Thyroid Dysfunction _________________________________________________________________________
Only rarely is radiation therapy necessary after surgery. When it is used, external beam radiation and intensity modulated radiation therapy (IMRT) are both options in the treatment of medullary or anaplastic thyroid cancers. External beam radiation is aimed at the site of the cancer from outside the body. It may be used for treatment of inoperable tumors, tumors that have metastasized, or in patients for whom the risk of recurrence is great. IMRT is a more focused treatment using computer-controlled x-ray accelerators. The treatment is mapped by computed tomography to ensure optimum accuracy. This limits the amount of radiation to surrounding tissue [31; 46] . Alcohol ablation treatment for recurring thyroid cancers is a process by which the thyroid is injected with ethanol, which compresses the nodules and reduces the excretion of T 4 . This approach is mainly used for patients with limited recurrence in the neck and is effective for tumors that cannot be treated with radioactive iodine or for tumors that are difficult to reach surgically [42; 46] . THYROID DYSFUNCTION IN OLDER PATIENTS As with all body systems, the endocrine system changes as a person ages. There are differences in functioning of the thyroid glands, with an associated increase in variances of symptoms of thyroid disorders and alterations in laboratory testing results. Detection of thyroid conditions in older adults can be more difficult than in younger patients. This may be due in part to failure of the clinician to accurately recognize the patient’s symptoms as potential thyroid dysfunction and instead to associate the problems with typical conditions of aging. Fatigue, forgetfulness, constipation, and hair loss are all indicative of both aging and a low functioning thyroid gland. Similarly, hyperthyroidism may cause loss of appetite, congestive heart failure, depression, dementia, muscle rigidity, nervousness, palpitations, or weakness; these signs may occur as a result of other conditions common among older adults. Therefore, the signs and symptoms of thyroid dysfunction may be difficult to diagnose and/or categorize in older patients [5; 6; 7] . Treatment of thyroid dysfunction in elderly individuals is also complicated. Older patients may metabolize thyroxine more slowly than younger patients. So, when treated for hypothyroid- ism, these patients may require lower initial doses. It is also recommended that therapy for older adults should be titrated slowly in order to prevent untoward effects. There is some debate as to whether treatment should be initi- ated in older adults at all. Most experts agree that patients with symptomatic dysfunction should be treated, but only with the lowest possible dosage. In asymptomatic cases, many clinicians will adopt a watchful waiting philosophy and monitor the patient but not treat immediately [5; 6; 7] .
Part of the reason for the hesitancy to initiate pharmacologic treatment in older adults with thyroid dysfunction is the increased risk of drug interactions. Because the number of medications prescribed generally increases with age, there are more opportunities for interaction problems to develop. For example, many older women take calcium supplements to com- bat osteoporosis. However, some studies have shown that taking levothyroxine within four hours after taking calcium carbonate can decrease the amount of thyroid hormone absorbed. It is prudent to advise patients to take these medications four hours apart. Also, there are similar studies relating to taking thyroid supplements and iron at the same time. It is recommended that these drugs be taken two or more hours apart [5; 6; 7] . In addition to special considerations for diagnosis and treat- ment of thyroid dysfunction in the elderly population, there are several issues related to existing conditions commonly present in older adults. Hyperthyroidism is a risk factor for the develop- ment of osteoporosis; the administration of excessive amounts of thyroid-suppressing medication can lead to osteoporosis or the exacerbation of existing osteoporosis. Research has sug- gested that even normal doses of thyroid replacement hormone may lead to reduced bone density. Long-term treatment with 200 mcg or more of thyroid hormone has been associated with lower bone mineral density. However, there is some evidence that if TSH values are kept within the normal range, bone loss is minimized. Postmenopausal estrogen replacement therapy has also been found to offset this bone loss [5; 6; 7] . MANAGEMENT OF THE PATIENT WITH THYROID DYSFUNCTION Healthcare professionals encounter patients with thyroid disor- ders in virtually every possible setting, including in hospitals, physician offices, the home health venue, schools, and when interacting with friends and family. Thyroid disorders are so common that it is impossible to avoid them, and healthcare professionals may be asked questions about medication or about a lump found in the neck, or they may observe that someone has developed exophthalmos. PATIENT TEACHING Teaching is a valuable process for the general public as well as for those who have a diagnosed thyroid disease. The AACE recommends that the public be instructed on how to examine the neck on a regular basis for lumps, nodules, or other areas of enlargement. The following assessment steps are recommended as part of the AACE’s annual thyroid awareness campaign [45]: 1. Holding a mirror in one hand, focus on the lower front area of the neck, above your collarbones and below your larynx (voice box). The thyroid gland is located in this area. 2. While focusing on the mirror, tilt your head back. 3. Take a drink of water and swallow.
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