Primary hyperparathyroidism in the elderly

Primary hyperparathyroidism is a relatively common disease in elderly women. Many of its clinical presentations may be confused with normal aging. Among the elderly, renal dysfunction and skeletal disease, particularly osteoporosis, are the two aspects of the disease likely to cause the most morbidity. It is increasingly apparent, however, that a large group of patients with hyperparathyroidism are asymptomatic or only mildly symptomatic. When symptoms are present, or repeated serum calcium levels all exceed 11.0 mg/dL, surgery is considered the treatment of choice. Success of surgery and of postoperative recovery are not affected by the age of the patient, but are enhanced by the experience of the surgeon performing the parathyroidectomy. There are difficult management decisions to be made concerning the elderly asymptomatic patient with mild hypercalcemia. A conservative approach to therapy for these individuals would include maintenance of adequate hydration, and involvement in physical activity. Dietary restriction of calcium should be recommended only as long as there is no evidence that it is exacerbating negative calcium balance. Drugs likely to worsen hypercalcemia, such as thiazides, must be avoided, and blood chemistries should be monitored at regular intervals. Because the bone loss of hyperparathyroidism may develop insidiously, serial bone density measurements are probably reasonable in older women already at risk for osteoporosis. Accelerated bone loss is an indication for surgical intervention. A wide variety of medications have been proposed for the treatment of primary hyperparathyroidism, but none stands out as a particularly desirable therapeutic alternative. Future research in this area, particularly with the use of estrogens in postmenopausal women with hyperparathyroidism, may eventually lead to greater acceptance of this alternative to surgery.