French researchers study frailty in older people with HIV

• As all people age, including those with HIV, the risk for becoming frail increases
• In a French study of older people with HIV, 18% lost some physical ability over one year  
• Muscle strength and endurance exercises have shown effectiveness in reducing frailty

Thanks to effective HIV treatment (antiretroviral therapy, ART), researchers project that many people with HIV will have near-normal life expectancy. As ART users become older, issues related to aging require more attention from healthcare providers and more research.

One age-related concern is frailty. In general, when people age, they are at risk for becoming pre-frail or frail. This makes them more vulnerable to having unfortunate things happen. For instance, an infection or fall that could have minor consequences for a young person could have catastrophic effects on a frail older person. Researchers who study frailty have found that the risk for this condition increases with age and people who are frail can become less functional.

Assessing frailty

A commonly used assessment of frailty is called the Fried frailty score. Components of frailty with this score are as follows:

• loss of 5% or more of body weight or 4.5 kg of weight in the span of one year
• exhaustion
• decreasing levels of physical activity
• slowness in walking
• weakness (measured by grip strength)

Based on the Fried frailty scale, people can be assessed and placed into the following categories:

• robust – no impairment
• pre-frail – one or two of the above criteria indicating decreased functionality
• frail – three or more issues indicating decreased functionality

People can transition from robust to pre-frail and from pre-frail to frail. Some people can transition from frail to pre-frail or pre-frail to robust if their overall health improves.

A French study

A study in France with nearly 500 people with HIV (most over the age of 70) found that 18% experienced a deterioration of physical ability and/or strength over the course of one year. In some cases, having a low CD4+ cell count (less than 350 cells/mm³) and type 2 diabetes increased the risk for this deterioration.

Frailty screening and interventions are needed to improve the overall health of older people with HIV and decrease their risk for frailty.

Study details

A team of researchers from 16 clinics across France analyzed health-related information collected from 491 participants, all of whom had HIV. The research team was interested in assessments of frailty. Upon entering the study, none of the participants had a life expectancy of less than six months. Participants underwent evaluation for frailty at study entry and 12 months later.

The average profile of participants when they entered the study between May 2019 and February 2020 was as follows:

• age – 73 years
• 82% males, 18% females
• years since HIV diagnosis – 23
• 75% had a CD4+ count greater than 350 cells/mm³
• 94% had an undetectable viral load
• 48% had been diagnosed with HIV prior to the approval of effective HIV treatment
• 28% had been diagnosed with a life-threatening infection or cancer in the past

Results

At the start of the study, people who were pre-frail or frail were significantly older and were more likely to have symptoms of depression and difficulty with memory and thinking clearly. People who were diagnosed with frailty compared to people who were robust were more likely to have the following characteristics:

• born in sub-Saharan Africa
• high blood pressure
• type 2 diabetes
• low body mass index (BMI) – less than 22 kg/m²

Issues such as low grip strength and exhaustion were most commonly associated with pre-frailty or frailty.

Transitions between different states

Overall, 68% of participants stayed in their initial assessment category (robust, pre-frail or frail) over the one-year course of the study. Among the remaining participants, 18% had their functional status decline (they became pre-frail or frail) and 14% improved.

Robust category

Among people who were initially assessed as robust, 43% developed pre-frailty over the course of the study and 1% moved directly to frailty. The researchers stated that HIV-related factors were not linked to this deterioration in status.

Pre-frail category

Among people who were pre-frail, 75% remained in this category over the course of the study and 11% deteriorated and moved to a state of frailty. Pre-frail people whose CD4+ counts fell below the 350 cell/mm³ mark or who developed diabetes were more likely to experience a decline in their status. The remaining 14% of people in the pre-frail category improved and became robust. Male participants were less likely to improve their frailty status than women.

Frail category

Among people who were frail at the start of the study, 47% improved over the course of the study and became pre-frail. This occurred because they were able to become more physically active. However, none of the people who entered the study in the frail category improved to a condition considered robust by the researchers.

Survival

A total of 17 participants died during the study. These people were more likely to be frail and to have a lower socio-economic status than those who survived.

Bear in mind

The French study found that the overall state of health of people with HIV who are older than 70 can change over the course of one year. It also found that it is possible for some people to improve their functional capacity over the short-term. This finding should encourage healthcare providers to screen their older patients for frailty and to refer them for rehabilitation when necessary. Long-term studies are needed to assess changes in frailty in older people with HIV and the effectiveness of different interventions.

A promising study in Spain

A separate study in Madrid, Spain, investigated interventions for 40 people with HIV (four of whom were frail) and 20 without HIV (none of whom were frail); all participants were over the age of 50. Researchers devised a series of exercises designed to improve muscle strength and endurance. Participants engaged in an exercise program in or near their homes and wore equipment that monitored them. Over the course of 12 weeks, among participants with an adherence of at least 50% to the exercise regimen, there was a significant improvement in muscle strength, endurance and physical performance. Improvement occurred in exercise-adherent people regardless of HIV status. Three of the four people with HIV who were frail had an improvement in status—two from frail to pre-frail and one from frail to robust.

Among participants who had poor adherence to the exercise program, their overall function declined. The Madrid study shows that exercise can improve physical functioning and that it is possible for people to do such exercise in or near their homes.

A larger and longer study is needed to better understand factors that drive improvement in frailty status and to find ways to motivate people to engage in physical activity.

—Sean R. Hosein

Resource

HIV and aging - CATIE

REFERENCES:

1. Achour J, Abulizi D, Makinson A, et al. One-year fragility transitions among persons living with HIV aged 70 years or more on antiretroviral therapy. Open Forum Infectious Diseases. 2024; in press.
2. Brañas F, Díaz-Álvarez J, Fernández-Luna J, et al. A 12-week multicomponent exercise program enhances frailty by increasing robustness, improves physical performance, and preserves muscle mass in older adults with HIV: MOVIhNG study. Frontiers in Public Health. 2024 Apr 17;12:1373910.