As the population ages, endocrinologists will be faced increasingly with older patients with endocrine disorders who may present difficult clinical challenges. Fortunately, the Endocrine Society is poised to improve the “geriatric competency” of endocrine practitioners, researchers, and trainees.
According to a 2015 United Nations World Population Ageing Report, the number and proportion of older persons (60 years and older) increased in nearly every country in the world. The rate of growth of persons 60 years and older is expected to accelerate in the coming decades, increasing from 901 million in 2015 to 1.4 billion by 2030, and more than doubling by 2050; an even faster growth rate is predicted in people 80 years and older, more than tripling by 2050 to 125 million.
The ever-increasing aging population has and will continue to have implications for nearly every sector of society, including healthcare and specifically for every subspecialty of medicine, including endocrinology. As a consequence of this changing demographic, endocrine clinicians will be faced increasingly with the challenges in caring for older persons in the geriatric age group and the need to incorporate geriatric principles into their clinical practice. Likewise, endocrine researchers will need to further expand the investigation and knowledge of the effects of aging and age-associated comorbidities on the endocrine system and the clinical evidence-base to inform and guide clinical practice. And endocrine educators will need to incorporate geriatric care principles into endocrine training programs.
“Endocrine researchers will need to further expand the investigation and knowledge of the effects of aging and age-associated comorbidities on the endocrine system and the clinical evidence-base to inform and guide clinical practice.”
Clinically, compared to younger patients, the manifestations of endocrine disorders in older persons are often atypical (e.g., apathy, depression, psychomotor retardation, anorexia, and constipation in the absence of a goiter in older patients with apathetic thyrotoxicosis); present as nonspecific geriatric syndromes (e.g., weight loss, weakness, functional decline and falls, depression, confusion and cognitive impairment in older patients with hypothyroidism or hyperthyroidism); or are attributed to “old age” by patients.
Manifestations of endocrine disease in older patients may also be mistakenly attributed to worsening of comorbid illnesses or medications by clinicians (e.g., exacerbations of congestive heart failure, atrial fibrillation or angina precipitated by hyperthyroidism in older patients with preexisting cardiac disease).
Finally, it is increasingly common for endocrine “disorders” in older persons to present with only biochemical abnormalities in the absence of appreciable symptoms (e.g., asymptomatic mild hypercalcemia secondary to primary hyperparathyroidism or subclinical hypothyroidism or hyperthyroidism) and for which appropriate management is not always clear.
Older patients with endocrine disorders often suffer from multiple chronic medical conditions (or “multimorbidity”) that can complicate and confound clinical manifestations, evaluation, and management. The presence of concomitant comorbidities, medications used to treat these conditions, and changes in nutritional status may affect and confuse the biochemical evaluation of endocrine disorders (e.g., alterations in thyroid function tests by non-thyroidal illness, so-called euthyroid sick syndromes, or alterations in sex hormone binding globulin, SHBG, by illness, medications or aging that lower total testosterone levels but may not affect free testosterone levels).
“Older patients with endocrine disorders often suffer from multiple chronic medical conditions that can complicate and confound clinical manifestations, evaluation, and management.”
The management approach for geriatric patients with endocrine disease should take into account coexisting medical illnesses, medications, alterations in clearance rate of hormones (e.g. reduced clearance of thyroid hormone and testosterone replacement with aging), and interaction with other medications (particularly in the presence of polypharmacy which occurs commonly in older patients), changes in target organ sensitivity with older age, and the clinical outcomes desired (e.g. more favorable benefit to risk with early vs. late postmenopausal estrogen replacement).
In order to minimize drug toxicity, polypharmacy, and iatrogenic disease in geriatric patients, hormone treatment should generally be initiated at low doses and increased gradually with careful monitoring to achieve the lowest dosage needed to achieve the desired therapeutic benefits without adverse effects. As with all medications, the need for hormone treatment should be reviewed periodically and stopped if it is no longer needed.
In older patients with endocrine disorders, management should be patient-centered and goals of care should focus on improvement of function and quality of life within the social context and care setting of the individual. The endocrinologist should recognize that interdisciplinary care models may be needed for optimal care of geriatric patients with endocrine disorders (e.g., treatment of vitamin D deficiency and primary and secondary osteoporosis by an endocrinologist and prevention of falls by a physical and occupational therapist, nurse, and pharmacist).
As the population ages, endocrinologists will be faced increasingly with older patients with endocrine disorders who may present difficult clinical challenges (e.g., atypical presentations; age-related alterations endocrine physiology and pharmacology; and confounding influences of age-associated co-morbid illnesses and medications) and for whom the existing evidence-base to inform quality care is scant.
“In older patients with endocrine disorders, management should be patient-centered and goals of care should focus on improvement of function and quality of life within the social context and care setting of the individual.”
The Endocrine Society is poised and should make efforts to improve the “geriatric competency” of endocrine practitioners, researchers and trainees, e.g., by state-of-art clinical and research presentations at annual meetings, identifying and highlighting key unanswered clinical and research questions in geriatric endocrinology, and creating and disseminating a practical and well-informed geriatric endocrinology core curriculum for training programs.
Alvin M. Matsumoto, MD
R. Paul Robertson, MD
University of Washington, Seattle
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