Abstract
Objectives. To analyse the relation between results of the Aging Males' Symptoms (AMS) questionnaire for aging males, and of quality of life (QOL) questionnaire SF-12 and cardiovascular risk factors.
Methods. 1,927 men aged 55–85 years were interviewed by 56 general practitioners. During the interview the men were asked to fill in the AMS scale and the QOL questionnaire SF-12.
Results. Of 1,927 men 1,806 men filled correctly the AMS questionnaire. The mean SF-12 mental index was respectively 55.9 in men with a total AMS score indicating no impairment, 50.9 mild, 42.8 moderate, and 32.8 severe impairment. The corresponding values for the physical index were 51.2, 46.7, 40.8 and 32.3.
A history of diabetes was associated with an increased risk of reporting moderate/severe impairment: in relation to the total AMS score the odds ratio, (OR), of moderate/severe impairment in comparison with no impairment was 1.6 (95%CI 1.2–2.1). A history of myocardial infarction and hypertension increased the risk (respectively OR 1.4 (95%CI 1.1–18) and 1.7 (95%CI 1.2–2.4)).
Conclusions. This study shows that higher AMS scores are associated with lower SF-12 indices and suggests that elevated values of the AMS score are associated with cardiovascular risk factors or diseases.
Introduction
Symptoms of aging males affect several aspects of life Citation[1]. The most common are sexual aspects, but psychological and physical aspects are also affected.
A recent study conducted in France has shown a lower quality of life (QOL), as measured with the generic quality of life scale SF-12, in men with higher values on the Aging Male Symptoms (AMS) questionnaire for the symptoms of aging males Citation[2]. Similar results also emerged from a study conducted in Germany Citation[3]. In consideration of the potential role of socio-cultural determinants of QOL, it is important to obtain data from different countries.
An association between testosterone levels and the risk of cardiovascular diseases has been suggested Citation[4]. This aspect has a relevant impact in terms of public health, in consideration of the frequency of symptoms and cardiovascular diseases.
In this paper we present the results of a large cross sectional study conducted in five Italian areas on the relation between aging male symptoms, QOL and determinants of cardiovascular risk Citation[5],Citation[6].
Methods
Men aged over 55 years were identified, during the period May 2005–March 2006, by 56 general practitioners (GP) among their registered patients, using a computerized generated random numbers list. The GPs were located in the following areas: Desio, Palmanova/Gorizia in the north of Italy (24 GPs), Parma and Firenze in the centre (21 GPs) and Naples in the south of the country (11 GPs).
The identified men were invited to a confidential interview by their GP. Using a questionnaire shared by all GPs, data were obtained about the general characteristics and habits of study subjects. During the interview, the men were also asked to fill the AMS questionnaire. This is a well known questionnaire originally developed in Germany and now validated into more than 15 languages Citation[7-10]. It is a self-administered questionnaire designed to assess symptoms of aging. The original AMS questionnaire was validated into Italian: the process of this validation has been published Citation[11].
Quality of life was measured using the SF-12 questionnaire. This questionnaire is a 12-item generic QOL measure that assesses physical and mental functioning over the previous four weeks. Scores range from 0 to 100 for each dimension, 100 indicating optimal QOL Citation[12],Citation[13].
A total of 1,927 men entered the study. Each subject gave his written informed consent before the interview. The study protocol did not include any clinical or diagnostic procedures, and was approved by the Ethical Committee of Institutions of each area.
The average number of interviews for each GP was 34 (range 10–49). We collected information on the numbers of eligible men who did not enter the study in a subset of 20 GPs. Among eligible subjects identified by these GPs, 9% refused to participate (4% for ‘personal’ reasons and 5% on account of their clinical condition) and 5% were not contacted due to organizational problems.
A man was considered a smoker if he had smoked more than one cigarette/day for at least one year; an ex-smoker if he had smoked more than one cigarette/day for at least one year, but had stopped more than one year before the interview; and a non-smoker if he had never smoked more than one cigarette/day in his life.
With regard to medical history, whenever relevant, information given by the patient was checked by his GP with medical records. Subjects were considered to suffer from diabetes or hypertension if they were following a dietary or pharmacological treatment for these conditions, or after a medical diagnosis.
Out of the 1,927 interviewed men, 1806 men (93.7%) filled correctly the AMS questionnaire. The data analysis presented in this paper is based on these subjects.
Data analysis
Descriptive statistics such as the mean, standard deviation (SD) and median were used to describe the summary measures of AMS and SF-12 questionnaire. Confidence intervals (CI) of estimated percentages of frequency of impairment as defined by the AMS questionnaire were based on Poisson's approximation. Comparison between AMS and SF-12 scores were performed using a generalized linear model with adjustment for age and centre. Odds ratio (OR) as estimators of relative risk of reporting moderate/severe impairment according to the results of AMS questionnaire versus no/mild impairment and corresponding 95% confidence interval (CI) were computed using unconditional multiple logistic regression Citation[14]. The terms included in the equation are indicated in the footnotes to the tables.
Results
Study population
The distribution of study subjects according to their general characteristics is shown in . The mean age of the interviewed men was 67 years (SD 7.2). A total of 784 men were recruited by GPs placed in the north, 638 in the centre and 384 in the south of Italy. Primary or intermediate school degree was reported by 1,112 men (62.0%), high school degree by 482 (26.9%) men and university degree by 200 men (11.2%).
Table I. Characteristics of study subjects1.
The body mass index (kg m−2) was <25 in 596 subjects (33.2%), 25–30 in 949 (52.8%) and >30 in 253 men (14.1%).
AMS score
shows the results of AMS score. Considering the total score, a severe impairment was reported by 3.5% of subjects: the values were 1.3% (95% CI 0.7–3.0), 3.3% (95% CI 2.7–4.9) and 6.2% (95% CI 4.5–8.9) considering separately men aged ≤62, 63–70 and ≥71 years. The values for the total populations were 13.5% (95% CI 11.9–15.3), 7.3% (95% CI 6.4–8.8) and 37.0% (95% CI 34.2–40.1) respectively for psychological, somatovegetative and sexual symptoms score. The frequency of subjects reporting severe impairment increased with age for all the three scores, but the increase was more marked for sexual factors.
Table II. Distribution of study subjects according to the results of the AMS score and age1.
With regard to the frequency of moderate impairment, the values were for the total population 17.8% (95% CI 15.9–20.0) for the total score, 21.7% (95% CI 19.7–24.0) for psychological symptoms, 30.5% (95% CI 27.9–33.4) for somatovegetative symptoms and 32.2% (95% CI 29.7–34.9) for sexual symptoms.
Relation between AMS score and results of the SF12 questionnaire
The mean scores for physical and mental components of the SF-12 in relation to the results of AMS questionnaire are shown in , the lower scores indicating more impairment. QOL, as assessed by both mental and physical functioning from the SF-12, decreased with increasing impairment of symptoms as measured with the AMS score: the mean SF-12 mental index was respectively 55.9 in men with a total AMS score indicating no impairment, 50.9 (mild impairment), 42.8 (moderate impairment) and 32.8 (severe impairment). The corresponding values for the physical index were 51.2, 46.7, 40.8 and 32.3.
Table III. Mean SF12 score (DS) according to impairment as evaluated by the AMS score.
The correlation coefficients for the analysis presented ranged from 0.36 to 0.65. The mental domain of the SF-12 score was more associated with the psychological subscale of the AMS score (r = 0.65) with regard to the total score (r = 0.62) and the somatovegetative subscale (r = 0.56). With regard to the physical domain of the SF-12, this was more correlated with the somatovegetative AMS subscores (r = 0.57) than with other AMS subscores.
We have further analysed the relation between SF-12 results and total score in strata of age: similar findings emerged ().
Table IV. Mean SF-12 score (±DS) according to AMS total score and age.
Risk factors for moderate/severe impairment
A history of diabetes was associated with an increased risk of reporting moderate/severe impairment: considering the total score the OR was 1.6 (95% CI 1.2–2.1). Likewise a history of myocardial infarction and hypertension increased the risk (respectively OR 1.4 (95%CI 1.1–18) and 1.7 (95% CI 1.2–2.4)) (). No association emerged with body mass index, education, smoking, alcohol and coffee consumption from our data.
Table V. Risk factors for reporting moderate/severe impairment according to the AMS total score.
Discussion
Limitations of the study
Potential limitations of this study must be considered. First of all, the study population consisted of men randomly identified on the lists of a network of GPs. The GPs, however, were not randomly identified among all Italian GPs, so their patients cannot be considered representative of the Italian population. Nevertheless, GPs participating in this study were located in the three main areas of the country and there were no marked differences in results among them (data not shown), giving strong support to the consistency of the general findings of the study. Further, the mean scores for physical and mental components on the SF-12 for the men reporting no or mild impairment were comparable to the overall Italian population Citation[13]. Finally, participation in the study was very high (more than 90% of the patients in the subgroups of GPs who collected this information). The patients were interviewed by their GP, therefore information regarding medical history should be particularly accurate.
Association between AMS and SF-12 scores
The results of this study indicate a relation between high AMS scores and low QOL scores, with regard of both mental and physical SF-12 indices. The results of this analysis agree with previous published data Citation[2],Citation[3]. For example a recent study conducted in France on a representative sample of 963 males aged 15 years or more, has shown a good correlation between AMS questionnaire score values and the generic quality of life scale SF-12 Citation[2].
The relation between the AMS and the SF-36 score was also investigated in a German study including 116 males aged 40 to 70 years. The total scores and the three subscores of the AMS scale were compared with subscales of the SF-36. A statistically significant correlation emerged between the AMS total score and the mental and physical scores of the SF-36. The correlation of the somatic AMS subscore and the physical subscore of SF-36 was high as well as the psychological subscore of AMS and mental subscore of SF-36 Citation[3].
We found that the mental domain of the SF-12 score was more positively associated with the psychological subscale of the AMS score and that the physical domain was more positively correlated with the somatovegetative AMS subscore.
It is interesting to note that the impact on QOL of higher AMS score increased with age, but was already observed in the age group of men 55–60 years old. A similar finding has been reported previously Citation[2]. As previously suggested Citation[2], the similarities in the results observed in different countries give strong support to the comparability of the AMS across countries.
Relation between AMS scores and cardiovascular risk factors
Another interesting result of this study is the relation between higher AMS scores (indicating moderate or severe impairment) and a history of diabetes, hypertension, and myocardial infarction. These results suggest that the aging male syndrome is often associated with the risk profile of cardiovascular diseases. We have to emphasize, however, that we observed this relation retrospectively.
Testosterone deficiency in hypogonadism or testosterone deprivation in normo-gonadotropic men increases fat mass. Citation[15]. Smokers have higher testosterone levels than non-smokers Citation[16], while the relation between alcohol consumption and testosterone level is less clear Citation[17]. In our study we did not observe a statistically significant elevated risk of reporting moderate/severe sexual symptoms in men with elevated BMI, and no association emerged with smoking and alcohol drinking.
In conclusion this study shows that higher AMS scores are associated with lower SF-12 indexes and suggests that elevated values of the AMS score are associated with cardiovascular risk factors or diseases.
Acknowledgement
The study was supported by a grant of Schering Italia.
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