care of the older

adults ncm 114

ENDOCRINE
FUNCTIONS
and ALTERATIONS/DISORDERS in
OLDER ADULTS
ENDOCRINE SYSTEM
-consists of a group of glands and organs that regulate and control various body
functions by producing and secreting hormones.

HORMONES
-are chemical substances that affect the activity of another part of the body. In
essence, hormones serve as messengers, controlling and coordinating activities
throughout the body.
ENDOCRINE
FUNCTION
LOCATION OF THE
MAJOR ENDOCRINE
GLANDS
 AGING CHANGES
(COMMON HORMONE
ALTERATIONS)
HYPOTHALAMUS
-functional changes in a group of the
hypothalamic neurons contribute to age-
associated decline in energy homeostasis,
hormone balance, circadian rhythm, and
reproduction.
HYPOTHALAMUS
● Sits between the cerebrum and brainstem
● Houses the pituitary gland and hypothalamus
● Regulates:
○ Temperature
○ Fluid volume
○ Growth
○ Pain and pleasure response
○ Hunger and thirst
HYPOTHALAMUS HORMONES

• Releasing and inhibiting hormones

• Corticotropin-releasing hormone
• Thyrotropin-releasing hormone
• Growth hormone-releasing hormone
• Gonadotropin-releasing hormone
• Somatostatin-inhibits GH and TSH
PITUITARY
GLAND
-gland reaches its maximum size in middle age and
then gradually becomes smaller
- growth hormone is produced in this gland.

● Sits beneath the hypothalamus

● Termed the “master gland”
● Divided into:
○ Anterior Pituitary Gland
○ Posterior Pituitary Gland
thyroid GLAND
- with aging, the thyroid may become lumpy (nodular)

● Butterfly shaped
● Sits on either side of the trachea
● Has two lobes connected with an isthmus
● Functions in the presence of iodine
● Stimulates the secretion of three hormones
● Involved with metabolic rate management and serum
calcium levels
thyroid HORMONES

• 2 hormones: T3 and T4
• Follicular cells—excretion of triiodothyronine (T3) and thyroxine (T4)
—Increase BMR, increase bone and protein turnover, increase response
to catecholamines, need for infant G&D
• Thyroid C cells—calcitonin. Lowers blood calcium and phosphate
levels
parathyroid GLAND
-parathyroid hormone levels rise with age, which may
contribute to osteoporosis.

● Embedded within the posterior lobes of the thyroid

gland
● Secretion of one hormone
● Maintenance of serum calcium levels
● Parathyroid hormone—regulates serum calcium
adrenal GLAND
-decrease aldosterone can contribute to lightheadedness and a
drop in blood pressure with sudden position changes
(orthostatic hypotension)

● Pyramid-shaped organs that sit on top of the kidneys

● Each has two parts:
○ Outer Cortex
○ Inner Medulla
adrenal medulla
○ Secretion of two hormones
○ Epinephrine
○ Norepinephrine
○ Serve as neurotransmitters for sympathetic
system
○ Involved with the stress response
adrenal cortex
● Mineralocorticoid—aldosterone. Affects sodium absorption,
loss of potassium by kidney

● Glucocorticoids—cortisol. Affects metabolism, regulates

blood sugar levels, affects growth, anti-inflammatory action,
decreases effects of stress

● Adrenal androgens—dehydroepiandrosterone and

androstenedione. Converted to testosterone in the periphery.
thymus

● Releases thymosin and thymopoietin

● Affects maturation of T lymphocytes
pancreas
● Located behind the stomach between the spleen and
duodenum
● Has two major functions
● Digestive enzymes
● Releases two hormones: insulin and glucagon
kidney
-kidneys filter about a half cup of blood every minute,
removing wastes and extra water to make urine

● dihydroxyvitamin D—stimulates calcium absorption from

the intestine
● Renin—activates the Renin-Angiotensin System (RAS)
● Erythropoietin—Increases red blood cell production
pineal gland
● Melatonin - a hormone that your brain
produces in response to darkness
● Affects sleep, fertility and aging
ovaries
lower levels of estradiol and other estrogen hormones after
menopause

● Estrogen - development of female secondary sexual

characteristics. These includes breasts, endometrium,
regulation of the menstrual cycle etc
● Progesterone—important in menstrual cycle, maintains
pregnancy,
testes
With aging, men sometimes have a lower level of
testosterone.

● Androgens, testosterone—secondary sexual

characteristics, sperm production

● In males, estrogen helps in maturation of the sperm and

maintenance of a healthy libido.
EFFECT OF CHANGES

Hormones
that usually decrease:
• Aldosterone
• Calcitonin
• Growth hormone
• Renin
EFFECT OF CHANGES

Hormones that slightly

decrease:
• Cortisol
• Epinephrine
• Insulin
• Thyroid hormones
EFFECT OF CHANGES

Hormones that
decrease:
•Follicle-stimulating hormone
•Luteinizing hormone
•Norepinephrine
•Epinephrine, in the very old
•Parathyroid hormone
COMMON
ENDOCRIN
E
DISORDER
S
IN AGING
 Vitamin D
deficiency
In aging, body becomes less efficient at converting
vitamin D in the body
Half of residents suffering from hip fracture have
been found to have vitamin D deficiency
 MANAGMENT
● Maintain adequate vitamin D levels include getting the patient
outside for 10-15 minutes during the appropriate day desired.
● Encourage foods fortified with Vitamin D such as milk and orange
 HYPOGONADISM
• Many men remain potent and fertile until their
death
• However, sexual acitivity, libido and potency
decline gradually and progressively from midlife
onwards.
 SIGNS AND SYMPTOMS
● Symptoms of Hypogonadism and normal ageing overlap;

● Reduced lean body mass

● Impaired muscle function

● Increased fat mass

● Reduced libido / virility

● Decreased sexual desire

● Reduced overall well- being

● Normal ranges of testosterone in men of different ages have not yet been well established
 MANAGMENT
● Testosterone replacement
 METABOLIC BONE
DISEASE
- Primary osteoporosis occurs due to ageing and the
decline in the hormones needed for healthy bones
- A lifelong lack of calcium plays a role in the
development of osteoporosis. Low calcium intake
contributes to diminished bone density, early bone
loss and an increased risk of fractures
 MANAGMENT
● antiresorptive agents that reduce bone loss
● anabolic agents that increase bone formation
● Denosumab - It works to prevent bone loss by blocking a certain
receptor in the body to decrease bone breakdown
 OSTEOMALACIA
- refers to a marked softening of your bones, most
often caused by severe vitamin D deficiency
 SIGNS AND SYMPTOMS
● Aches and pains in bones
● Muscle weakness
 MANAGMENT
Can osteomalacia be cured?
Yes, getting enough vitamin D through oral supplements for
several weeks to months can cure osteomalacia. To
maintain normal blood levels of vitamin D, you'll likely have
to continue taking the supplements.
 MANAGMENT
● Vitamin D (at least 800 IU daily)
● Calcium for the common vitamin D deficient type
● Phosphate replacement for Vit D resistant type
Assessment and Management
of Patients with Endocrine
Disorders
 PAST MEDICAL HISTORY
● Hormone replacement therapy
● Surgeries, chemotherapy, radiation
● Family history: diabetes mellitus, diabetes insipidus, goiter, obesity,
Addison’s disease, infertility
● Sexual history: changes, characteristics, menstruation, menopause
PHYSICAL ASSESSMENT
General appearance
● Vital signs, height, weight
Integumentary
● Skin color, temperature, texture, moisture
● Bruising, lesions, wound healing
● Hair and nail texture, hair growth
PHYSICAL ASSESSMENT
Face
● Shape, symmetry
● Eyes, visual acuity
● Neck
PHYSICAL ASSESSMENT
Extremities
● Hand and feet size
● Trunk
● Muscle strength, deep tendon reflexes
● Sensation to hot and cold, vibration
● Extremity edema
PHYSICAL ASSESSMENT
Thorax
● Lung and heart sounds
Older Adults and Endocrine
Function
● Relationship unclear
● Aging causes fibrosis of thyroid gland
● Reduces metabolic rate
● Contributes to weight gain
● Cortisol level unchanged in aging
 ABNORMAL FINDINGS
Ask the client:
● Energy level

● Fatigue

● Maintenance of ADL

● Sensitivity to heat or cold

● Weight level
 ABNORMAL FINDINGS
Ask the client:
● Bowel habits

● Level of appetite

● Urination, thirst, salt craving

 ABNORMAL FINDINGS
Ask the client:
● Cardiovascular status: blood pressure, heart rate, palpitations, SOB

● Vision: changes, tearing, eye edema

● Neurologic: numbness/tingling lips or extremities, nervousness, hand tremors, mood

changes, memory changes, sleep patterns

● Integumentary: hair changes, skin changes, nails, bruising, wound healing

 DIAGNOSTIC TESTS
● GH: fasting, well rested, not physically stressed

● T3/T4, TSH: no specific preparation

● Serum calcium/phosphate: fasting may or may not be required

● Cortisol/aldosterone level
● 24 urine collection to measure the level of catecholamines (epinephrine,
norepinephrine, dopamine).- Your adrenal glands send catecholamines into
your blood when you're physically or emotionally stressed
DISORDERS AND DISEASES
N ENDOCRINE FUNCTION
OF OLDER ADULTS
DIABETES MELLITUS
● serious disease, and it affects many older adults.
People get diabetes when their blood glucose,
also called blood sugar, is too high.
● normal blood sugar for seniors: level between 70
and 100 mg/dL
DIABETES MELLITUS
● Older adults are at high risk for the development
of type 2 diabetes due to the combined effects of
increasing insulin resistance and impaired
pancreatic islet function with aging.
 MANAGMENT
● Meal planning
● Physical activities, exercise
● Medications: Oral agents (sulphonylureas, insulin,
thiazolidinediones)
● Monitoring of blood sugars
● Cognitive and physical ability to self manage diabetes ie.
CBG monitoring and self-injection
hyperthyroidism
● Hyperthyroidism is the second most prevalent
endocrine disorder, after diabetes mellitus.
● Graves' disease: the most common type of
hyperthyroidism, results from an excessive output
of thyroid hormones.
● May appear after an emotional shock, stress, or an
infection
● Other causes: thyroiditis and excessive ingestion of
thyroid hormone
● Affects women 8X more frequently than men
(appears between second and fourth decade)
● Test for hyperthyroidism: thyroid scan, blood test
 clinical manifestations
Clinical Manifestations (thyrotoxicosis):
1. Heat intolerance.
2. Palpitations, tachycardia, elevated systolic BP.
3. Increased appetite but with weight loss.
4. Menstrual irregularities and decreased libido.
5. Increased serum T4, T3.
 clinical manifestations
6. Exophthalmos (bulging eyes)
7. Perspiration, skin moist and flushed ; however,
elders’ skin may be dry and pruritic
8. Insomnia.
9. Fatigue and muscle weakness
10. Nervousness, irritability, can’t sit quietly.
11. Diarrhea
 medical
MANAGMENT
Radioactive therapy
Medications:
● Propylthiouracil and methimazole
● Sodium or potassium iodine solutions
● Dexamethasone
● Beta-blockers
 medical
MANAGMENT
Surgery:
● Subtotal thyroidectomy
● Relapse of disorder is common
● Disease or treatment may result in hypothyroidism
 hypothyroidism
-is the disease state caused by insufficient production of
thyroid hormone by the thyroid gland.
INCIDENCE
● 30-60 years of age
● Mostly women (5 times more than men)
hypothyroidism
Causes:
● Autoimmune disease (Hashimoto’s thyroiditis,
post–Graves' disease)
● Atrophy of thyroid gland with aging
● Therapy for hyperthyroidism
● Radioactive iodine
● Thyroidectomy
hypothyroidism
Medications:
● Radiation to head and neck
clinical manifestations
● Fatigue
● Constipation
● Apathy
● Weight gain
● Memory and mental impairment and decreased concentration
● masklike face
● Menstrual irregularities and loss of libido
● Coarseness or loss of hair
 clinical manifestations
● Dry skin and cold intolerance.
● Menstrual disturbances
● Numbness and tingling of fingers
● Tongue, hands, and feet may enlarge
● Slurred speech
● Hyperlipidemia
● Reflex delay
● Bradycardia.
● Hypothermia
● Cardiac and respiratory complications
 treatment
LIFELONG THYROID HORMONE REPLACEMENT

● levothyroxine sodium (Synthroid, T4, Eltroxin)

● IMPORTANT: start at low does, to avoid hypertension, heart failure and MI
● Teach about S&S of hyperthyroidism with replacement therapy
thyroiditis
(INFLAMMATION)
● Inflammation of the thyroid gland.
● Can be acute, subacute, or chronic (Hashimoto's
Disease)
● Each type of thyroiditis is characterized by
inflammation, fibrosis, or lymphocytic infiltration of
the thyroid gland.
● Characterized by autoimmune damage to the
thyroid.
● May cause thyrotoxicosis, hypothyroidism, or both
thyroid TUMORS
● Can be being benign or malignant.
● If the enlargement is sufficient to cause a visible
swelling in the neck, referred to as a goiter.
● Some goiters are accompanied by hyperthyroidism,
in which case they are described as toxic; others are
associated with a euthyroid state and are called
nontoxic goiters.
thyroiD CANCER
● Much less prevalent than other forms of cancer; however, it accounts
for 90% of endocrine malignancies.
● Diagnosis: thyroid hormone, biopsy
● Management
● The treatment of choice surgical removal. Total or near-total
thyroidectomy is performed if possible. Modified neck dissection or
more extensive radical neck dissection is performed if there is lymph
node involvement.
● After surgery, radioactive iodine.
● Thyroid hormone supplement to replace the hormone.
WHAT CAUSES GOITER?
● Lack of Iodine
● Graves’ Disease
● Hashimoto’s Disease
● Thyroid Cancer
● Pregnancy
● Inflammation
types of goiter
● 1.Simple goiters- which happen when your thyroid gland doesn't make enough hormones.
The thyroid grows larger to make up for this.
● 2.Endemic goiters - Sometimes called colloid goiters, these are caused by a lack of iodine in
your diet. Your thyroid uses iodine to make its hormones. Few people get this kind of goiter in
countries where iodine is added to table salt, like the United States.
● 3.Sporadic or nontoxic goiters - which usually have no known cause. Certain drugs and
medical conditions can trigger them.
● 4.Multinodular goiters - which happen when lumps called nodules grow in your thyroid.
● Note: A goiter is described as "toxic" when it's linked to hyperthyroidism. That means your
thyroid makes too much thyroid hormone. A "nontoxic" goiter doesn't cause ether
hyperthyroidism or hypothyroidism (not enough thyroid hormone).
thyroidectomy
● - surgical removal of all or part of your
thyroid gland
● -treatment of choice for thyroid cancer
post-op care

• Monitor dressing for potential bleeding and hematoma formation; check posterior
dressing
• Monitor respirations; potential airway impairment
• Assess pain and provide pain relief measures
• Semi-Fowler’s position, support head
• Assess voice but discourage talking
• Potential hypocalcemia related to injury or removal of parathyroid glands; monitor for
hypocalcemia
complications of operation

• Hemorrhage
• Laryngeal nerve damage.
• Hypoparathyroidism
• Hypothyroidism
• Sepsis
• Postoperative infection
myxedema
● severely advanced hypothyroidism
myxedema
● Rare serious complication of untreated
hypothyroidism
● Decreased metabolism causes the heart muscle to
become flabby
● Leads to decreased cardiac output
● Leads to decreased perfusion to brain and other
vital organs
● Leads to tissue and organ failure
problems seen w/ myxedema
● Coma
● Respiratory failure
● Hypotension
● Hyponatremia
treatment of myxedema coma
● Patent airway
● Replace fluids with IV.
● Give levothyroxine sodium IV - is used to treat hypothyroidism
● Give glucose IV
● Give corticosteroids
● Check temp, BP every hour
● Monitor changes LOC ( loss of consciousness) every hour
● Aspiration precautions, keep warm
hyperparathyroidism
● Primary hyperparathyroidism is 2–4 X more
frequent in women.
● Manifestations include:
● elevated serum calcium,
● bone decalcification,
● renal calculi,
● apathy,
● fatigue, muscle weakness,
● nausea,
● vomiting, constipation,
● hypertension, cardiac dysrhythmias
hyp0parathyroidism
● Deficiency of parathormone usually due to
surgery
● Results in hypocalcemia and
hyperphosphatemia
● Manifestations include tetany, numbness and
tingling in extremities, stiffness of hands and
feet, bronchospasm, laryngeal spasm,
carpopedal spasm, anxiety, irritability,
depression, delirium, ECG changes
● Trousseau’s sign and Chvostek’s sign
management of hypoparathyroidism
● Increase serum calcium level to 9—10 mg/dL
● Calcium gluconate IV
● May also use sedatives such as pentobarbital to decrease neuromuscular irritability
● Parathormone may be administered; potential allergic reactions
● Environment free of noise, drafts, bright lights, sudden movement
● Diet high in calcium and low in phosphorus
● Vitamin D
● Aluminum hydroxide is administered after meals to bind with phosphate and promote its
excretion through the gastrointestinal tract.
adrenal insufficiency
● Adrenal cortex function is inadequate to meet the
needs for cortical hormones
● Primary: Addison’s Disease
● Secondary
● May be the result of adrenal suppression by
exogenous steroid use
 clinical manifestations
● Muscle weakness, anorexia, GI symptoms, fatigue, dark pigmentation of skin
and mucosa, hypotension, low blood glucose, low serum sodium, high serum
potassium, mental changes, apathy, emotional lability, confusion
● Addisonian crisis: circulatory collapse
● Diagnostic tests; adrenocortical hormone levels, ACTH levels, ACTH
stimulation test
adrenal crisis
Medical Management:
● Immediate
● Reverse shock
● Restore blood circulation
● Antibiotics if infection
● Identify cause
● Supplement glucocorticoids during stressful
procedures or significant illness
adrenal crisis
Nursing Management
● Assess fluid balance
● Monitor VS closely
● Good skin assessment
● Limit activity
● Provide quiet, non-stressful environment
 interventions
● Risk for fluid deficit; monitor for signs and symptoms of fluid volume
deficit, encourage fluids and foods, select foods high in sodium, administer
hormone replacement as prescribed
● Activity intolerance; avoid stress and activity until stable, perform all
activities for patient when in crisis, maintain a quiet nonstressful
environment, measures to reduce anxiety
● Teaching
(See Chart 42-10)
cushings syndrome
● Due to excessive adrenocortical activity or
corticosteroid medications
● Women between the ages of 20 and 40 years are
five times more likely than men to develop
Cushing's syndrome.
 clinical manifestations
● Hyperglycemia which may develop into diabetes, weight gain, central type
obesity with “buffalo hump,” heavy trunk and thin extremities, fragile thin
skin, ecchymosis, striae, weakness, lassitude, sleep disturbances,
osteoporosis, muscle wasting, hypertension, “moon-face”, acne, increased
susceptibility to infection, slow healing, virilization in women, loss of
libido, mood changes, increased serum sodium, decreased serum potassium

● Diagnosis: Dexamethasone suppression test, ↑ Na+ ↑ glucose, ↓ K+,

metabolic alkalosis
 medical management
● Pituitary tumor
● Surgical removal
● radiation
● Adrenalectomy
● Adrenal enzyme inhibitors
● Attempt to reduce or taper corticosteroid dose
 nursing management
● Prevent injury
● Increased protein, calcium and vitamin D in diet
● Medical asepsis
● Monitor blood glucose
● Moderate activity with rest periods
● Provide restful environment
interventions
● Decrease risk of injury; establish a protective environment; assist as
needed; encourage diet high in protein, calcium, and vitamin D.
● Decrease risk of infection; avoid exposure to infections, assess patient
carefully as corticosteroids mask signs of infection.
● Plan and space rest and activity.
● Meticulous skin care and frequent, careful skin assessment.
● Explanation to the patient and family about causes of emotional
instability.
● Patient teaching.
diabetes insipidus
● A disorder of the posterior lobe of the pituitary
gland that is characterized by a deficiency of ADH
(vasopressin). Excessive thirst (polydipsia) and large
volumes of dilute urine.
● It may occur secondary to head trauma, brain
tumor, or surgical ablation or irradiation of the
pituitary gland, infections of the central nervous
system or with tumors
● Another cause of diabetes insipidus is failure of the
renal tubules to respond to ADH
 medical management
● The objectives of therapy are
● to replace ADH (which is usually a long-term therapeutic program),
● to ensure adequate fluid replacement, and
● to identify and correct the underlying intracranial pathology.
 THANKS
for listening!
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