Lisa Pierce
October 12, 2015
Professor Cressy

Informative Outline
Title: Primary Hyperparathyroidism in the Elderly
General Purpose: To inform
Specific Purpose: To inform the audience of the effects of primary hyperparathyroidism and the cure for the condition.
Central Idea: Primary hyperparathyroidism causes vague symptoms in the elderly, is statistically found more often in elderly women than in elderly men, although it effects all ages, and it quite often goes undiagnosed or misdiagnosed for other conditions mostly due to a lack of knowledge of the condition throughout the medical profession.
I. INTRODUCTION
A. It is benign, yet will slowly kill you within about twenty years if left untreated. It is one of the most underdiagnosed, undertreated and underreported endocrine conditions in the world, especially among the elderly, according to university studies performed at UCLA and Second University of Naples, Italy, Tulane Medical Center Department of Endocrinology, Norman Parathyroid Center in Tampa, Florida and the Center for Endocrine Surgery at Cleveland Clinic. Very noticeable symptoms in the young can seem quite vague in the elderly. So, what is it? It’s called primary hyperparathyroidism.
B. Though there are two types of hyperparathyroidism, primary and secondary, I am going to focus on primary hyperparathyroidism for the purpose of this discussion as it is the most common according to the American Association of Clinical Endocrinologists. Our four parathyroid (PT) glands, each normally the size of a grain of rice, are usually located in the neck on the backside of the thyroid gland, but have also been found higher or lower in the neck and chest area. So as to not confuse the two, the PT and the thyroid glands have completely different functions even though they are usually physically connected to one another. Our PT glands regulate calcium levels in our blood and bones by either increasing, decreasing, or temporarily halting production of parathyroid hormone (PTH) based on the body’s needs. During normal increases in PTH, very small amounts of calcium is leached out of the bones and released into the bloodstream, so when the blood calcium has reached a safe level, the parathyroid (PT) glands slow the pace of PTH production back down to normal. However, in the case of primary hyperparathyroidism (PHPT), tumor growth on one or more of the PT glands causes a continuous overproduction of PTH without ever slowing down which, in turn, causes leaching of very high amounts of calcium from bone into the bloodstream (hypercalcemia). Over time this process results in osteopenia, osteoporosis, hardening of the arteries, decrease in cognitive function, risks for breast, colon, kidney and prostate cancer, organ failure and ultimately, death.
C. In 2006 my grandmother was rushed to the emergency room with symptoms of severe dehydration. Her blood tests came back with a slightly elevated serum calcium level. Her doctor administered three bags of intravenous fluids and retested her calcium level. The level had not decreased, but since he treated the dehydration to the point of no more symptoms he released her with orders to take in plenty of fluids, but told her to see her primary care physician for further evaluation. When my grandmother told me what happened, I immediately started researching high calcium levels and the two main causes that kept coming up were cancer and hyperparathyroid disease. I called her and asked her about specific symptoms she was having and I was pretty sure I figured it out. I told my aunt, gram’s caregiver, to ask her primary care physician about hyperparathyroidism. She said he had heard of the disease, but he would have to refer her to an endocrinologist for an accurate diagnosis. Sure enough the diagnosis was confirmed, but unfortunately this particular endocrinologist did not recommend surgery as he was not experienced in minimally invasive procedures. My aunt did not seek a second opinion. At the time of diagnosis my Gram was eighty-six years of age, but had been having symptoms of the condition for several years prior to diagnosis. She is now ninety-six and in fourth stage renal failure due to the ignorance and stubbornness of her caregiver, so I feel if I can help shed some light on this condition with others it might help save someone else’s life down the line.
D. In order to give you a clearer understanding of the disease I will focus on three areas of concern. First, primary hyperparathyroidism causes very vague symptoms in the elderly as opposed to younger individuals. Secondly, statistics show it is more prominent in women than in men. Lastly, the condition often goes undiagnosed or is misdiagnosed as other conditions and is therefore left untreated mainly due to lack of knowledge about the disease throughout the medical profession with the exception of endocrinologists.
II. BODY
A. In order to diagnose primary hyperparathyroidism physical and physiological symptoms are usually key factors, but if physiological symptoms are so vague that they’re just written off as signs of aging, then physical symptoms usually become apparent only when the disease is already in its advanced stages.
1. Physiological symptoms can include one or more of the following; weakness, fatigue, joint and bone pain, muscle aches and spasms, fractures, constipation, acid reflux, frequent urination, depression, confusion, memory problems, hair loss, anxiety and heart palpitations.
2. Physical symptoms can include one or more of the following; osteopenia, osteoporosis, kidney stones, kidney failure, high blood pressure, high blood calcium and low vitamin D levels, atrial fibrillation, blood clots, stroke, heart attack, heart failure, and cancers of the breast, prostate, colon and kidneys.
a. According to an article in Surgery Magazine in December of 2013, “High calcium levels in the blood increases the risk of stroke, heart attack and heart failure due to the aggressive build-up of calcium in the arteries.”
b. According to an article on researchgate.net regarding a study at the Second University of Naples, Italy in August of 2014, “Primary hyperparathyroidism is the leading cause of high blood calcium levels and is responsible for nearly ninety percent of all cases. Once the tumor or tumors are removed symptoms begin to disappear, blood calcium levels drop and bone begins the regeneration process.”
B. Statistics from studies performed at UCLA, primary hyperparathyroidism is more prominent in women than men, but even more so in the elderly.
1. According to an article on mdindia.net in February, 2013, “Researchers from UCLA conducted a study utilizing a patient database from Kaiser Permanente Southern California using data from lab results which identified over 15,000 cases of chronic high calcium levels. Of those 15,000, 13,000 were diagnosed with primary hyperparathyroidism. The number of cases per 100,000 per year is as follows:
African-American 92 women / 46 men
Caucasian 81 women / 29 men
Asian 52 women / 28 men
Hispanic 49 women / 17 men
Under age 50 12 to 24 cases for both genders
Ages 50+ 80 women / 36 men
Ages 70+ 196 women / 95 men
The researchers coined it as an undertreated, underreported condition that affects mainly women and the elderly.”
C. Primary hyperparathyroidism often goes undiagnosed or is misdiagnosed as other conditions and is therefore left untreated. This is due to lack of knowledge about the disease throughout the medical profession with the exception of endocrinologists, so unless you or your primary care physician have any reason to believe you should see an endocrinologist such as symptoms of diabetes for example, then you may never find out you have the disease. If they are unaware of the disease or its symptoms then why would they? So, they evaluate your symptoms, give you prescriptions for medications that should help alleviate your symptoms and send you on your way. In other cases, if you’re over a certain age and complain of bone pain, they’ll order a bone scan. If the scan indicates osteopenia or osteoporosis, they’ll give you a prescription for that and send you on your way. Therefore, the patient completely misses out on any further testing such as thyroid and parathyroid ultrasound or sestamibi scans which would pinpoint a parathyroid tumor’s location. Unfortunately, a lot of general practitioners have this “wham bam thank you m’am” way of treating their patients. They don’t dig deep enough like an endocrinologist normally would. The majority of them are so overloaded with patients, especially during cold and flu season, and just want to get everyone in and out of there in a jiffy. This is a great disadvantage for elderly people who have insurance, namely Medicare, that requires a referral to see a specialist or that refuses to cover testing unless “Medicare” deems it’s absolutely necessary. Another problem with general practitioners is that they are not informed enough about the endocrine system in general, therefore other types of endocrine diseases go undiagnosed as well. If a patient is lucky enough to be referred to an endocrinologist, the diagnosis and proper treatment will make all the difference in the world for them. The only treatment is a cure and that is surgical removal of the tumor or tumors. There are two parathyroid specialists that I have researched who specialize in minimally invasive parathyroidectomy surgery. They are Emad Kandil, MD of Tulane Medical Center in New Orleans, Louisiana and Jim Norman, MD of Norman Parathyroid Center in Tampa, Florida. Both of these surgeons get referrals from all over the world and have been teaching their expertise to hundreds of other endocrine surgeons from around the world in order to spread awareness among the medical community that no one is too old for this type of surgery. The minimally invasive outpatient procedure only requires local anesthesia and a maximum of 20 minutes on the operating table. Dr. Norman has an especially busy office. His practice of 6 surgeons performs 11 to 16 parathyroid surgeries per day. His youngest patient was 3 months old and his eldest was 105.
1. In an article on his website from 2012, parathyroid.com, Jim Norman, MD of Norman Parathyroid Center in Tampa, Florida states, “Most doctors don’t understand that the labs don’t correct normal ranges of blood calcium according to the patient’s age. Most people with a PT tumor have only slightly or modestly elevated calcium levels, so a doctor who sees this is not really alarmed and a potential tumor can go undiagnosed for years. Only an endocrinologist pays close enough attention to this. Many with PHPT will have normal serum calcium levels, but high ionized calcium as it is the high ionized calcium levels that make you feel bad. Most doctors aren’t aware that ionized calcium should be measured in parathyroid patients. Furthermore, it’s not how high the calcium levels are, it’s the duration of the high calcium levels over time that really does the damage.”
2. In an article on consultant360.com in December 2013, Allen Siperstein, MD, Chairman of the Center for Endocrine Surgery at Cleveland Clinic states, “Physicians may not be aware of how common hyperparathyroidism is, or that it is the most common cause of elevated serum calcium values. There is also the misconception that hyperparathyroidism is, for the large part, an asymptomatic condition such that the diagnosis is less important to pursue or treat. The condition is three times as common in women as in men and increases with advanced aging. Normal procedure is that when there are high calcium levels detected the next step is to measure parathyroid hormone (PTH) levels. In a two year study sample of 7,260 patients, all of whom had primary care physicians in the hospital system and serum calcium values greater than 10.5 mg/dl (hypercalcemia), more than two-thirds (67%) of hypercalcemic patients had never obtained PTH value testing.”
3. According to a WWLTV News Medical Watch video on youtube.com in 2010, “Dr. Emad Kandil of Tulane Medical Center in New Orleans is one of the few and top endocrine surgeons in the country who specializes in minimally invasive thyroid and parathyroid surgery through use of the DiVinci Robotic surgical device which leaves no neck scar as he makes a transaxillary (armpit) incision to perform the procedure.”
4. According to an article in June 2013 on the American Association of Endocrine Surgeons webpage, endocrinediseases.org, “all patients with primary hyperparathyroidism should be considered for surgery regardless of age, 60’s, 70’s, 80’s and even 90’s, as unfortunately the elderly are missing an opportunity to be cured of PHPT with a low risk operation. These procedures are increasingly being performed on the elderly under local anesthesia.”
5. In reference to an article in 2012 on parathyroid.com, Dr. Jim Norman of Norman Parathyroid Center in Tampa, Florida states, “Over 99.8% of all people who have a blood test that shows too much calcium will have a parathyroid problem. If you have high blood calcium and low vitamin D nearly 100% of the time you have a parathyroid tumor. Giving vitamin D to a patient with high calcium can be dangerous and shows that the doctor doesn’t understand parathyroid disease very well.”
III. CONCLUSION
A. We have discussed the vague symptoms that primary hyperparathyroidism can cause as well as the statistics that conclude the disease is more often found in women and the elderly. We also discussed that this disease is often undiagnosed throughout the medical community due to the lack of knowledge of the disease among anyone other than an endocrinologist. With that said, it is definitely a disease that needs more publicity and whatever way endocrinologists can figure out to get the word out to the public and the medical community would be a great help to all who are affected by this disease but just don’t know it yet.
B. In the case of my grandmother, she will never get the chance to have this surgery due to ignorance on her caregiver’s part, but if you or anyone you know exhibits symptoms such as the ones I mentioned earlier, just know that it’s never too late to get the diagnosis and cure this dreaded disease for good. If all it takes is one simple 20 minute procedure to prolong and improve quality of life for you or a loved one, isn’t it worth it?

If you would like more information about primary hyperparathyroidism please visit the following websites: www.parathyroid.com www.endocrineweb.com http://endocrinediseases.org If you or a friend or loved one is experiencing any of the symptoms I spoke of in this discussion and would like to get an evaluation, I have included two highly recommended parathyroid surgeons’ contact information below. Emad Kandil, MD Tulane University Thyroid Center 1430 Tulane Avenue, 8th Floor New Orleans, LA 70112 504-988-5451

Jim Norman, MD Norman Parathyroid Center at Tampa General Hospital 2400 Cypress Glen Drive Wesley Chapel, FL 33544 813-972-0000

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