Andropause: is it time for the geriatrician to treat it?

Gender differences in upper extremity motor performance of older persons

BACKGROUND

Motor performance declines with age. Although gender differences in motor strength and speed have been widely reported, the extent to which these differences are maintained in old age has not been well established.

METHODS

Upper extremity motor performance was assessed in 234 men and 530 women Catholic clergy members aged 65 years or older with no clinical evidence of dementia who were participants in the Religious Orders Study. As part of a uniform clinical evaluation, upper extremity motor performance including strength (grip and pinch dynamometry), movement speed including finger tapping and Purdue pegboard and muscle bulk of the arm were collected.

RESULTS

Men were stronger than women at all ages but this difference became less prominent at older ages. Women scored higher on the Purdue Pegboard than men whereas men had faster maximal finger tapping rates than women. Gender differences in speed were not modified by age. Men had greater muscle bulk than women at all ages and these differences were not modified by age. These relationships were not modified by participants with a clinical diagnosis of Parkinson's disease or stroke or by hormone replacement therapy in women.

CONCLUSIONS

Gender differences in upper extremity speed and muscle bulk appear to be relatively stable with increasing age, whereas gender differences in strength were reduced in the oldest old. Longitudinal studies are needed to determine if men and women differ in the rate of decline of strength in old age.

Age-Related Structural and Metabolic Changes in the Pelvic Reproductive End Organs

In this work, we provide preliminary data and a review of the literature regarding normal structural and functional changes that occur in the aging uterus, ovary, testicle, and prostate gland. It is expected that such knowledge will help physicians to distinguish physiologic changes from pathologic changes at an early stage. We retrospectively reviewed pelvic magnetic resonance imaging (MRI) scans of 131 female and 79 male subjects ages 13 to 86 years to determine changes in volume of the uterus, ovary, and prostate gland with age. Scrotal ultrasound examinations of 150 male subjects ages 0 to 96 years also were analyzed retrospectively to determine changes in testicular volume with age. In addition, (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG-PET) scans of 145 male subjects ages 11 to 90 years were analyzed retrospectively to assess for changes in maximum standardized uptake value (SUV(max)) of the testicles with age. The uterus had a mean volume of 38.55 +/- 3.68 cm(3) at 17 to 19 years of age, increased to a peak volume of 71.76 +/- 19.81 cm(3) between 35 to 40 years, and then declined to 24.02 +/- 8.11 cm(3) by the eighth decade of life. The maximal ovarian volume per subject maintained a relatively stable size in early life, measuring 9.46 +/- 3.25 cm(3) during the second decade of life, 8.46 +/- 3.32 cm(3) in the mid-fourth decade of life, and 7.46 +/- 3.33 cm(3) at 45 years of age, after which it declined to 4.44 +/- 2.02 cm(3) by the late fifth decade of life. The ovaries were not identifiable on MRI in subjects beyond the sixth decade of life. The volume of the prostate increased from 23.45 +/- 6.20 cm(3) during the second decade of life to 47.5 +/- 41.59 cm(3) by the late eighth decade of life; the central gland of the prostate increased from 9.96 +/- 3.99 cm(3) to 29.49 +/- 28.88 cm(3) during the same age range. Mean testicular volume was 11.2 +/- 5.9 cm(3). Testicular volume increased with age from birth to 25 years. After age 25, there was a significant decline in the testicular volume. The mean SUV(max) for the testicles was 1.9 +/- 0.5. Testicular metabolic activity demonstrated an increasing trend until the age of 35 years. A plateau in SUV(max) was observed after the age of 35 years until the age of 65 years. A slight decrease in SUV(max) was observed after the age of 65 years. The pelvic structures of men and women change both structurally and functionally over the lifespan, and such changes can be quantified using ultrasound, MRI, and (18)F-FDG-PET.

Comparison of screening questionnaires for the diagnosis of hypogonadism

Three questionnaires, the St. Louis University Androgen Deficiency in Aging Male (ADAM), the Aging Male Survey (AMS) and the Massachusetts Male Aging Study (MMAS), have been developed as potential screening tools for hypogonadism in older males. We compared these questionnaires in 148 males aged 23-80 years using bioavailable testosterone as the "biochemical gold standard" for diagnosis of hypogonadism. The sensitivity for the ADAM was 97%, for the AMS 83% and the MMAS 60%. Specificity was 30% for the ADAM, 59% for the MMAS and 39% for AMS. Both bioavailable testosterone and the calculated free testosterone correlated significantly with a number of the individual questions. Total testosterone correlated poorly with most of the questions. In conclusion, the ADAM and AMS may be useful screening tools for hypogonadism across the adult lifespan, but both are relatively nonspecific.

Anti-aging medicine--the good, the bad, and the ugly

Complementary and alternative medicine has flourished since the beginning of time because of a human need to postpone the aging process and to reverse disease. Complementary and alternative medicine sells, because in some cases it works as well or better than mainstream medicine. In addition, many practitioners of complementary medicine understand Hippocrates' aphorism: "It is more important to know the person that has the disease than the disease the person has." It is important to recognize that spending time with the patient is often as therapeutic as drugs. CAM offers patients the time, touch, attention, and level of personal interaction that are increasingly uncommon in contemporary medical care. There is a major need for large and appropriately designed studies to test the effectiveness of complementary techniques. As in other areas of health care, studies in the elderly are consistently lacking. With the growing interest in CAM, it is important for medical providers to keep an open mind--to both the potential benefits and potential harms of alternative treatments. When treatments are shown to be dangerous or ineffective, we must educate the public and work to remove these therapies from the market place. When treatments are proven effective, Western and Eastern medical providers must work together with patients to provide the most appropriate and comprehensive health care.

Hormonal fountains of youth

Any hope of a fountain of youth to stop people from getting older is a long way off, with science just beginning to understand the complex genetic, physical, and hormonal causes of aging. Clearly, modem research has demonstrated that the concept of a hormonal fountain of youth is predominantly mythology. The best evidence supporting use of hormonal replacement is vitamin D and estrogen replacement to prevent hip fractures. Other than that, treatment should be limited to hormone replacement in persons who have endocrine disease.

Erectile dysfunction: etiology and treatment in young and old patients

This study shows that endocrine and vascular etiologies of erectile dysfunction are more common in the older age group, whereas depression and marital discord are more common in the younger age group. There is considerable overlap between various factors pointing to the multifactorial nature of erectile dysfunction. Review of the treatment option chosen reveals that the invasive modalities were least common as compared with the popular vacuum tumescence device (although cumbersome) and testosterone replacement. Persons with low testosterone have an improved efficacy of sildenafil when hypogonadism is treated. Sildenafil with its ease of administration and high efficacy seems to be the logical first choice for most of the patients. If contraindications exist or treatment failures occur, other treatment options should be offered to patients.

Endogenous sex hormones and cardiovascular disease in men

Unlike women, men do not experience an abrupt reduction in endogenous sex hormone production. It has, however, become clear that an age-associated decrease in the levels of (bioactive) sex hormones does occur. Whether endogenous sex hormones have an impact on cardiovascular disease has for many years remained largely unknown, but during the last decade more attention has been drawn to the importance of testosterone, estrogens, and adrenal androgens in etiology, prevention, and treatment of male cardiovascular disease. The purpose of this article is to summarize the evidence currently available on the association between endogenous sex hormones and cardiovascular disease in males. Published studies dealing with the relationship between circulating levels of sex hormones and cardiovascular disease in males were reviewed. The studies reviewed in this article suggest that circulating endogenous sex hormones and estrogens have a neutral or beneficial effect on cardiovascular disease in men.

Female sexuality

Female sexuality is an extraordinarily complex process. The physician needs to be aware of the patient's sexuality and whether or not there are sexual concerns. Physiologic changes over the lifespan can interact with sexual performance as can a variety of disease processes. Partner and relationship issues must also be taken into account. Physicians need to include a sexual history as part of their general history and should not be judgmental of their patients' sexual practices. Sexual disorders in women are defined and delineated by those issues causing personal distress. Again, one person's distress may be quite normal to another. The important aspects of care consist of listening, educating, and providing support to the patient. There is increasing interest but a continued need for data in the use of testosterone in women with decreased libido. The use of sildenafil for female sexual dysfunction remains controversial as a benefit. Overall, there is a need for the development of well-organized, randomized, controlled studies on appropriate assessment and intervention for sexual dysfunction in women.

Sex hormones and male health: effects on components of the frailty syndrome

Physicians are seeing an increasing number of older male patients with chronic diseases and conditions. However, the potential relevance of low levels of circulating endogenous androgens in connection with these diseases and conditions is generally poorly understood. Research findings have suggested that androgens play a distinct role in bone metabolism, body composition such as muscle and fat mass and fat distribution, cognitive functioning, mood and well being. The aim of this paper is to summarize the currently available data on the association between endogenous androgens and the intermediate or clinically manifest indicators of chronic conditions in men that might contribute to the phenomenon "frailty". The evidence that reductions in endogenous androgens play a role in age-related health problems is circumstantial. Therefore, large-scale randomized trials are needed to establish whether aging males with low serum androgen levels benefit from androgen supplementation.

Sexuality and disease

Disease is commonly associated with sexual dysfunction in both men and women. In many cases, effective treatments are available that can improve libido, erectile dysfunction, and vaginal dryness. Sexual problems in older persons with disease often lead to anxiety, marital discord, and withdrawal. It is the responsibility of all health care professionals to inquire about sexuality in all patients, no matter what the patient's age, and to be aware that frailty [79-81] is not, in itself, a barrier to sexuality. Health professionals need to give education, support, and counseling on sexuality for patients with disease.

Medications and sexual function

There seems to be a reluctance to self-report sexual dysfunction during clinical interviews. The rate of reported sexual dysfunction increases when information is sought aggressively in the clinical interview. The relationship to a specific therapeutic agent, however, can be clouded by the patient's perception and coexisting morbidity. Most of the data relating sexual dysfunction to specific drugs are anecdotal. The strongest proof of a casual effect is improvement in sexual function after withdrawal of the medication. Most of the adverse sexual effects of commonly used medications can be predicted from a simplified understanding of the human sexual response and physiologic mediators. Alternative therapeutic agents can be substituted by understanding these physiologic mechanisms and a careful clinical interview. Although polypharmacy is a problem for older persons, in some cases sildenafil can be used to correct drug-induced impotence.

Andropause:

There is increasing evidence that the common condition of hypogonadism in older men when associated with symptoms responds well to testosterone replacement. Over the last few years there has been a marked increase in the awareness and treatment of the andropause [137]. Long-term side effects of testosterone are uncertain with only eight people over 50 years having been studied for 10 years [138]. Testosterone needs to be considered a quality-of-life drug, similar to sildenafil, and at present it should be used only if it produces symptomatic improvement. There is a need for a men's health study to determine the long-term efficacy and safety of testosterone replacement in older persons.

Androgen treatment of male hypogonadism in older males

The treatment of primary and secondary hypogonadism with testosterone is well established. Recently, there has been increased awareness that low testosterone levels also occur in chronically ill persons and aging males. Because of sex hormone binding globulin changes, it is more appropriate to make the diagnosis using either free or bioavailable testosterone. A small number of controlled studies have suggested that testosterone replacement in older men improves libido, quality of erections, some aspects of cognition, muscle mass, muscles strength, and bone mineral density. It also decreases fat mass and leptin levels. A number of screening questionnaires for the andropause have been developed. Insufficient numbers of older men have been treated with testosterone to characterize the true incidence of side effects. There is a desperate need for well designed, large controlled trials to establish the value or otherwise of testosterone treatment in older males.

Andropause: knowledge and perceptions among the general public and health care professionals

BACKGROUND

Andropause, the natural age-related decline in testosterone in men, has been debated in the literature. The nonsexual benefits of testosterone replacement therapy (TRT) in male hypogonadism are well documented, but whether health care professionals (HCPs) and members of the general public are aware of these benefits is not known. This study assesses the knowledge and perceptions of andropause and TRT among HCPs and members of the general public.

METHODS

Brief surveys were administered to HCPs and members of the general public who called a medical information telephone line. Trained clinical interviewers surveyed participants for experiences with andropause and TRT and knowledge about nonsexual effects of low testosterone in men.

RESULTS

Of 443 general public callers, 377 (85%) agreed to participate in the survey. Of these participants, 77% had heard of andropause or male menopause, and 63% had taken TRT. Of 88 HCP callers, 57 (65%) participated. Of these participants, 65% were pharmacists, 80% had encountered patients with symptoms of low testosterone, and 50% reported that patients rarely or never initiated conversations about low testosterone. Among HCPs and the general public, respectively, 98% and 91% knew that low testosterone is treatable with medication, and 60% and 57% knew that it results in osteoporosis. Only 25% of HCPs and 14% of the general public knew that low testosterone does not cause loss of urinary control.

CONCLUSIONS

HCPs and members of the general public are knowledgeable about some aspects of low testosterone and have misconceptions about others. Educational initiatives are needed.

Orexigenic and anabolic agents

Anorexia and weight loss represent a major cause of morbidity and mortality. At present in the United States two effective anorectic agents are commonly used, namely, megestrol acetate and dronabinol. These two agents are compared in Table 1. In persons with a large excess cytokine production. megestrol acetate should be tried at a does of 800 mg per day for no longer than 3 months. Megestrol acetate should be administered with testosterone in men. It should be avoided in persons who are bed-bound because of the risk of deep vein thrombosis. Dronabinol should be used for most anorectic patients. Dronabinol should initially be given in a low dose (2.5 mg) in the evening. The dose should be increased to 5 mg per day if no improvement in appetite is seen after 2 to 4 weeks. Dronabinol can be continued indefinitely. It seems to have a particularly good profile for persons with anorexia who are at the end of life. In persons with depression and anorexia. mirtazapine seems to be the antidepressant of choice. In addition, the use of taste enhancers can be considered in persons who complain that the food does not taste good. The appropriate use of anabolic agents in older persons with weight loss is controversial. Certainly all older men who are losing weight should have bioavailable testosterone measured and, if the testosterone level is low, should receive testosterone replacement therapy. Women who are losing weight may benefit from the use of low-dose testosterone (eg, Estratest). Anabolic agents, such as oxandrolone, should be reserved for those who have profound cachexia. An approach to the management of anorexia and weight loss in older persons is given in Fig. 1. Thomas et al have provided a more complex algorithm the management of weight loss in nursing home residents.

Pathophysiology of anorexia

A physiologic decline in food intake occurs with advancing age. The physiologic anorexia of aging and its associated weight loss predispose older persons to develop protein-energy malnutrition. In older persons a variety of social and psychologic factors, diseases, and medications can aggravate the physiologic anorexia and lead to severe weight loss. Many of these factors are amenable to treatment, resulting in a reversal of the underlying malnutrition. This article first reviews the physiologic factors responsible for anorexia in older persons. It then reviews the major pathologic processes responsible for producing protein-energy malnutrition in older persons.

Facilitated feeding in disabled elderly

Nutrition and health are major concerns to older individuals. Whereas illness associated with overnutrition has been well characterized, poor health associated with undernutrition has received less attention. Malnutrition continues to plague the elderly in developed and underdeveloped countries alike, and is becoming of more concern as global demographic changes predict increasing proportions of elderly in all societies. Nutrition influences many chronic disease processes affecting older individuals. In addition, changes in physiology, metabolism, and function accompanying aging result in altered nutritional requirements. The enhancement and maintenance of health and function are now more possible with the new knowledge of nutritional needs in old age. Designing nutritional therapy to treat malnutrition associated with illness in older patients requires an understanding of the aging processes, a careful setting of treatment goals, and multidisciplinary collaboration.

What was the disease of the bones that affected King David?

BACKGROUND

Elderly people have suffered from pain in their bones, which may be associated with various diseases, for thousands of years.

METHODS

This report analyzes the disease that affected the Biblical King David, the second and greatest of Israel's Kings, who ruled the country 3000 years ago.

RESULTS

The sentences "My strength failed.and my bones are consumed," and "My bones wasted away through my anguished roaring all day long" indicate that King David suffered from osteoporosis, which affected his bones. Among the various diseases that may be associated with osteoporosis, the most likely are senile osteoporosis, hyperparathyroidism, or malignant disease. Among these diseases, the diagnosis of malignancy is the most acceptable.

CONCLUSION

This report demonstrates that the roots of contemporary modern gerontology can be traced to Biblical times.

Nutrition in the elderly

It is now well accepted that older persons experience a physiologic anorexia, the anorexia of aging, which is caused by alterations in hedonic qualities of food, fundal compliance, and increased leptin levels. Depression is the most common pathologic cause of weight loss in older persons. Older persons fail to recognize thirst and as such have an increased risk of dehydration. Alterations in brain membrane fatty acids can lead to cognitive impairment in older persons.

Andropause: coming of age for an old concept?

Sex hormones have a broad range of actions in regulating very diverse systems through life as well as critical reproductive and growth processes. Sex hormone biology in its satisfaction of the early demands of species survival and reproductive advantage may be leading a destructive process resulting in frailty and the less desirable aspects of aging that may, in men, be termed andropause. One important system associated directly with aging is interleukin-6, which increases as androgens decline. This may be taking place regardless of androgen receptor activity. It is currently acknowledged that androgens are the first but not the only possible treatment for andropause. There is an acute appreciation of the potentially undesirable impact of androgens on the biology of prostate cancer, as well as, possibly, the cardiovascular system. Most authors agree that careful evaluation and surveillance of the prostate must attend androgen therapy in aging men.