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A Little Dab'll Do You

You won't hear it being bantered about in the locker room,
nor will most men even breathe a word of it to their doctors.
But the condition is so common that up to half a million men
suffer from it. The dreaded disorder hypogonadism or
testosterone deficiency causes a multitude of social and
physical problems in men of all ages, though men over 60 are at
greater risk. Men who have it frequently complain of
unexplained fatigue, loss of sexual interest or function,
sparse facial hair, osteoporosis or spinal fractures and
increased body fat. And while good treatments do exist, they
have traditionally been cumbersome or carry a number of
unpleasant side effects.

Now, doctors at Duke are testing a new testosterone
derivative in gel form that may hold the same benefits of
traditional testosterone replacement therapy but without the
side effects. Because the gel contains a derivative of
testosterone, called dihydrotestosterone, it, theoretically,
won't pose the same risks to the prostate as could a recently
approved testosterone gel, used for younger men with the same
condition. If the new gel proves successful in clinical trials
at Duke and elsewhere, it could replace existing therapies such
as intramuscular injections, skin patches or pills. Duke
doctors say all are somewhat impractical: injections require
biweekly visits to the doctor and cause serious fluctuations in
hormone levels; skin patches can cause allergic reactions to
the skin and often don't adhere well due to perspiration; and
pills must be taken three times daily and held under the tongue
until they dissolve, to prevent liver toxicity. The new gel
need only be applied once a day to the forearm or chest. Its
alcohol base allows the gel to evaporate quickly, leaving the
testosterone derivative to be absorbed throughout the day. Dr.
Thomas Weber of Duke says the three-month clinical trial should
confirm its safety and effectiveness.

The Quickest Route to a Nursing Home

Flexibility and balance-geriatricians say they're the
cornerstones of living independently because they allow us to
walk, bend, reach for an object, even rise from a bed or chair
all the skills necessary to feed, bathe and dress ourselves.
Losing them is often the quickest route to a nursing home. And
for patients with debilitating diseases, the loss of these
skills can speed their demise much faster than is
necessary.

But doctors at Duke have shown that a simple exercise
routine, even among people with degenerative conditions like
Parkinson's disease, can instill a degree of balance and
flexibility that drugs themselves often cannot, according to
Dr. Margaret Schenkman, co-director of the Claude D. Pepper
Older Americans Center at Duke.

In a series of studies among older Americans with disabling
diseases, Schenkman and her colleagues have shown that
Parkinson's patients who exercised for a 10-week period had
significantly greater spinal flexibility and balance control
than those who did not. Exercisers reported having more energy
and greater ability to complete activities like housework and
turning to see behind while driving. On the other hand, those
in the control group actually declined slightly on a number of
physical measures during the 10-week study period.

Schenkman says the exercise data are important because drug
therapy for Parkinson's disease has a number of limitations.
First, the drugs tend to ease the primary impairments
associated with Parkinson's disease, such as tremor and rigid
posture, but are often less effective in reversing or
preventing losses in spinal flexibility. Second, the drugs can
begin to lose their effectiveness over time. As a result,
patients experience increasing disability both from the disease
process and from side effects of the drugs themselves.

Schenkman says further study is needed to determine when in
the disease process exercise should be started, and what are
the long-term benefits in delaying the onset of disability.

Conditioned to Sleep

Many a senior citizen can be heard lamenting the difficulty
they encounter falling or staying asleep. But a quick-fix
remedy like a sleeping pill will only mask the symptoms, not
erase the problems, say Duke sleep researchers.

In a three-month study comparing two sleep remedies, the
researchers found that behavior modification worked better than
a sleeping pill because patients learned to build self-efficacy
and to not rely on artificial means to achieve sleep.

"Many older people attempt to stay in bed longer to
compensate for sleep missed during the night," says Gail Marsh,
associate professor in the department of psychiatry at Duke.
"But staying in bed too long can make their sleep fragmented.
Because a period of sleep is divided into distinct stages, each
with its own purpose and benefit, the interruption of any phase
can disturb the entire sleep pattern."

Marsh teaches patients to make their time in bed more
efficient. First, he advises, don't go to bed until you feel
sleepy. Second, if you wake up during the night, don't stay in
bed awake for more than 20 minutes. Get up and do a quiet
activity such as reading or watching TV. "Otherwise, you get
negatively conditioned toward the bedroom and you begin to view
it as a torture chamber," he says. Third, make sure you keep
regular sleep and wake times. And finally, be exposed to as
much daylight as possible. "People need light to reset their
circadian clocks," he says. "Older people stay indoors a lot
and aren't exposed to much light. The more light you get in the
morning, the better your circadian rhythm will run."

Among the other successful therapies are taking a hot bath
in the late afternoon or early evening, as well as being
physically fit. While a single bout of exercise actually
interfered with a person's ability to sleep among people who
were sedentary, those who were in better physical shape slept
better, their research showed.

Controlling Pain in the Elderly

Among anesthesiologists, there's a long-held belief that the
older the patient, the less anesthesia is required. But that
may not be so, according to Dr. Madan Kwatra, a researcher in
anesthesiology at Duke. While it's true that older adults
respond differently to drugs than younger ones, and they have a
harder time recovering from the effects of anesthesia after
surgery, that doesn't necessarily mean cutting the level of
anesthesia will achieve adequate pain control, he says. As a
result, Kwatra says, many elderly patients may be suffering
unnecessary pain and discomfort.

But finding the optimum dosing is a complicated issue.
Little research exists on the unique effects of drugs on the
elderly because few clinical trials include them. Elderly
patients present a higher risk, so pharmaceutical companies are
fearful that any deaths during a trial would be blamed on the
drug being tested, Kwatra says.

Now, anesthesiologists at Duke, led by chairman Dr. Jerry
Reves, are raising the level of understanding on this
issue.

Last year marked the first of what is planned to be biennial
national meetings at Duke where experts from across the country
can meet and exchange the latest findings. And, as Kwatra
explains, anesthesiology residents at Duke and other
institutions will begin to receive formal training in the
special circumstances posed by the elderly.

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