Running head: HYPOTHYROIDISM: PREVALENCE INCREASES WITH AGE 1

Hypothyroidism: Prevalence Increases with Age

Sandra G. Fleet

School of Nursing, James Madison University

NSG 325: Concepts in Aging

Professor Janelle Garman

November 21, 2021

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Abstract

Hypothyroidism affects 4.6% of our country’s population. It is the most common chronic

endocrine disorder in the elderly and is caused by thyroid hormone deficiency. It is common

among aging adults and is often unrecognized which is associated with morbidity. It is often

difficult to diagnose hypothyroidism in the older population because symptoms can vary among

individuals or there may be no symptoms at all. Diagnosing the condition is more challenging in

the older adult population because mildly elevated TSH levels are not always an outcome of the

disease, just a normal aspect of the aging process. Body weight, overall health condition,

comorbidities, and polypharmacy must be considered when evaluating TSH levels. Once

diagnosed, every effort should be made to maintain the best thyroid function. Levothyroxine is

the first line of treatment and gold standard for thyroid replacement therapy. Treatment will

include a lifetime of routine follow-ups to evaluate function and discuss if the current treatment

plan is the right plan.

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Hypothyroidism: Prevalence Increases with Age

A gradual decline in all physiological functions happen throughout adulthood and that

decline continues with the aging process. Age related changes affect the functions of all body

systems, and the endocrine system is no exception. Hypothyroidism, the most common chronic

endocrine disorder in the elderly, is caused by thyroid hormone deficiency and is often difficult

to diagnose in the older population (Duntas & Yen, 2019). Compared to younger people, the

elderly population have more comorbidities making diagnosis and treatment more complex

(Duntas & Yen, 2019). Once a confirmed diagnosis is made, care needs to be taken with the

treatment such as frequent cardiovascular monitoring and personalized medicine (Duntas & Yen,

2019).

Lage et al. (2020) noted that this disease affects 4.6% of our country’s population, 0.3%

for the overt and 4.3% for the subclinical, and is often unrecognized due to serious illness and

symptoms characteristic of other common disorders in the elderly. Gosi & Garla (2021) stated

that hypothyroidism and subclinical hypothyroidism (SCH) share the same origin. Worldwide,

the most common cause of hypothyroidism is iodine deficiency; however, in the United States,

autoimmune (Hashimoto) thyroiditis is the most common cause of hypothyroidism (Gosi &

Garla, 2021). Lage et al. (2020) went on to say that a thyroid condition will originate in more

than 12% of Americans during their life span. Over the 2007-2015 timeframe, the prevalence of

hypothyroidism climbed from 5.62% to 8.24% in the older adult population (Lage et al., 2020).

In this population, it affects 5–20% of women and 3–8% of men (Duntas & Yen, 2019).

Overt hypothyroidism and subclinical hypothyroidism present with some differences.

Overt hypothyroidism presents with increased thyroid-stimulating hormones (TSH) and a

decreased thyroxine level. Subclinical hypothyroidism, usually asymptomatic, normally presents

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with elevated TSH and normal levels of thyroxine and affects up to 10% of the adult population

(Biondi, Cappola, & Cooper, 2019). A misdiagnosis of SCH can be caused by numerous non-

thyroid related factors that can elevate TSH such as chronic renal failure, adrenal insufficiency,

medications, age, nonthyroidal illness, and laboratory assay interference (Gosi & Garla, 2021).

Gosi & Garla (2021) explained it is crucial to determine whether the elevation in TSH is a non-

thyroid cause or if it is truly subclinical hypothyroidism. Subclinical hypothyroidism is seen

more often in older individuals because of the increasing occurrence and frequency of

Hashimoto’s thyroiditis (Kim, 2020). SCH also has an association with an increased threat of

cardiovascular disease, cognitive decline, and a decline in functional capabilities (Gosi & Garla,

2021).

Due to the physiological aging process, the hypothalamus-pituitary-thyroid (HPT) axis

and its hormones experience major changes (Borzi, Biondi, Basile, & Vacante, 2020). Borzi et

al. (2020) explained that thyroid-stimulating hormone has a major role balancing thyroid

hormone release and thyroid gland development; however, with age the thyroid gland undergoes

serious functional changes like fibrosis and atrophy. Kim (2020) noted structural changes in the

thyroid such as size and appearance are not known to enlarge with aging. Lage et al. (2020)

explained that diagnosing the condition is even more challenging in the older adult population

because mildly elevated serum TSH levels are not always an outcome of the disease, just a

normal aspect of the aging process. A few metabolic functions are associated with thyroid

hormones such as helping to maintain body temperature, oxygen intake, glucose uptake,

mobilization of cholesterol, and expression of the low-density lipoprotein (LDL) receptor gene in

the liver (Calsolaro et al., 2019). Since the thyroid hormone has an impact on cholesterol

metabolism, this should be considered in cases of unexplained high cholesterol levels (Duntas &
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Yen, 2019). Per the third National Health and Nutrition Examination Survey, the frequency of

hypothyroidism in patients with high cholesterol was 1.4-13% (Duntas & Yen, 2019).

The old may have mild signs and symptoms of hypothyroidism or have no symptoms at

all, while others present with unusual symptoms making diagnosis challenging (Duntas & Yen,

2019). According to Duntas & Yen (2019), the most common symptoms include high

cholesterol, diastolic hypertension, heart failure, constipation, psychiatric problems, balance

problems, and joint or muscle pain. Other physical findings observable in the elderly with

hypothyroidism are bradycardia, pallor, hoarseness, course hair, dry skin, slurred speech, and

changes in mental status (Kim, 2020). Borzi et al. (2020) noted that older individuals may also

show variations in lab tests related to hypothyroidism such as hyperlipidemia, hyponatremia,

hypochromic microcytic anemia, high creatine phosphokinase levels, and increased

homocysteine and lipoprotein(a) values. With this known, people 65 years of age and older need

careful monitoring and assessment before being treated for hypothyroidism (Calsolaro et al.,

2019).

Before administering thyroid replace therapy, current health status, comorbidities, age-

related changes, and polypharmacy should be evaluated and considered (Borzi et al., 2020).

Typically, the first treatment for hypothyroidism in the elderly population is sodium

levothyroxine (Kim, 2020). Levothyroxine (LT4) is still the drug of choice for hypothyroidism

regardless of age (Borzi et. al., 2020). Hormone replacement with LT4 is in the top 10 of most

prescribed drugs and since thyroid hormones vary among individuals because of demographic,

genetic, and environmental factors it is key to personalize treatment (Calsolaro et al., 2019).

When using Levothyroxine replacement therapy, titration should start at a minimum dose of

25μg per day gradually increasing every six to eight weeks, focusing to keep a target serum TSH
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of 4–6 mIU/L for patients 75 years and older (Borzi et al., 2020). Duntas & Yen (2019)

concluded that routine follow-up and frequent monitoring of LT4 treatment should be strongly

encourage throughout the life span.

Many older adults may not be receiving the proper medical treatment according to recent

clinical guidelines put forth by the American Thyroid Association (ATA) and American

Association of Clinical Endocrinologists (AACE) regarding hypothyroidism in this population

(Lage et al., 2020). According to the guidelines, screening for hypothyroidism should include

individuals over 60 years of age and individuals diagnosed with other common diseases among

older Americans such as hypertension, congestive heart failure, and cardiac conditions (Lage et

al., 2020). According to Lage et al. (2020), overtreating hypothyroidism can result in serious

complications especially in the older population including irregular heartbeats, bone

deterioration, and even death. To avoid overtreatment, individuals should have TSH monitoring

on a regular basis and thyroid function assessed periodically (Duntas & Yen, 2019).

Simultaneously, undertreating hypothyroidism can result in uncontrolled hypothyroidism which

can lead to atherogenic lipid profiles, cardiovascular disease, and significant morbidity (Lage et

al., 2020). All treatment requires much thought, continuous cardiovascular monitoring, and

personalized medicine (Duntas & Yen, 2019).

The population worldwide is living much longer with millions living into their tenth

decade of life (Duntas & Yen, 2019). Thyroid disease, mainly hypothyroidism, is widespread

among the elderly and as the population ages this is expected to increase (Duntas & Yen, 2019).

Thyroid-stimulating hormone levels have been known to increase with age whether a thyroid

disease is present or not (Calsolaro et al., 2019). With this known, Calsolaro et al. (2019) says

people 65 years of age and older need careful monitoring and assessment before being treated for
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hypothyroidism. It is important to educate the patient regarding the correct administration if

levothyroxine is chosen for therapy (Calsolaro et al., 2019). Duntas & Yen (2019) conclude that

every effort should be made to maintain the best thyroid activity with a lifetime of routine

follow-ups to evaluate function and discuss if the current treatment plan is the right plan.
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References

Biondi, B., Cappola, A., & Cooper, D. (2019). Subclinical hypothyroidism: A

review. JAMA, 322(2), 153–160. https://doi.org/10.1001/jama.2019.9052

Borzì, A., Biondi, A., Basile, F., & Vacante, M. (2020). Diagnosis and treatment of

hypothyroidism in old people: A new old challenge. Wiener klinische

Wochenschrift, 132(5-6), 161–167. https://doi.org/10.1007/s00508-019-01579-8

Calsolaro, V., Niccolai, F., Pasqualetti, G., Calabrese, A., Polini, A., Okoye, C.,

Magno, S., Caraccio, N., & Monzani, F. (2019). Overt and subclinical

hypothyroidism in the elderly: When to treat? Frontiers in Endocrinology, 10, 177.

https://doi.org/10.3389/fendo.2019.00177

Duntas, L., & Yen, P. (2019). Diagnosis and treatment of hypothyroidism in the elderly.

Endocrine, 66(1), 63–69. https://doi.org/10.1007/s12020-019-02067-9

Gosi, S., & Garla, V. (2021). Subclinical Hypothyroidism. StatPearls [Internet].

https://www.ncbi.nlm.nih.gov/books/NBK536970/

Kim, M. (2020). Hypothyroidism in older adults. Endotext [Internet].

https://www.ncbi.nlm.nih.gov/books/NBK279005/

Lage, M., Espaillat, R., Vora, J., & Hepp, Z. (2020). Hypothyroidism treatment among older

adults: Evidence from a claims database. Advances in Therapy., 37(5), 2275–2287.

https://doi.org/10.1007/s12325-020-01296-z
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