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Review of Systems:

The thyroid gland is a butterfly-shaped organ located in the lower neck anterior to the trachea. It consists of two lateral lobes connected by an isthmus. The gland is about 5 cm long and 3 cm wide and weighs about 30 g. The blood flow to the thyroid is very high (about 5 m !min per gram of thyroid tissue"# about five times the blood flow to the liver. This reflects the high metabolic activity of the thyroid gland. The thyroid gland produces three hormones$ thyro%ine (T&"# triiodothyronine (T3"# and calcitonin. Thyro%ine and triiodothyronine are referred to collectively as thyroid hormone. THYROID FUNCTION: 'arious hormones and chemicals are responsible for normal thyroid function. (ey among them are thyroid hormone# calcitonin# and iodine. Thyroid Hormone The two separate hormones# thyro%ine (T&" and triiodothyronine (T3"# that are produced by the thyroid gland and that make up thyroid hormone# are amino acids that have the uni)ue property of

containing iodine molecules bound to the amino acid structure. T& contains four iodine atoms in each molecule# and T3 contains only three. These hormones are synthesi*ed and stored bound to proteins in the cells of the thyroid gland until needed for release into the bloodstream. +bout ,5- of bound thyroid hormone is bound to thyro%ine-binding globulin (T./"0 the remaining bound thyroid hormone is bound to thyroid-binding prealbumin and albumin. ROLE OF IODINE Iodine is essential to the thyroid gland for synthesis of its hormones. In fact# the ma1or use of iodine in the body is by the thyroid# and the ma1or derangement in iodine deficiency is alteration of thyroid function. Iodide is ingested in the diet and absorbed into the blood in the gastrointestinal tract. The thyroid gland is e%tremely efficient in taking up iodide from the blood and concentrating it within the cells# where iodide ions are converted to iodine molecules# which react with tyrosine (an amino acid" to form the thyroid hormones.

REGUL TION OF THYROID HOR!ONE The secretion of T3 and T& by the thyroid gland is controlled by thyroid-stimulating hormone (T23# or thyrotropin" from the anterior pituitary gland. T23 controls the rate of thyroid hormone release. In turn# the level of thyroid hormone in the blood determines the release of T23. If thyroid hormone concentration in the blood decreases# the release of T23 increases# which causes increased output of T3 and T&. This is an e%ample of negative feedback. Thyrotropin-releasing hormone (T43"# secreted by the hypothalamus# e%erts a modulating influence on the release of T23 from the pituitary. 5nvironmental factors# such as a decrease in temperature# may lead to increased secretion of T43# resulting in elevated secretion of thyroid hormones.

FUNCTION OF THYRO"INE ND TRIIODOTHYRONINE The primary function of the thyroid hormone is to control the cellular metabolic activity. T&# a relatively weak hormone# maintains body metabolism in a steady state. T3 is about five times as potent as T& and has a more rapid metabolic action. These hormones accelerate metabolic processes by increasing the level of specific en*ymes that contribute to o%ygen consumption and altering the responsiveness of tissues to other hormones. The thyroid hormones influence cell replication and are important in brain development. Thyroid hormone is also necessary for normal growth. The thyroid hormones# through their widespread effects on cellular metabolism# influence every ma1or organ system. C#$%itonin 6alcitonin# or thyrocalcitonin# is another important hormone secreted by the thyroid gland. It is secreted in response to high plasma levels of calcium# and it reduces the plasma level of calcium by increasing its deposition in bone.

Geronto$o&i% Consider#tions:
7ost patients with primary hypothyroidism are &0 to ,0 years ofage and present with long-standing mild to moderate hypothyroidism. 2ubclinical disease is common among older women and can be asymptomatic or mistaken for other medical conditions. 2ubtle symptoms of hypothyroidism# such as fatigue# muscle aches# and mental confusion# may be attributed to the normal aging process by the patient# family# and health care provider. The higher prevalence of hypothyroidism in elderly people may be related to alterations in immune function with age. 4egular screening of T23 levels is recommended for people older than 80 because they are at high risk for hypothyroidism. The signs and symptoms of hypothyroidism are often atypical in elderly people0 the elderly patient may have few or no symptoms until the dysfunction is severe. 9epression# apathy# or decreased mobility or activity may be the ma1or initial symptom. The ma1or symptoms of hypothyroidism may be depression and apathy# and may be accompanied by significant weight loss. :ne fourth of affected elderly patients e%perience constipation. In the elderly patient with mild to moderate hypothyroidism# thyroid hormone replacement must be started with low dosages and increased gradually to prevent serious cardiovascular and neurologic side effects. +ngina# for e%ample# may occur with rapid thyroid replacement in the presence of coronary artery disease secondary to the hypothyroid state. 3eart failure and tachydysrhythmias may worsen during the transition from the hypothyroid state to the normal metabolic state. 9ementia may become more apparent during early thyroid hormone replacement in the elderly patient. 5lderly patients with severe hypothyroidism and atherosclerosis may also become confused and agitated if their metabolic rates are raised too )uickly. 7arked clinical improvement follows the administration of hormone replacement0 such medication must be continued for life# even though signs of hypothyroidism disappear within 3 to ;< weeks. 7y%edema and my%edema coma generally occur e%clusively in patients older than 50 years. The high mortality rate of my%edema coma mandates immediate intravenous administration of high doses of thyroid hormone as well as supportive care. The elderly patient re)uires periodic follow-up monitoring of serum T23 levels because poor compliance with therapy may occur or the patient may take the medications erratically. + careful history may identify the need for further teaching about the importance of the medication. .ecause of the prevalence of hypothyroidism# testing of serum T23 levels in elderly people every 5 years has been recommended. In addition# the patient is reminded of the importance of participating in general health promotion activities and recommended health screening.