How to manage fall risk in patients with hypothyroidism?

Managing Fall Risk in Patients with Hypothyroidism

Patients with hypothyroidism require a multifactorial fall risk assessment and targeted interventions to address both thyroid-specific and general fall risk factors. 1

Thyroid-Specific Fall Risk Management

Optimal Thyroid Hormone Replacement

• For patients with overt hypothyroidism (elevated TSH and low free T4), initiate levothyroxine therapy to normalize thyroid function, which can improve symptoms that contribute to fall risk such as fatigue, cognitive issues, and muscle weakness 2, 3
• For patients with subclinical hypothyroidism:
  • TSH >10 mIU/L: Treat with levothyroxine as these patients benefit from hormone replacement 4, 3
  • TSH 4.5-10 mIU/L: Consider treatment if symptomatic (fatigue, cognitive issues) that may contribute to fall risk 1
  • Monitor TSH every 6-8 weeks after initiating therapy or changing dose until stable, then annually 3

Age-Appropriate Dosing

• For adults <60 years without cardiac disease: Start levothyroxine at 1.5-1.8 mcg/kg/day 3
• For adults >60 years or with coronary artery disease: Start at lower doses (12.5-50 mcg/day) and increase gradually to avoid cardiac complications that could increase fall risk 4, 3
• Monitor for signs of overtreatment (tachycardia, tremor, sweating), which can increase fall risk 5

General Fall Prevention Strategies

Exercise Interventions

• Implement exercise programs that include balance, gait, and strength training components 1
• Recommend balance training 3 or more days per week for patients with recent falls or difficulty walking 1
• Consider physical therapy referral for patients with significant gait or balance impairments 1

Vitamin D Supplementation

• Provide vitamin D supplementation (800 IU daily) for patients at increased risk for falls 1
• Continue supplementation for at least 12 months to achieve benefit 1

Medication Review

• Review all medications, especially those that may increase fall risk (sedatives, antihypertensives, etc.) 1
• Consider medication withdrawal or dose adjustment when appropriate 1

Environmental Assessment

• Evaluate home environment for hazards 1
• Recommend appropriate footwear with low heels and hard soles for better balance 1

Special Considerations

For Hospitalized Patients with Hypothyroidism

• Implement fall prevention programs including bed alarms, scheduled voiding times, and placing call buttons within reach 1
• Consider sitters for high-risk patients 1
• Start safe ambulation as soon as possible 1

For Patients with Severe Hypothyroidism

• Recognize that severe untreated hypothyroidism can lead to myxedema with bradycardia, hypothermia, and altered mental status, significantly increasing fall risk 2, 3
• Hospitalize patients with myxedema for intensive management 3

For Patients with Immune-Related Hypothyroidism

• For patients with hypothyroidism due to immune checkpoint inhibitors, follow specific management protocols based on symptom severity 1
• Continue monitoring thyroid function every 4-6 weeks during immune checkpoint inhibitor therapy 1

Monitoring and Follow-up

• For patients with recent falls or at high risk:

  • Perform multifactorial risk assessment including balance, mobility, vision, and orthostatic hypotension evaluation 1
  • Provide comprehensive management of identified risk factors 1
  • Schedule regular follow-up to reassess fall risk and thyroid function 1

• For all patients with hypothyroidism:

  • Educate about fall prevention strategies 1
  • Monitor for improvement in hypothyroid symptoms that may affect fall risk (fatigue, muscle weakness, cognitive issues) 2, 3
  • Ensure TSH remains in target range (0.5-2.0 mIU/L for primary hypothyroidism) 4