THYROID DISEASE IN THE NURSING HOME
CLINICAL PRACTICE GUIDELINE

 

DISEASE RECOGNITION

Hypothyroid

System

Hyperthyroid

  • Weakness, fatigue
  • Cold intolerance

General

  • Fatigue, nervousness, apathy
  • Heat intolerance
  • Weakness with exertion
  • Insomnia
  • Pretibial or facial edema
  • Pallor, dry, coarse skin
  • Brittle hair, nails
  • Loss of outer third of eyebrows

Integumentary

  • Smooth skin, fine hair with loss
  • Sore, gritty eyes with exophthalmos
  • Dyspnea, orthopnea, PND

Pulmonary

  • Dyspnea
  • CHF, ECG changes
  • increased cholesterol & triglycerides
  • Angina, bradycardia

Cardiovascular

  • Atrial fibrillation, tachycardia, CHF, angina
  • Fecal impaction or ileus, constipation
  • Unexplained weight gain

Gastrointestinal

  • Increased appetite, diarrhea
  • Unexplained weight loss
  • Arthritis, muscle aches
  • Carpal tunnel syndrome

Musculoskeletal

  • Muscle atrophy & weakness
  • Osteoporosis
  • Proximal muscle wasting
  • Depression, lethargy, somnolence
  • Slowed thinking, speech & memory
  • Change in cognition & confusion
  • Ataxia, paresthesia, syncope, seizure
  • Hypoactive DTRs

Neurological

  • Coarse tremor
  • Hyperactive DTRs
  • Confusion, excitability
  • Depression, insomnia
  • Anxiety, nervousness
  • Macrocytic anemia

 

  • Polydipsia
  • Thyromegaly, palpable thyroid nodule

 

  • Goiter

 

CONTEXT / / COMMUNICATION

If the resident is moribund or on comfort care measures or refuses blood work no laboratory evaluation is required. The facility nurse should contact the health care agent with follow-up by MD or NP if requested by the agent.

 

ASSOCIATED RISKS

Hypothyroidism

  • Medications: Lithium, Amiodarone, antithyroid drugs, iodine excess, Prednisone >20 mg/d,, iron sulfate, Cholestyramine, colestipol, calcium carbonate
  • History of head & neck radiation
  • Goiter, previous radioiodine therapy
  • Pituitary or hypothalamic disorders
  • Age > 50, female gender
  • History of subtotal thyroidectomy

Hyperthyroidism

  • Diffuse toxic goiter or multinodular goiter
  • Thyroiditis, thyroid cancer, pituitary tumor
  • Excessive thyroid replacement medication
  • Excessive iodine ingestion
  • Other autoimmune disorders: DM, pernicious anemia, myasthenia gravis

 

PHYSICAL EXAMINATION

  • Vital signs (current and over time)[systolic hypertension]
  • Exophthalmos, pretibial myxedema, acropachy )Graves’ disease only)
  • Cardiac examination [angina, HF, AF]
  • Integumentary, facial or pretibial edema
  • Thyroid, neck examination
  • Neurological: DTRs, mental status, gait

 

DIAGNOSTIC WORK-UP

Check TSH - if elevated check free T4 - if decreased check free T4 & T3

Clinical hypothyroidism: increased TSH and decreased T4

Subclinical hypothyroidism: increased TSH and nl T4

Clinical hyperthyroidism: decreased TSH and increased or nl T4, and increased T3

Subclinical hyperthyroidism: decreased TSH, nl T4, nl T3

 

TREATMENT OPTIONS

Clinical Hypothyroidism

Clinical Hyperthyroidism

  • Levoxyl 0.025 mg P.O. QD
  • Recheck TSH Q 4-6 weeks & increase dose by 0.025 mg until euthyroid
  • Recheck TSH  Q yr or more often if on Lithium, iron, Amiodarone, Coumadin
  • If caused by thyroid replacement decrease dose and monitor TSH, free T4
  • If from overactive gland start Propylthiouracil (PTU) 100 mg PO TID or Tapazole PO 5 mg TID
  • Recheck T4 and CBC with diff Q 4 weeks until euthyroid (stop med for sign of  infection) then decrease to lowest effective dose
  • Consider >ß-blocker (Atenolol or Metoprolol) for rate control (unless uncompensated HF or  bronchospasm present)

Subclinical Hypothyroidism

Subclinical Hyperthyroidism

  • No treatment beyond monitoring TSH Q 6 months
  • No treatment beyond monitoring thyroid profile Q 6 months unless goiter/adenoma present



References for Thyroid Disease

  1. Adlin, V.: Subclinical Hypothyroidism: Deciding When to Treat in American Family Physician, Vol. 57, No. 4, February 15, 1998, 776-780.
  2. Begany, T. Thyroid Disease When to screen, when to treat in Patient Care, March 30, 1997, 18-47.
  3. Chiu, AC et al: Hypothyroidism in Cortland Forum, December 2000, 111-118. 
  4. Coll, PP, Taxel P.: The Management of Thyroid Disorders in Long-Term Care in  Annals of Long-Term Care, Vol. 12, No. 3, 2004, 26-30.
  5. Czenis, AL: Thyroid Disease In the Elderly in Advance for Nurse Practitioners, September, 1999, 38-44.
  6. Demester, N.: Disease of the Thyroid in Clinician Reviews, Vol. 11, No. 7, July 2001, 59-64.
  7. Falsetti, D: The Lifelong Lurker A Clinical review of Hypothyroidism in Advance for Nurse Practitioners, April 2001, 63-68.
  8. Fatourechi, v: Subclinical Hypothyroidism: When to Treat, When to Watch? in Consultant, April 1, 2004, 533-539.
  9. Kennedy, JW, Caro, JF: The ABCs of managing hyperthyroidism in the older patient in Geriatrics, May, 1996, Vol. 51, No. 5, 22-32.
  10. Mazzaferri, EL, Surks, MI: Recognizing Thyrotoxicosis in Hospital Practice, May 15, 1999, 43-58.
  11. Reuben, DB, Grossberg, GT et al: Endocrine Disorders in Geriatrics At Your Fingertips, 108, 1998/99 Edition.
  12. Trotto, NE: Hypothyroidism, hyperthyroidism, hyperparathyroidism in Patient Care, September 15, 1999, 186-206.
  13. White, RD: Hyperthyroidism: Current Standards of Care in Consultant, Vol. 44, No. 8, July 2004, 1085-1098.
  14. Winn, PA: Brief report of Clinical Experience of Thyroid Replacement Reduction in Nursing Home Patients in Annals of Long-Term Care, Vol. 6, No. 1, 1998, 11-15.

MS/10.99
© EMS
Revised 12.04

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