Thyroid Problems in Older Adults

What the thyroid does

The thyroid makes hormones that travel in the blood to every cell. A control centre in the brain (the pituitary gland) releases thyroid-stimulating hormone (TSH) to tell the thyroid how much to make. When thyroid hormone is low, TSH rises; when thyroid hormone is high, TSH falls. A TSH blood test, often with thyroid hormone levels, is therefore the main screening test.

Underactive thyroid (hypothyroidism)

Common causes in older adults: an autoimmune condition that gradually damages the gland, past radioactive iodine or surgery for an overactive gland, some medicines, iodine imbalance, and radiotherapy to the neck. It is commonly a lifelong condition requiring regular treatment.

Symptoms (often gradual and non-specific) - Tiredness, sleepiness, slowed thinking, poor concentration or forgetfulness that can mimic dementia. - Feeling cold, dry skin, thinning hair, brittle nails, hoarse voice, puffy face or eyelids. - Weight gain, constipation, poor appetite. - Low mood or depression. - Muscle aches, weakness, joint stiffness, cramps, tingling in the hands (carpal tunnel). - Slow heart rate, swollen legs, shortness of breath on effort. - Falls, slow movements. - High cholesterol.

Severe hypothyroidism (myxoedema) can cause marked drowsiness, very low body temperature, slow breathing and confusion. This is an emergency: call 112.

Overactive thyroid (hyperthyroidism)

Common causes: an overactive nodule or goitre, autoimmune disease, inflammation of the gland, and sometimes too much thyroid medicine or iodine.

Symptoms: often atypical in older adults ("apathetic hyperthyroidism") - Weight loss despite normal or poor appetite; sometimes loss of appetite. - Tiredness, weakness, muscle wasting; a person may be listless and low rather than restless. - Fast or irregular heartbeat, atrial fibrillation, palpitations, breathlessness, angina or worsening heart failure; see atrial fibrillation and blood thinners: a family guide and heart failure at home: daily checks and warning signs. - Anxiety, tremor, restlessness, irritability, poor sleep, or, conversely, depression and confusion. - Heat intolerance, sweating, frequent bowel movements. - Bone loss and fractures over time. - Swelling in the neck (goitre) or bulging eyes in some conditions.

Severe hyperthyroidism (thyroid storm) with fever, very fast heartbeat, agitation, confusion, vomiting or collapse is an emergency: call 112.

Why it is easily missed in later life

• Symptoms resemble ageing, depression, dementia, anaemia, heart or kidney disease, and side effects of medicines.
• Older people may have fewer or different symptoms.
• Other illnesses can temporarily alter thyroid blood tests.
• Subtle (subclinical) thyroid disease, with abnormal TSH but normal hormone levels, is common, and whether to treat it depends on the level, symptoms and other health factors; the doctor decides.

Thyroid disease should be considered in older adults with unexplained tiredness, weight change, low mood, memory problems, falls, a slow or irregular heartbeat, constipation, or high cholesterol; see fatigue and anaemia in older adults, depression in older adults and mild cognitive impairment: what it is and what families can do.

Testing

• TSH, often with free thyroxine (T4) and sometimes T3.
• Thyroid antibodies, which show autoimmune causes.
• Ultrasound and sometimes a thyroid scan or needle test (biopsy) if a lump or swelling is found.
• Other tests: blood count, cholesterol, sugar, electrocardiogram.

Practical points for the test - Tell the lab about all supplements: biotin (found in hair, skin and nail supplements and some multivitamins) can distort thyroid test results; the doctor may ask to pause it for a few days before testing. Ask the doctor or lab how long. - Test at a similar time of day if the doctor is monitoring, and note when the last dose of thyroid medicine was taken, as some doctors prefer testing before the morning dose. - Recent illness, hospital stay, and some medicines can change results; mention them.

Treatment in general terms

• Underactive thyroid: treated by replacing the missing hormone with a daily tablet, started at a low dose in older adults, particularly with heart disease, and increased gradually by the doctor, with regular blood tests. Treatment is usually lifelong.
• Overactive thyroid: treatment options chosen by a specialist include tablets that reduce hormone production, radioactive iodine or surgery, plus treatment to control heart rate and symptoms; heart rhythm and bone health are managed.
• Subclinical disease: may be observed with repeat tests or treated, depending on circumstances.
• Nodules and goitre: assessed by ultrasound and, if needed, a needle test; most are benign.

Never start, stop or change thyroid medicine on your own. The right dose is delicate: too little leaves symptoms, too much can cause palpitations, bone loss and irregular heartbeat, particularly in older adults. Adjustments are made by the doctor using blood tests.

Taking thyroid medicine reliably

• Take it at the same time every day, commonly in the morning on an empty stomach with water, and wait about thirty to sixty minutes before breakfast or tea, or as the doctor instructs; some doctors advise bedtime dosing. Consistency matters.
• Separate from certain products that reduce absorption: calcium and iron supplements, antacids, multivitamins with minerals, soy products and high-fibre supplements, usually by about four hours; ask the pharmacist about your parent's list; see supplements and medicine interactions: a safety guide, calcium and vitamin D after 60: doses, food and sun and iron and anaemia in older adults.
• Coffee and some foods can reduce absorption if taken right after the tablet; keep a gap.
• Do not double up if a dose is missed; follow the doctor's or pharmacist's advice.
• Use a pill organiser and reminders; see pill organiser guide and medicine reminders for forgetful parents.
• Keep the same brand or formulation where possible, and tell the doctor if the pharmacy changes it, since absorption can differ slightly.
• Do not take extra "for energy" or to lose weight; this is dangerous.
• Tell every doctor about thyroid disease and medicines, including before surgery and when new medicines are started.
• Periodic blood tests are essential, commonly every six to twelve months once stable, and sooner after a dose change, weight change or illness.

Home monitoring and care

• Weight: weigh weekly at the same time; note unexplained gain or loss and tell the doctor; see weighing scales and unplanned weight loss in older adults.
• Pulse and blood pressure: a persistently very slow or fast pulse, palpitations or irregular rhythm need review; see how to measure blood pressure at home accurately.
• Body temperature: in severe hypothyroidism, temperature may be low; check when the person seems unwell; see digital thermometers: choosing and using them for older people.
• Bowels: constipation is common in underactive thyroid; see constipation in older adults: fibre, fluids and movement.
• Mood, sleep, memory and energy: note changes in a simple diary; improvement may take weeks to months after treatment starts.
• Skin and cold: keep warm in winter; see cold-weather health risks for older adults.
• Bone health: overactive thyroid and over-treatment can thin bones; ask about calcium, vitamin D and falls prevention; see osteoporosis at home: preventing fractures and living well.
• Heart: in older adults, thyroid problems can worsen angina, heart failure and rhythm problems; report chest pain or breathlessness.
• Nutrition: a balanced diet; iodine is needed in small amounts, and most Indian households use iodised salt; do not use iodine or seaweed supplements, or kelp products, without medical advice, since too much can cause or worsen thyroid disease. Do not stop or restrict foods such as cabbage or soya on the basis of internet claims; ask the dietician if worried.
• Beware of "thyroid fix" supplements and unproven therapies that may contain hidden hormones or interfere with treatment.

Special situations

• Dementia or confusion: thyroid disease can cause or worsen it; make sure thyroid function has been tested; see confusion, hallucinations and sudden change: when to call.
• Hospital stays: thyroid tablets should continue; tell the staff; see hospital admission and discharge for older adults: a checklist.
• Heart disease: doses are started low; report chest pain or palpitations after starting or changing doses.
• Swallowing difficulty or tube feeding: ask the doctor and pharmacist how to give thyroid medicine; tablets must not be crushed or mixed without advice; see swallowing problems (dysphagia) in older adults.
• Neck swelling, a lump, difficulty swallowing or breathing or a hoarse voice need prompt medical review.
• After surgery or radioactive iodine, lifelong follow-up.

Emergency signs: call 112

• Extreme drowsiness, very low body temperature, slow breathing, unresponsiveness, or confusion in someone with known or suspected underactive thyroid.
• High fever, very fast heartbeat, agitation, vomiting or confusion in someone with overactive thyroid.
• Chest pain, severe breathlessness, fainting or sustained palpitations.
• Stroke signs: facial droop, weakness, speech difficulty; irregular heartbeat from thyroid disease can raise stroke risk.
• Severe swelling of the neck with difficulty breathing or swallowing.

When to ask a professional

Ask the doctor to check thyroid function in older adults with unexplained tiredness, weight change, mood or memory problems, falls, palpitations or high cholesterol. Ask an endocrinologist about overactive thyroid, nodules or complex cases. Ask a pharmacist about timing and interactions. Ask for regular blood tests, and keep results in your health record; see keeping a health record at home. Seek urgent help for the emergency signs above.