Approach to the Patient: Diagnosis and Management of Cushing's Syndrome in the Elderly - How Different is It?

Cushing's syndrome in older adults is uncommon but clinically consequential. The diagnostic tests are largely the same as in younger adults, yet the clinical threshold for testing, the interpretation of biochemical results, and the therapeutic endpoint often differ. Older patients may lack classic cushingoid features and instead present with poorly controlled diabetes or hypertension, recurrent falls, rapid bone loss, proximal weakness, venous thromboembolism, cognitive decline, or an adrenal incidentaloma. These features overlap with common age-related disorders and create a dual risk: missing clinically important hypercortisolism or overdiagnosing mild biochemical abnormalities with limited clinical relevance. A practical approach begins by excluding exogenous glucocorticoid exposure, identifying progressive and discriminatory features, and selecting screening tests that account for renal function, sleep pattern, drug interactions, and the probability of non-neoplastic hypercortisolism. Late-night salivary cortisol is convenient but should be repeated and interpreted cautiously in patients with diabetes, sleep disturbance, or acute illness; urinary free cortisol may be falsely low in chronic kidney disease; and dexamethasone suppression testing requires careful review of interacting medications and, in selected cases, dexamethasone levels. Management should be based on etiology and functional status rather than chronological age. Fit older adults should generally be offered standard curative therapy, whereas vulnerable or frail patients may benefit more from staged, less invasive, or symptom-directed treatment. Preservation of mobility, cognition, independence, and quality of life should be explicit treatment goals.