disease-free survival rates were 87.6% in Group A and 70.8% in Group B (P<0.0001).

CONCLUSION

Differentiated thyroid cancer in patients aged above 60 years are more aggressive biologically and associated with a worse prognosis, and the morbidity is significantly high as compared to patients aged below 60 years.

Thyroid Disease and Oral Lichen Planus as Comorbidity: A Prospective Case-Control Study

BACKGROUND

Thyroid disease has been mentioned to have a possible relation to the development of oral lichen planus (OLP).

OBJECTIVE

Because goiter is considered endemic in many countries, we proposed to determine whether thyroid disease constitutes a comorbidity of OLP.

METHODS

Two hundred and fifteen patients diagnosed as having OLP were evaluated concerning their serum thyroid-stimulating hormone and thyroxine (T4) levels. The results were contrasted with those obtained in control series of the same number of subjects matched for age and sex.

RESULTS

Diagnosis of thyroid disease was present in 15.3% of OLP patients (33/215) and in 5.2% (12/215) of the control group. In relation to OLP patients, the odds ratio of presence of thyroid disorders was 3.06 and that of using levothyroxine medication 3.21.

CONCLUSIONS

In the present study, OLP patients were associated with thyroid disease, specifically with hypothyroidism. Because most thyroid patients need T4 treatment, our findings confirmed that OLP and thyroid disease could be comorbidities.

Differentiated thyroid cancer in people aged 85 and older

OBJECTIVES

To describe the characteristics and treatment patterns of differentiated thyroid cancer in older adults.

DESIGN

Retrospective cohort study.

SETTING

The National Cancer Institute Surveillance, Epidemiology, and End Results database.

PARTICIPANTS

Individuals age 85 and older with a primary thyroid cancer diagnosis of papillary or follicular histology diagnosed between 1988 and 2007 (N=424).

MEASUREMENTS

Age, sex, histology, extent of disease, tumor size, treatment, type of surgery, cause of death, and length of survival.

RESULTS

Tumor size and extent of disease were significantly related to cause of death (P=.02). Participants who did not have surgery were more likely to die of their thyroid cancer than of any other cause (P=.01), and whether a participant had surgery was significantly related to age (P=.002). Participants who had surgery had significantly longer survival than those who did not (P<.001). Type of surgery (P=.92) and adding radioactive iodine after surgery (P=.07) did not appear to influence length of survival.

CONCLUSION

Although differentiated thyroid cancer is typically considered a relatively indolent disease, this is not the case in older adults. Surgery appears to reduce the likelihood of death from thyroid cancer in this population and confers a survival benefit. Type of surgery and adding radioactive iodine therapy do not seem to improve the survival benefit of surgical management.

Differentiated thyroid cancer in the elderly: our experience

INTRODUCTION

The objective of this retrospective study was to investigate clinical and pathologic characteristics of differentiated thyroid cancer in elderly patients and to evaluate the results of surgical treatment in this age group.

METHODS

The clinical records of patients who underwent total thyroidectomy between 2002 and 2012 with histopathological diagnosis of differentiated thyroid cancer were analyzed. Patients were divided into two groups: those 65 years old or older were included in group A (101), those younger in group B (354).

RESULTS

The mean surgical time was 100.9 ± 30.5 min in group A and 100.7 ± 27.6 in B. Postoperative stay was significantly longer in group A (2.8 ± 1.5 days vs 2.4 ± 0.7; p < 0.01). Classic papillary carcinoma was more frequent in group B, whereas follicular variant of papillary carcinoma and tall cell carcinoma in A. In group B node metastases were nearly twice. In Group A transient hypoparathyroidism occurred in 25 patients (24.8%), permanent hypoparathyroidism in 4 (4%), hematoma in 6 (5.9%), recurrent nerve palsy in 2 (2%), and wound infection in 2 (2%). In group B transient and permanent hypoparathyroidism occurred in 48 and 7 patients respectively (13.6% and 2%), hematoma in 4 (1.1%), recurrent nerve palsy in 5 (1.4%), and wound infection in 1 (0.3%).

CONCLUSIONS

Differentiated thyroid carcinoma is more aggressive in elderly patients for biological causes connected to age and to histotype but also for the diagnostic delay. Thyroid surgery in elderly patients is safe when the procedure is carried out by experienced staff. Total thyroidectomy is the surgical operation of choice.

The thyroid gland and the process of aging; what is new?

The endocrine system and particular endocrine organs, including the thyroid, undergo important functional changes during aging. The prevalence of thyroid disorders increases with age and numerous morphological and physiological changes of the thyroid gland during the process of aging are well-known. It is to be stressed that the clinical course of thyroid diseases in the elderly differs essentially from that observed in younger individuals, because symptoms are more subtle and are often attributed to normal aging. Subclinical hypo- and hyperthyroidism, as well as thyroid neoplasms, require special attention in elderly subjects. Intriguingly, decreased thyroid function, as well as thyrotropin (TSH) levels - progressively shifting to higher values with age - may contribute to the increased lifespan.This short review focuses on recent findings concerning the alterations in thyroid function during aging, including these which may potentially lead to extended longevity, both in humans and animals.

Clinical and economic outcomes of thyroid surgery in elderly patients: a systematic review

The U.S. population is undergoing a dramatic shift in demographics, with a rise in the proportion of elderly Americans. Given an increased prevalence of thyroid disease and malignancy with age, understanding the safety of thyroid surgery in this age group is increasingly pertinent. There remains disagreement regarding the clinical outcomes of elderly patients after thyroidectomy and the applicability of single-institution cohorts to the population at large. This paper reviews the epidemiology of thyroid disease in the elderly, current surgical indications and practice patterns, and the clinical and economic outcomes of elderly patients with thyroid disease after surgical intervention.

Free Triiodothyronine and Cholesterol Levels in Euthyroid Elderly T2DM Patients

Thyroid function regulates lipid metabolism. Despite the fact that T2DM is more prevalent in the elderly, often associates with thyroid dysfunction and increases cardiovascular risk both per se and via high TC and LDL-C levels, the association of the latter with FT(3) and FT(4) levels has not yet been fully investigated in T2DM. While trying to fill this gap in 296 elderly outpatients with T2DM, we found that TC and LDL-C correlated negatively with FT(4) and positively with FT(3). When divided according to treatment by oral hypoglycaemic agents (OHA) and insulin (IT), they reacted differently with respect to investigated associations: in the OHA's TC and LDL-C correlated negatively with FT(4) and showed no association with FT(3), whereas, in the IT's TC and LDL-C correlated positively with FT(3) and negatively with FT(4). When controlled for possible confounding factors, these associations did not change in the IT's but were missing in the OHA's. Recent literature reports upon complex hypothalamic and peripheral interactions between T2DM and thyroid, and suggests T(3) to enhance cholesterol synthesis and to have a role in insulin resistance states. Further investigations are needed to understand the intimate mechanisms of lipid metabolism in T2DM with respect to thyroid function.