Thanks to the many benefits of potent combination anti-HIV therapy (commonly called ART or HAART) more HIV-positive people in Canada and similar countries are living longer. The power of ART is so profound that researchers increasingly expect that some HIV-positive people will have near-normal life spans.
As people with HIV enter their later years, changes will be needed in the care that they receive; they and their care providers will have to be more attentive to issues of aging. For the average HIV-positive young adult starting ART today, goals would likely include a simple regimen with minimal side effects so that a low viral load in the blood can be achieved and maintained. As people age, goals may increase or shift to include maintaining a good quality of life as well as physical, mental and emotional health. To enable successful aging, elements of geriatric care will have to be incorporated into regular medical visits.
Geriatric syndromes
Doctors use the term geriatric syndromes to refer to common conditions seen in older people that can have several underlying causes. Examples of symptoms found in geriatric syndromes include the following:
- falls
- dizziness
- fainting
- being frail
- urinary incontinence
- delirium – a disturbance of consciousness with several features, including problems with attention and awareness; memory difficulties; perception problems, such as seeing or hearing things that are not real (hallucinations); being unsure about one’s physical location; disturbances in speech and language. In cases of delirium a person’s mental status can suddenly change over hours or days. Delirium can render people confused and disoriented. Some people may also become violent and disruptive. Delirium is not the same as dementia.
In general, the underlying cause(s) of the problems in geriatric syndromes may involve several organ-systems, and each element of geriatric syndrome increases the vulnerability of older people to further problems.
Aging and HIV
Given that older HIV-positive people are going to need care appropriate for their age, a team of researchers who study infectious diseases and aging at the University of Connecticut have proposed that doctors caring for aging HIV-positive people incorporate “geriatric assessment” into regular care. Such assessments would evaluate patients for what the researchers called “specific conditions that may predispose [patients to become less functional],” such as the following:
- visual difficulties – problems in this area could impact falls and medication adherence
- inner ear infections and hearing difficulties – problems in this area could affect balance, falls, ability to understand instructions and communication with care providers
- issues with balance and walking – this could increase a person’s likelihood of falls
In San Francisco
A team of researchers in San Francisco has begun to try to understand the effect of aging on HIV-positive people. The team specifically sought to assess the presence of geriatric syndromes in people who were more than 50 years old and who had been taking ART and had a low viral load for several years.
The study of 155 people found that geriatric syndromes were present. Participants with a greater number of co-existing health conditions were at increased risk for developing geriatric syndromes.
Study details
Researchers recruited participants from two major infectious disease clinics in San Francisco. Participants completed questionnaires, had a physical exam and had blood samples drawn. All of this data was analysed together with their medical records.
Researchers focused on the following issues:
- falls
- urinary incontinence
- impaired mobility
- impaired ability to carry out certain everyday activities (including housework, managing medications, bathing, dressing, shopping)
- problems with hearing and vision
- depression
- difficulty thinking clearly and problems with memory
- frailty (see below)
The research team defined frailty and pre-frailty by assessing the presence of the following symptoms:
- unintentional weight loss
- self-reports of exhaustion
- low physical activity
- slow walking speed
- physical weakness (assessed by hand-grip strength)
Researchers classified people as frail if they had three or more of these issues and pre-frail if they had one or two.
Data from 155 people were available for analysis. The average profile of these participants was as follows:
- age – 57 years
- 94% men, 6% women
- duration of HIV infection – 21 years
- CD4+ count – 537 cells/mm3
Results
On average, participants had four co-existing health conditions (comorbidities). The most common were as follows:
- abnormal levels of cholesterol and triglycerides in their blood
- higher-than-normal blood pressure
- injured and painful nerves in the hands, arms, legs or feet (peripheral neuropathy)
Participants took an average of nine non-HIV drugs as part of their daily regimen.
Complex issues
Researchers found that 54% of participants had at least two geriatric syndromes, such as the following:
- pre-frailty – 56%
- difficulty with one or more activities of daily living – 47%
- forgetfulness and problems thinking clearly – 47%
Other problems included the following:
- falls – 26% disclosed that they had fallen in the past year; on average there were two falls per person per year. In about 13% of such cases medical care was sought.
- urinary incontinence – 25%
- impaired hearing – 41%
- impaired vision – 50%
- depressive illness – 22% of participants had mild depression and 18% had moderate-to-severe depression
Possible links
Bear in mind that the study was observational and cross-sectional in nature. That is, data were captured largely at one point in time and participants were not recruited at random. Such studies are good at finding associations between a potential risk factor and an outcome (one of the geriatric syndromes mentioned earlier), but they cannot prove that a purported risk factor causes a particular outcome. Their findings must be taken cautiously.
In the study, researchers found that people who had low pre-ART CD4+ counts were at greater risk for the future development of geriatric syndromes. They also found that people of colour were at increased risk for such syndromes.
It is likely that participants who reported peripheral neuropathy were exposed to a group of older anti-HIV drugs—commonly called “d-drugs”—that can be toxic for nerve cells:
- ddI (didanosine, Videx)
- d4T (stavudine, Zerit)
- ddC (zalcitabine, Hivid)
Cross-sectional studies such as the present one are a good first step and can be used to establish that there is a medical problem that requires further investigation in a larger and more expensive study of robust statistical design. Such a study could investigate additional potential risk factors for geriatric syndromes. Based on the findings in the present study, the researchers recommended that earlier initiation of ART may be one way of delaying or avoiding the development of geriatric syndromes. However, given that advice in treatment guidelines and clinical practice in high-income countries is generally moving toward initiating ART early in the course of HIV infection, such a recommendation from the researchers may not be as important in the present era.
The San Francisco researchers should be praised for doing the preliminary work necessary to document that geriatric syndromes are occurring even in middle-aged HIV-positive people. A future study should enroll HIV-positive and HIV-negative people—including more women—of similar socio-economic backgrounds so that relevant and meaningful comparisons can be made. Such a study needs to explore a combination of other potential risk factors for geriatric syndromes including the following (as mentioned by the researchers):
- psychosocial factors (social isolation, substance use)
- the presence of several co-morbidities
- the burden of taking multiple medications for multiple conditions
- chronic inflammation
Resources
Management of Human Immunodeficiency Virus Infection in Advanced Age
Long-term HIV infection and health-related quality of life – CATIE News
Dutch doctors explore intersection of aging and HIV – CATIE News
Report to the NIH about Aging and HIV
CIHR’s HIV Comorbidity Research Agenda: Relevant Research Areas
HIV and Aging – Healthy living tips for people 50 and over living with HIV
HIV and Aging – CATIE Webinar Series: Building Blocks
Factsheets on HIV and aging in Canada – Canadian AIDS Society
—Sean R. Hosein
REFERENCES:
- Greene M, Covinsky KE, Valcour V, et al. Geriatric syndromes in older HIV-infected adults. Journal of Acquired Immune Deficiency Syndromes. 2015; in press.
- Chirch LM, Hasham M, Kuchel GA. HIV and aging: a clinical journey from Koch's postulate to the chronic disease model and the contribution of geriatric syndromes. Current Opinion in HIV/AIDS. 2014 Jul;9(4):405-11.
- Brothers TD, Kirkland S, Guaraldi G, et al. Frailty in people aging with human immunodeficiency virus (HIV) infection. Journal of Infectious Diseases. 2014 Oct 15;210(8):1170-9.
- Justice A, Falutz J. Aging and HIV: an evolving understanding. Current Opinion in HIV/AIDS. 2014 Jul;9(4):291-3.
- Greene M, Steinman MA, McNicholl IR, et al. Management of human immunodeficiency virus infection in advanced age. JAMA. 2013 Apr 3;309(13):1397-405.