The Endocrine System Normal Changes of Aging Decreased secretion of insulin Potential for thyroid function problems with

th systemic symptoms that may be attributed to normal aging Decreased sensitivity to insulin resulting in variation of blood glucose levels Peripheral tissues may become insulin resistant, especially with obesity Review of Thyroid Hormones o Thyroxine (T4) o Triiodothyronine (T3) o Thyrotropin-releasing hormone (TRH) producing of thyroid-stimulating hormone (TSH) [T4 + T3] production + increased carbohydrate, protein, and lipid metabolism negative feedback decreased TSH + TRH Altered Thyroid Function with Aging o Gland atrophy o Nodularity of thyroid gland, especially areas with low iodine levels o Elevated thyroid antibody levels o Decreased T4 production but serum T4 unchanged because of diminished use Decline in lean body mass o Decreasing T3 levels o Elevated TSH levels Impact of age-related changes on endocrine function. Diabetes Mellitus (DM) Statistics for older adults o Highest prevalence ages 65 to 74 o Second highest, > 75 years o Thirteen times > than in persons < 45 years old o Ethnic groups Higher for African Americans and Hispanics o African American women < 75 years of age at highest prevalence, except Hispanic males after age 75

More likely to develop microvascular complications More lower limb amputations than Caucasians Statistics for Older Adults o Higher death rates from other illnesses Pneumonia Influenza Heart disease o Greater functional disability o More coexisting illness o Greater risk Depression Cognitive impairment Urinary incontinence Falls Persistent pain Pathophysiology o Defective insulin secretion and/or defective utilization of insulin abnormally high blood glucose damage to multiple organs + blood vessels + nervous system Type 1 o -cell destruction lack of or underproduction of insulin o Cause Autoimmune disease Idiopathic o Insulin dependent o At risk for ketoacidosis Type 2 o Most prevalent in all age groups o Decreased insulin ability to stimulate glucose uptake by skeletal muscle + failure to inhibit hepatic glucose production Insulin resistance + insulin secretory defect rising glucose levels + more insulin production o Symptoms Visceral/abdominal obesity Hypertension Hyperlipidemia Coronary artery disease

 Others Rare ketoacidosis Complications of DM o Eye disease loss of vision or even blindness o Kidney failure o Heart disease o Nerve damage loss of feeling or pain in the hands, feet, legs, or other parts of the body (peripheral neuropathies) o Stroke o Poor wound healing Impaired immune response Poor tissue perfusion in peripheral vascular disease Blood Glucose Elevations without DM o Glucocorticoids o Some diuretics o Peritoneal dialysis o Infection o Acute event, such as myocardial infarction Diagnostics for DM o Physical examination Especially sites at high risk for micro- and macrovascular disease o Nutritional assessment including weight o Eye examination o Electrocardiogram if patient has not had one within 10 years Diagnostics for DM Laboratory tests o Thyroid function tests (TSH) o Urinalysis to test for albuminuria, and serum creatinine for renal function o Fasting lipid profile to assess cardiovascular risk o Glycosylated hemoglobin (HbA1c) Medication review Psychosocial assessment Gait and balance evaluation NKHHC Symptomatic hyperglycemia + inadequate fluid intake NKHHC Complication of type 2 DM with high mortality rate

o Widespread thrombosis o DIC Symptoms of hyperglycemia o Dry mouth o Extreme thirst o Excessive urination o Fatigue o Blurred vision o Weight loss o Nausea and vomiting o Abdominal pain Laboratory values for NKHHC o Hyperglycemia (> 500 mg/dl) o Hyperosmolarity o Metabolic acidosis o Serum Na and K levels, usually normal o Increased blood urea nitrogen (BUN) and serum creatinine levels Prevalence of Thyroid Disease in Older Persons Hypothyroidism o Women > men of all ages o Higher in institutionalized elderly than in older community-residing elderly Hyperthyroidism o Similar general population rates Hypothyroidism Symptoms Hypothyroidismnot the classic symptoms o Fatigue o Increased need for sleep o Muscle aches o Dry skin o Bradycardia, decreased contractility and stroke volume o Increased cholesterol levels (elevations in LDL) o Ataxia and balance difficulties o Hearing loss Hypothyroidism o Depression o Cold intolerance o Hair loss

o o o o

Voice changes Hypothermia Periorbital swelling Decreased appetite and weight loss

Other symptoms o Neurological Headache Vertigo Relaxation of DTRs Psychiatric disorders Cognitive deficits Visual disturbances o Sensory Numbness, tingle, and paresthesias Other symptoms o Musculoskeletal Muscle fatigue Cramps and myalgias Joint effusions Osteoporosis Pseudogout o GI Constipation and gaseous distention o Achlorhydria and pernicious anemia Note: Older patients may have fewer symptoms than younger patients. Hypothyroidism Diagnosis Thyroid function testing o Free T4 and TSH TSH gold standard Serum T4 High sensitivity for elderly o T3 Low in only 50% of hypothyroid elders Nutritional deficiencies can slow peripheral conversion Thyroid Function Testing o Other tests T3-resin uptake Assesses thyroxine and Triiodothyronine

 Thyroglubulin levels Marker for thyroid cancer Thyroid antibody levels Hashimotos thyroiditis I 131 uptake Graves disease Physical examination Comprehensive health assessment Hyperthyroidism Graves disease Toxic nodular goiters Medication o Amiodarone o Levothyroxine Hyperthyroidism Signs and Symptoms Exhibit fewer and different in elderly than in younger adults Most common in older adult o Tachycardia, > 90 beats/minute in older adults Atrial fibrillation o Weight loss o Fatigue o Weakness or apathy Hyperthyroidism Diagnosis Comprehensive health history Physical examination o Emphasize Cardiovascular assessment BP, pulse rate, and rhythm Thyroid palpation Neuromuscular examination Eye exam with vision assessment Laboratory tests o TSH level o Serum T3, T4, and thyroglobulin levels are lower in elders with hyperthyroidism Ultrasound Fine-needle aspiration

Risk factors to health for the older person with an endocrine problem Risk Factors for Diabetes Mellitus Genetics Environmental factors Type 2 DM Overweight (BMI > 25) with higher percentages of body fat Weight may be normal with upper-body obesity increased waist-to-hip ratio (> 1) Age over 45 risk increases with age African American, Hispanic/Latino American, Asian American or Pacific Islander, or Native American ethnic groups Parent, brother, or sister with DM Blood pressure above 140/90 Low levels of HDL (< 40 for men and < 50 for women) (good cholesterol) and high levels of triglycerides (> 250 mg/dL). Gestational diabetes while pregnant or giving birth to a large baby (more than 9 pounds) Sedentary lifestyleexercising less than three times per week Impaired glucose tolerance Random blood glucose levels > 160 mg/dL (NDEP, 2003) Risk Factors for Developing Hypothyroidism Older age Female gender History or diagnosis of thyroid disease o Goiter o Thyroid nodules o Thyroiditis o Hyperthyroidism Treatment of head or neck cancer o External radiation o Iodine131 Risk Factors for Developing Hypothyroidism Family history

 Medications o Lithium o Amiodarone o Sulfonylureas o Salicylates o Furosemide o Phenytoin o Rifampin o Radioactive contrast dyes Unique presentation of diabetes and thyroid problems in the older person. Symptoms of DM in Older Persons Anorexia Incontinence Falls Pain intolerance Cognitive or behavioral changes Symptoms of hyperglycemia (usually > 200 mg/dl) o Polydipsia (excessive thirst) o Weight loss o Polyuria (excessive urination) o Polyphagia (excessive hunger) o Blurred vision o Fatigue o Nausea o Fungal and bacterial infections Older women o Perineal itching as a result of vaginal candidiasis o Frequent urinary tract infections (UTIs) Type 1 DM in the Elderly Slower onset of hyperglycemia symptoms Absence of ketoacidosis Note: Pancreatic cancer should be considered in older adults with rapid onset weight loss, polyuria, polydypsia, and polyphagia with elevated blood glucose. Complications of DM are accelerated in the elderly. Blood glucose levels before breakfast are exaggerated in older patients with DM. Euthyroid sick syndrome

o Body compensates for decreased metabolic rates decreased TSH levels + low T4 levels Nursing interventions directed toward assisting older adults with endocrine problems to develop self-care abilities. High-Risk Diabetic Foot Exam Presence of protective sensation Vascular status Skin integrity Foot structure Saving the Diabetic Foot Identification of feet at risk Prevention of foot ulcers Treatment of foot ulcers Prevention of recurrence of foot ulcers Hygiene o Lubricate dry areas o Dry between toes Protection o Mirror on or near the floor o Have podiatrist cut toenails Management Goals of DM in the Older Person Control of hyperglycemia and its symptoms Prevention, evaluation, and treatment of macrovascular and microvascular complications Self-management through education Maintenance or improvement of general health status Individualized Goals of DM Highly functional older person o A fasting blood glucose level between 100 and 120 mg/dL o A postprandial glucose level of less than 180 mg/dL o An HbA1c under 8% Older person with advanced microvascular complications o A fasting glucose level of less than 140 mg/dL

o A postprandial glucose level of less than 200 to 220 mg/dL o An HbA1c under 10% Controlling DM in the Older Person Weight management o Address elevated lipids o Maintain protein and calcium requirements o Maintain sodium restrictions o Control carbohydrate and fat intake at mealtimes o Eat a high-fiber diet o Snack during peak insulin or oral hypoglycemia action o Avoid alcohol Physical exercise o Avoid strenuous activities because of risk for retinal detachment o Exercise carefully with peripheral neuropathies o Check blood glucose prior to exercise if taking insulin If < 100 mg/dL, eat additional carbohydrates o Avoid exercise if fasting glucose > 250 mg/dL o Obtain medical assessment prior to implementation of program Graded exercise test Radionuclide stress test Physical exercise o Benefits of walking Getting more energy Reducing stress Improving sleep Toning muscles Controlling appetite Increasing the number of calories burned by body daily Preventing complications of diabetes Appropriate Use of Medications Monotherapy or combination o Combinations

 Simplify dosing May be less expensive Antihyperglycemic drugs Biguanides enhanced glucose uptake + muscle utilization increased insulin sensitivity Metformin o Weight loss o Improved lipid profile o Rare hypoglycemia o Do not use if > 80 years or renal failure if serum creatinine > 1.5 for men or > 1.4 for women -glucosidase inhibitors slow digestion + delayed absorption of carbohydrates decreased postprandial hypoglycemia o Good for normal baseline blood glucose but hyperglycemic after eating a meal o GI with flatulence and bloating Thiazolidinediones activate intracellular receptors + repress hepatic glucose production enhanced insulin sensitivity o Contraindicated Acute liver disease ALT > 2.5 times upper limit CHF AHA class III or IV Oral Hypoglycemic Drugs Sulfonylureas o Second-generation stimulates beta cells increased insulin hypoglycemia Glyburide If low blood sugar, monitor in hospital for 2 to 3 days Weight gain Check sulfa allergy Meglitinide stimulates insulin release in response to meal

o Rapid onset with short duration o Do not take with a meal Insulin Used primarily with type 1 Long acting o Control blood glucose levels o Provide insulin after meal is digested Short acting o Provide insulin after meal or snacks Prevention of Complications Acute illness o Vaccinations Annual influenza Pneumococcal at age 65 Revaccinate if > 5 years and under 65 years at initial vaccination Hypoglycemia o Symptoms Feeling nervous or shaky Sweaty Onset of excessive fatigue Check blood twice, including after a snack Hyperglycemia o Tendency for blood glucose level to rise before breakfast is exaggerated in older patients with DM Lipids o LDL < 100 mg/dL o HDL > 45 mg/dL for men > 55 mg/dL for women Educate Regarding Acute Illness Acute illness can cause hyperglycemia Call healthcare provider if o Unable to keep food or liquids down or eat normally for more than 6 hours o Occurrence of severe diarrhea o Unintentional weight loss of 5 pounds o Oral temperature higher than 101 F

o Blood glucose levels lower than 60 mg/dL or more than 300 mg/dL o Presence of large amounts of ketones in the urine o Difficulty breathing o Feeling sleepy or unable to think clearly Nursing interventions Six Geriatric Syndromes Associated with DM Requiring Careful Management Polypharmacy Depression Cognitive impairment Urinary incontinence Injurious falls Pain The Goals of Therapy for Hypothyroidism Relieve symptoms Provide sufficient thyroid hormone to decrease raised serum TSH levels to the normal range o If history of heart disease cardiac stress testing and complete cardiovascular risk assessment before initiating treatment Tailored to meet the needs of the individual patient o T4 replacement = Levothyroxine sodium > 65 years 0.075 to 0.1 mg/day CAD then begin 0.0125 to 0.025 mg/day Increase gradually (0.025 mg) for 4 week intervals o TSH below normal Decrease dose of levothyroxine o TSH above normal Slowly increase dose of levothyroxine Monitor Medications with Levothyroxine Interfere o Aluminum hydroxide o Calcium preparations o Cholestyramine o Colestipol o Iron preparations o Sucralfate Accelerate metabolism

o Rifampin o Anticonvulsants Monitoring Older Persons Receiving Treatment for Hyperthyroidism I131 o Treatment of choice for older adults Other antithyroid drugs o Prophylthiouracil o Methimazole o Side effects of both drugs dose related Skin rash, nausea, hepatitis, and arthritis Careful monitoring for granulocytopenia Watch for signs and symptoms of illness Surgery Beta-blockers for Hashimotos disease o Monitor cardiac status Nursing Diagnoses for Older Patients with Endocrine Disorders Type 2 DM and obesity o Imbalanced nutrition: more than body requirements o Risk for infection o Risk for sensory/perceptual alterations: tactile Thyroid disorders o Sleep deprivation o Fatigue o Risk for activity intolerance o Ineffective thermoregulation o Risk for imbalanced body temperature