Hartsell & Associates National Legal Nurse Consultants Newsletter

Male Menopause: Myth or Reality?

"Hormone changes are a natural part of aging for men. But male menopause is not an accurate description. Unlike the more dramatic hormone plunge that occurs in women during menopause, hormone changes in men occur gradually, over a period of many years, the effects of which are often subtle and not noticed until much later in life. Some men are never affected by lower hormone levels at all — while some have physical and psychological symptoms that can include changes in sexual function, energy levels or mood.

While the term "male menopause" is sometimes used to describe decreasing testosterone levels related to aging, Todd Nippoldt, M.D., an endocrinologist at Mayo Clinic, Rochester, Minn., prefers the term "andropause." "There needs to be a distinction because we're dealing with two different situations," he says. "In women, ovulation ceases and female hormone production plummets over a relatively short time frame. In men, there's a gradual decline in the production of male hormones." Age-related decline in testosterone levels are also called testosterone deficiency, androgen decline in the aging male (ADAM) or late onset hypogonadism (LOH).

Male hormones over time

In general, older men have lower testosterone levels than do younger men. After age 40, testosterone levels in the blood begin to decline gradually — at a rate of about 1 percent a year. While there's a steep drop between the ages of 45 and 50, reduction in testosterone levels are rarely significant enough to be noticeable in men younger than 60. By the time men reach their 80s, about half have low testosterone. But testosterone levels vary greatly among men — and some men maintain normal testosterone levels into old age. Other men who have low testosterone levels don't have bothersome signs or symptoms.

What are the symptoms of andropause?

Lower than normal testosterone levels do not cause symptoms in all men — and signs and symptoms of low testosterone vary from person to person. Some of these signs and symptoms are a normal part of aging. The only sure way to know whether you have low testosterone levels is through blood tests.

Signs and symptoms of low testosterone can include:

Reduced sexual desire
Infertility
A decrease in spontaneous erections (such as during sleep)
Swollen or tender breasts (gynecomastia)
Loss of body and pubic hair
Small or shrinking testes
Height loss and thinning bones
Reduced muscle bulk and strength
Hot flushes and sweats

Other signs and symptoms can include:

Decreased energy, motivation and self-confidence
Feeling sad or depressed
Poor concentration and memory
Sleep apnea or other sleep problems
A low red blood cell count (mild anemia)
Increased body fat
Diminished physical or work performance.

Testosterone replacement therapy

"Treatment of low testosterone due to aging with testosterone replacement therapy (TRT) is controversial. The benefits of TRT are not clear, and it may increase the risk of prostate cancer. While certain men who have symptoms related to abnormally low testosterone may benefit from testosterone replacement therapy, it isn't appropriate treatment for most aging men. While it has been shown to help some men with low testosterone, TRT has risks, especially for men with certain health conditions such as prostate cancer and heart disease — and it may not improve your symptoms. More studies need to be done to determine the effectiveness and safety of TRT in aging men, and who can benefit most from this type of treatment. As it turned out with hormone replacement for women, TRT may have possible long-term risks that are not yet known."

Herbal supplements: Do they work?

"Although many herbal supplements are widely marketed with the claim that they can relieve symptoms, none have been proven safe and effective for aging-related low testosterone. One of the most common supplements marketed to treat this condition, DHEA, may increase the risk of prostate cancer. More studies are needed to evaluate possible health benefits — and dangers — of taking DHEA or other supplements. Talk with your doctor before taking any herbal supplements, as some can cause side effects or cause problems with medications.

Is it low testosterone — or is it something else?

Symptoms caused by testosterone deficiency are similar to symptoms caused by other things. Signs and symptoms can include:

A number of other health problems such as liver disease, kidney failure, or an overactive or underactive thyroid
Side effects of medications
Lifestyle choices such as excessive alcohol use or use of illegal drugs
Psychological conditions, such as depression or emotional distress related to life changes that come with middle age (the so-called midlife crisis)

Steps that may help

While there's no way to avoid lower testosterone levels caused by aging, there are a few things you can do to help prevent or improve symptoms caused by the condition:

Eat right and stay active. Regular exercise and a healthy diet can help you maintain your strength, energy and lean muscle mass. It can also improve your mood and help you stay sharp as you get older.
Talk to your doctor about sexual problems. Erectile dysfunction and other sexual issues are common as men get older. Your doctor can help you find the best way to cope. Medical treatment, lifestyle changes or changes to the dose or types of medications you take may help.
Seek help if you feel down. Many older men suffer from depression. It often goes undiagnosed — but treatment can make a big difference in how you feel. Depression in men doesn't always mean having the blues. You may have depression if you feel irritable, isolated and withdrawn. Other signs of depression common in men include working all the time, drinking too much alcohol, using street drugs or seeking thrills from risky activities.

If you are an older man and you have bothersome symptoms you think might be caused by low testosterone, see your doctor to get a firm diagnosis and find out your treatment options. While low testosterone does cause signs and symptoms in some men, your symptoms may be caused by normal aging or something else. Identifying and treating other health issues that can cause or worsen symptoms, making lifestyle changes, or changing the type or dose of medications you take may be enough."

The Mayo Clinic Staff

What Do Patients
Really Want From Their Physician?

The results of a study in the UK (England) of 1000 patients tell us that the number one thing patients want is thoroughness. Do those who have a national healthcare system (as they do in Great Britain) and what we Americans, who have a private system, want different things?

In order after thoroughness, here is what British patients report as most valuable:
* Seeing a doctor who knows them well.
* Seeing a doctor with a warm and friendly manner.
* Having a shorter waiting time for an appointment.
* Having flexibility in selecting appointment times.

As nurses in America, we want:

* a doctor (or other provider) who is competent and knows what she/he is doing
* a doctor who can explain what is going on in the body and what the options are for fixing it
* a doctor who will take enough time to oversee treatment so that no mistakes are made: no drug errors, no surgical errors, and no infections acquired if we have to be in the hospital
* a doctor who will coordinate care, follow up when we've been to see another doctor, and help to keep the big picture in mind so treatment is not being done by drive-by specialists.

Medscape Nursing Article - June 2008

The Inhospitable Hospital: No Peace
and No Quiet

Have you ever heard patients in a hospital complain that they need to go home, just to get some rest? Besides the obvious interruption of sleep in those who may need it the most, studies have documented a relationship between noise and delayed wound healing, aggressive behavior, psychiatric symptoms, and increased rehospitalization rates. Surgical patients identified noise as the biggest irritant during hospitalization. Postoperatively, surgical patients in a noisy environment require more pain medication than those in a quiet setting.

We never talk loudly in libraries, churches, or funeral homes out of respect for their traditions of quiet. We even whisper in museums. Isn't it odd that in the one place where we can actually disturb someone, we don't worry as much about making noise? The same culture of quiet just doesn't exist in a hospital the way it does in a theater during a play.

Healthcare just keeps getting noisier. Nighttime hospital noise is just as severe as daytime noise, and weekends are no quieter than weekdays.

Some sounds are pervasive in hospitals, adding significantly to the overall sound level, although we might not notice their sources. Examples are hospital ventilation, cooling and heating systems, refrigerators, vending and ice machines, automatic doors, water running, paper towel dispensers, pneumatic tube systems, printers, and carts rattling down the hallway. Outside, helicopters land on the roof several times a day, and the sound of sirens can be heard approaching the emergency entrance. Even with the use of personal pagers, the overhead paging system is necessary to alert the staff of code situations and other events requiring urgent attention. The typical hospital is people-dense, and people generate a tremendous amount of speech noise. The most frequent sources of noise in one intensive care unit -- rubbish bins, chair scraping, and talking -- are all caused by human activities.

Hospital noises can affect staff and patients differently. A patient may be more bothered by the sound of inappropriate laughter than the sound of the ice machine. Staff, on the other hand, might be more annoyed by alarm sounds. Frequent alarm sounds contribute to overall noise levels in patient rooms and intensive care units. The high number of false alarms can render clinical staff impervious to the sound of alarms.

How Noise Affects Patients

Noise is antithetical to a therapeutic environment. More than a nuisance, noise is a real health hazard.Although the burden of morbidity attributable to noise isn't known, there are indictors that the effects of noise on physical and mental health are significant. One of the most serious implications for patients in a continuously noisy environment is an increased risk of hypertension and ischemic heart disease. Noise-induced secretion of cortisol may be a mediator of cardiovascular responses to noise. Noise studies have also documented delayed wound healing, aggressive behavior, psychiatric symptoms, and increased rehospitalization rates. Moore and colleagues found that surgical patients identified noise as the biggest irritant during hospitalization, and, postoperatively, surgical patients in a noisy environment require more pain medication than those in a quiet setting. Noise can even increase symptoms of heartburn in patients with gastroesophageal reflux disorder.

Noise also interrupts sleep in hospitalized patients, some of whom are particularly vulnerable to sleep disruption. Patients at high risk of having their sleep disturbed by noise include children, very low birth weight infants, pregnant women, anxious individuals, the elderly, and residents of long-term care facilities. The WHO recommends that for good sleep, background sound levels should not exceed 30 dB(A), with individual sounds no greater than 45 dB(A). Intermittent noise might be more disruptive to patients' sleep than continuous noise.

How Noise Affects Staff

Noise is an environmental stressor. No one likes noise intruding into their personal or work space. The problem is, noise is pervasive in the hospital, so we become accustomed to it and miss opportunities to reduce it. We may not even be aware of the impact of noise on our ability to concentrate on tasks, or if we are, we tend to try to work around excessive noise rather than eliminating it. When our work environment becomes noisy, we compensate by moving away, raising our voices, or repeating ourselves; in essence, by exerting more effort and working harder.

Sound is considered part of the "psychosocial work environment" in healthcare facilities. Excessive noise can increase perceived work pressure, stress, and annoyance. Noise contributes to fatigue, emotional exhaustion, and burnout. Tachycardia and other physiological responses to noise stimuli have also been demonstrated.

Noise is a constant threat to patient safety by making patient-staff and staff-staff communication more difficult. Although the Joint Commission doesn't specify maximum sound levels for different patient care environments, they mandate that the ambient sound environment should not exceed a level that would prohibit clinicians from clearly understanding each other. Speech intelligibility is compromised most in environments with excessive reverberation.

Controlling noise is an important intervention in creating a healing environment. Excessive noise, and its effect on rest, are high on the list of complaints made by patients on post discharge patient satisfaction surveys.

There is no "one-size-fits-all" plan for noise reduction. Facilities aiming to solve their noise problems must first examine the sound environment by conducting a sound and noise study.

Medscape Nursing Article by Laura Stokowski RN, MSN