Search

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.

Erectile dysfunction is defined as a consistent inability to obtain or sustain an erection sufficient for intercourse in at least 50% of attempts. The term erectile dysfunction has replaced the more pejorative term impotence. A revolution over the past 10 years in the understanding, diagnosis, and treatment of this disorder has enhanced the ability to discuss it more openly than ever before, by both patients and physicians. This disorder affects 10 million to 30 million men in the United States and more than 140 million men worldwide. 12,33 In 1996, there were 1.3 million office visits for the treatment of erectile dysfunction, reported by the National Ambulatory Medical Care Survey, more than double the rate found in 1985. 7,32 There are few disorders that impact quality of life, sense of self and esteem, and relationships with significant others in quite the same way. Although erectile dysfunction is discussed more openly, many myths remain. With aging, the prevalence of erectile dysfunction increases. This prevalence does not represent normal aging, however, any more than hypertension is considered to be normal in an older adult, and erectile dysfunction is not an inevitable effect of aging. Further, a decline in sexual function may relate to matters other than erectile difficulties, such as illness on the part of an individual or his partner, lack of a partner, loss of libido, or environmental issues (e.g., institutional living).

Falls following a meal occur commonly in older persons. These falls have been related to a decrease in postprandial blood pressure due to carbohydrates in the meal. The mechanism by which this occurs is not known. In this study, we examined the possible role of a vasodilatory peptide, calcitonin gene-related peptide (CGRP), which is released following carbohydrate loading in the pathophysiology of postprandial hypotension. Levels were assessed in 29 community-dwelling individuals aged 20-83 years during an oral glucose tolerance test, and heart rate and blood pressure were measured. Five subjects exhibited a postprandial reduction in systolic blood pressure (SBP) greater than 15 mmHg (mean reduction -30 +/- 4 mmHg). Four were aged over 60 (40% of the individuals in that group) and one was middle aged (11%). One individual in the older group was temporarily symptomatic, complaining of light-headedness. Linear regression analysis showed a significant association between the changes in CGRP and in blood pressure: SBP (r = 0.39, P = 0.037), and mean blood pressure (MBP) (r = 0.356, P = 0.06) in the oldest group. Individuals in this group with a greater than 15 mmHg drop in blood pressure, exhibited significantly greater changes in CGRP (SBP: P = 0.001, diastolic blood pressure (DBP): P = 0.05, MBP: P = 0.006). This association of log CGRP delta and BP change was not present in young or middle aged individuals. Thus, increases in CGRP levels were associated with blood pressure reduction, with older individuals more susceptible to these changes than younger individuals. CGRP may play a role in the pathogenesis of postprandial hypotension.

Tests of thyroid function may present a challenge in their use and interpretation, but careful consideration of the patient's clinical state, the role of nonthyroidal disease, or medication on the patient's thyroid function tests can make this task easier

Corticosterone increases with aging but pregnenolone, dehydroepiandrosterone, and testosterone decrease. The marked decrease in hormones that occurs with aging may contribute to the age-related deficit in learning and memory. Administration of these hormones after training was found to improve long-term memory processing in normal young mice. SAMP8 (P8) mice show an age-related loss of learning and memory for a variety of tasks whereas age-matched control mice of the closely related SAMR1 (R1) strain do not. In this study, we found an age-related decrease in serum testosterone levels of 71% between P8 mice 4 and 12 months of age, but only a 26% decrease between R1 mice of the same ages. The difference between the P8 mice was significant (p < 0.01) and the difference between the R1 mice was not. The decrease in testosterone in 12-month-old P8 mice was not accompanied by gross morphological change in the testes. A SC testosterone implant, sufficient to increase plasma testosterone levels to 414 +/- 25 ng/dl, alleviated impaired learning and memory of a foot shock avoidance task in P8 mice. Castration of 4-month-old P8 mice did not produce a deterioration in learning and memory, indicating that low levels of testosterone per se are not responsible for the impairment seen in 12-month-old P8 mice. This suggests that impaired cognitive functioning of the older P8 mice was due to an interaction of aging and reduced testosterone levels.

The sexuality of older women has been an area that has received very little investigation until recently. This article explores myths, realities, and alterations in the physiologic function of older women. In addition to hormonal, physical, and functional parameters, other issues also must be considered in this population, such as relationship /interpersonal issues, levels of expectations, "libido mismatch," partner availability, and partner and self-health. Sexual function is a quality of life issue that remains an integral part of successful aging

Comprehensive geriatric assessment has much to offer older women. In this article, differences between comprehensive geriatric assessment and the traditional internal medicine approach are delineated, and specific methods are described for assessing sensory function, continence, nutritional status, risk for falls, upper extremity function, cognition, affect, bone integrity, sexual function, alcohol problems, medication use, socioeconomic milieu, and the home environment. Advanced planning, screening, and prevention also are discussed, and a prototypic form for the initial assessment of the older woman is provided

Decreased sexual function commonly occurs with aging but should not be considered a normal event. This article discusses normal physiologic changes and the pathologic events that can lead to erectile difficulties. Proper evaluation can lead to a more appropriate choice of therapeutic agent or device and can benefit the quality of life of the older man and his partner.

Diabetes mellitus is a common condition in the geriatric population. In older subjects it may present in unusual ways and may be associated with unusual conditions. Hyperglycemia produces a variety of effects, including osmotic diuresis and cognitive dysfunction, which seriously impair the quality of life of the older individual. Older diabetics need to have their diabetes well controlled. The approach to diabetic control in older individuals is similar to that in younger individuals, with some notable exceptions.

From the Geriatric Research, Education and Clinical Center, Sepulveda Veterans Administration Medical Center, Sepulveda, California, and the Department of Medicine, University of California, Los Angeles, California. Dr. Kaiser is a John A. Hartford Faculty Development Award Fellow in Geriatric Medicine. Requests for reprints should be addressed to Dr. John E. Morley, Geriatric Research, Veterans Administration Medical Center, 16111 Plummer Street, Sepulveda, California 91343. Manuscript submitted February 2, 1987, and accepted March 3, 1987. Diabetes mellitus in elderly patients is exceedingly common, with a prevalence in the United States of 6.9 percent in men older than 65 years and 8.9 percent in women older than 65 [I]. Among persons older than 80, 16 to 20 percent have diabetes mellitus [2]. The National Nursing Home Survey estimated that 14.5 percent of nursing home residents have diabetes mellitus [3]. In the United Kingdom, two thirds of all diabetic patients who are hospitalized are older than 65 years [4]. Diabetes mellitus is often missed in the elderly, as demonstrated by a screening program in a Canadian old people’s home, where 32 percent of the residents were reclassified as diabetic over a three-year period [5]. Furthermore, diabetic residents of nursing homes have a higher rate of hospitalization for diabetic complications compared with ambulatory diabetic patients older than 65 [6]. Thus, diabetes mellitus represents one of the major chronic disorders of the growing elderly population. Despite these impressive numbers, little attention has been paid to the special needs of elderly diabetic patients [7].

Impotence occurs commonly with advancing age. Approximately one half of impotent males over 50 years of age have a vascular cause for their impotence. Vascular impotence is often the harbinger of vascular disease in other organs of the body. Hypogonadism occurs in up to one fourth of older men. The relationship of hypogonadism to impotence is uncertain. Medications and neurologic diseases (both central and peripheral) are other major causes of impotence. The treatment of impotence has been revolutionized with the widespread availability of vacuum tumescent devices. The alterations in female sexuality with advancing age have been less well studied. Hysterectomies and bilateral oophorectomies are most probably done more often than necessary in the United States and may alter sexuality. There is some evidence supporting a role for estrogens and testosterone in the regulation of female libido. Physicians need to be more aware of the rapid changes in our understanding of human sexuality and aging.

Studies relating to pathogenetic mechanisms resulting in impotence in diabetic subjects have been reviewed. Erectile dysfunction was reported to occur in 50 to 75 percent of diabetic patients and the prevalence appeared to increase with age. Contributions of vascular, endocrine, and neurologic system alterations result in this disturbing condition, but a detailed analysis of all the parameters was not found in any individual study. In our review of 301 veterans presenting to a sexual dysfunction clinic, the clinical and hormonal alterations in the diabetic patients closely resemble those seen in nondiabetic impotent subjects. Atherosclerotic vascular changes play an important predisposing role in the development of impotence. A difference exists between the prevalences of associated medical conditions in diabetic patients taking insulin, compared with those receiving oral agents or receiving dietary management. The high prevalence of impotence in diabetic patients seems to be due to the high prevalence of its vascular complications. Considering the availability of useful therapeutic approaches, it is mandatory to evaluate all diabetic men for the presence of impotence.