Hypothyroidism as a Predictor of Surgical Outcomes in the Elderly

[helvella]

Shame this paper, which has some good points, ends up doing what they all do, assessing hypothyroidism by TSH.

Is there any good research which shows that TSH reflects thyroid hormone status however old we are? Of course not.

Front Endocrinol (Lausanne). 2019; 10: 258.

Published online 2019 Apr 24. doi: 10.3389/fendo.2019.00258

PMCID: PMC6491643

Hypothyroidism as a Predictor of Surgical Outcomes in the Elderly

Marco Vacante,1 Antonio Biondi,1 Francesco Basile,1 Roberto Ciuni,1 Salvatore Luca,1 Salomone Di Saverio,2 Carola Buscemi,3 Enzo Saretto Dante Vicari,3 and Antonio Maria Borzì3,*

Abstract

There is a high prevalence of hypothyroidism in the elderly population, mainly among women. The most important cause is autoimmune thyroiditis, but also iodine deficiency, radioiodine ablation, and surgery may be responsible for hypothyroidism in elderly hospitalized patients. Thyroid-related symptoms are sometimes comparable to physiological manifestations of the aging process, and hypothyroidism may be related with many symptoms which can be present in critical patients, such as cognitive impairment, cardiovascular, gastrointestinal, and hematological alterations, and eventually myxedema coma which is a severe and life-threatening condition in older adults. Adequate thyroid hormone levels are required to achieve optimal outcomes from any kind of surgical intervention. However, only few randomized clinical trials investigated the association between non-thyroidal illness (or low-T3 syndrome), and adverse surgical outcomes, so far. The goal of this review is to discuss the role of thyroid function as a predictor of surgical outcomes in the elderly.

Keywords: hypothyroidism, elderly, surgery, thyrotoxicosis, low T3 syndrome

ncbi.nlm.nih.gov/pmc/articl...

[SilverAvocado]

I'm sure I've seen a paper showing that the older we are the less sprightly the TSH response is to a given hormone result, with young people having a large TSH and each decade older we are the responding TSH is a lower number. Can't remember whether it was freeT4 or freeT3.

But it seems more common to hear the argument that older people will inevitably have higher TSH and worse thyroid hormone levels, and it's not worth treating them.

These two ideas seem quite contradictory to me. Unfortunately I haven't got a system to record papers I read, so no idea the details of the sluggish TSH paper

[helvella Administrator in reply to SilverAvocado]

I agree with you.

Many aspects of our brains work less effectively as we age so I think your thoughts/arguments are spot on.

[Aurealis in reply to SilverAvocado]

Yes it does worry me the tendency to confuse illness with ageing - not treat low hormones just because of older age. I know that my long term suppressed tsh could be a massive problem if I needed an op and it would be a massive problem if they attempted to raise it first. And as over 60 there’d be concern about effects on heart, whereas I’d be concerned about effects if dose lowered. The only way forward is to try to stay well!

[Smelly12 in reply to Aurealis]

And you've also got to remember not that long ago I think I read that thyroid meds were waist of money. And that wasn't age related

[Smelly12 in reply to SilverAvocado]

Where is this England.?

[SilverAvocado in reply to Smelly12]

I can't remember the exact details of the paper that says TSH responds more sluggishly in older people (for a given thyroid hormone level, the older a person is the lower their TSH will be), so don't know if it was from UK or over seas.

The idea that older people naturally have worse thyroid panels and therefore shouldn't be treated comes up often, in both research and treatment guidelines, and probably from throughout the world

[Smelly12 in reply to SilverAvocado]

Well I'm that age so have to look to use all my money to go private if start all that 🙁This world changing for everybody

[Hidden in reply to SilverAvocado]

PLEASE post it if you find it

[SilverAvocado in reply to Hidden]

I'm sure I will have heard about it on the forum originally, so it may be possible to search for it!

[Hidden in reply to SilverAvocado]

Tried. No success so far

[SilverAvocado in reply to Hidden]

I had a try, too, and didnt find anything I know it was a long time ago.

[SilverAvocado in reply to SilverAvocado]

Hidden , This may be the paper I mentioned:

Age Modifies the Pituitary TSH Response to Thyroid Failure

liebertpub.com/doi/abs/10.1...

[Aurealis]

Thanks helvella , I’ll continue to try to avoid surgery then, oh ... and medics !

[Greekchick]

Thanks for posting this, helvella! I so enjoy reading your posts and they are always informative. Have a great weekend.

[BadHare]

There is a high prevalence of hypothyroidism in the younger population, they just refuse to diagnose it effectively!

[m7-cola]

Thank you for posting this paper. I shall be very careful when/if I need an operation.

[Hidden]

My idea to stay as far away from the GP might have been spot on then, hurrah.

Thank you for the post it's probably as most on here expected.

[Wildbird]

The suggested target for people aged 70+ is TSH 4-6. I despair 😩, Drs will be lowering our meds to keep us within these targets, regardless of how ill this makes us. I cannot imagine this rule being applied to a healthy blood sugar range or a blood pressure reading. Thyroid disease is truly the least understood and worst treated and that frightens me.

[BadHare in reply to Wildbird]

It seems like a cruel form of slow euthanasia.

[kissemiss in reply to Wildbird]

If the suggested target for people aged 70+ suffering from Hypothyroidism is TSH 4-6 the ft3 and t4 will be below 0.001.......So what happens to the body??

[helvella Administrator in reply to kissemiss]

You simply cannot work out FT3/FT4 numbers from a TSH result. (Nor the other way round.) That is half the problem.

[kissemiss in reply to helvella]

Well that's what is so worrying because high up endos are relying entirely on tsh only even if you are on t3 only. The gp is told to reduce the t3 tablets until the tsh is well within range test every 3 month to reach target. Nobody seems interested in if the patient if able to function on any level what so ever (brain heart liver etc) AS LONG AS THE TSH IS WITHIN RANGE.

What is going on in the medical profession in this country?

[Judithdalston]

Interesting article...is odd when so many refs. to low T3 syndrome yet only one to FT3 that, as you say, then rely on TSH to assess hypothyroidism ( with very obvious link American use of TSH). But at least they are thinking about importance of thyroid health long term!

[SilverAvocado in reply to Judithdalston]

The point I've reached now, whenever I hear 'low T3 syndrome' it sets alarm bells ringing.

I just don't believe it's a real thing in any way, I just think it's way of describing a patient whose been a victim of badly interpreted thyroid panels

[NWA6 in reply to SilverAvocado]

Hi SilverAvocado can you explain your thoughts on low T3 Syndrome a little? As I’ve been thinking that this is a familial trait in my family?

[SilverAvocado in reply to NWA6]

My understanding of low T3 syndrome would be that a person has low T3 in the absence of a thyroid condition, and that the other numbers in the thyroid panel are 'normal'.

My interpretation would be that if a person has low T3, by definition they DO have a thyroid condition, and should proceed accordingly. I'm also very skeptical about whether the other two thyroid panel results could be 'normal', as normal is always an opinion.

In my view there are many different ways thyroid illness can present, because we are all different and in our own personal version of normal. Medics assume their set of blood tests perfectly captures what thyroid illness is, and that if a person doesn't have the exact set of blood tests they expect then they don't have thyroid illness (or even don't have Hashimotos which is the most common form of being hypo). This is actually the best case scenario. Worst case scenario is that a person has a completely textbook set of hypothyroid bloods, but one or a few doctors that look at them know absolutely nothing about thyroid, and make it something more complicated.

[NWA6 in reply to SilverAvocado]

Ok so my interpretation of it is that I am/was living mainly on the T3 coming directly from my thyriod because I don’t convert well so I wasn’t getting adequate T3 from conversion. Hence low T3 syndrome. Hindsight tells me that I’ve had this all my life from childhood when I didn’t have Hashimotos, I would have had normal TSH (one record of it in my 20’s) and I bet if my T4 was taken it would have been in range too but I bet T3 would have always been low as it is on 6 recorded tests.

I’m just getting my parents and daughter tested. So far Daughter is below range but lower in range TSH.

Just waiting on more tests.

I think they’re all linked but if it wasn’t called a ‘thyriod’ condition maybe it wouldn’t be lumped in with the ranges of a damaged thyriod. If it was it’s own condition, a conversion issue maybe we could get treatment. I don’t think it’s common but it may be a hereditary thing in my family. I know it’s not going to make the slightest bit of difference to any medical professionals that I come across, the most recent response from our GP about my daughters FT3 results 4 (4.7-7.2) is that it’s of no consequence because her TSH is below 1. I’m waffling now but just trying to be as informed as I can. In summary though I think people can have low T3 without a damaged Thyriod.

[SilverAvocado in reply to NWA6]

It makes me very sad and angry to hear your daughter is being dismissed by the GP Its really shocking that they are happy to leave her ill at a time when she has her whole life ahead of her

It might be worth making a post specifically about getting full investigation for central htypothyroid, because it seems its common for doctors to have not even heard of it. The guidelines are also very vague about anything besides primary hypothyroid, but some members are extremely good at digging through and finding out what your rights are and who to turn to.

It sounds like you and your daughter may be exactly in the group of patients who is badly served by the idea of low T3 syndrome Doctors acting as if the low T3 is caused by something magical, and not doing the digging into the illness that is causing it in the first place.

Although I agree with Angel_of_the_North, its appropriate to use the term in cases of starvation or other extreme illness.

[SilverAvocado in reply to SilverAvocado]

I just saw there was part of your post I hadn't replied to about being ill for many years. Many members on the forum with Hashimotos feel that they've been ill since childhood or teen years, even though they were only diagnosed decades later, so that is not an unusual pattern.

[Aurealis in reply to SilverAvocado]

I have regular fT3 tests because I take T3 and it is noticeable that if I have a test just after being poorly for other reasons, the fT3 result comes out much lower than usual.

[SilverAvocado in reply to Aurealis]

That's very interesting!

Isuspect a similar thing happens with raising activity levels, and having an illness is quite similar - the equivalent of doing more work.

[Aurealis in reply to SilverAvocado]

Increased activity doesn’t seem to show through my results, though I sometimes feel that I have to adjust upwards temporarily if increasing exercise levels for many consecutive days. The lower fT3 happens even at the incubation stage of a virus before I know I’ve got it. .

[Angel_of_the_North in reply to NWA6]

Low T3 syndrome is can be another name for the low T3 that results from chronic disease or starvation when thyroid needs to put the brakes on to ensure survival. But there doesn'tseem to be enough differentiation between that and low T3 because of poor conversion or undermedication.

[BadHare in reply to SilverAvocado]

A victim of ignorant medics. >

[Judithdalston in reply to SilverAvocado]

Quite, I agree...badly ‘diagnosed’ or / and treated

[Hidden]

A major worry is the idea that older people don't NEED TSH as low or thyroxine as high as younger ones. Think I read it in the official guidelines or a paper that was posted on here. Higher TSH and lower thyroid hormones are common symptoms of ageing. The assumption seems to be that that, as long as the patient feels reasonably well, this decline in thyroid levels is "Normal" and needs to be maintained! Or perhaps they don't like the thought of so many galloping grannies who have got their energy and zest for life back with the help of proper treatment!

[DippyDame in reply to Hidden]

"Galloping grannies".....love that!

[diogenes Remembering]

A paper to look at:

Oncotarget. 2017 Nov 7; 8(55): 94580–94590.

Published online 2017 Oct 10. doi: 10.18632/oncotarget.21811

PMCID: PMC5706897

PMID: 29212251

Low fT3 is associated with diminished health-related quality of life in patients with acute coronary syndrome treated with drug-eluting stent: a longitudinal observational study

Chao Xue,, Ling Bian,, Yu Shui Xie, Zhao Fang Yin, Zuo Jun Xu, Qi Zhi Chen, Hui Li Zhang, Yu Qi Fan, Run Du, and Chang Qian Wang

This paper looks at FT3 in sickish people.

[diogenes Remembering]

Looking further at the paper I note that the aim for elderly people for TSH, by suitable (T4 of course) therapy is 4-6 mIU. That's crazily high - most elderly will be at least subclinical hypothyroid with that value and some will be hypo definitely. Researchers simply can't get away from categorising patients in a group and totally forget individual response. Treatment by categorisation is going to be hung on to for ages, unless the medics get it into their heads that they treat people not panels.

[Smelly12 in reply to diogenes]

That's why we need sites like this to help u u derstand what our readings are🙏

[vocalEK]

The full PDF can be downloaded from Research Gate. researchgate.net/publicatio...