HORMONAL AND METABOLISM DISORDERS

Vina Yanti Susanti

Division of Endocrinology Internal Medicine Department
School of Medicine
Gadjah Mada University/Dr Sardjito Hospital
Yogyakarta
INTRODUCTION
 The endocrine and metabolic control
systems prevent disabilities associated with
aging
 Thyroid diseases
 Diabetes mellitus
 Dyslipidemia
 Hyperparathyroidism
 Menopause
 Hypogonadism
Aging leads changes of the endocrine
system
 Hormone production and secretion rates
 Metabolic clearance rates
 Tissue responsiveness or sensitivity
 Effects of age on serum hormone levels
Increased levels Normal levels Decreased levels

Atrial natriuretic Calcitonin Corticotropin+

peptide Cortisol* TSH #
Insulin Epinephrine Growth hormone
Norephinephrine Prolactin IGF-I
Vasopressin Thyroxine (T4) Renin
Aldosterone
Triiodothyronine T3

* Mildly increased in some studies

+ May be normal
# May be normal; in15% of age >65, increased
TSH due to autoimmune thyroiditis not age
Changes in hormone levels
 Hormone changes are interrelated, one
often serving as a compensatory response
for another
 Increased gonadotropin because of
decreased gonadal hormone
 Increased insulin because of age-related
insulin resistance
 Hyperparathyroidism due to fall in serum
1,25-dihydroxycholecalciferol
Changes in hormone levels
 Increased vasopressin due to over-
production
 Increased norepinephrine? numbers of ß-
adrenergic receptors, postreceptor
resistance, abnormal baroreceptor function
 Increased ANP? Expansion of intravascular
volume (physiologic aging changes or sub-
clinical heart failure?)
Effects of age on serum levels of steroids and related
hormones
Increased levels Normal levels Decreased levels

Elderly women
FSH Total Androsterone, DHEA
LH testosterone DHEA sulfat
Ovarian testosterone* Estradiol, estrone
Progesterone
Elderly men
DHT+, FSH, LH Androstenedion
Free estradiol Androsterone, DHEA
Free estrone DHEA sulfat, testosterone
Bioavailable testosterone

* May be normal
+ High in BPH, tends to be normal without BPH
Clinical Significance of Changes
 Knowledge of expected hormonal changes may
be clinically useful
 Insulin resistance leads to hyperinsulinemia and
requires weight loss and exercise
 Hyperparathyroidism leads to accelerated bone
resorption and requires (in women) calcium
supplement and estrogen replacement therapy
 Increased vasopressin predisposes to
hyponatremia
 Increased ANP contributes nocturia
Thyroid Disease in The Elderly
 Aging causes the thyroid gland undergoes
atrophy, fibrosis, increasing numbers of colloid
nodules, and lymphocytic infiltration
 The decline of T4 is physiologic compensation to
the decline of lean body mass
 Euthyroid sick syndrome is common
 2-5% of >65 with hypothyroidism; 5-14% of ≥65 with
subclinical hypothyroidism
 Hyperthyroidism: 0.4%; multinodular/uninodular
toxic goiter (9% of women 1.5% of men by ≥80)
Alterations in Thyroid Physiology With Aging

T4 production ↓
T4 clearance ↓
T4 to T3 conversion ↓
T3 clearance ↓
Serum FT4 N
Serum total T4 N
HYPOTHYROIDISM
 Cause: Hashimoto’s disease, irradiation or surgery,
idiopathy
 Symptoms and signs: most develop nonspecific
syndromes, <33% with characteristic symptoms and
signs of hypothyroidism
 Laboratory findings: TSH and FT4
 Differential diagnosis: normal aging, euthyroid sick
syndrome, depression, dementia, idiopathic
obesity, Cushing’s syndrome, myopathies,
neuropathies, others.
 Therapy: replacement of levothyroxine
HYPERTHYROIDISM
 Cause: Graves’ disease, a single hyper-functioning
adenoma, a multinodular goiter, sub acute and
chronic thyroiditis, a primary TSH-producing
pituitary lesion or excessive TSH production due to
pituitary resistance to thyroid hormone
 Symptoms and signs: 25% with specific symptoms
and signs. Decreased complaints of increased
perspiration, heat intolerance, increased appetite,
irritability, and thyroid enlargement
Hyperthyroidism
 Symptoms and signs: apathetic thyroidism (apathy,
anorexia, marked weight loss, weakness, mental
confusion) may be classified primarily as
depression. Cardiovascular features and GI picture
may exclude hyperthyroidism due to high
prevalence of cardiac disease and malignancy
 Laboratory findings: TSH
 Treatment: 131I therapy for Graves’ disease or single
autonomous nodule. Surgery for multinodular toxic
goiter. Antithyroid drugs
DIABETES MELLITUS
 Aging increases insulin resistance, postprandial
plasma glucose will increase
 Aging affects carbohydrate metabolism: poor diet,
physical inactivity, decreased lean body mass,
impaired insulin secretion, and insulin resistance
Factors affecting diabetes control in the
elderly
Altered sense Neoplasia
decreased vision Inactivity, drugs
decreased smell Neuropsychiatric problems
altered taste perception depression, cognitive
decreased proprioception impairment, dementia
Difficulties in food preparing Social factors
tremor, arthritis, poor dentition inadequate education
alteration in GI function poor dietary habits
Altered recognition of hunger & thirst living alone
Altered renal & hepatic function
Acute infections
ADA’s recommendations for older adults
with diabetes

• Older adults who are functional, are cognitively

intact, and have significant life expectancy, the
goals of care are similar with younger adults
• if not meeting the above criteria, glycemic goals
may be individualized, but hyperglycemia leading
to symptoms or acute complications should be
avoided
•
Recommendations cont.
• Other cardiovascular risk factors should be
treated with consideration of the frame time of
benefit and the individual patient
• Screening for diabetes complications should be
individualized, but particular attention should be
paid to complications that would led to functional
impairment (vision disorder, low extremities
complication)
20% older adults (age >65 years) have diabetes

Older adults are at greater risk than other

older adults for several common geriatric
syndromes, such as polypharmacy, depression,
cognitive impairment, urinary incontinence,
injurious fall, and persistent pain
Heterogeneity

 Some developed diabetes years earlier and may have

significant complications
 Some are newly diagnosed and may have years of
undiagnosed with resultant complications, or may have
few complications
 Some are frail and have other underlying chronic
conditions, substantial diabetes-related co-morbidity,
or limited physical or cognitive functioning
 Some with little co-morbidity and are active
 Life expectancies are highly variable
DYSLIPIDEMIA
 The absolute excess risk of CAD mortality
attributable to plasma total cholesterol rises with
age
 Cholesterol lowering might actually produce
greater reduction in CAD mortality in elderly men
than in middle-aged men
 LDL-C & Lp (a) are risk factors for CAD, stroke, and
carotid artery atherosclerosis
 HDL-C is negative risk factor
Factor affecting lipoprotein cholesterol levels
 Age: in men, plasma total cholesterol levels
increase until about age 70 ( up to 25%, due to the
increase of HDL-C). In women, at about age 55-60,
plasma total cholesterol level exceed those in men
(due to the increase of LDL-C)
 Postmenopausal estrogens: in women undergo
menopause, LDL-C and Lp(a) levels increase, and
HDL-C levels decrease
 Laboratory examination: full lipid profile
DISORDERS OF MINERAL METABOLISM
 In elderly, total serum calcium may be normal, but
ionized calcium is high due to low level of albumin
 The level of PTH needed to maintain a normal
serum calcium level increases with age, capacity
of intestine to absorb calcium decreases, the
response to calcitriol is blunted
 Vitamin D and calcium deficiencies are common
causes of hypocalcemia in the elderly
 Increased bone resorption is common in the elderly
(primary hyperparathyroidism in postmenopausal
women), immobilization
HYPOCALCEMIA AND HYPERCALCEMIA
HYPOCALCEMIA
(corrected calcium level <8.8 mg/dl,
ionized calcium level <4.8 mg/dl)
Mild: asymptomatic
Severe or when an associated
alkalosis: tetany (paresthesias,
muscle spasm), Chvostek’s sign,
Trousseau’s sign
HYPERCALCEMIA
(corrected calcium level >10.4 mg/dl,
ionized calcium level >5.2 mg/dl)
Elderly with primary
hyperthyroidism: hypertension,
muscular weakness, irritability,
mild GI disturbance, renal colic,
bone cyst, decreased bone
mass