Parathyroidectomy is the definitive treatment for symptomatic primary hyperparathyroidism. However, age bias effects treatment decisions. Elderly patients are less likely to receive surgery, even when indicated. Only 24% of those aged 70+ meeting surgical criteria undergo parathyroidectomy. Surgical outcomes are generally favourable, with high biochemical cure rates, improved bone mineral density, reduced fracture risk, and enhanced quality of life post-surgery. Despite the perception of higher surgical risk due to comorbidities, studies suggest that age alone should not preclude surgery. Individual health status assessments are advocated, with contemporary techniques showing complication rates under 5% and mortality rates under 1%, comparable to younger populations. For those over 50 with a life expectancy beyond five years, surgery is also more cost-effective compared to medical therapy. Surgical complications include transient hypocalcaemia, infection, and temporary recurrent laryngeal nerve injury. Minimally invasive procedures can facilitate same-day discharges, reducing hospital-associated risks.
Romosozumab, a monoclonal antibody for osteoporosis, shows efficacy in fracture prevention but has potential cardiovascular risks. The BRIDGE study highlighted increased cardiovascular events, leading to FDA warnings and mandated further studies. However, meta-analyses have shown mixed results regarding these risks. Until more data is available, individual risk assessments are necessary. Here, we discuss a case of an elderly gentleman with various hyperparathyroidism related complications including complex osteoporosis with neck of femur fracture on a background of peripheral vascular disease. We will review the case in light of the available literature to understand the management options and explore the concept of age bias in elderly patients with primary hyperparathyroidism.