Not only AF and Osteoporosis, but now we'll get dementia too so best not treat the elderly for hypothyroidism at all! We're going to get brain fog whichever way we go... Are these people for real?
"This is yet another reason for us to be vigilant about not overtreating people with thyroid hormone, especially in older adults," Mammen said. "We already know that atrial fibrillation rates are increased in people who are hyperthyroid. We know that fracture and osteoporosis is affected by hyperthyroidism. And now we also have an association with higher rates of cognitive disorders."
Question Is excess thyroid hormone associated with a higher risk of cognitive disorders in older adults?
Findings In this cohort study among 65 931 patients 65 years and older receiving primary care within a single health care system, a low thyrotropin level from either endogenous or exogenous thyrotoxicosis was associated with increased risk of incident cognitive disorder, with an adjusted hazard ratio of 1.39.
Meaning Practice patterns favoring aggressive case detection and treatment with thyroid hormone in older adults should be reconsidered in light of the frequency of overtreatment and the potential for harm associated with excess thyroid hormone.
Abstract
Importance Thyroid hormone is among the most common prescriptions in the US and up to 20% may be overtreated. Endogenous hyperthyroidism may be a risk factor for dementia, but data are limited for iatrogenic thyrotoxicosis.
Objective To determine whether thyrotoxicosis, both endogenous and exogenous, is associated with increased risk of cognitive disorders.
Design, Setting, and Participants This cohort study performed a longitudinal time-varying analysis of electronic health records for patients receiving primary care in the Johns Hopkins Community Physicians Network between January 1, 2014, and May 6, 2023. Patients 65 years and older with at least 2 visits 30 days apart to their primary care physicians were eligible. None of the 65 931 included patients had a history of low thyrotropin (TSH) level or cognitive disorder diagnoses within 6 months of their first visit. Data analysis was performed from January 1 through August 5, 2023.
Exposure The exposure variable was a low TSH level, characterized based on the clinical context as due to endogenous thyrotoxicosis, exogenous thyrotoxicosis, or unknown cause, excluding those attributable to acute illness or other medical factors such as medications.
Main Outcomes and Measures The outcome measure was cognitive disorders, including mild cognitive impairment and all-cause dementia, to improve sensitivity and account for the underdiagnosis of dementia in primary care.
Results A total of 65 931 patients were included in the analysis (median [IQR] age at first visit, 68.0 [65.0-74.0] years; 37 208 [56%] were female; 46 106 [69.9%] were White). Patients exposed to thyrotoxicosis had cognitive disorder incidence of 11.0% (95% CI, 8.4%-14.2%) by age 75 years vs 6.4% (95% CI, 6.0%-6.8%) for those not exposed. After adjustment, all-cause thyrotoxicosis was significantly associated with risk of cognitive disorder diagnosis (adjusted hazard ratio, 1.39; 95% CI, 1.18-1.64; P < .001) across age groups. When stratified by cause and severity, exogenous thyrotoxicosis remained a significant risk factor (adjusted hazard ratio, 1.34; 95% CI, 1.10-1.63; P = .003) with point estimates suggestive of a dose response.
Conclusions and Relevance In this cohort study among patients 65 years and older, a low TSH level from either endogenous or exogenous thyrotoxicosis was associated with higher risk of incident cognitive disorder. Iatrogenic thyrotoxicosis is a common result of thyroid hormone therapy. With thyroid hormone among the most common prescriptions in the US, understanding the negative effects of overtreatment is critical to help guide prescribing practice.
Does anyone notice that the word "hypothyroidism" isn't mentioned in this Abstract at all?
It is all based on TSH and nothing else. T4 and T3 don't get a mention. If someone has a low TSH then this paper suggests that the patient is hyperthyroid, apparently even if they are hypothyroid and taking thyroid hormones.
Doctors have reduced thyroid science to something that a 5-year-old can understand. In other words, TSH is under the range? Patient is hyperthyroid. No doubt about it.
What I took from this article was that they were advocating a reduction or even withdrawal of thyroid hormone treatment from elderly hyPOthyroid patients for fear of driving them into hyPERthyroidism and causing AF, osteoporosis and now dementia too… which is total nonsense, of course. A hypo- patient does not become hyper- , they can only be over-medicated. And to go by TSH alone without taking FT 4 and FT3 into account is tantamount to medical negligence!
There is no doubt that doctors are so afraid of hyperthyroidism that they would prefer hypothyroid people to suffer rather than be over-medicated. And if someone is on 175mcg Levo, for example, for hypothyroidism and needs a dose reduction there is quite a strong likelihood that a patient will have 100mcg of their dose removed because doctors don't realise that a delicate hand is needed, not a sledgehammer.
That’s pretty much what I’ve taken from it too. We might make them hyper so we won’t treat them at all. Might help if they did regular blood tests to see what was actually happening to their patients levels. They don’t have to let them actually become hyper.
So have I read this right… they are saying supressed TSH causes cognitive issues in elderly patients treated with thyroid replacement. Hmmm so much wrong with this study. They’ve assessed 1 thing and drawn conclusions about another thing without looking at the variable factors. 🤷🏽♀️
I was puzzled by it as well - it's just so poorly written and is of really low quality. But I think we are being told that :
Low TSH is caused by thyrotoxicosis or hyperthyroidism and this leads to brain fog /cognitive problems.
It also implies, but doesn't explicitly say so, that someone who is on thyroid hormones and has a low TSH is hyperthyroid. This is not true when dealing with hypothyroid people. People can't become hyperthyroid if they've been hypothyroid for a long time because their thyroid probably doesn't work and if they have autoimmune disease they might have very little thyroid left.
By the logic that is being used in the Abstract, someone who has had a thyroidectomy could be hyperthyroid or have thyrotoxicosis. And that is 100% nonsense. Why do endocrinologists dealing with thyroid use such imprecise language all the time? Why are they so afraid of saying "over-medicated" if that is what they think? Do they just want to blind their patients with long words?
But it deals with the whole problem of diagnosis and cognitive problems in people with thyroid problems in such a simplistic way that, in my opinion, it is 100% nonsense.
For example, I mentioned that the word "hypothyroidism" wasn't used. But hypothyroid people who are under-treated or late in getting a diagnosis at all often complain of brain fog at any age, and therefore have a high TSH
People with Central Hypothyroidism (i.e. unable to produce enough TSH for their needs and have low TSH and low levels of thyroid hormones) will probably suffer from brain fog.
The whole proposal of the authors seems to be that once you are 65+ and have thyroid disease of any kind your thyroid hormone levels are probably too high if you have brain fog. But that is such a huge over-simplification.
In the article linked by Zephybear it says :
Often, older patients may complain of symptoms such as constipation, feeling cold, or tiredness, which can be symptoms of hypothyroidism. But these symptoms could also be from anemia, vitamin deficiencies, depression, perimenopause, menopause, insulin resistance, and sleep apnea.
The list of alternative explanations for hypothyroid symptoms is quite peculiar. I found from experience throughout life that doctors rarely test for mineral and vitamin deficiency. They only do a Full Blood Count to check if haemoglobin (Hb) is in range. If Hb is in range then doctors think there can be no deficiencies.
Perimenopause or menopause? In a woman 65+? I don't know how likely that is. I doubt it is common at that age.
But the whole premise of the list of symptoms given is that people with them might have other causes for them rather than thyroid disease. But checking for differential diagnoses is part of a doctor's job, and so even if the patient has constipation, feels cold or tired, they still need to check for thyroid disease rather than just rely on extra blankets, a laxative, and sleeping pills.
I totally agree with you! It seems as though the medical profession are incapable of just going for the most obvious diagnosis given the combination of symptoms without having gone all around the houses (probably more than once) costing the NHS thousands as they go! In the meantime the patient suffers and has parts of their body permanently destroyed by this disease which will never be rectified instead of ‘catching it in time’ and perhaps preventing some of this damage! 🤬
I struggle to understand scientific writing. The key word that stood out for me was ‘thyrotoxicosis’ causing low THS. That’s from untreated hyperthyroidism?
Related if your hypothyroidism is autoimmune / Hashimoto’s as the swings into Hyper that happens can I believe cause thyrotoxicosis albeit temporarily. So different to in Graves. 🌱
Oh dear - is it just me or is the lack of understanding about matters thyroid is astonishingly worrying. Things seem to be getting worse instead of better. I’m left with the feeling that it might almost be easier just to exterminate all us oldies.
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