Age and social gradients in the intensity of aging males' symptoms in Poland

Abstract

Background. We performed the study in order to describe the age-related changes and social gradients in the intensity of aging males' symptoms in healthy men in Poland.

Methods. We examined 405 men aged 32–79, healthy inhabitants of Poland. Severity of aging males' symptoms was assessed using the Polish version of AMS scale. The social position was expressed using their educational level, commonly accepted as a reliable and specific index of social status in Poland.

Results. Male aging in Poland was accompanied by an increase in the intensity of all groups of evaluated symptoms (psychological, sexual and somato-vegetative symptoms, respectively: r = 0.36, r = 0.72, r = 0.59, all p < 0.0001). The results of ANOVA revealed the independent effects of both age and social status on the intensity of psychological symptoms (F = 17.89, p < 0.0001 and F = 9.51, p < 0.0001 for age and educational level, respectively), sexual (F = 114.70, p < 0.0001 and F = 5.90, p < 0.01), and somato-vegetative symptoms (F = 52.86, p < 0.0001 and F = 3.85, p < 0.05). The better the education of Polish men, the less intense the aging males' symptoms, irrespective of their age.

Conclusions. Age and social position constitute major determinants of the intensity of aging males' symptoms in Poland.

Keywords:

• Male aging
• social gradients
• AMS
• Polish population

Introduction

The Aging Males' Symptoms (AMS) scale has been translated from the original German version into English and several European and Asian languages, and has been culturally and linguistically validated [1-7]. Subsequently, the magnitude of age-related changes in aging males' symptoms has been assessed using various linguistic versions of AMS scale in many countries in North America, Western Europe and Asia [1-7]. So far there are no analogous data from Eastern Europe. In particular, the Polish version of AMS scale has not been applied and published anywhere. Taking into consideration the cultural and social backgrounds of the aging process, it is presumed there might be quantitative differences in the phenomenon of male aging between Western and Eastern European and Asian populations [5].

In Poland, regular social gradients have been established regarding several parameters of health status, e.g. indices of obesity, vital capacity [8],[9] and even structure of mortality [10]. Recently, Myon et al. demonstrated that family income determined AMS total score in French men [4]. But otherwise, social differences in the prevalence and the intensity of aging males' symptoms, being an important issue of public health of contemporary aging societies, have not been comprehensively studied.

Therefore, the study aimed: 1) to describe the age-related changes in the intensity of aging males' symptoms in the sample of Polish healthy men and 2) to evaluate the social gradients in the intensity of these symptoms in the examined population. Moreover, in this study we prepared the Polish version of AMS scale.

Methods

Studied population

We studied an ethnically homogeneous (with no national, linguistic, religious or racial minorities) sample of 405 men aged 32–79. The men were healthy inhabitants of the city of Wroclaw, Lower Silesia, Poland. In 2000 they were medically examined in the course of the health screening surveys in the Silesian Centre for Preventive Medicine ‘DOLMED’ in Wroclaw.

Men included in the study did not suffer from any essential chronic diseases (in particular, those resulting in hormonal pathologies) and had not done so in the past. Subjects taking medications (in particular, drugs that could interfere with hormone metabolism) were excluded from the analysis. On physical examination they presented no pathologies. Body mass index, waist/hip ratio, smoking, alcohol consumption, physical activity, nutritional factors, level of education, profession and financial status were not taken into consideration when selecting the men.

The study protocol was approved by the local ethics committee, and all participants gave written informed consent.

Assessment of the severity of aging males' symptoms

Data on the intensity of aging males' symptoms were assessed using the Polish version of AMS scale (17 symptoms divided into 3 clusters: psychological, sexual and somato-vegetative ones) which was fulfilled by the responders themselves. The scale was aimed to assess various symptoms related to male aging and to investigate changes in their magnitude during the process of aging and/or any hormonal intervention [3],[7],[11].

The English version of AMS scale [1],[3],[11] was translated into Polish. The aim of this process was to subsequent questions were understood by Polish men in the same way as by German speakers. Therefore, it was not a simple word-by-word translation, but rather a special pressure was laid on the conceptual similarity with the consideration of specific words and phrases reflecting the language and culture of Poland. The preliminary version was amended and finally accepted by bilingual medical experts. Then, the Polish AMS scale was tested in 18 monolingual Polish men aged 40–63 who came from different social classes and represented various levels of educations. The questionnaire was well understood by all responders. There were no differences in the understanding of the questions between better and worse educated Polish men. The Polish version of AMS scale is available on the official website of the ISSAM.

Following the original version of AMS scale, each item of the scale was rated according to five intensity grades for subsequent symptoms with allocated points (1–5) [1],[3],[7],[11]. For each group, the severity of symptoms was expressed as the sum-scores of all points obtained for the relevant questions [1],[3],[7],[11].

Particular groups of aging males' symptoms were categorized, following cut-off values proposed by Heinemann and co-workers [1],[7],[11] and applied by the others [3-6]. Namely, no, mild, moderate and severe psychological symptoms were observed if psychological score was equal to 5, 6–8, 9–11, ≥12 points, respectively [1],[4-7],[11]. No, mild, moderate and severe sexual symptoms were observed if psychological score was equal to 5, 6–7, 8–10, ≥11 points, respectively [1],[4-7],[11]. No, mild, moderate and severe somato-vegetative symptoms were observed if psychological score was equal to 8, 9–12, 13–18, ≥19 points, respectively [1],[4-7],[11].

Statistical analyses

The independent effects of age and social status were estimated using the two-way analysis of variance (ANOVA). This method allows the extract ion of the independent (‘netto’) effects of particular factors included in the analytical model (i.e. age and educational level) on the variance of analysed variables (i.e. aging males' symptoms). The social position of examined men was expressed using their educational level which was commonly accepted as the reliable and specific index of social status in Poland [9],[11]. For the purpose of this analysis all subjects were assigned to one of the following categories of educational level: 1) completed university (N = 162); 2) completed secondary school (N = 149); 3) basic trade or primary school at the very most (N = 94). The following age categories were used: 1) 32–45 years (N = 136); 2) 46–55 years (N = 148); 3) 56–65 years (N = 81); 4) 66–79 years (N = 40).

Results

Table I demonstrated mean sum-scores for psychological, sexual, somato-vegetative and all aging males' symptoms together with the prevalence of these symptoms of particular severity in subsequent age categories in 405 healthy Polish men.

Table I.  Severity of psychological, sexual, somato-vegetative and all aging males' symptoms in 405 healthy Polish men.

Groups of symptoms	Age categories (years)				Statistical significance
	32–45 N = 136	46–55 N = 148	56–65 N = 81	66–79 N = 40
Psychological symptoms
points	8.4 ± 3.1	10.0 ± 3.6	10.6 ± 3.2	11.8 ± 3.5	F = 14.55, p < 0.0001
Sexual symptoms
points	7.8 ± 2.9	10.6 ± 3.2	13.8 ± 3.4	16.8 ± 3.2	F = 114.51, p < 0.0001
Somato-vegetative symptoms
points	11.7 ± 4.2	15.6 ± 4.5	17.8 ± 4.5	20.5 ± 4.4	F = 57.69, p < 0.0001
All aging males' symptoms
points	27.9 ± 8.5	36.2 ± 9.6	42.2 ± 9.6	49.1 ± 9.4	F = 73.43, p < 0.0001
Psychological symptoms (%)
no	29.4	6.1	3.7	0	χ^2 = 71.72
mild	21.3	35.8	18.5	15.0	p < 0.0001
moderate	33.1	32.4	40.8	37.5
severe	16.2	25.7	37.0	47.5
Sexual symptoms (%)
no	30.1	3.4	0	0	χ^2 = 164.32
mild	22.8	14.9	2.5	0	p < 0.0001
moderate	28.7	32.4	12.3	5.0
severe	18.4	49.3	85.2	95.0
Somato-vegetative symptoms (%)
no	28.0	4.7	0	0	χ^2 = 133.75
mild	33.8	20.3	8.6	5.0	p < 0.0001
moderate	31.6	47.3	49.4	27.5
severe	6.6	27.7	42.0	67.5

All sum-scores reflecting the intensity of psychological, sexual, somato-vegetative, and all andropausal symptoms significantly increased with age (all p < 0.0001). Association between the magnitude of sexual symptoms and age was the strongest among all analysed here. Moreover, the older the age category, the more prevalent the moderate or severe andropausal symptoms in all groups.

Results of the two-way ANOVA evaluating the independent effects of age and educational status on the intensity of aging males' symptoms in Polish men were shown in Table II.

Table II.  Independent effects of age and educational level on the severity of psychological, sexual, somato-vegetative and all andropausal symptoms in 405 healthy Polish men (results of a two-way ANOVA).

Factors	Categories	Groups of aging males' symptoms			All aging males' symptoms
		Psychological symptoms	Sexual symptoms	Somato-vegetative symptoms
Age	1: 32–45 years	F = 17.89	F = 114.70	F = 52.86	F = 73.95
	2: 46–55 years	p < 0.0001	p < 0.0001	p < 0.0001	p < 0.0001
	3: 56–65 years
	4: 66–79 years
Educational level	1: completed university	F = 9.51	F = 5.90	F = 3.85	F = 7.96
	2: completed secondary school	p < 0.0001	p = 0.003	p = 0.02	p < 0.0001
	3: basic trade or primary school at the very most
Interactions	–	F = 0.99	F = 1.70	F = 0.93	F = 0.88
		p = 0.43	p = 0.13	p = 0.47	p = 0.51

Both age and social status (expressed as educational level) significantly differentiated the variance of psychological, sexual, somato-vegetative and all aging males' symptoms. However, within each group of symptoms, the effect of age was greater than the analogous effect of educational level. Irrespective of age, the better the education of Polish men, the less severe the psychological, sexual, somato-vegetative and all andropausal symptoms. The lowest sum-scores for all groups of symptoms were found in men who had graduated from university as compared to those who finished secondary school or those who attended the basic trade or primary school at the very most (Figure 1). The independent effect of education on the variance of andropausal symptoms was the strongest regarding psychological symptoms.

Figure 1. Psychological, sexual, somato-vegetative, and all aging males' symptoms in 405 healthy Polish men in particular age and educational categories (means ± 95%CI). (A) Psychological symptoms, (B) Sexual symptoms, (C) Somato-vegetative symptoms, (D) All aging males' symptoms.

Discussion

In our study, we have observed the phenomenon of age-related changes in the magnitude of aging males' symptoms assessed using the Polish version of AMS scale. Additionally, we have revealed that there is a social stratification in the prevalence and the intensity of andropausal symptoms accompanying male aging in Poland.

In the light of current literature, close associations between the AMS score and age-related androgen deficiency are controversial [6],[13-15]. T'Sjoen et al. reported that circulating testosterone level did not correlate with all sum-scores for psychological, sexual, somato-vegetative and all andropausal symptoms among self-referred men in an aging male clinic [13], and as well in elderly men aged 74–89 [14]. However, in multivariable analysis performed by Kratzik et al., bioavailable testosterone was inversely related to the severity of both psychological and somato-vegetative symptoms in Austrian men aged 40–60 [6]. Also Morley et al. demonstrated negative relationships between the AMS total score, and both serum bioavailable testosterone and calculated free testosterone in aged 23–80 [15]. Moreover, according to Tsuimura et al., a hormone intervention resulting in a significant increase in circulating testosterone was followed by a marked reduction in the severity of all groups of andropausal symptoms in Japanese men aged 55–79 [16].

T'Sjoen et al. revealed that in healthy elderly men aged 74–89 there were strong correlations between psychological, sexual and somato-vegetative sub-scores and the questionnaires reflecting quality of life (Short Form–36 and Rapid Disability Rating Scale-2) [17]. These observation indicates that the AMS scale, among the others, may also reflect the quality of life and the general self-assessed health status expressed by responders themselves in three dimensions of symptoms [7],[17].

The AMS scale is commonly accepted as a valuable tool for the assessment of the intensity of symptoms related to male aging, which enables the comparison of the magnitude of aging males' symptoms under certain diverse conditions and estimate their changes over time [1-3],[7],[17], in particular as a result of any treatment [7],[11],[16].

We have demonstrated that the male aging of Polish men is accompanied by an increase in the AMS scores in all three dimensions, indicating the increase in the intensity of psychological, sexual and somato-vegetative symptoms in older men as compared to younger individuals. These age-related changes in the AMS total score and three sub-scores are seen across all social classes in Poland. Age is the major determinant of the variance of andropausal symptoms in Polish men. The relationship between age and sexual symptoms is the strongest correlation in our analyses. It is commonly known that age itself significantly affects the occurrence of sexual disorders in men [18-20]. Other authors also confirmed positive relationships between age and the severity of sexual [4-6] and somato-vegetative symptoms [4],[6], and as well the AMS total score in male populations [4],[5].

Some authors suggest that a pattern of age-related changes in the severity of andropausal symptoms may differ between particular studied populations [5]. This is presumed to be due to differences in a translation of the original German version of AMS scale, but may as well result from various cultural and socio-economic backgrounds [2],[3],[5].

In the study of Yoshida et al. performed in men aged 40–70 (with 80% individuals younger than 60) without depressive disorders, the AMS total score and sub-scores were in similar ranges as those observed in Polish men (AMS total score: 41.1 ± 7.25 points, psychological symptoms: 9.79 ± 3.11 points, sexual symptoms: 13.6 ± 3.54 points, somato-vegetative symptoms: 17.6 ± 3.91 points) [21]. In the study of Tsujimura et al., the AMS total score and sub-scores for Japanese men aged 55–79 complaining of andropausal symptoms were slightly higher than those seen in our population in analogous age groups (AMS total score: 53.6 ± 9.4, psychological symptoms: 15.0 ± 3.9, sexual symptoms: 16.0 ± 2.9, somato-vegetative symptoms: 22.7 ± 4.7) [16]. When comparing the European data we have observed that among men aged 40 and less, sum-scores and the prevalence of moderate/severe AMS symptoms were comparable between Polish and French men [4]. However, among those aged 40 and over, the magnitude of andropausal symptoms is greater in Poland than in France [4]. However, it was difficult to perform precise comparisons as French data applied only two age categories (> versus <40 years) for younger and older men, respectively [4], whereas we established in total four age groups in our analyses (32–45, 46–55, 56–65, 66–79 years).

Sexual sub-score was similar between Japanese and Polish men up to the age of 70, but only in the oldest age category, the sexual complaints were more severe in Polish men as compared to Japanese males [5]. Sexual symptoms of the moderate-to-severe magnitude were seen in approximately 70% of Japanese men aged 50–59 and in more than 90% of those aged 60 and over [5]. In Poland, the prevalence of sexual symptoms of the moderate-to-severe magnitude was comparable (70% of Polish men aged 46–55, and more than 95% of those aged 56 and over). However, psychological and sexual symptoms remained constant across a broad age range in a Japanese population [5], whereas in Poland both psychological and somato-vegetative sub-scores significantly increased with age.

Finally, we would like to emphasize the social gradients observed in the intensity of all andropausal symptoms revealed in an examined sample of healthy Polish men. Social differences in health indices are of great significance for public health both in Poland and other countries. Also in this context, general health status is strictly related to all-cause mortality within particular social classes. For example, the so-called premature mortality, i.e. deaths among those aged 25–65, is reduced among subjects of better social status assessed by better education, higher income or more prestigious occupation/job both in countries. This phenomenon has been observed in North America, Western Europe [22] and Poland as well [10],[12]. Moreover, in Poland, Rogucka demonstrated the strong relationship between the poorer education of men and their greater mortality when compared to women in analogous age categories [23].

To our knowledge, there is scarcity of evidence on social differences in the intensity of aging males' symptoms in healthy elderly men. So far, in only one study, socio-economic factors were taken into account as potential determinants of the AMS scores [4]. Namely, among 903 French men aged 15–90, being a representative national population panel, age and family income (but neither geographical location nor population density) determined the AMS total score [4].

Our study is the first analysis where the effect of social position (expressed as a level of obtained education) on the variance of select aging males' symptoms has been revealed. In Poland, the strength of the educational effect on the aging males' symptoms varies between particular groups of andropausal symptoms (the strongest effect of education on the variance of psychological symptoms, the weakest effect – on sexual symptoms). Some authors confirm the relationships between erectile dysfunction in elderly men and their educational level [24], whereas the others deny such associations, suggesting rather the relationships between erectile dysfunction and occupation [18].

In other words, we have revealed that in Poland the perception of andropausal symptoms is determined by social environment, and the strongest effect was seen with regard to psychological symptoms. Moreover, the effect of education was the greatest in those aged 66 and more (psychological sub-score for those who graduated university versus those with trade or primary school at the very most – 10.4 ± 2.2 versus 14.4 ± 5.2 points, AMS total score for those who graduated university versus those with trade or primary school at the very most – 46.9 ± 7.5 versus 53.6 ± 12.7 points) as compared to younger age groups (for example, 32–45 years, psychological sub-score for those who graduated university versus those with trade or primary school at the very most −7.9 ± 3.2 versus 8.9 ± 3.0 points, AMS total score for those who graduated university versus those with trade or primary school at the very most – 26.3 ± 9.1 versus 29.9 ± 8.2 points) (Figure 1). We presume that unfavourable health factors related to lower social position may accumulate throughout life, and reveal unfavourable effects on health status just in older age. This may also be a potential explanation of strong relationships between age and the severity of andropausal symptoms seen in Poland. It is also worthy to note that age determines psychological symptoms only in Polish men, but not in French, Japanese and Austrian male populations [4-6]. It cannot be excluded that the effect of education on a perception of andropausal symptoms is specific for Poland and/or for this region of Europe. It would be interesting to investigate analogous associations in other populations.

In conclusion, we have confirmed the applicability of the Polish version of the AMS scale for the differentiation of the severity of andropausal symptoms. In Poland, age is a strong determinant of all evaluated symptoms. Observed social gradients in the intensity of aging males' symptoms suggest that Polish men from lower social classes are at an increased risk of the development of andropausal syndrome (probably due to unfavourable environmental factors). Therefore, the potential anti-aging interventions should be directed in particular to these groups.

Acknowledgements

The study was financially supported by the grant of the National Scientific Committee in Poland No Nr 6POC 04820.