|Year : 2020 | Volume
| Issue : 3 | Page : 110-117
Thyroid disease in older people: Nursing perspectives
Suresh K Sharma, Shiv K Mudgal, Anindita Mandal
College of Nursing, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
|Date of Submission||08-Apr-2020|
|Date of Acceptance||18-Apr-2020|
|Date of Web Publication||20-Jan-2021|
Prof. Suresh K Sharma
College of Nursing, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
Source of Support: None, Conflict of Interest: None
Old age refers to ages nearing or surpassing the life expectancy of human beings. Older people are an important and distinct yet sometimes the heterogeneous group of persons living with thyroid diseases. They have a unique biomedical, psychological, and social constitution. Their needs are different from those who are young adults. This implies that special care must be taken while planning, implementing, and evaluating nursing care for them. Management of different thyroid diseases in the elderly should provide attention on limitation of geriatric syndromes (medical conditions encountered in elderly persons) and neurocognitive dysfunction (impairment in the functioning of the brain and nervous system). This review takes a practical approach to the assessment, medical intervention along with nursing care for the elderly with thyroid diseases. It highlights major challenges and suggests solutions to these commonly encountered clinical nursing problems.
Keywords: Hyperthyroidism, hypothyroidism, nursing perspective, subclinical hypo- and hyperthyroidism, thyroid disease in elderly
|How to cite this article:|
Sharma SK, Mudgal SK, Mandal A. Thyroid disease in older people: Nursing perspectives. Thyroid Res Pract 2020;17:110-7
| Introduction|| |
Aging brings several physical, physiological, psychosocial, cognitive, behavioral, and financial changes. Compliant of weakness, memory impairment, depression, insomnia, tiredness, muscle cramp, and temperature sensitivity may be perceived as a natural part of the aging process. However, it may be associated with underlying diseases such as thyroid dysfunctions. Therefore, nurses play a crucial role in assessment and enforcement for compliance of treatment prescribed by the physicians, which helps in early diagnosis and prevention of disease-associated morbidities and mortalities.
Increasing expectancy in life, changing lifestyle, and stress of modern life have significantly contributed in the increased prevalence of older people living with thyroids disease. The clinical presentation of thyroid dysfunction in the elderly is more difficult to identify and diagnose because signs and symptoms of are often attributed to the normal aging process. Thyroid dysfunction is very common among the elderly and present in more than 10% of individuals over the age of 80 years in the form of clinical, subclinical hypo- and hyperthyroidism, nodules, and thyroid cancer. Therefore, the geriatric population requires not only medical attention but also nursing care, as both are equally important for managing the issues in this age group. Rather, such management could be done by involving comprehensive interdisciplinary team approach involving nursing, medical, and other team members as elderly patients with thyroid disease need individual consideration for specific treatment and careful lifelong follow-up. This review provides an overview about the thyroid diseases in the elderly and issues that need nursing attention for patients.
| Epidemiology of Thyroid Diseases|| |
Thyroid disorders can be categorized according to the function (hyper- and hypothyroid) and etiology (autoimmune, neoplastic, and nutritional). The prevalence of hypothyroidism, neoplasmic disease, and thyroid autoimmune disorders is more common among elder population, while hyperthyroidism is more prevalent among younger individuals. It was reported by epidemiological studies that subclinical hypothyroidism (SCH) occurs in 3.1%–8.5% in the general population. With consideration of both gender and age >60 years, the prevalence of SCH and overt hypothyroidism varied from 1.5%–15% and 0.2%–10%, respectively., The overall prevalence of hyperthyroidism is 1.3%; which increased to 4%–5% in older women. Hyperthyroidism is also more common in smokers. Graves' disease is seen most often in younger women, while toxic nodular goiter is more common in older., The prevalence of thyroid nodules increases with advancing age and approximately 50% of people >65 years of age have thyroid nodules living in iodine-sufficient regions, while 74% of patients and 54% of patients have multi-nodular goiter aged 55–75 years and 76–84 years, respectively, living in iodine-deficient regions., The estimated prevalence of thyroid tumor in elder (50–70 years of age) is 0.1%.
| Changes in Thyroid with Aging|| |
With the advancement of age, the thyroid gland develops continuous and gradual atrophy with fibrosis, which may cause a decrease in gland size and make it difficult to palpate. It is reported that morphological changes in the thyroid gland associated with more number of autoantibodies in elderly people (reach up to 20% in older women). As age advances, the risk of thyroid nodules and thyroid malignancy increases.
Several research studies tried to identify but reported controversial results about the act of thyroid in the elderly. Recent studies have reported an elevated level of serum thyroid-stimulating hormone (TSH) with aging in the absence of antithyroid antibody, whereas some studies have shown contradictory values as decrease serum TSH in the elderly., People with related pathology of thyroid deficiency secondary to Hashimotos show a tendency for an increased level of TSH with aging. While in iodine-deficient population, studies show a reverse relationship between TSH and aging.
Some studies have shown a decrease level of triiodothyronine (T3) and increase level of reverse triiodothyronine with no significant change in free thyroxine (T4) level with aging.,, The cause for these changes reported by various epidemiological and clinical based studies that with aging, there is a decrease of iodine uptake, which may lead to less amount of T4 secretion, but it is compensated by a reduction in T4 metabolic clearance due to less 5'deiodinase activity in the elderly.
| Symptomatology|| |
Elderly people may experience geriatric syndromes, which may have a significant effect on quality of life and functionality. Most of the geriatric syndromes are associated with four risk factors, i.e., advanced age, mobility impairment, deterioration of baseline functionality, and cognition. The symptoms of the geriatric syndrome include weakness, fatigue, irritability, weight loss, memory impairment, palpitation, tremors, anxiety, nervousness, cold sensitivity, dry skin, constipation, and depression. These signs and symptoms may also be seen in the hypo- and hyperthyroidism among the elderly, as presented in [Table 1].
|Table 1: Symptoms of geriatric syndrome in the elderly with thyroid diseases,,|
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| Assessment|| |
Diagnosis of thyroid diseases in elderly persons is a tedious task because of atypical symptoms of disease and the presence of comorbidities. Untreated thyroid disease is linked with an increased risk of hyperlipidemia and cardiovascular morbidities in old people. Therefore, it is essential to carry out comprehensive assessment to diagnose thyroid disease in the elderly. A comprehensive assessment includes physical, social, and psychosocial aspects of an individual. It needs a careful and in-depth clinical evaluation with laboratory testing. After the 1980s, immunometric assays for TSH emerged as the most cost-effective diagnosis for thyroid disease screening., Furthermore, the second- and third-generation immunoassays can detect TSH values of 0.1 mIU/L and 0.01 mIU/L, respectively.
The elderly with hyperthyroidism may have symptoms of enlarged thyroid gland, rapid pulse, tremor, hyperreflexia, moist, smooth skin, and eye abnormalities (if Graves' disease). It is diagnosed through serum thyroid hormones (low TSH, high T3, and T4). Graves' disease can be diagnosed by a high level of serum levels of thyrotropin-receptor antibodies, thyroid scan, and thyroid iodine uptake test.,,
Hypothyroidism in the elderly requires more careful assessment because the clinical presentation is nonspecific like cognitive impairment, fatigue, muscle weakness and cramps, cold sensitivity, constipation, dryness of skin, and cold sensitivity, which may be mistaken as aging itself. Therefore, careful detailed medical and family history must have obtained like about the thyroid surgery, radiation therapy for head-and-neck cancer, medication (amiodarone, lithium, interferon-alpha, and interleukin-2, etc.), and any family member with thyroid disease. Hypothyroidism can be confirmed by serum TSH and T4 levels.,, In addition, it also important to assess for lipid profile and detailed cardiovascular morbidity risk assessment.
Apart from their physical problems, the elderly also struggles with psychological and social issues. These may include a wide range of problems including irritability, forgetfulness, depression, social isolation, and cognitive impairment. Therefore, it is an essential component of clinical assessment to identify an individual's psychosocial needs and support system. Screening of an individual's quality of life, cognitive function, stress level, and depression could be assessed using reliable and validated tools, as illustrated in [Table 2].
|Table 2: Psychosocial health and quality life assessment tools for the elderly|
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| Medical Management|| |
The main aim of managing the elderly with thyroid disease through holistic care is to attain comfort and highest level of quality of life, relief from symptoms as much as possible, and minimize side effects of drugs and occurrence of complications. Therefore, it is much more require to achieve the symptomatic well-being of an elderly than to achieve fix target thyroid hormone level. It is recommended that TSH target level could be relaxed for elderly persons. The pharmacological and nonpharmacological tools could be utilized in the same manner for elderly and young patients for managing thyroid disease, but it is reported by studies that elderly persons require lower doses and do not need aggressive management of thyroid disease. The recommended treatment options are listed in [Table 3].
|Table 3: Summary for medical management of thyroid disease in the elderly,|
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| Nursing Management|| |
Elderly patients with thyroid disease need multidisciplinary approach to manage that includes not only physicians, nurses, dieticians, and physiotherapists but also family members and social workers. The subsequent part of this review is focused on the nursing management of elderly patients with thyroid disease. As there are enough evidences about the changes of thyroid functions in elderly so the current practice of managing every patient in the same manner is inappropriate. Therefore, it is mandatory for nurses to develop an individual specific nursing care plan for each elderly. A summary of nursing interventions under different dimensions of care for the elderly with thyroid disease is enumerated in [Table 4]. In this section, we are presenting evidence-based nursing care for the elderly with thyroid disease.
|Table 4: Evidence-based nursing care interventions for the elderly with thyroid disorders|
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| Nutritional Management|| |
Nutrition level of an elderly may be impaired due to various reasons. It is important to assess the patient's weight, appetite, dietary pattern, and precise accurate diagnosis of thyroid disease and comorbidities before planning of a diet. In hyperthyroidism condition, a high caloric diet is recommended to fulfill the body requirements and prevent damage. This goal could be achieved by providing six full meals in a day. The diet should be high in protein, carbohydrate, minerals, and vitamin but with low dietary fibers. In hypothyroidism condition, it is necessary to teach patient and provide low caloric, high protein diet, and high roughage food. Nursing care plan should include encouragement of patient to take small, frequent meals, meal supplementation, and snack replacement.
Iodine is a vital nutrient in the body and essential to thyroid function; thyroid hormones are comprised iodine. If a person has an iodine deficiency, consider adding iodized table salt to meals or eating more iodine-rich foods like seaweed, fish, dairy, and eggs. Calcium supplements interfere with the proper absorption of thyroid medications, so patients must consider the timing when taking both. Studies recommend spacing between calcium supplements and thyroid medications by at least 4 h. Coffee and fiber supplements lower the absorption of thyroid medication, so patients should take them 1 h apart.
Millet, a nutritious gluten-free grain, suppresses the thyroid function even in people with adequate iodine intake. If a dietary recall indicates frequent millet consumption in patients with hypothyroidism, it may be wise to suggest them to choose a different grain.
Hyperthyroidism, particularly Graves' disease, is known to cause bone loss, which is compounded by the Vitamin D deficiency. This bone mass can be regained with adequate bone-building nutrients along with Vitamin D supplements. Foods that contain some Vitamin D include fatty fish, milk, dairy, eggs, and mushrooms. Sunlight is also a potential source, but the amount of vitamin production depends on the season and latitude. For this reason, elderly with low vitamin D serum level, require supplemental vitamin D.
Foods that are rich in omega-3 should be included in the diet. Omega-3s can help to reduce inflammation in the body, as well as boost immunity. Iron deficiency is common in thyroid disease; so iron-rich diet is also recommended. Pumpkin seeds are remarkably high in zinc, a nutrient that is commonly low for thyroid patients. The process of converting inactive T4 into active T3 is dependent on an essential mineral, selenium. Mushrooms provide a good amount of selenium to the diet. Oxidation occurs during the conversion of inactive T4 into the active T3., Foods which are highly antioxidant help in it such as, cherries, green tea, Haldi, Amla, Kalmegh, Giloy, and papaya leaf. Polyphenols and ascorbic acid were shown in studies to benefit thyroid, insulin, and adrenal functions. It is also suggested that vitamin A is also requires for a healthy immune system and the production of T3. Sweet potatoes are also recommended for thyroid patients as it has phytonutrients, which help in decreased inflammation, and iron which helps with white and red blood cell production and stress resistance.,
Eight principles of diet for thyroid patients
- Take medicine early in the morning
- Take breakfast 30–60 min after taking medicine
- Avoid soya-based product which interacts with medicine
- Eliminate hydrogenated fat
- Eat cooked veggies
- Avoid gluten
- Avoid coffee and preworkout
- Take pharmaceutical grade vitamins.
Activity and mobility management
The activity level of an elderly should be assessed carefully. Attain an optimal level of activity and mobility is a vital and essential component of integral nursing management. We should plan activities of daily living and rest in such a manner that enhance patient's tolerance and comfort level. Regular exercise based on patient's abilities helps in the reduction and prevention of muscle wasting and joint stiffness., Therefore, recent studies recommended that flexibility exercises and yoga should be encouraged and integrated with care of the elderly with thyroid disease.
Body temperature regulation
Maintaining normal body temperature in the elderly is an integral part of nursing care. In hypothyroidism, an elderly has the problem related to cold intolerance, so extra layer of clothing or extra blanket should be provided and avoid external heating sources such as electric or warming blanket and heating pads because elderly may be decreased cutaneous sensation and may have burn. However, nurses must understand that patients with hyperthyroidism may feel too warm even in a normal room temperature. Therefore, it is recommended to maintain a cool, comfortable temperature, and clothing for them.,
Associations between vitiligo (hypopigment patches on the skin) and thyroid diseases have been reported repeatedly. Symptoms of pretibial myxoedema is also very common in the elderly with a thyroid issue. It is hard for patients to cope with these undesirable changes in his/her appearance. Therefore, nursing care plan must include the evidence-based interventions for the skin care of an elderly such as maintaining adequate hydration, application of adequate moisturizer, avoid alcohol and caffeine, avoid hot water shower, keeping skin moist, and keeping fingernails and toenails clean and trimmed along with healthy diet, regular exercise, and adherence of medication.
Prevention of potential complications
Nursing care plan for the elderly with thyroid disease must also include the measures to prevent thyroid disease-related complications such as heart failure, atrial fibrillation, and other heart diseases. Nurses should focus on cardiac and respiratory functions assessment continuously. Along with micromanagement of the elderly, macromanagement of his/her surroundings is also recommended. It is required to encourage the elderly to change in his/her lifestyle, physical environment, and diet because studies reported that a decreased level of TSH is linked with increased bone loss, vertebral, and hip fracture. Cognitive function is to be assessed for the elderly with hypothyroid, as myxoedema coma is very common, and for it, ventilator support is needed. If symptoms of respiratory failure present, T4 would be administered with extreme precaution and the use of sedative, hypnotic, and analgesics would be avoided.,
The nurse should use a calm, unhurried approach while providing reassurance and professional counseling to the elderly. Nursing care plan must include the use of nonpharmacological interventions to prevent cognitive impairments and dementia in the elderly such as exercise, cognitive training, mediation, brain games, adequate sleep, social connections, and activities of daily living. Furthermore, age-friendly environment is recommended for better psychosocial welling of the elderly. There are some standard tools such as COPE, Ways of Coping Questionnaire, and Coping Response Inventory to assess the coping ability of the elderly, while cognitive function could be assessed by mini-mental status examination, 6-cognitive impairment test, and abbreviated impairment test.,
It is a core component of nursing care plan to carry out therapeutic interventions for the elderly with thyroid disease. Hormone replacement drugs to maintain euthyroidism is usually prescribed and self-administered. Therefore, patients and their families must be educated about the safe administration of prescribed drugs, which may include teaching about how and when to take medication, recommended diet plan, needs for lifetime medication, avoidance of over-the-counter medication, regular thyroid hormone tests, and when to meet a physician.
Specific pre- and post-surgical and intervention nursing care should be planned if an elderly is planned to undergo thyroid surgery and or radioactive iodine therapy, which may include obtaining informed consent for surgery, instruction regarding the risk of surgery like lifelong thyroid hormone dependence, expected complication of anesthesia, bleeding; scar issue in transcervical approach, pain management, infection control with wound healing, postoperative calcium replacement. In addition, a family must be provided the genetic counseling because most of the thyroid illnesses have a genetic predisposition and younger family members may have risk of developing thyroid disease.
Management of home and social environment
Social and home environmental should be modified to maintain optimum environmental temperature, promote adequate rest, and facilitate cognitive adjustment and prevention of fall. Elderly people with thyroid disorders have bone fragility, muscle weakness, and problem with gait and balance, which can contribute as intrinsic contributing factors of fall because bone fragility in hyperthyroidism elderly may have fractures. There are several home-based extrinsic factors which may contribute in fall such as slippery floors; poor lighting; torn carpets; staircases without railings; poorly arranged furniture; absence of grab bars in toilets, and bathroom; and cluttered home., Therefore, it is important for nurses to assess the intrinsic and extrinsic factors related to risk of fall among elderly with thyroid disorders, they may use Check for Safety: A Home Fall Prevention Checklist for Older Adults developed by Centers for Diseases for Control and Prevention. Furthermore, they also must advice about the desired modification in home environment [Table 4] to prevent fall and improve cognitive adjustment with home environment. Social support is as important as maintaining the physical environment for the elderly with chronic diseases. Elderly people need a wide range of social supports to live in the society and reduce frequency of hospitalization.
| End of Life Care|| |
At this stage of life, the goal of management shifts from achieving the fix or rigid hormonal targets to symptomatic well-being and protection of their dignity or quality of life. Therefore, nursing care plan should focus on minimizing the symptoms, avoid complications, and enhance quality of life by essential interventions and with minimum disturbance or pain. Management at this level should be based on shared decision-making that includes patients with thyroid disease, family members, treating consultant, nurses, and other members of the health team.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]