what might be a presenting symptom of hyperthyroidism in the elderly

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Can an elderly person have hyperthyroidism?

HYPERTHYROIDISM IN THE OLDER PATIENT. As in all hyperthyroid patients, if there is too much thyroid hormone, every function of the body tends to speed up (see Hyperthyroidism brochure). However, while the younger patient often has multiple symptoms related to the overactive thyroid, the elderly patient may only have one or two symptoms.

What are the symptoms of an overactive thyroid in the elderly?

However, while the younger patient often has multiple symptoms related to the overactive thyroid, the elderly patient may only have one or two symptoms. For example, patient number 1, above, experienced only a sensation of her heart fluttering, and some chest discomfort on climbing stairs.

What are the symptoms of hyperthyroidism?

Due to the presence of high levels thyroid hormones, a number of symptoms can be seen in hyperthyroidism. This includes : With Grave’s disease, the eyes appear to pop out of the sockets, a condition known as exopthalmus.

How is the presence of thyroid disease determined in the elderly?

An important clue to the presence of thyroid disease in an elderly patient is a history of thyroid disease in another close family member such as a brother, sister or child of the patient.

Are symptoms of hyperthyroidism the same for adults as they are for older adults?

Two-thirds of older adults with hyperthyroidism will present similarly to younger patients. Symptoms will be consistent with sympathetic overactivity and include tremors, anxiety, palpitations, weight loss and heat intolerance. However, one-third of older adults will present with apathetic hyperthyroidism.

What are 4 major clinical symptoms of hyperthyroidism?

The classic symptoms of hyperthyroidism include heat intolerance, tremor, palpitations, anxiety, weight loss despite a normal or increased appetite, increased frequency of bowel movements, and shortness of breath.

Is hyperthyroidism common in elderly?

Overt hypothyroidism occurs in 2–5% of the patients older than 60 years. [3,6] Hyperthyroidism, on the other hand, is more common in the younger population. The prevalence in the elderly is approximately 0.5–3%,[1,6–8] but 10–15% of the patients with hyperthyroidism are older than 60 years.

What are 3 symptoms of hyperthyroidism?

SymptomsUnintentional weight loss, even when your appetite and food intake stay the same or increase.Rapid heartbeat (tachycardia) — commonly more than 100 beats a minute.Irregular heartbeat (arrhythmia)Pounding of your heart (palpitations)Increased appetite.Nervousness, anxiety and irritability.More items...•

What is the most common cause of hyperthyroidism?

Graves disease (most common cause of hyperthyroidism) Inflammation (thyroiditis) of the thyroid due to viral infections, some medicines, or after pregnancy (common) Taking too much thyroid hormone (common) Noncancerous growths of the thyroid gland or pituitary gland (rare)

Which of the following includes signs of hyperthyroidism?

What are the symptoms of hyperthyroidism?weight loss despite an increased appetite.rapid or irregular heartbeat.nervousness, irritability, trouble sleeping, fatigue.shaky hands, muscle weakness.sweating or trouble tolerating heat.frequent bowel movements.an enlargement in the neck, called a goiter.

Which group of symptoms of hyperthyroidism is most commonly found in elderly clients?

Instead, cardiovascular symptoms and signs often predominate in older patients, including atrial fibrillation. Other findings more common in older patients with hyperthyroidism include fatigue, anorexia, weight loss, apathy, agitation, or cognitive decline (11-14).

Which symptom of thyroid disease is seen in older adults?

However, while younger people with thyroid disorders often experience multiple symptoms related to the over-active thyroid (weight loss, palpitations, sweating, nervousness, tremors) older people may only have a few symptoms, for example some heart palpitations and chest discomfort on climbing stairs.

What are the symptoms of thyroid problems in older females?

SymptomsFatigue.Increased sensitivity to cold.Constipation.Dry skin.Weight gain.Puffy face.Hoarseness.Muscle weakness.More items...•

How does hyperthyroidism affect the body?

Hyperthyroidism, also called overactive thyroid, is a condition where your thyroid makes and releases high levels of thyroid hormone. This condition can make your metabolism speed up. Symptoms of hyperthyroidism include a rapid heartbeat, weight loss, increased appetite and anxiety.

Does hyperthyroidism cause high blood pressure?

When the thyroid gland doesn't produce enough thyroid hormone (hypothyroidism) or produces too much thyroid hormone (hyperthyroidism), high blood pressure can result.

How do you feel when you have hyperthyroidism?

nervousness, anxiety and irritability. hyperactivity – you may find it hard to stay still and have a lot of nervous energy. mood swings. difficulty sleeping.

What are the symptoms of hyperthyroidism in females?

Common symptoms include:Unplanned weight loss.Rapid heartbeat, abnormal heartbeat, or pounding of the heart.Nervousness, anxiety, or touchiness.Tremors (trembling of the hands and fingers)Changes in menstrual patterns, such as lighter flow or less frequent periods, in women.Increased sensitivity to heat.More items...•

How do you feel when you have hyperthyroidism?

nervousness, anxiety and irritability. hyperactivity – you may find it hard to stay still and have a lot of nervous energy. mood swings. difficulty sleeping.

What are early warning signs of thyroid problems?

7 Early Warning Signs of Thyroid IssuesFatigue.Weight gain.Weight loss.Slowed heart rate.Increased heart rate.Sensitivity to heat.Sensitivity to cold.

What happens if hyperthyroidism is left untreated?

If hyperthyroidism isn't treated, it can cause some serious health problems, including: An irregular heartbeat that can lead to blood clots, stroke, heart failure, and other heart problems. An eye disease called Graves' ophthalmopathy. It can cause double vision, light sensitivity, and eye pain.

Definition: What Do The Following Patients Over The Age of 60 Years Have in Common?

1. A 72 year old woman with “fluttering of the heart” and vague chest discomfort on climbing stairs 2. An 80 year old man with severe constipation...

Hyperthyroidism in The Older Patient

As in all hyperthyroid patients, if there is too much thyroid hormone, every function of the body tends to speed up (see Hyperthyroidism brochure)....

Treatment of The Older Patient With Hyperthyroidism

As with younger patients, treatment of hyperthyroidism in the older patient includes antithyroid drugs and radioactive iodine (see Hyperthyroidism...

Hypothyroidism in The Older Patient

Hypothyroidism is very common in patients over 60 years of age and steadily increases with age (see Hypothyroidism brochure). Up to 1 in 4 patients...

Treatment of The Older Patient With Hypothyroidism

As with the younger patient, pure synthetic thyroxine (L-T4), taken once daily by mouth, fully replaces the function of the thyroid gland and succe...

What are the symptoms of hyperthyroidism?

When to see a doctor. If you experience unexplained weight loss, a rapid heartbeat, unusual sweating, swelling at the base of your neck or other signs and symptoms associated with hyperthyroidism, see your doctor. It's important to completely describe the changes you've observed, because many signs and symptoms of hyperthyroidism may be associated ...

How to treat hyperthyroidism?

Several treatments are available for hyperthyroidism. Doctors use anti-thyroid medications and radioactive iodine to slow the production of thyroid hormones. Sometimes, hyperthyroidism treatment involves surgery to remove all or part of your thyroid gland.

What is the name of the lump that forms when the thyroid gland produces too much T4?

An adenoma is a part of the gland that has walled itself off from the rest of the gland, forming noncancerous (benign) lumps that may cause an enlargement of the thyroid. Thyroiditis.

What is the term for overactive thyroid?

Overview. Hyperthyroidism (overactive thyroid) occurs when your thyroid gland produces too much of the hormone thyroxine. Hyperthyroidism can accelerate your body's metabolism, causing unintentional weight loss and a rapid or irregular heartbeat. Several treatments are available for hyperthyroidism.

What is Graves disease?

Graves' disease is an autoimmune disorder in which antibodies produced by your immune system stimulate your thyroid to produce too much T4. It's the most common cause of hyperthyroidism. Hyperfunctioning thyroid nodules (toxic adenoma, toxic multinodular goiter or Plummer's disease).

Why is T4 so high?

Reasons for too much thyroxine (T4) Normally, your thyroid releases the right amount of hormones, but sometimes it produces too much T4. This may occur for a number of reasons, including: Graves' disease.

Where is the thyroid gland located?

Thyroid gland. Your thyroid gland is located at the base of your neck, just below the Adam's apple. Hyperthyroidism can be caused by a number of conditions, including Graves' disease, Plummer's disease and thyroiditis. Your thyroid is a small, butterfly-shaped gland at the base of your neck, just below your Adam's apple.

How common is hypothyroidism in elderly?

Hypothyroidism is very common in patients over 60 years of age and steadily increases with age (see Hypothyroidism brochure ). Up to 1 in 4 patients in nursing homes may have undiagnosed hypothyroidism. Unlike symptoms of hyperthyroidism, the symptoms of hypothyroidism are very non-specific in all patients, even more so in the older patient. As with hyperthyroidism, the frequency of multiple symptoms decreases in the older patient. For example, memory loss or a decrease in cognitive functioning, often attributed to advancing age, may be the only symptoms of hypothyroidism present. Symptoms and signs of hypothyroidism may include weight gain, sleepiness, dry skin, and constipation, but lack of these symptoms does not rule out the diagnosis. To make this diagnosis in the elderly patient, a doctor often needs a high index of suspicion. Clues to the possibility of hypothyroidism include a positive family history of thyroid disease, past treatment for hyperthyroidism, or a history of extensive surgery and/or radiotherapy to the neck.

What is the treatment for hyperthyroidism in older patients?

As with younger patients, treatment of hyperthyroidism in the older patient includes antithyroid drugs and radioactive iodine (see Hyperthyroidism brochure ). Surgery is rarely recommended due to increased operative risks in the older patient. While Graves’ disease is still a common cause of hyperthyroidism, toxic nodular goiter is seen more frequently in the older patient. During therapy, the effects of change in thyroid function on other body systems must be closely monitored, due to an increased likelihood of co-existing cardiac, central nervous system and thyroid disease in older patients. Most often, thyroid function is brought under control first with antithyroid drugs (propylthiouracil or methimazole (Tapazole®)) before definitive treatment with radioactive iodine.

How to treat hyperthyroidism?

Symptoms of hyperthyroidism may be brought under control with adjunctive medications, such as beta-adrenergic blockers (propranolol [Inderal®], metoprolol [Lopressor ®]), which are often given to slow a rapid heart rate, although they must be given with caution in the patient with co-existing congestive heart failure and the dose should be reduced once thyroid function is controlled in the normal range. Symptoms and signs of angina pectoris and heart failure must be treated in tandem with the treatment to bring thyroid function under control.

What determines the dose of thyroid hormone replacement?

The presence or absence, and severity, of thyroid-related symptoms and co-existing diseases such as coronary artery disease or heart failure will determine the dose of thyroid hormone replacement that is given.

Can radioactive iodine be used for thyroid?

Once thyroid function is maintained in the normal range with oral medication, the doctor and patient can make a decision on definitive treatment with radioactive iodine together. There is some controversy about what the normal level of TSH is for elderly patients. In general, an attempt is made to render thyroid function either normal or low in an elderly patient treated with radioactive iodine. Treatment of an underactive thyroid condition (hypothyroidism) is usually more straightforward than the problem of recurrent hyperthyroidism in the older patient, because of the effect hyperthyroidism can have on the heart, as indicated above. A frequent clinical concern is the treatment of patients with normal T4 and T3 with suppressed TSH. An isolated low TSH is particularly common in older patients. Most clinicians will follow these patients, without treatment unless they are symptomatic.

Can hyperthyroidism cause heart fluttering?

For example, patient number 1, above, experienced only a sensation of her heart fluttering, and some chest discomfort on climbing stairs. Other patients may also have few symptoms, such as patient number 6, whose main symptoms are depression and tremor. Such a patient may withdraw from interactions with friends and family.

Can hypothyroidism cause constipation?

For example, memory loss or a decrease in cognitive functioning, often attributed to advancing age, may be the only symptoms of hypothyroidism present. Symptoms and signs of hypothyroidism may include weight gain, sleepiness, dry skin, and constipation, but lack of these symptoms does not rule out the diagnosis.

What are the signs of hypothyroidism in older people?

Any of the following signs and symptoms can indicate hypothyroidism in an older person. Unexplained high cholesterol. High cholesterol is sometimes the only evidence of an underactive thyroid in an older person. Because this sign may stand alone, high cholesterol warrants a thyroid evaluation. Heart failure.

When does hypothyroidism start in 2020?

Hypothyroidism symptoms and signs in an older person. November 24, 2020. Some people over age 60 have few, if any, symptoms of an underactive thyroid gland (hypothyroidism), while others experience the same symptoms younger people do.

What is the pain in the legs from hypothyroidism?

Joint or muscle pain. Vague joint pain is a classic hypothyroidism symptom. It sometimes is the only symptom of hypothyroidism in an older person. Many people experience general muscle aches, particularly in large muscle groups like those in the legs.

Can depression affect older people?

Psychiatric problems. Clinical depression—a common symptom in younger people with hypothyroidism—can also affect older people with the condition. The difference is that in older people it can be the only hypothyroidism symptom. Some older adults also develop psychosis with delusional behavior or hallucinations.

What are the symptoms of hyperthyroidism?

This includes : nervousness. irritability. tremors. restlessness. weight loss. increased appetite. difficulty sleeping.

How do you know if you have thyroid disease?

Due to the presence of high levels thyroid hormones, a number of symptoms can be seen in hyperthyroidism. This includes : 1 nervousness 2 irritability 3 tremors 4 restlessness 5 weight loss 6 increased appetite 7 difficulty sleeping 8 diarrhea 9 nausea 10 excessive perspiration

What is the name of the condition that causes the thyroid gland to function excessively?

Hyperthyroidism is an excessive functional activity of thyroid gland that can be caused by an auto-immune condition known as Graves’ disease or excessive replacement of thyroid hormones in hypothyroidism.

What is the term for a thyroid gland that is toxic?

It is also known as thyrotoxicosis. Hypothyroidism may be associated with diffuse toxic goiter and less frequently with toxic nodular goiter or toxic adeno ma. Most of these conditions of the thyroid gland occur in the early to mid adulthood.

What is the best medicine for thyroid gland?

Treating an Overactive Thyroid Gland. Antithyroid drugs include carbimazole, methylthiouracil and potassium perchlorate .The drugs are usually prescribed in combination with beta blocker drugs such as propranolol. Beta blockers are contraindicated in patients with cardiac failure, asthma and diabetes. This is a major concern when treating ...

Can hyperthyroidism cause nodules?

Hyperthyroidism can also be caused due to formation of a nodule within the gland. This is a less common cause of hyperthyroidism in most cases overall, however it is significant in the elderly. The condition is termed as toxic nodular goiter and is a non-cancerous growth of the gland. Thyroditis, a condition where there is inflammation ...

Is hyperthyroidism more common in elderly people?

Although hypothyroid ism (underactivity of the thyroid gland) is more common in the elderly, hyperthyroidism may also be seen in seniors. Excessive thyroid hormone causes generalized increase in metabolic rate of all body tissues. Hyperthyroidism is an excessive functional activity of thyroid gland that can be caused by an auto-immune condition ...

What is thyrotoxicosis in the elderly?

Another term for thyrotoxicosis in the elderly is "apathetic hyperthyroidism ." Coined by Frank Lahey 14 of the Lahey Clinic, this term described certain older patients whose thyroid glands were small and who lacked such typical hyperthyroid features as exophthalmos; tachycardia; and smooth, moist skin. These patients did not appear to be severely ill; nevertheless, Lahey 14 observed that if they were subjected to physiologic stress, these fragile, elderly persons could "quietly and peacefully sink into coma and die."

Why are elderly people euthyroid?

These researchers hypothesized that the reduced T 4 distribution space (the fraction of body tissues penetrated by thyroid hormone) present in the aged may result from a reduction in overall "metabolic mass." Despite reduced T 4 output, elderly persons remain euthyroid because this lower T 4 level is matched by a reduction in T 4 turnover and in the need for thyroid hormone. 3

How long after thyroid replacement can you measure TSH?

Measurement of thyroid hormone levels 6 weeks after reaching the projected long-term replacement dosage is critical, because elderly patients seldom can tolerate iatrogenic hyperthyroidism for very long. At that time, make sure that the TSH level is in the normal range and not suppressed.

How much radioiodine should I give to elderly with Graves disease?

For patients of any age with diffuse toxic goiter (Graves disease), a fairly standard total dose of radioiodineis 10 to 15 mCi, whereas a patient with multinodular toxic goiter usually requires a total dose of 25 to 30 mCi.

How often should you do thyroid function tests after radioiodine?

Obtain thyroid function tests (free T 4 and TSH) at least every year , and more frequently (twice or even 3 times a year) if you suspect the patient has hypothyroidism.

What are the effects of age related anatomic and physiologic alterations in the thyroid gland?

November 1, 2002. ABSTRACT: Age-related anatomic and physiologic alterations in the thyroid gland have a variety of clinically important effects. Hypothyroidism, which is common in older persons, raises cholesterol and triglyceride levels; hyperthyroidism may be masked by the severity of the cardiac problems it causes.

How does thyroid function change as you age?

Thyroid physiology and microscopic anatomy are altered, and the rate at which thyroid hormone is secreted and cleared is reduced.

What are the physical symptoms of hypothyroidism in elderly people?

Physical findings evident in hypothyroid elderly individuals may include bradycardia, diastolic hypertension, pallor, dry skin, coarse hair, hoarseness, dysarthria, delayed relaxation of deep tendon reflexes, and mental status changes (31). The severity of specific findings may be exacerbated by comorbid cardiovascular, neuropsychiatric, dermatologic, or rheumatologic conditions that are more common among the elderly (32). In some cases it may be necessary to evaluate responses to thyroid hormone replacement to determine the extent to which certain findings represent manifestations of thyroid hormone deficiency.

Why is hypothyroidism more common in elderly people?

Hypothyroidism is more common among elderly individuals due to the increasing incidence and prevalence of autoimmune thyroiditis that occurs with aging.

What is mild hypothyroidism?

Mild or subclinical hypothyroidism, which is characterized by an increased TSH level with concomitant free thyroid hormone levels that fall within normal limits , is very common among elderly men and women. The estimated prevalence of this condition has varied from 4-15%. A study evaluating a community of healthy elderly adults in the southwest of France reported that 4.2% of subjects presenting with increased TSH levels had normal free T4 levels (111). Within this group, mild hypothyroidism was linked with an increased prevalence of symptoms of depression. A study that evaluated thyroid function profiles in a bi-ethnic urban community reported that mild hypothyroidism was more commonly identified in females and non-Hispanic white subjects than Hispanic subjects (112). Stratified analysis of the impact of mild hypothyroidism in this population revealed no significant alterations in health status measures in subjects with TSH levels ranging between 4.7-10.0 mIU/L. A study that inventoried clinical findings of hypothyroidism in a population of geriatric clinic patients reported that while 15.4% of the men and 14.6% of the women screened met criteria for mild hypothyroidism, the incidence of symptoms and signs consistent with thyroid hormone deficiency detected in these subjects was similar to that reported for euthyroid subjects (113). An array of studies that have tracked changes in thyroid function in cohorts of aging subjects in the United States, Australia, the Netherlands, Spain, the United Kingdom, and China have reported that the development of hypothyroidism in elderly patients does not appear to be associated with any change in cognitive function, increased levels of depression, or diminished ability to perform activities of daily living (114–120). A study that measured an array of anthropometric, biochemical, and neuropsychiatric parameters in Korean subjects aged 65 years and older showed that subclinical hypothyroidism did not appear to be associated with any discernible metabolic or neuropsychiatric derangements (121). A study that evaluated subgroups of subjects enrolled in the Health, Aging, and Body Composition study found that those determined to have mild subclinical hypothyroidism (defined by a TSH level of 4.5-7.0 mIU/L with normal thyroid hormone levels) demonstrated better mobility, cardiorespiratory fitness, and walking ease than subjects who were euthyroid or determined to have moderate subclinical hypothyroidism (defined by a TSH level of 7.0-20.0 with normal thyroid hormone levels) (122). An analysis of subgroups in this cohort study identified increased odds of prevalent metabolic syndrome among subjects with TSH levels > 10 (123). A study that evaluated postmenopausal women at risk for development of osteoporosis reported that subclinical hypothyroidism was not associated with decreased bone mineral density or an increased risk of vertebral or non-vertebral fracture (124).

What is the TSH level of a person over 80?

Future estimates of the prevalence of hypothyroidism among the elderly based on current definitions may need to factor in growing evidence that normal TSH distribution curves appear to be shifted towards higher value ranges in older individuals. Age-specific analysis of TSH levels and anti-thyroid antibody titers measured as part of the most recent NHANES study demonstrated that 12% of subjects aged 80 and older without any evidence of underlying autoimmune thyroiditis had TSH levels greater than 4.5 mIU/L (13). In this analysis, the upper 95% confidence limit for TSH in euthyroid individuals over age 80 was 7.5 mIU/L (13).

How accurate is a TSH test for primary hypothyroidism?

Accurate diagnosis of primary hypothyroidism in the elderly relies primarily, as it does in all patients, on the measurement of a sensitive serum TSH level. Although data from the NHANES III study has established that median TSH levels appear to increase with advancing age, the normal upper limit of an established reference range may still be used as a cutoff to confirm the diagnosis of primary hypothyroidism in most elderly patients. While a blood spot TSH level has been shown to be an adequate screening test for the detection of overt primary hypothyroidism in the elderly, it may not be sensitive enough to detect cases of subclinical hypothyroidism characterized by elevated serum TSH levels with normal T4 or free T4 levels (53). One study has determined that there may be a negative correlation between age and the degree to which TSH levels are elevated in elderly patients presenting with primary hypothyroidism (54).

Why do elderly people need thyroxine?

Thyroxine dose requirements in elderly patients may be related to several factors including declining metabolic clearance, progression of underlying thyroid failure, declining body mass, and interactions with other medications prescribed for the treatment of co-morbid conditions (88,89). On average, elderly patients with primary hypothyroidism receive initial daily doses that are 20 mcg lower and maintenance daily doses that are 40 mcg lower than those prescribed for younger and middle-aged patients (90–92). One study suggested that lean body mass may be a better predictor of daily replacement doses than age or weight alone (93). Another reported that most of the age-dependent differences in thyroxine requirements noted might be attributed to the effects of chronic disease, since substantially lower average daily replacement doses were reported by elderly patients treated for other chronic medical disorders (94). A study that tracked changes in elderly patients’ thyroxine requirements over time based on the etiology of their primary hypothyroidism reported that daily replacement doses increased in patients who initially presented with autoimmune thyroiditis or postsurgical hypothyroidism, decreased in patients who initially presented with post-ablative hypothyroidism, and did not change in patients who initially presented with subclinical hypothyroidism or drug-induced hypothyroidism (95).

What is the most common cause of hypothyroidism in the elderly?

Autoimmune thyroiditis is the most common cause of hypothyroidism among the elderly, as it is in younger persons (16–18). A survey of endocrinology clinic patients revealed that 57% of patients aged 55 and older presenting with primary hypothyroidism carried a diagnosis of autoimmune thyroiditis, while 32% carried a diagnosis ...

Why are thyroid function tests performed?

Thyroid function tests were performed because of the previous documentation of thyrotoxic hypokalemic periodic paralysis in the Asian population. 68-72 The patient was discharged at his request pending the results of thyroid function tests with instructions to continue the oral potassium supplement, and he was advised to attend the endocrine clinic the following week.

What is Graves disease?

As the disorder was characterized further, it became clear that Graves' disease is a systemic disorder involving T lymphocytes and therefore manifests involvement of multiple organs. 57 Characteristic presentations include: orbitopathy, e.g., conjunctival and corneal inflammation because of widened palpable fissure, proptosis secondary to retro-orbital infiltration, thickening and lengthening of one or more extraocular muscles leading to paresis as well as lengthening and/or compression of the optic nerve, rarely leading to optic atrophy resulting in blindness ( see Table 1 ); thyroid enlargement with hyperthyroidism as the most common presentation, although infrequently both euthyroid state or hypothyroidism is present in an individual patient; 58 cutaneous involvement of the fingers (acropachy) and pretibial myxedema, secondary to infiltration of the subcutaneous tissue with mucinous material; and other systemic manifestations including generalized lymphadenopathy and hepatosplenomegaly.

What are the symptoms of bilateral total blindness?

The patient denied history of premonitory symptoms, e.g., fever, chills, eye pain, headache, nausea, vomiting, chest pain, palpitations, dysphagia, dysphonia, choking sensation, including parasthesia and neurological problems. However, he reported an increased appetite and weight loss of 15 pounds along with disturbed sleep and excessive sweating for the previous two months. Past and family histories were noncontributory. He did not smoke, abuse alcohol, or use any illicit drugs. The physical examination revealed a complete lack of vision in both eyes, including absent pupillary reflexes without any other neurological deficit. Bilateral proptosis was present. The thyroid gland was enlarged (about 50 g), nontender, soft, and mobile on swallowing. A bruit was heard over the gland, indicating increased vascularity secondary to local vasodilation. Examination of the heart revealed hyperdynamic apical impulse with a rate of 110/min and an irregular irregular rhythm. Pretibial myxedema was present along with brisk knee and ankle reflexes bilaterally. His palms were warm and moist. An ECG showed the presence of atrial fibrillation with a rapid rate as well as left atrial and left ventricular hypertrophy. An MRI of the brain demonstrated bilateral infarcts in occipital lobes. MRA revealed occlusion of both posterior cerebral arteries without collateral circulation. An echocardiogram showed left atrial enlargement with the presence of a thrombus as well as left ventricular hypertrophy with an ejection faction of 40%. Laboratory tests showed a normal coagulation profile and elevated T4 and T3 concentrations with undetectable TSH. Thus, the diagnosis of Graves' disease with hyperthyroidism was confirmed. Bilateral blindness was attributed to emboli from left atrial thrombus secondary to atrial fibrillation.

What were the symptoms of a white man in the emergency room?

He denied any other symptoms including nausea, vomiting, dysphagia, dysphonia, weakness, or imbalance. His past history was unremarkable. The pertinent family history included a 36-year-old daughter with Graves' disease who had received treatment with I-131 for hyperthyroidism. He denied smoking or abusing alcohol and was receiving no medications. The physical examination revealed ptosis of the right eye, with a decreased upward gaze and a normal pupillary reaction to light. The rest of the neurological as well as other systemic examination was reported to be unremarkable. His blood chemistries were normal, and brain CT scan with contrast showed no distinct abnormalities. He was admitted for further assessment. The next day during the ward rounds, a detailed physical examination showed the previously described eye findings. Moreover, exophthalmus of the left eye, sinus tachycardia, moist warm palms, and brisk tendon reflexes without muscle weakness or sensory deficit were also noted. The thyroid gland was not enlarged, and the carotid arteries were well palpated without bruits. The rest of the examination remained unremarkable. A provisional diagnosis of Graves' disease with hyperthyroidism was entertained, particularly because of the eye findings, other subtle signs and symptoms of hyperthyroidism, and his daughter's history of Graves' disease. The diagnosis was confirmed by orbital CT scan. ( See Figure 1.) Simultaneously, elevated serum Free T4 3.2 ng/dL and undetectable serum TSH less than 0.01 mIU/L confirmed the presence of hyperthyroidism. The patient was treated with a beta-blocker, methimazole, and prednisone with relief of symptoms including some improvement in diplopia and photophobia. The patient was referred to neuro-ophthalmology for further management.

Is hyperthyroidism common in the elderly?

Moreover, hyperthyroidism frequently is heralded in the elderly by supraventricular tachyarryhthmias, with atrial fibrillation being the most common, and with a rapid ventricular rate, refractory or new onset congestive heart failure, or angina pectoris. Although thyrotoxic heart disease does occur in patients in the absence of heart disease, as noted in this patient, it is more common in the presence of underlying heart disease and therefore explains the increased frequency of this presentation in the elderly who are more likely to have previously unknown cardiac dysfunction. 9-21 Sandler and Wilson have demonstrated that congestive heart failure occurs only in about 5% of thyrotoxic patients without underlying heart disease. 10 Therefore, unexplained cardiac decompensation, decompensation out of proportion to the underlying cardiac disease, or decompensation refractory to conventional therapy should prompt an evaluation for occult hyperthyroidism.

Is masked hyperthyroidism a congestive heart failure?

This patient exemplifies masked hyperthyroidism with congestive heart failure but without underlying cardiac disease . The diagnosis is often not entertained because the symptoms are attributed to a worsening of the underlying disease including the more common causes (e.g., coronary artery disease, hypertension, as well chronic obstructive pulmonary disease with hypoxia) as opposed to the occurrence of a new entity. The elderly patient often lacks ocular signs, tremor, smooth skin, nervousness, heat intolerance, and other symptoms associated with classic or hyperkinetic hyperthyroidism. 6-8 Thyroid functions are often obtained only because of an enlarged thyroid gland. However, the diagnosis must not be overlooked even in the absence of prominent thyromegaly because hyperthyroidism frequently occurs in the elderly without a goiter. 6

Can thyrotoxicosis cause seizures?

Occasionally, seizures can be a presenting manifestation of thyrotoxicosis. Up to 60% of patients with thyrotoxicosis have EEG abnormalities, 74 and in one series, three of 31 thyrotoxic patients presented with seizures. 75 Frequently, higher daily doses of anticonvulsants required for control of seizures may be the clue to the presence of hyperthyroidism. Choreoathetoid movements responsive to beta blockers have been reported as the only manifestation of hyperthyroidism. 76 Psychiatric manifestations including agoraphobia have been described as presenting features. 77 Finally, the disease also may mimic other systemic illnesses such as Lyme disease. 78