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Module 24

Module Leader:

Kwame Osei, M.D.

Geriatric Objectives:

  1. Discuss manifestations of diabetes, thyroid and dyslipoproteinemia disorders in the older adult.
Learning Resources:

Chapter 75: “Thyroid Diseases”, pgs. 973-989 in Principles of Geriatric Medicine and Gerontology (Fourth Edition), (1999) by Hazzard, Blass, Ettinger, Halter, and Ouslander. McGraw-Hill.

Chapter 76: “Diabetes Mellitus”, pgs. 991-1011, in Principles of Geriatric Medicine and Gerontology (Fourth Edition), (1999) by Hazzard, Blass, Ettinger, Halter, and Ouslander. McGraw-Hill.

Chapter 77: “Dyslipoproteinemia”, pgs. 1013-1028, in Principles of Geriatric Medicine and Gerontology (Fourth Edition), (1999) by Hazzard, Blass, Ettinger, Halter, and Ouslander. McGraw-Hill.

Short Summary/Outline:

  1. Diabetes in Older Adults
    1. Introduction.
      1. One of the most common chronic diseases affecting older adults.
      2. Prevalence of those 65 years and over range between 15 and 20%
      3. 90% of all cases are type II diabetes
    2. Diagnostic Criteria in Older Adults (p. 994)
      1. ADA recommends fasting glucose levels
      2. Symptoms of polyuria, polydipsia and unexplained weight loss plus plasma glucose of >200mg/dl at any time of day
    3. Diabetes Complications (p. 995)
      1. Older adults are susceptible to all common complications of diabetes
      2. Risks of myocardial infarction, stroke and end-stage renal disease are greatly increased (about twofold). Risk of vision loss is increased about 40 percent in older adults with diabetes
    4. Effects of Aging (p. 996)
      1. Debate about age-related decline in insulin action is effect of age or secondary to age related changes in body composition and physical activity
      2. Hypertension and hyperlipidemia common in older adults have been associated with with decreased insulin sensitivity
      3. Drugs used by older adults may contribute to hyperglycemia (see Table 76-1)
    5. Evaluation (p.998)
      1. Medical evaluation
      2. Diabetes Knowledge
      3. Functional Status
      4. Cognitive and Psychosocial status
    6. Management of Diabetes in Older Patients (p. 1001)
      1. General Approach
        • Establish treatment goal
        • Factors to consider include: patient preference and commitment, availability of support services, financial issues, coexisting health problems, complexity of medical regimen
        • Diabetes Education
        • Dietary issues in older adults
          • Limited mobility
          • Dietary habits well established
          • Cultural background
          • Problems with oral health and taste
        • Exercise
      2. Medications (p. 1004)
  2. Thyroid Disease in Older Adults
    1. Introduction
      1. Thyroid disorders are common and overlooked in the older adults.
      2. Clinical presentation may be subtle and nonspecific signs may be attributed to aging
    2. Screening for Thyroid Disease
      1. Warranted in those older adults with recent decline in cognitive or functional status
      2. Those recently admitted to the hospital or nursing home
    3. Hypothyroidism (p. 976)
      1. Prevalence in older adults ranges from 2-10 percent
      2. Etiology in the Older Adult (Table 75-2)
        • Primary: radiation, surgical, drugs
        • Secondary: Hypothalamic tumors, pituitary tumors, radiation
      3. Clinical Manifestations (Table 75-3, p. 979)
        • Tend to be nonspecific in older adult. More gradual onset
        • More classic signs such as cold intolerance, weight gain and muscle cramps are less frequent in older adults (Table 75-4, p. 979)
        • May see symptoms of carpal tunnel syndrome, hair loss or dry skin, weight loss and decreased appetite
      4. Diagnosis
        • Elevated TSH. FT4 indicates degree of failure
      5. Treatment
        • Older adults require about 25 percent less synthetic levothyroxine as compared to young adults
        • Titrate up at 6 week intervals until serum TSH is in therapeutic range
        • A number of drugs interfere with absorption. Can be avoided in large part by allowing 3-4 hours between levothyroxine ingestion and other medications
    4. Hyperthyroidism (p. 982)
      1. Prevalence varies from 0.5 to 2.3 percent in older adults. However 10-17 percent of all hyperthyroid patients are over age of 60 years.
      2. Etiology
        • Most common cause is Graves’ disease or diffuse toxic goiter
        • Toxic multinodular goiter is more common in older adults
      3. Clinical Manifestations (Table 75-5, p. 983)
        • Diagnosis may be overlooked due to common presentation of apathy
        • Other dominant findings may be weight loss or cardiac or gastrointestinal manifestations
        • Clinical features often differ compared to young adults (Table 75-6, p. 983)
      4. Diagnosis
        • Elevated serum T4 in 86 percent of older adult patients
        • Elevated serum T3 level in combination of en elevated serum T4 is strong confirmation of hyperthyroidism
      5. Treatment
        • Preferred therapy in older adults is radioactive iodine-131
        • Warn against side effect of agranulocytosis (1/250) and symptoms to look for.
  3. Dyslipoproteinemia in Older Adults
    1. Lipoprotein risk factors for coronary heart disease in older adults
      1. Elevated total and low-density lipoprotein cholesterol concentrations
      2. Reduced concentrations of high-density lipoprotein cholesterol
      3. Atherogenic low-density lipoprotein pattern B phenotype
      4. Apolipoprotein E4 allele (presence has shown to be risk factor for CHD
      5. Elevated lipoprotein (a)
    2. Screening and treatment of older adults remains controversial
    3. Factors favoring and factors against treatment of hyperlipidemia in older adults (Table 77-4)
    4. Treatment by age (60-75, >75) and levels of prevention (primary, secondary, tertiary) (Table 77-5)