Hypothyroidism and Hyperthyroidism in Seniors

Patient Expert

Thyroid disease affects as many as 60 million Americans and a substantial percentage of them are over the age of 60. The risk of developing thyroid disease also increases as we age. With a population that is living longer, you may develop a thyroid condition as you get older. Or, you may be a caretaker or advocate for your senior parents as they manage thyroid challenges. The best outcome requires that senior patients, caretakers, and advocates are all informed about the many challenges in the diagnosis and treatment of thyroid conditions.

When should seniors be evaluated for a thyroid problem?

Thyroid symptoms in seniors can be vague, subtle, or even quite different from the better-known symptoms found in the younger population. As a result, it can be difficult for seniors, their doctors, and caregivers to recognize thyroid symptoms. The American Thyroid Association (ATA) even estimates that up to 25 percent of patients in nursing homes have undiagnosed hypothyroidism.

The American Academy of Family Physicians recommends screening for patients over 60 years old, but this screening is not yet a standardized part of regular check-ups for seniors. Seniors or caregivers can, however, specifically request that thyroid screening is conducted at every annual checkup.

Thyroid symptoms may be attributed — correctly or not — to normal aging or other health issues. Some experts recommend that any change in a previously stable senior patient should warrant thyroid evaluation, especially when symptoms appear that are common to both thyroid disease in seniors and aging. These common signs and symptoms include:

Seniors should have a complete thyroid evaluation, including thyroid stimulating hormone (TSH), free thyroxine (free T4), and free triiodothyronine (free T3) tests, along with a clinical examination and medical history from a physician familiar with diagnosing thyroid disease in older patients. Note, however, that physical examination of the thyroid gland can be more difficult in seniors because in older people, the thyroid can shrink or atrophy and become more difficult to feel externally. Goiter — an enlarged thyroid that is a classic symptom of both hypothyroidism and hyperthyroidism — is also rarely seen in seniors.

Which medications increase the risk of thyroid conditions?

Many seniors take various prescription drugs and supplements for their health conditions. That makes it especially important for seniors, caregivers, and healthcare practitioners to be aware of medications that increase the risk of thyroid problems, and periodically screen for thyroid disease. Some of the key medications and supplements that can affect thyroid function include:

  • Lithium — prescribed for bipolar disease

  • Amiodarone — prescribed for atrial fibrillation

  • Glucocorticoids/steroids — prescribed for pain and inflammation

  • Dopamine agonists — prescribed for Parkinson's disease

  • Metformin — prescribed for type 2 diabetes

  • Heparin — prescribed for blood clots

Diagnosing hypothyroidism in older people

The most common signs and symptoms of hypothyroidism — an underactive thyroid — in seniors include:

  • Congestive heart failure

  • Anxiety, agitation

  • Poor appetite

  • Weight changes

  • Dry skin

  • Constipation or fecal impaction

  • Apathy and depression

  • Fatigue and sleepiness

  • Muscle weakness, impaired mobility

  • Memory problems, decreased cognitive functioning

  • Dementia

  • Unexplained increases in cholesterol or triglyceride levels

  • Macrocytic anemia

  • Joint and muscle pains

  • Fainting

  • Neuropathy

Whenever a senior has any of these symptoms, a complete thyroid evaluation, including clinical examination and medical history, should be performed by a physician.

Treating hypothyroidism in older people

When hypothyroidism is diagnosed in a senior, typically, treatment with thyroid hormone replacement medication is started. Typically, the starting dose is lower than the anticipated full dose because too much thyroid hormone, or too rapid an increase in dose, puts stress on the heart.

If a senior has any heart disease, stroke, or dementia, a dose of around 25 percent of the eventual dose is typically used at the start of treatment. In those with no evidence of heart disease, stroke, or dementia, around 50 percent of the anticipated full dose may be recommended at the start of treatment.

The dosage is increased by small amounts every two to six weeks. The pulse rate should be monitored for changes. If the doctor fails to wait an appropriate amount of time before an increase in the dosage, toxic levels of thyroid hormone can result, causing heart-related symptoms or temporary hyperthyroidism.

Pay particular attention to refills of levothyroxine drugs used for thyroid hormone replacement. Different generic and brand-name levothyroxine drugs can have variations in potency and bioavailability. In older patients, these differences can easily cause overmedication or undermedication. Seniors should be on a brand-name levothyroxine or get the same generic maker with each refill. Experts caution that any senior who isn’t taking a consistent brand of levothyroxine is at risk of over- or under-medication with each refill.

Also, be aware that if a senior is taking levothyroxine along with other medications or supplements, there is the potential for interference with the absorption of thyroid medication. Some of the medications and supplements that can affect thyroid medication absorption include:

  • Iron

  • Calcium

  • Aluminum hydroxide — antacid

  • Cholestyramine (Questran) — for high cholesterol

  • Colestipol (Colestid) — for high cholesterol

  • Sucralfate — for gastroesophageal reflux disease and ulcers

  • Raloxifene (Evista) and Tamoxifen (Nolvadex), after breast cancer treatment

  • Phenobarbitol — for seizures

  • Phenytoin (Dilantin) — for seizures

  • Rifampin — an antibiotic

  • Tyrosine kinase inhibitors (Imatinib, axitinib, motesanib, vandetanib) — for cancer

  • Metformin — for type 2 diabetes

  • Propranolol — beta blocker for high blood pressure

  • Steroid drugs — for pain/inflammation

  • Estrogen — for hormone replacement

  • Androgens/male hormones — for testosterone support

Rarely, seniors can develop a complication of hypothyroidism called myxedema coma or "myxedema madness." It is more common in people over 75. Myxedema coma is the result of longer-standing hypothyroidism and can be precipitated by factors such as septic infection, alcohol intoxication, or exposure to cold temperatures. The symptoms include:

  • Mental deterioration

  • Confusion and disorientation

  • Psychosis

  • Lethargy

  • Dry, scaly skin

  • Yellowish coloring

  • Slow heart rate

  • A hoarse voice

  • Low body temperature

  • Hair loss

Treatment is higher doses of thyroid hormone-replacement medication, in some cases by intravenous infusion or injection.

Diagnosing hyperthyroidism in older people

Diagnosing hyperthyroidism — an overactive thyroid — in older patients can be a challenge. According to the ATA, hyperthyroidism in seniors is “a great masquerader.” The striking symptoms of hyperthyroidism seen in younger patients are often more subdued in seniors.

Some seniors have what’s called “monosymptomatic hyperthyroidism” — hyperthyroidism with just one symptom. Others have “apathetic hyperthyroidism” with depression, apathy, lethargy, muscular weakness, weight loss, and heart rhythm issues.

Even acute and life-threatening hyperthyroidism can be missed or misdiagnosed in seniors, for a number of key reasons:

  • The symptoms of hyperthyroidism in seniors are usually atypical and frequently include heart problems, such as atrial arrhythmias, atrial fibrillation, congestive heart failure, and angina (chest pain), as well as apathy, depression, muscle weakness, lethargy, agitation, confusion, and dementia.
  • Symptoms may be masked. For example, if the senior is taking a beta blocker for high blood pressure, an elevated heart rate may not be evident.

  • Weight loss and loss of appetite are more common in seniors, compared to increased appetite in younger people.

  • Loose stools and diarrhea, which are common in younger people, aren’t a common complaint in seniors. Seniors may have improvement in constipation, but this may not be noticed.

  • Seniors rarely have a goiter or any eye-related symptoms of hyperthyroidism.

Treating hyperthyroidism in older patients

There are three treatments for hyperthyroidism: antithyroid drugs, radioactive iodine (RAI), and surgery. For the treatment of hyperthyroidism in seniors, RAI is the preferred treatment, followeding by antithyroid drug therapy. Surgery is rarely recommended due to age-related risks.

For any hyperthyroidism treatment, heart function should be monitored, because changing thyroid hormone levels can affect the heart in seniors.

The downside of RAI is that it can take weeks or months to reverse the hyperthyroidism. If there are heart-related problems, they need to be carefully and aggressively managed until the hyperthyroidism is resolved.

If a senior needs rapid correction of hyperthyroidism, the antithyroid drugs methimazole or propylthiouracil (PTU) may be used, because these drugs can act quickly and help resolve heart-related symptoms. Once stabilized, however, doctors may recommend RAI treatment as a follow-up to antithyroid drug pre-treatment.

After RAI, follow-up thyroid monitoring should be conducted at least annually — more often if symptoms are evident — because the risk that the senior will become hypothyroid and require treatment is significant, and symptoms can be easily overlooked.

A rare complication of untreated or poorly managed hyperthyroidism — especially after surgery, anesthesia, and infections — is a life-threatening condition called thyroid storm. In seniors, thyroid storm symptoms can include fever, delirium, elevated heart rate, low blood pressure, vomiting, diarrhea, and jaundice. Thyroid storm requires immediate hospitalization and intensive care treatment.

See more helpful articles:

The Risks for and Symptoms of Hypothyroidism

The Risks for and Symptoms of Hyperthyroidism

Becoming Your Own Thyroid Advocate