Chapter 43: Endocrine Disorders

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  • 1. Chapter 43: Endocrine Disorders What You Will Learn • Cause, characteristics, risks, and treatment of diabetes • Nursing interventions used to monitor and control diabetes • Symptoms and treatments of thyroid disorders and vitamin D deficiency Author: Key Terms Carol Harrington RN, BC, ANP, Creatinine — Indicators of kidney function CDE, Kansas City Internal Medicine, Kansas City, MO. Diabetes Mellitus (DM) — A chronic syndrome of impaired carbohydrate, protein, and fat metabolism owing to insufficient secretion of insulin or to target tissue insulin resistance. either type 1 d. mellitus or type 2 d. mel- litus, which differ in terms of etiology, pathology, genetics, age of onset, and treatment Free T4 — Hormone produced by the thyroid gland. A laboratory test can be done to measure the amount of free or unbound T4 in the blood Glucagon Emergency Kit — A pre-packaged kit used for the emergency injection of glucagon in case of severe diabetic hypoglycemia (needed during seizures and/or unconsciousness by an insulin user who is unable at that point to help themselves) Hyperglycemic Nonketotic State — Severely elevated blood glucose lev- els, usually > 600 mg/dl; emergency requiring immediate medical care Hyperthyroidism — Condition caused by excessive production of iodinat- ed thyroid hormones Hyponatremia — Deficiency of sodium in the blood Hypothyroidism — Deficiency of thyroid activity, characterized by de- crease in metabolic rate, fatigue, and lethargy Macrovascular — Pertaining to the macrovasculature (the large vessels of the body) Microvascular — Pertaining to the microvasculature (the portion of the vasculature of the body comprising the finer vessels, sometimes described as those with an internal diameter of 100 microns or less) Thyroid Stimulating Hormone (TSH) — Hormone produced by the pitu- itary gland at the base of the brain in response to signals from the hyper- thalmus gland in the brain; promotes the growth of the thyroid gland in the neck and stimulates thyroid hormone production FENCE Student Manual 316
  • 2. The endocrine system is complex and consists of glands that secrete hormones that are transported through the blood to targeted tissues for specific responses. This system is responsible for the body to grow and de- velop, reproduce, metabolize energy, maintain homeostasis, and respond to stress and injury. A blend of knowledge and skill is required to identify and interpret symp- toms pointing to an underlying syndrome. Understanding these disorders and associated vague symptoms helps the nurse to gather a full clinical picture to report to the provider. Diabetes Diabetes is defined by two fasting Diabetes affects approximately 180 million people worldwide with 23 blood sugars of 126 or greater, a million of those in the United States. It is expected that the rate will con- two-hour oral glucose tolerance tinue to rise, doubling by the year 2030. Diabetes affects over 25 percent blood sugar of 200 or greater, or of nursing home residents. These residents have twice as many major a random blood sugar greater than diseases than those residents without diabetes. Diabetic residents have a 200. higher risk of falls, disability, and chronic pain. The elderly in long-term care are often not concerned about the actual complications from high blood sugar, but are concerned about daily functioning, mood, mental function, and quality of life. Risks for developing diabetes include decreased physical activity, obesity, age, certain medications, such as steroids, and family history. Traditional signs of hyperglycemia (high blood sugar) are often less specific in the elderly. The symptoms can include: falls, incontinence, weight loss, poor healing, fatigue, visual changes, and confusion. Complications of diabe- tes include eye changes, gum disease, heart and vascular disease, kidney disease, neuropathy (nerve damage), and increased infections. There are four strategies of diabetes management: meal planning, physi- cal activity, medications, and monitoring of blood sugars. For the general population, the goals of diabetes management are aimed at prevention of microvascular (eyes, kidneys, and nerves) and macrovascular (cardio- vascular) complications. Intensive blood sugar control has not proven to have a significant impact on prevention of macrovascular disease. How- ever, controlling blood sugars can have significant impact on the preven- tion of diabetes-related dehydration, fatigue, and confusion. For very frail elderly residents, goals of treatment may be better focused on avoidance of high and low blood sugars. Moderate control of blood sugars is achiev- able in weeks and may reduce mental fatigue and urinary frequency. Most studies suggest that diabetic diets in the long-term care setting do not help to control blood sugars. Restrictive diets have been associated with malnutrition. Up to 20 percent of long-term care residents are un- derweight. It is recommended that these residents be placed on a regular diet with no added sugar. They should be offered a bedtime snack prefer- FENCE Student Manual 317
  • 3. ably balanced with protein and carbohydrate (cheese and crackers, cottage cheese, yogurt). Protein helps to balance blood sugars. Residents need to be monitored closely for weight loss. Decrease in abdominal fat will lead to a reduction in blood sugars. If not monitored closely, the resident may be at risk of severely low blood sugars. If a de- clining trend in blood sugar is noted, the provider should be notified. A hyperglycemic nonketotic state Hydration is also very important in diabetic patients. Elderly patients have is characterized by symptoms that diminished thirst and many have difficulty accessing liquids. In the pres- can include weakness, increased ence of high blood sugars, dehydration can lead to a life-threatening situa- thirst, nausea, lethargy, confusion, tion called hyperglycemic nonketotic state, also known as hyperosmolar and ultimately, convulsions and coma; onset can be slow, building hyperglycemic syndrome. over a period of days or weeks; Regular physical exercise in the long-term care resident will also help to can frequently happen in elderly control blood sugars. This must be undertaken with caution in patients and usually preciptated by another with disabilities to prevent against falls, but can be performed with the illness, such as infection or flu (sometimes a chronic condition, assistance of physical therapy assistants or restorative aides, even in chair- such as congestive heart failure bound residents. or renal failure); a hyperglycemic There are many medications available today to treat diabetes. However, nonketonic state is an emergency as noted above, tight blood sugar control is often inappropriate for the that requires immediate medical frail elderly. Severe hypoglycemia may cause arrhythmias, stroke, or heart care. attack. The risk of low blood sugar is higher in the elderly because of decreased kidney function, altered digestion, unpredictable food intake, poor hydration, and multiple drug therapy. Low blood sugar in the elderly may not produce symptoms until the sugar is well below 70mg/dl. Pre- senting symptoms of hypoglycemia may include unsteadiness, dizziness, and lack of concentration, confusion, sweating, tremor, or palpitations. The oral agents to treat diabetes include sulfonylureas, biguanides, thiazo- lidinediones, meglitinides, alpha-glucosidase inhibitors, DPP-4 inhibitors, and combination agents. Sulfonylureas stimulate insulin secretion by the pancreas. Side effects include low blood sugars and weight gain. Caution should be taken in patients with sulfa allergies. These drugs are inexpensive and can be given one to two times a day. The biguanides reduce blood sugar production in the liver and increase the body’s sensitivity to insulin. Stomach upset, including nausea and di- arrhea, are the most common side effects. This medication is inexpensive, has no associated hypoglycemia, no weight gain, and can reduce choles- terol levels. It should not be used in the presence of kidney disease and should be used with caution in residents at risk for dehydration. Before having any diagnostic testing that requires contrast dye, the resident must be off this medication for two days and have blood tests (BUN and creati- nine) to check for kidney function. FENCE Student Manual 318
  • 4. Thiazolidinediones (TZDs) increase the body’s sensitivity to insulin. Adverse effects are weight gain, edema, anemia, and congestive heart failure. These drugs should not be used in residents with history of heart failure and should be used with caution in those with known CAD. They are commonly used and very effective in lowering blood sugar, yet do not cause hypoglycemia. There are no generic drugs in this class, so they are expensive. Meglitinides stimulate insulin secretion by the pancreas in response to an elevated glucose. Side effects include low blood sugar and weight gain. These medications are an option for residents with erratic eating habits and symptoms of hyperglycemia. There is less risk of hypoglycemia than the sulfonylureas. Alpha-glucosidase inhibitors slow the absorption of dietary glucose in the intestine. Side effects include nausea and gas. They cannot be used in residents with kidney impairment. DPP-4 inhibitors are the newest addition to the oral agents. They increase insulin secretion from the pancreas and reduce circulating glucagon (glu- cose produced by the liver). There are no common side effects from this classification with the exception of the rare occurrence of hives and swell- ing associated with allergic response. Kidney function must be monitored before and during treatment for dose adjustment. Caution must be used in residents with liver disease. Beyond oral medication there are a variety of injectable therapies. The newer insulins (basal insulin given once a day alone or in combination with the analogs, which are given with each meal) work more like normal body’s response to carbohydrate metabolism. These are rapidly replacing the use of older insulins, such as NPH and regular. The newer insulins are generally safer for the elderly resident because there are fewer risks for hypoglycemia. The rapid-acting insulins (called analogs) start working in 10 to 15 minutes and last three to five hours. With the new, rapid-acting insulins, the dose could be given at the time of the meal or after the patient completes a meal. This is ideal for the long-term care resident as meal consumption is often unpredictable. Insulin dose can be altered if To consider diabetes as controlled, the resident only eats a partial meal or held if no food is consumed. The the American Diabetes Association new, long-acting (basal) insulins start working within one hour with no recommends pre-meal blood sugars peak and a duration of 18 to 24 hours. The continuous dose level prevents of 90 and one-hour, post-meal hypoglycemia and can be administered once daily. The newer insulins are blood sugar of < 180. more expensive. Glucose monitoring is important for daily management of diabetes. Residents on new oral medications or on insulin should be monitored closely. Those residents on a stable oral medication regimen will need less frequent monitoring. Fasting and post-meal sugars are both valuable tools to assist with medication adjustment. Hemoglobin A1C is a laboratory FENCE Student Manual 319
  • 5. measurement that evaluates an average blood sugar over a three-month span. The American Geriatric Society recommends A1C < 7 percent for the healthy older adult and < 8 percent for frail elderly with life expec- tancy less than five years. The long-term care facility generally has proto- cols for bedside blood sugar monitoring. Protocols will define when the nurse should call the health care provider (common guidelines are to call The glucagon emergency kit for blood sugars < 60 – 70 mg/dl and > 300 - 400mg/dl). The facility must includes rDNA-synthesized human have readily accessible emergency treatment for hypoglycemia. Sources glucagon in a freeze-dried form may include glucose tablets, glucose gel, and a glucagon emergency kit. within a vial, a sturdy syringe pre- Guidelines for monitoring A1C, yearly dilated eye exams, and regular foot filled with a sterile diluting solu- exams should be established for all diabetic residents. End-of-life manage- tion, and a conspicuous, orange- ment of diabetes should be discussed by the provider with residents and colored, plastic storage box, which their families. includes instructions. Glucagon will facilitate release of stored glucose Care of the residents with diabetes requires individualization of treatment back into the bloodstream, raising goals. Ongoing communication with the residents, families, and staff will the blood glucose level. ensure appropriate treatment goals are made. Hypothyroidism Hypothyroidism is the second most-common endocrinology problem in adults. Failure to produce sufficient amounts of thyroid hormone occurs in all ages, but significantly increases with aging. In adults over the age of 50, hypothyroidism is more common in females at a ratio of two to one. Additionally, institutionalized elderly are much more likely to develop hypothyroidism than those living in the community. Hypothyroidism is a deficiency of The classic signs of hypothyroid include fatigue, weight gain, constipa- thyroid activity characterized by tion, depression, slowed heart rate, cold intolerance, hair loss, dry skin, a decrease in metabolic rate and and muscle cramps. As with many other disorders, the elderly often do fatigue. not have classic symptoms of thyroid disease. Symptoms, such as weak- ness, falling, weight loss, and joint aching, are more common. Confusion or slowed thought processes are seen as well. Complications for untreated hypothyroid disease include high blood pressure and elevated cholesterol levels. Less-common side effects can include heart attack, heart failure, and coma. Nursing interventions to screen for low thyroid function include routine measurements of blood pressure, pulse, and weight. The nursing staff should be evaluating residents for change in mental status, progressive weakness, or depression. Based on the increased frequency of thyroid disease in aging adults, admission blood test often includes thyroid func- tions. Continued monitoring is generally recommended yearly. Screening should include TSH, free t4, and total t3. Medical treatment of hypothyroid disease in the elderly involves start- ing thyroid replacement. L-thyroxine is started at low doses and titrated slowly based on repeat laboratory tests at six- to eight-week intervals until FENCE Student Manual 320
  • 6. thyroid levels normalize. Overtreatment may cause problems such as os- teoporosis and muscle weakness. Hyperthyroidism Hyperthyroidism is characterized Hyperthyroidism is an overproduction of circulating thyroid hormone. If by: there is too much thyroid hormone, every body system tends to speed up. • Goiter The prevalence of hyperthyroidism in the elderly is similar to the general population. The most common cause of overactive thyroid in the elderly is • Tachycardia or atrial fibril- goiter. In a person with goiter, benign nodules on the thyroid gland pro- lation duce and secrete excessive thyroid hormone. Iodine-induced hyperthy- • Widened pulse pressure roidism is another common cause of hyperthyroidism in the elderly. This can be caused by medications such as amiodarone, a cardiac medication • Palpitations that contains iodine. Additionally, an overdose of thyroid replacement (L- • Fatigability thyroxine) can cause hyperthyroidism. • Nervousness and tremor As with hypothyroidism, symptoms of hyperthyroidism in the elderly are vague. The classic symptoms include enlarged thyroid, weight loss, and • Heat intolerance and exces- increased hunger, changes in the shape of the eye, anxiety, agitation, heart sive sweating irregularities, heat intolerance, and tremor. The most common complica- • Warm, smooth, moist skin tion of hyperthyroid in the elderly is atrial fibrillation. • Weight loss Diagnosis and monitoring of hyperthyroidism is done by blood testing • Muscular weakness (TSH, free t4). The treatment of choice for the elderly patient is radioac- tive iodine. Radioactive iodine is easy to administer and has less risk than • Excessive defecation surgical treatment. Anti-thyroid medications, beta-blockers, and antide- • Emotional lability pressants can be used to give temporary relief of symptoms. • Ocular signs (e.g., stare and Nursing interventions for hyperthyroidism are similar to those in hypo- slowing of eyelid move- thyroidism. Residents should be screened with the lab tests defined above ments) upon admission and annually thereafter. Nursing should monitor vital signs for a change in pulse rate and rhythm, blood pressure changes, and weight loss. Any change in mental function and ability to perform daily functions should be reported. The incidence of thyroid cancer is less common in older adults. If a suspi- cious thyroid nodule is found on examination, the provider may order a fine needle biopsy. A biopsy will identify the presence of cancer. Most thyroid cancers are relatively slow growing so reevaluation at three to six months may be the choice. Treatment options for thyroid cancer are generally discussed with the resident and their family to determine the ap- propriate treatment for that individual. Vitamin D Deficiency Vitamin D deficiency is a common disorder in the older patient. Expo- sure of the skin to sunlight is required to obtain adequate amounts of vitamin D. Many long-term care residents do not get adequate amounts of vitamin D from diet or sun to maintain normal blood levels of vitamin D. FENCE Student Manual 321
  • 7. In addition, the aging body becomes less efficient at converting vitamin D in the body. Half of residents suffering from hip fracture have been found to have a vitamin D deficiency. Outside of increased fracture risk, most residents have no symptoms with low vitamin D levels. Severe deficiency, osteomalacia, is rare and does cause severe muscle pain and weakness. Nursing interventions to maintain adequate vitamin D levels include get- ting the residents outside for 10 to 15 minutes during the day when appro- priate and desired. In addition, the nursing staff should encourage foods fortified with vitamin D, such as milk and orange juice. Medical treatment consists of over-the-counter or prescription vitamin D. Most residents would benefit from a minimum daily dose of vitamin D (3800 IU) daily. Vitamin D supplementation has been shown to reduce hip fracture and overall disease rates by 15 percent. Low-dose vitamin D supplementation is generally well tolerated without common side effects. Hyponatremia Low sodium is one of the most Hyponatremia is a low blood sodium level. In one year, up to 50 percent common causes of mental sta- of nursing home residents may experience hyponatremia. Most cases of tus change in the elderly. Other mild hyponatremia occur without symptoms, but in residents who have symptoms include fatigue, muscle more severe cases, the symptoms can develop quickly. weakness and nausea. Hyponatremia is generally a result of excessive water retention or over hydration. Causes of hyponatremia in long-term care can also include enteral feeding, psychiatric medications, brain tumors, lung cancer, hypo- thyroidism, heart failure, or liver disease. Intravenous fluids and an in- creased consumption of gastric tube flushes or oral intake are also causes. Hyponatremia can be prevented with adequate nutrition for the tube-fed resident. For the non-tube-fed resident, the nursing staff should be aware of patients with low levels of blood sodium and ensure that the patient is not consuming large amounts of liquids. Limitation of fluids in residents with mild hyponatremia will prevent severe hyponatremia. When the resident has persistent low levels of sodium (< 120meq/liter), prescription medication may be required along with fluid restriction. Medications that could be precipitating the low sodium may need to be discontinued. As well, the provider may need to further evaluate the resi- dent for other causes of hyponatremia. Replacing sodium intravenously may result in heart failure. Nurses are very instrumental in the care and treatment of residents with endocrine disorders. Quality of life is greatly improved when these basic metabolic disorders are controlled. FENCE Student Manual 322
  • 8. Chapter 43 Review Questions Define the following terms: Complete the following: 1. Creatinine — 15. Describe the criteria that define type 2 diabetes. 2. Diabetes Mellitus (DM) — 3. Free T4 — 16. List the four strategies in diabetes management. 4. Glucagon Emergency Kit — a. 5. Hyperglycemic Nonketotic State — b. c. 6. Hyperthyroidism — d. 7. Hyponatremia — 17. Describe the potential side effects of insulin therapy. 8. Hypothyroidism — 9. Macrovascular — 10. Microvascular — 18. What should the nurse do if the resident’s blood sugar drops below 70? 11. Thyroid Stimulating Hormone (TSH) — Circle “True” or “False” as appropriate for the following statements: 19. ____________ is a deficiency of thyroid activ- ity characterized by a decrease in metabolic 12. (True/False) — Diabetes affects 25 percent rate and fatigue. of nursing home residents. 13. (True/False) — The elderly resident has 20. List five classic symptoms of hypothyroidism. similar symptoms to the younger adult with a. hypothyroidism. b. 14. (True/False) — Low sodium is one of the most common causes of mental status change c. in the elderly. d. e. continued... FENCE Student Manual 323
  • 9. Chapter 43 Review Questions, Continued 21. How is thyroid disease diagnosed? 22. What is the best source for vitamin D? 23. Low blood sodium is called ____________. FENCE Student Manual 324