Decision-making in primary hyperparathyroidism in older patients: surgical or conservative management?

Primary hyperparathyroidism (PHPT) is a frequent endocrine disorder, with prevalence increasing with age, affecting approximately 1.5% of adults aged over 65. While management is well codified before the age of 50, with surgery being preferred, recommendations for older individuals are less clear. In this population, however, surgery is still the only curative option, and several studies demonstrated improvement in cognitive and neuropsychiatric symptoms, following parathyroidectomy. However, this indication must be weighed against the patient's co-morbidities, frailty and wishes. Drug-based alternatives are a valid option for patients unable or unwilling to undergo surgery. The fundamental question, however, is to evaluate the suitability of one treatment over another, depending on the patient's phenotype. A transdisciplinary approach involving endocrinologists, endocrine surgeons and geriatricians can ensure personalized care. A robust older patient may benefit from surgery, just like a younger patient, whereas a frail patient would benefit more from conservative management. In what are known as "pre-frail" patients, comprehensive geriatric assessment can optimize of the patient's general condition prior to surgery, and help anticipate postoperative complications. The present article firstly describes the clinical and biological specificities of PHPT in older adults, secondly compares the therapeutic strategies available, and thirdly identifies geriatric markers to guide the therapeutic decision.