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MINERVA ENDOCRINOL 2011;36:211-31

Thyroid diseases in elderly

IN C ER O V P A Y R M IG E H DI T C ® A

A. FAGGIANO 1, M. DEL PRETE 2, F. MARCIELLO 2, V. MAROTTA 2, V. RAMUNDO 2, A. COLAO

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Thyroid diseases are the commonest endocrine disorders in the general population. In most of the cases, they are consistent with benign conditions which may be asymptomatic or affect people at a variable extent. Since they often represent chronic conditions their prevalence increases by age and reaches in elderly the highest rates. Thyroid nodules are a common clinical finding. Most subjects with thyroid nodules have few or no symptoms. Thyroid nodules are more commonly nonfunctioning. However, in elderly, toxic multinodular goiter is the most frequent cause of spontaneous hyperthyroidism and often, it emerges insidiously from nontoxic multinodular goiter. Although autoimmune thyroiditis is the most common cause of hypothyroidism in elderly subjects, other causes, such as drugs, neck radiotherapy, thyroidectomy or radioiodine therapy, are frequently observed among these subjects. A small subset of medications including dopamine agonists, glucocorticoids and somatostatin analogs affect thyroid function through suppression of TSH. Other medications that may affect TSH levels are metformin, antiepileptic medications, lithium carbonate and iodine-containing medications. Other drugs can alter T4 absorption, T4 and T3 transport in serum and metabolism of T4 and T3, such as proton-pump inhibitors and antacids, estrogens, mitotane and fluorouracil, phenobarbital and rifampin. Amiodarone administration is associated with thyrotoxicosis or hypothyroidism. Thyroid cancer has similar characteristics in elderly as in general population, however the rate of aggressive forms Corresponding author: A. Faggiano, MD, PhD, National Cancer Institute “Fondazione G. Pascale”, Naples, Italy. E-mail: [email protected]

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1National

Cancer Institute “Fondazione G. Pascale” 2Department of Molecular and Clinical Endocrinology and Oncology, Federico II University, Naples, Italy

such as the anaplastic histotype, is higher in older than younger subjects. Diagnosis of thyroid diseases includes a comprehensive medical history and physical examination and appropriate laboratory tests. A correct diagnosis of thyroid diseases in the elderly is crucial for proper treatment, which consists in the removal of medications that may alter thyroid function, in the use of levo-thyroxine in case of hypothyroidism, anti-thyroid drugs in case of hyperthyroidism and use of surgery, radioiodine therapy and percutaneous ablative procedures in selected cases. In conclusion, thyroid diseases in patients older than 60 years deserve attention from different points of view: the prevalence is different from the young adult; symptoms are more nuanced and makes difficult the diagnosis; age and comorbidity often force therapeutic choices and may limit safety and efficacy of therapy. Finally, in elderly patients for whom specific therapy is necessary, more gradual and careful therapeutic approach and close follow-up are recommended in order to minimize the alterations of thyroid function which are induced by many drugs commonly used in clinical practice. Key words: Hyperthyroidism - Hypothyroidism - Thyroid nodule - Thyroid neoplasms - Aged.

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hyroid diseases are the most common endocrine disorders in the general popu-

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Endocrine dysfunction in Fabry disease

Table I.—Main causes of hyperthyroidism in elderly. Endogenous causes: –– Graves’ disease (15%) –– Toxic adenoma (30%) –– Toxic multinodular goiter (40%) Exogenous causes: –– Hormone therapy with levo-thyroxine at suppressive doses in patients with differentiated thyroid carcinoma (10%) –– Excessive hormone replacement therapy with levothyroxine in hypothyroid patients (5%)


lation. In the great majority of cases they are consistent with benign conditions which may be asymptomatic or affect people at a variable extent. Since they often represent chronic conditions their prevalence increases by age and reaches in elderly the highest rates. Elderly impacts significantly on clinical features and outcome of thyroid diseases. On a hand, elderly subjects may be less symptomatic than younger ones, on the other hand, many systemic pathologies often affecting elderly people and inducing a variable degree of cardiac, pulmonary, hepatic or renal impairment may make more difficult to manage hyperthyroidism, hypothyroidism, thyroid goiter and cancer. This article aims to review thyroid diseases in elderly people by underlining and discussing all age-related peculiarities in clinical presentation and management. Hyperthyroidismin elderly Epidemiology

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Hyperthyroidism is a thyroid gland hyperfunction framework characterized by increased synthesis and secretion of thyroid hormones. This condition can occur at any age but is more common in adults. In elderly, the excess of thyroid hormones particularly impacts on quality of life and life expectancy because of high cardiovascular mortality and morbidity and increased risk of osteoporosis and bone fractures. The prevalence of hyperthyroidism as well as of subclinical hyperthyroidism is increased in subjects over 60 years of age.1 Overt hyperthyroidism has been reported in 0.7-2% of elderly subjects. Subclinical hyperthyroidism, defined as serum TSH levels below the lower limit of the normality range when serum FT4 and T3 concentrations are within the normality range, has been reported to vary from 3% to 8% in elderly. Etiology

The most common forms of hyperthyroidism include diffuse toxic goiter (Graves’

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disease), toxic multinodular goiter and toxic adenoma (Plummer disease). Together with subacute thyroiditis, these conditions constitute 85-90% of all causes of thyrotoxicosis (Table I). However, it is not uncommon in elderly that TSH concentrations are below the normality range due to a decreased clearance or to an altered hormonal set-point of the hypothalamic-pituitary-thyroid axis. In elderly, toxic multinodular goiter is the most frequent cause of spontaneous hyperthyroidism. Toxic multinodulare goiter and toxic adenoma represent about 60% of cases of hyperthyroidism in areas of iodine deficiency. Toxic multinodulare goiter increases by age and is more prevalent in women. This condition can be characterized by the coexistence of normal-hypo-and/or hyperfunction in nodules, with gradual suppression of TSH over the years. Often, it emerges insidiously from nontoxic multinodular goiter. Toxic thyroid adenoma is a benign tumor of the thyroid gland and represents the most common cause of hyperthyroidism in women and middle age. Graves’ disease is another frequent cause of thyrotoxicosis especially in iodine replete areas.2 Graves’ disease is an autoimmune disease where the thyroid is overactive, producing an excessive amount of thyroid hormones. This is caused by autoantibodies (TSHR-Ab) that activate the TSH-receptor (TSHR), thereby stimulating thyroid hormone synthesis and secretion, and thyroid growth. About 2530% of people with Graves’ disease will also suffer from Graves’ ophthalmopathy with variable degree of inflammation of the eye muscles. In elderly the onset of hyperthyroidism


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Table II.—Signs and symptoms of hyperthyroidism in elderly. –– Atrial fibrillation/palpitations –– Unexplained weight loss –– Depression/dementia/disorientation –– Lethargy/fatigue –– Vitiligo –– Alopecia –– Coarse or thinning hair –– Exophthalmia –– Heat intolerance –– Pretibial myxedema –– Sweating –– Diarrhea –– Tremor


after administration of excessive iodine intake (X-rays, computerized axial tomography) or medicines/foods with iodine (amiodarone, steroids) is common.3 Amiodarone, a class III anti-arrhythmic agent, which is frequently used in elderly subjects with ventricular arrhythmias, atrial fibrillation or congestive heart failure, is particularly frequent in elderly. It can cause two types of thyrotoxicosis: a) amiodarone-induced thyrotoxicosis type 1, which is attributed to underlying thyroid pathology (such as autonomous nodular goiter or Graves’ disease) exacerbated by the iodine load which is released when amiodarone is metabolized; b) amiodarone-induced thyrotoxicosis type 2, a destructive thyroiditis, where prestored thyroid hormones are released leading to thyrotoxicosis.4 Hyperthyroidism may be due to inappropriate secretion of TSH for TSH-secreting pituitary adenoma but is a really rare condition of hyperthyroidism and is still more rare in elderly. Clinical features

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In elderly, symptoms are often vague or absent. However, hyperthyroidism could be more severe in elderly than in younger people.5 This is particularly true for cardiovascular manifestations such as atrial fibrillation, paroxysmal tachycardia, heart failure. Hyperthyroidism is also a major cardiovascular risk factor. Heart failure may occur both in overt hyperthyroidism and subclinical hyperthyroidism. Thyroid hormones excess may be responsible for increased incidence of supraventricular arrhythmias, especially atrial fibrillation and embolic events. Subclinical hyperthyroidism may also be a risk factor for the onset of atrial fibrillation itself and can often be the first sign of subclinical hyperthyroidism in elderly.6, 7 Hyperthyroidism in elderly is defined as “apathetic form” and is characterized by the presence of a predominant symptom among lethargy, fatigue, depression, confusion, disorientation, loss of appetite, anorexia and weight loss, muscle weakness, proximal muscle wasting, severe osteoporosis and increased

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fracture risk (Table II).1 Heat intolerance, tremor, nervousness and sinus tachycardia noted in younger patients may be absent in the elderly. Typical hyperadrenergic symptoms of thyrotoxicosis may also be masked by medications such as beta-blockers, which are frequently used in elderly patients for treatment of cardiovascular diseases. In addition, gastrointestinal symptoms such as diarrhea, constipation and persistent vomiting or neurological symptoms such as mania, depression, cognitive impairment or incident dementia can be manifestations of hyperthyroidism in elderly.1, 8 Hyperthyroidism may be responsible for changes in bone structure and bone mineral metabolism due to the predominance of osteoclastic activity. Elderly patients with hyperthyroidism may present a severe osteoporosis and a higher risk of fracture that requires proper medical treatment.9, 10 Furthermore, subclinical hyperthyroidism also can increase the risk of osteoporosis with reduced cortical bone mineral density especially in postmenopausal women and may aggravate pre-existing heart disease and can lead to atrial fibrillation, impaired left ventricular diastolic filling and worsening of angina pectoris.10, 11 Moreover, subclinical hyperthyroidism may be associated with insulin resistance and cognitive impairment.12, 13 Diagnosis Initial evaluation of suspected hyperthyroidism includes a comprehensive medical


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Therapy Treatment of hyperthyroidism in elderly patients should be properly established both in the overt and subclinical form. It is crucial in these patients before establishing a definitive therapy to perform ECG and Holter-ECG in order to point out arrhythmic conditions and echocardiogram to point out structural and functional cardiac abnormalities.16 Radioiodine rather than prolonged administration of anti-thyroid drugs is the preferred treatment option in most cases of Graves’ disease and toxic nodular goiter in elderly. However, a short course of antithyroid drugs may be used prior to the use of radioiodine, to deplete the thyroid gland of stored hormone and reduce the risk of excessive post-treatment hyperthyroidism. Beta blocking agents may be used, both in combination with antithyroid drugs and after administration of radioiodine, to reduce the risk of tachyarrhythmias. After treatment with radioiodine, patients should have follow-up examinations at frequent intervals, since most patients will become hypothyroid and require thyroid hormone replacement therapy. Due to increased risk of surgical complications in older patient, surgery is commonly reserved to large goiters with obstructive symptoms or when malignancy is suspected. Subacute thyroiditis is usually self-limiting. Treatment is mainly supportive, involving management of pain with non steroidal anti-inflammatory drugs and control of hyperadrenergic symptoms with beta-blockers. If symptoms persist, glucocorticoid therapy can be used.16 Thionamides are the treatment of choice for amiodarone-induced thyrotoxicosis type 1. The addition of potassium perchlorate may increase the response to thionamides by inhibiting thyroid iodine uptake. Amiodarone-induced thyrotoxicosis type 2 is usually self-limiting; however, it may present with severe symptoms which require intervention.17 This is of particular concern, since patients treated with amiodarone usually have significant underlying cardiac disease and may not tolerate any significant degree

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history and physical examination (to identify goiter, tremors, nodules, exophthalmos or other signs) and appropriate laboratory tests. Measurement of TSH levels is the initial test necessary in a patient with a possible diagnosis of hyperthyroidism. An inappropriately low value of TSH is diagnostic of hyperthyroidism. Measuring specific antibodies, such as TSHR-Ab in Graves’ disease, or anti-thyroid-peroxidase in Hashimoto’s thyroiditis may contribute to the differential diagnosis. Thyroid-stimulating antibody titles can be used to monitor the effects of treatment with antithyroid drugs in patients with Graves’ disease. The diagnosis of hyperthyroidism is confirmed by blood tests that show a decreased TSH level and elevated FT4 and FT3 levels. Current studies suggest that TSH values 1 cm) detected by ultrasonography did escape detection by clinical examination.93 Six to ten percent of older patients have solitary nodules by palpation; goiters and multinodular glands tend to be more common in the elderly.94 By the age of 65 years, approximately 50% of individuals have nodules by ultrasonagraphy.95 The high prevalence of thyroid nodules in elderly requires evidence-based rational strategies for their differential diagnosis, risk stratification, treatment, and follow-up. These strategies should take in account the wide spectrum of clinical manifestations of thyroid nodules ranging from the small 50%) decrease in nodule volume is obtained with levothyroxine therapy in a minority of patients with palpable thyroid nodules.105 Long-term levothyroxine suppression treatment in elderly patients with large nodular goiters is not recommended because it is poorly effective and is associated with adverse effects on the cardiovascular system and bones. In fact, this kind of therapeutic ap-

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proach has revealed a three-fold increase in atrial fibrillation, low serum TSH levels in individuals aged 60 years or older are associated with increased mortality from all causes and, in particular, from circulatory and cardiovascular diseases.106 In addition, some studies found a deleterious effect of suppressive TSH therapy on bone mass.107 Therefore, the use of levothyroxine should be avoided in postmenopausal women, in men older than 60 year and in patients with osteoporosis, cardiovascular disease, or systemic illnesses.106, 107 Neck pressure, dysphagia, choking sensation, shortness of breath, dyspnoea, hoarseness, pain are indications for surgical treatment in a patient with a benign thyroid nodule.93 Surgical complications are reported in 7-10% whereas the mortality rate is about 0.5%.108 The morbidity and mortality of thyroid surgery are increased in elderly patients.109 Furthermore, hypothyroidism, hypoparathyroidism, recurrent nerve lesions often may follow surgery, which could represent difficult conditions to manage in older subjects affected with several comorbidities. On the other hand, a recent study reported that surgical treatment could be safe as in younger subjects also in those who are ≥70 years old. Radioiodine is indicated for the treatment of hyperthyroidism attributable to a hyperfunctioning nodule or a toxic multinodular goiter. The aims of radioiodine treatment are the ablation of the autonomously functioning areas, the achievement of euthyroidism, and the reduction of goiter size.110 Autonomously functioning thyroid nodules are usually more radio-resistant than toxic diffuse goiters, and higher radiation doses may be needed for successful treatment. Radioiodine treatment is generally thought to be effective and safe. Because of surgery and suppressive therapy contraindications, radioiodine treatment is widely prescribed in elderly patients. However, due to higher incidence of radioiodine non-avid lesions and adverse events from hypothyroidism, outcome of radioiodine therapy in elderly patients was less favourable than in younger patients. In addition, some investigators


mass or patients with haemoptysis indicating potential involvement of surrounding structures. Other important indications include cervical lymphadenopathy or when limits of the goiter cannot be determined clinically such as retrosternal goiter. Thyroid scintigraphy is the only technique that allows assessment of thyroid regional function and detection of areas of autonomously functioning. Thyroid scintigraphy is indicated in the following settings: with a single thyroid nodule and suppressed TSH level; for multinodulare goiters to identify cold or indeterminate areas for FNC and hot areas that do not need cytologic evaluation; for large multinodular goiter, especially with substernal extension; in the diagnosis of ectopic thyroid tissue; in subclinical hyperthyroidism to identify occult hyperfunctioning tissue; in follicular lesions to identify a functioning cellular adenoma that may be benign; however, most such nodules are cold on scintigraphy; to determine eligibility for radioiodine therapy; to distinguish low-uptake from high-uptake thyrotoxicosis.


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malignancies, differentiated thyroid carcinomas are the most common at any age, being papillary histotype the dominant, but some authors indicate a reduction of the female to male ratio in old patients compared to young subjects.122, 123 However, follicular thyroid carcinoma is more likely to occur in elderly.124 Medullary thyroid carcinoma and anaplastic thyroid carcinoma are considered rare diseases but the incidence of these histotypes is considerably higher in elderly.120 The anaplastic thyroid cancer typically occurs in subjects more than 60 years-old reaching an incidence of 50% of all cases of thyroid cancer in patients over 80 years.120, 125


indicated that radioiodine treatment is associated with increased cardiovascular and cancer mortality 111 and post-radioiodine hypothyroidism occurs in up to 60% after 20 years.112 Percutaneous ablative procedures, such as ethanol and laser thermal ablation, are reported to be safe but sometimes local adverse events may occur. Ethanol injection is quite effective in cystic thyroid nodules but not in large and toxic solid thyroid nodules, where this procedure is frequently accompanied by alcohol leakage outside the lesion, causing local pain and development of cervical adherence;113 laser ablation induces a 40-60% decrease in the size of thyroid nodules over a six-month period 114 but it requires up to three sessions or the insertion of multiple fibers for treating large nodules, which increases the risk of local adverse events. Radiofrequency thermal ablation (RTA) is a new approach to manage thyroid nodules. It has been firstly proposed for the treatment of thyroid nodules in elderly. The first experiences demonstrated that RTA is a well tolerated and simple procedure for obtaining lasting shrinkage of thyroid nodules, at the same time controlling pressure symptoms in the neck.20, 21, 115-117 RTA is effective in reducing volume of thyroid nodule by about 70-80% at one year follow-up.21 Further studies are now ongoing in order to assess the real impact of this new technique in managing thyroid nodules.

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Thyroid cancer

Epidemiology

The frequency of nodular thyroid disease is increased in elderly in both genders, with the highest prevalence in the seventh decade.118, 119 Thyroid carcinoma accounts for about 30% of all thyroid disorders in geriatric population compared to 6-8% in younger subjects.120 Furthermore, statistics performed at autopsy detected the presence of occult thyroid cancer in 30% of subjects aged from 65 to 75 years.121 Among thyroid

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Etiology

Radiation exposure has a recognized pathogenic role in differentiated thyroid cancer, particularly in papillary histotype. Indeed the incidence of papillary thyroid cancers is severely increased in radio-contaminated areas following a linear relationship with dose-exposition.126 Ionizing radiations promote carcinogenesis by inducing double-strand DNA breaks that lead to genetic alterations. A strong correlation between radiation exposure and the solid aggressive variant of papillary thyroid cancer harbouring the RET/PTC3 oncogene has been widely demonstrated.127 To date genetic alterations with a clear pathogenetic role have been found in a significant proportion of papillary thyroid cancer. In this regard the main oncogenes are BRAFV600E, RET/Pthyroid cancer and RAS mutations.128 Mutated BRAF is an independent predicting factor of poor outcome and is related to advanced age.129 Medullary thyroid cancer can be sporadic or hereditary. The latter is related to RET germline mutations.130 Pathogenesis of anaplastic thyroid cancer is unknown but in most cases the disease develops from a pre-existing follicular thyroid cancer.125 Clinical features According to the majority of authors thyroid nodules occurring in advanced age


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1 cm and for those with suspicious clinical or ultrasound findings (firm consistency of the nodule, regional lymphadenophaty, hypoechogenicity, micro-calcifications without shadowing, absence of halo sign, irregular margins, central blood flow).136 Anaplastic thyroid cancer typically occurs as a rapidly enlarging mass in the anterior region of the neck that is firm and fixed to surrounding structures.125 This clinical presentation in an elderly patient is quite suggestive. However, diagnosis can be confirmed by FNAC.

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have an higher risk of malignancy, particularly in male gender and must be investigated with caution.123, 124 To date age is considered one of the most important clinico-pathological factors affecting the prognosis of patients affected with thyroid cancer. The studies performed by Biliotti et al. and Ito et al.120, 131 clearly demonstrated higher rates of recurrence and death in elderly patients affected with differentiated thyroid cancer, showing that age is an independent predicting factor of poor outcome. To date the UICC/AJCC TNM classification. considers that patients affected with differentiated thyroid cancer more than 45 years-old have a significantly higher risk of death and applies a different staging for this subgroup. The higher aggressiveness of differentiated thyroid cancer in advanced age is probably related to several and heterogeneous factors. As before mentioned, old patients have an increased incidence of follicular thyroid cancer, that has a more aggressive behaviour than papillary thyroid cancer, particularly in elderly.132 Differentiated thyroid cancer in elderly is frequently associated with more aggressive histopathological features such as vascular invasion and extracapsular extension.133 Differentiated thyroid cancer in patients older than 60 years shows increased mitotic activity.122 The uptake of I-131 is age-related probably due to a minor grade of differentiation thereby decreasing the effectiveness of radioiodine therapy.134 Medullary thyroid cancer occurring in old patients is classically sporadic and has a worse prognosis.135 Anaplastic thyroid cancer is an aggressive tumour with an almost invariably fatal prognosis and an overall survival of about three-six months by the diagnosis.125 Diagnosis Thyroid nodules are mainly discovered by neck ultrasonography. FNAC is the most sensitive and accurate method to distinguish benign nodules from malignant ones.136 FNAC is strongly recommended in elderly,124 especially for nodules larger than

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Therapy

Because of the worst clinical behaviour several authors recommend to advice old patients affected with differentiated thyroid cancer to a radical surgery, despite of the higher operative risk.137, 138 Indeed total thyroidectomy followed by radioiodine ablation has been proved as the most effective therapeutic approach in reducing the risk of recurrence and mortality in elderly.139 This is why the major professional societies, such as the American Association of Clinical Endocrinologists, the American Association of Endocrine Surgeons, the National Comprehensive Cancer Network, and the ATA, have recommended near-total or total thyroidectomy as the initial procedure of choice for differentiated thyroid cancer and the addition of radioiodine ablation for patients who have functioning remnants in the thyroid bed or distant metastases.123, 136 Nevertheless, in clinical practice elderly patients affected with differentiated thyroid cancer usually receive a less aggressive treatment than younger subjects 139 though it has been demonstrated that total thyroidectomy is safe if performed by experienced surgeons. As in younger subjects, a suppressive therapy with levo-thyroxine is recommended postoperatively in order to reduce TSH levels below 0.1 mUI/L in more advanced disease and between 0.1 and 0.4 mUI/L in less aggressive tumours.124 However, subclinical hyperthyroidism in elderly patients can aggravate cardiovascular preexisting problems, can induce atrial fibrillation and impaired left ventricular diastolic


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la tiroidite autoimmune è la causa più comune di ipotiroidismo nei soggetti anziani, altre cause, come i farmaci, la radioterapia del collo, la tiroidectomia o la terapia con radioiodio, sono frequentemente osservate tra questi soggetti. Un piccolo sottogruppo di farmaci tra cui gli agonisti della dopamina, i glucocorticoidi e gli analoghi della somatostatina agiscono sulla funzione tiroidea attraverso la soppressione del TSH. Altri farmaci che possono influenzare i livelli di TSH sono la metformina, i farmaci antiepilettici, il carbonato di litio e i farmaci contenenti iodio. Altri farmaci possono alterare l’assorbimento della T4, il trasporto di T4 e T3 nel siero e il loro metabolismo, come inibitori di pompa protonica, antiacidi, estrogeni, mitotano, fluorouracile, fenobarbitale e rifampicina. La somministrazione di amiodarone può essere associata invece sia a tireotossicosi che a ipotiroidismo. Il cancro tiroideo ha caratteristiche simili alla popolazione generale, tuttavia, le forme più aggressive sono relativamente più frequenti nell’anziano. La diagnosi di tali patologie comprende un’anamnesi completa, esame obiettivo e appropriati test di laboratorio. Una corretta diagnosi delle patologie della tiroide nei pazienti anziani è fondamentale per impostare un corretto trattamento, che consiste nell’eliminazione di farmaci che possono alterare la funzione della tiroide, nell’uso di levo-tiroxina in caso di ipotiroidismo, di farmaci anti-tiroidei in caso di ipertiroidismo e dell’utilizzo di chirurgia, terapia con radioiodio o terapie ablative percutanee in casi selezionati. In conclusione, le patologie tiroidee nei pazienti di età superiore ai 60 anni meritano particolare attenzione perché la prevalenza è diversa da quella riscontrata nei giovani adulti, i sintomi sono più sfumati e questo rende difficile la diagnosi. Inoltre, età e comorbidità spesso forzano le scelte terapeutiche e possono limitare la sicurezza e l’efficacia della terapia. I pazienti più anziani con disturbi tiroidei richiedono una somministrazione graduale e attenta del trattamento e un follow-up costante. Infine, nei pazienti anziani per i quali è necessaria una terapia specifica, uno stretto follow-up è raccomandato al fine di ridurre al minimo o evitare le alterazioni della funzione tiroidea che possono essere indotte da molti farmaci, comunemente usati nella pratica clinica. Parole chiave: Ipertiroidismo - Ipotiroidismo - Nodulo tiroideo - Tiroide, neoplasie - Età anziana.


filling and decreases bone mineral density with an increase in the risk of fractures.9, 11 Thus, it is important to balance the aggressiveness of the disease and the comorbidities of the patients and to perform a careful clinical monitoring during the suppressive therapy. Treatment of medullary thyroid cancer is based mainly on surgical approach, followed by a substitutive therapy with levothyroxine.135 Treatment of anaplastic thyroid cancer is mostly palliative, based on surgery, radiotherapy or chemotherapy.125 Conclusions

In conclusion, thyroid diseases in patients older than 60 years deserve attention in order of several considerations: the prevalence is different from the young adult; symptoms are more nuanced and makes it difficult to diagnose. Moreover, age and comorbility often force therapeutic choices and may limit safety and efficacy of therapy. Older patients with thyroid disorders require special attention to gradual and careful treatment and require lifelong follow-up. Finally, in elderly patients for whom specific therapy is necessary, close follow-up is recommended in order to minimize or avoid the alterations of thyroid function which are induced by many drugs, commonly used in clinical practice.

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Riassunto

Le malattie della tiroide nell’anziano Le patologie della tiroide sono i più comuni disturbi endocrini nella popolazione generale. Si tratta nella maggior parte dei casi di condizioni benigne asintomatiche. Rappresentano frequentemente condizioni croniche la cui prevalenza aumenta con l’età e raggiunge negli anziani i più alti tassi. I noduli tiroidei sono molto frequenti nei pazienti anziani. La maggior parte dei soggetti con noduli tiroidei presentano pochi o nessun sintomo. Nella maggior parte dei casi sono noduli non funzionanti. Tuttavia, negli anziani, il gozzo multinodulare tossico è la causa più frequente di ipertiroidismo spontaneo e spesso emerge insidiosamente da una pre-esistente condizione di gozzo multinodulare non tossico. Sebbene

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