The increased incidence of hyperparathyroidism (HPT) reported in the elderly population has a number of implications for nursing. Nurses who specialize in the long-term care of the elderly, or who work with the elderly in acute and ambulatory care settings, need to have a good understanding of signs and symptoms that suggest the presence of HPT if they are to contribute to the detection and early intervention of this disorder. Although once believed to be rare, the incidence of HPT has been found to increase with age, with one survey showing that in persons over the age of 60, one in 1 ,000 men and one in 2,000 women is afflicted with this disorder.1
Greater awareness of this condition among health professionals prepared in gerontology has contributed to the increased incidence rate reported for HPT. However, Potts' cautions that HPT often goes undiagnosed because symptoms in the early stage are subtle. The symptoms may be so mild in this stage that they are easily overlooked or their appearance is attributed to old age, depression, or anxiety. Health professionals and families may attribute some of the symptoms to intensified losses experienced by the elderly, or to problems they are having in their relationships. The symptoms of HPT may also be mistaken for physical ailments common among the elderly, such as arthritis or chronic constipation. If the diagnosis is missed and this condition is not treated promptly, HPT can have a severe impact on the elderly.
PRESENTATION OF HPT IN THE ELDERLY
The symptoms of early HPT may be global or specific to one system. According to Camargo and KoIb, the elderly may report feelings of anxiety, nervousness, fatigue, weakness, and loss of strength (asthenia).2 They may also report vague abdominal discomfort, loss of appetite, nausea, and vomiting, and subsequently experience weight loss. They may also present with disturbance of affect, such as mild depression, confusion,3 lack of initiative and drive, and tend to stay in bed for more hours, varying notably from their accustomed pattern of sleep. Other complaints of the elderly with HPT may focus on problems with constipation, polyuria, polydipsia, or back and joint pain.2
By getting an accurate diagnosis and interventions when subtle symptoms are present, the elderly afflicted with HPT will not have to suffer with symptoms that intensify as the level of serum calcium continues to rise and other physiological and functional changes occur. For example, hypertension and kidney stones may produce marked problems and bone pain may increase. Severe psychiatric disturbances have also been reported with untreated HPT. The serum calcium may be elevated only a few tenths of a milligram per deciliter from the normal level for serum calcium (8.5 mg/dL to 10.3 mg/dL) for symptoms to occur with advancing primary HPT.
Other findings for this disorder that may be reflected in the laboratory values include low serum phosphate and elevated alkaline phosphatase, plasma chloride, or uric acid levels. It is important to recognize that the person may have primary HPT with a serum parathyroid hormone level within the normal range. The explanation for this finding is that a somewhat elevated level of serum calcium may suppress the parathyroid hormone.2 Obtaining a reading of the serum calcium level is essential to the diagnosis of HPT.
A case study of an elderly client who received services from a clinical specialist in gerontological nursing is presented to illustrate the subtle symptoms reported with HPT. The importance for nurses to take into consideration all of the assessment and laboratory findings and the medical diagnosis of HPT in identifying nursing diagnoses and formulating a plan of care for this client will also be discussed.
Mrs M is 75 years old and came to the clinic to be evaluated for a 9-month history of weakness, fatigue, and nervousness. Since September 1988, the patient has noted increased agitation, progressively decreasing appetite, and decreased energy level. Her family states that she basically only eats and sleeps. She has lost her outside interests, including going to church. Her other complaints consist of mild epigastric pain, which occurs approximately 5 to 10 minutes after meals. This symptom is not accompanied by nausea or vomiting and is relieved with antacids. She reports that it is more of a discomfort than a pain.
These symptoms have been occurring for the past 3 to 4 months and have been accompanied by a 14-pound weight loss. She has a history of peptic ulcer disease, which was diagnosed 8 years ago, but she denied melena, bright red blood from her rectum, or hematemesis. Her local physician started her on metoclopramide and rantidine hydrochloride. She was told that she was given the metoclopramide because her stomach was not emptying properly. The only other symptom noted on the review of symptoms was right hip pain.
Mrs M's past medical history indicated that she had a thyroidectomy for goiter in 1986. She also reported the onset of peptic ulcer disease (PUD) in 1981 , as well as diabetes mellitus. She has required insulin since 1988 to control her blood glucose level. Other historical data revealed that Mrs M had a hysterectomy in 1941 and that she had not received any supplemental hormone therapy.
Mrs M was taking the following medications at the time of her evaluation: metoclopramide 10 mg q.i.d. a half hour before meals to help her stomach empty after eating; ranitidine hydrochloride 300 mg q.h.s. to suppress acid production; Buspar 10 mg q.i.d. to control anxiety; Synthroid 0.025 mg q.d. to supplement thyroid hormone; and Lente UlOO 4OU and regular insulin 8U q.a.m. to supplement the pancreas.
Weight 159 pounds; blood pressure 140/30 mmHg. Physical exam findings were within normal limits. Mini Mental Status Examination 26/30 points. Laboratory values were as follows: calcium level 11.3 mg/dL (normal values 8.8 mg/dL to 10.4 mg/dL); random blood sugar at 5 PM 85 mg/dL (normal values 65 mg/dL to 110 mg/ dL); blood urea nitrogen 24 mg/dL (normal values 8 mg/dL to 20 mg/dL); creatinine 1.3 mg/dL (normal values 0.6 mg/dL to 1.0 mg/dL); specific gravity 1.039 (normal values 1.003 to 1.030); parathyroid hormone, C terminal 2.2 (normal values 0.5 to 1.5); parathyroid hormone, intact 183 (normal values 10 to 65); thyroid stimulating hormone 13.8 µU/mL (normal values 0.3 µU/mL to 6.0 µU/mL). Complete blood count, alkaline phosphatase, uric acid, and phosphorus levels were within normal limits.
Diabetes mellitus, insulin requiring; hypothyroidism, not adequately supplemented; history of PUD, rule out recurrence; question of gastrointestinal dysmotility; hypercalcemia/hyperparathyroidism, rule out multiple myelona/occult malignancy; question of iatrogenic symptoms secondary to medication; question of anxiety and depression.
Nutrition, alterations in: less than body requirements, related to anorexia. Sleep pattern disturbance, nocturnal insomnia, and daytime somnolence. Comfort, altered; chronic epigastric discomfort. Activity intolerance: fatigue and weakness. Self-care deficit: food preparation. Social interactions, impaired.
Medical Plan of Care
* Serum protein electrophoresis and urine for Bence Jones protein to rule out multiple myeloma.
* Six stools for Hemoccult to rule out gastrointestinal blood loss from PUD/gastrointestinal malignancy.
* Abdominal computed axial tomography scan.
* Send for previous and most recent gastrointestinal evaluation data to avoid duplication of diagnostic data.
* Refer for a gastrointestinal evaluation for abdominal pain, anorexia, and weight loss if the data appear unclear regarding etiology of gastrointestinal symptoms.
* Increase Synthyroid from 0.025 mg to 0.07S mg per day to normalize the thyroid level.
* Decrease Lente and regular insulin from 40/8U to 30/4U to increase sugars to the 120 mg/dL to ISO mg/ dL range to prevent possible episodes of hypoglycemia and to see if symptoms of weakness improve.
* Discontinue metoclopramide until further data document a diagnosis of gastrointestinal dysmotility as well as to eliminate depression as one of the possible side effects.
* Decrease Buspar from 40 mg to 10 mg per day to reduce the possible side effects of depression and lethargy.
* Split the ranitidine hydrochloride dose to 150 mg b.i.d. from 300 mg q.h.s. to prevent rebound acid production and abdominal pain.
* Refer the patient to an endocrinologist for further evaluation of HPT and possible surgical intervention if a parathyroid adenoma is present.
Whenever patients express symptoms of anxiety and depression, their symptoms are compared with the diagnostic criteria listed for these disorders in DSM-III R4 to arrive at a medical diagnosis. The NANDA (North American Nursing Diagnosis Association) Nursing Diagnostic Criteria5 is used to arrive at a nursing diagnosis that focuses on client responses as well as presentations of anxiety or depression. In the case of HPT, incomplete investigations can lead to patients being labeled incorrectly with diagnoses of depression/anxiety rather than undergoing an intensive investigation of the symptoms, which might be attributed to any number of health problems and that can be related specifically to HPT.6
Mrs M does not have five or more of the symptoms (of a possible total of nine) required to meet the DSM-III R criteria for depression. Although her symptoms have persisted for 2 weeks or longer, her only complaints are significant weight loss, insomnia at night, hypersomnolence during the day, and fatigue. It was also noted that Mrs M did not demonstrate agitated behavior during the clinical examination despite her report of increased agitation. She also does not meet the six or more criteria (of a possible 18) designated in the DSM-III R for anxiety.4 The only symptoms of anxiety she expresses are easy fatigability and a feeling of being "keyed up" or on edge. Similarly, Mrs M does not meet the NANDA Nursing Diagnosis Criteria for anxiety.5 She is experiencing some of the major defining characteristics of anxiety, such as the physiological symptoms of insomnia, fatigue, and weakness, and the emotional symptoms of nervousness and tension, or being "keyed up," but she is not experiencing any of the cognitive symptoms that must be present to give her this nursing diagnosis.
The plan of care outlined for Mrs M takes into consideration each of the nursing and medical diagnoses, her age, and state of health and function. Her preferences are also given priority whenever possible in planning and implementing the nursing interventions.
* Offer Mrs M a liquid nutritional supplement. This will improve the nutritional and caloric content of her diet and reduce dietary bulk (in light of her anorexia and disinterest in food preparation) to meet her metabolic needs and to control her diabetes mellitus.
* Assist her in establishing a sleep pattern that is more normal. Napping in the morning provides rapid eye movement sleep, which will make her feel more rested. If she sleeps later in the day, she will continue to have insomnia at night.
* Encourage Mrs M to take antacids 30 cm3 a half hour after meals and at bedtime on a regular schedule to prevent abdominal discomfort rather than attempting to treat the symptoms after they arise. Inform her that bed rest does not help to propel the food through the gastrointestinal tract.
* Educate Mrs M regarding the hazards of continuous bed rest. Explain that bed rest deconditions the body and causes muscle weakness rather than alleviating it. Encourage her to plan short periods of activity and rest (not sleep) to maximize her energy level and prevent deconditioning. It is important that Mrs M understand that this activity pattern may also help to relieve her symptoms of agitation.
* When Mrs M no longer has help with meal preparation, identify resources within the community for home meal delivery.
* Assist Mrs M in identifying relatives, friends, neighbors, church, and community people who will help to provide her with an adequate social support system. Help her to seek a lay reader or minister who could visit or find religious services that could be tape recorded.
Hyperparathyroidism is an entity that is not well-known and has a nonspecific presentation. It is crucial to know the serum calcium level; an elevation of only a few tenths of a milligram per deciliter may not look significant, but its identification is vital to the diagnosis of HPT. Some of the symptoms of this disorder may suggest anxiety and depression, but the overall cluster of symptoms presented with HPT does not fit DSM-III R or nursing diagnosis criteria for either of these conditions.
Since surgical intervention is needed in cases of HPT, nursing can offer elderly persons with this problem valuable assistance by providing emotional support and recommending strategies that will assist them in maintaining function until the treatment is completed. Nursing can make a critical difference in contributing to earlier diagnosis and treatment of HPT in the elderly by compiling comprehensive nursing histories. These can then be used ?? assist in sorting out symptoms and determining which ones are or are not related to the diagnostic categories suggested by the DSM-III R and the NANDA Nursing Diagnosis Criteria for conditions that present with some of the same symptoms reported by the elderly with HPT.
- 1. Potts J. Disease of the parathyroid and other hypercalcémie disorders. In: Brunwald E, Isselbaeher K, Petersdorf R, Wilson J, Martin J, Fauci A, eds. Principles of Internal Medicine. New York: McGraw Hill; 1987.
- 2. Camargo C, KoIb F, Schroeder S, Krupp M, Tierney L Jr, eds. Current Medical Diagnosis and Treatment. Norwalk, Conn: Appleton and Lange; 1987.
- 3. Haybara T, Hashimoto K, Izumi H, Moriofca E, Hosokawa K: Neuropsychiatrie disorders in primary hyperparathyroidism. Jpn J Psychiatry Neurol. 1987;41:13-40.
- 4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed, revised. Washington, DC: Autfior; 1980.
- 5. CarpenitoL. Nursing Diagnosis: Application to Clinical Practice. 2nd ed. Philadelphia: JB Lippincott Co; 1987.
- 6. Sherwood L. Diagnosis and management of primary hyperparathyroidism. Hosp Pract. 1988; 23:9-10, 15. Editorial.