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Emotional Impact of Premature Aging Symptoms in Long-Term Treated HIV-Infected Subjects
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JAIDS Journal of Acquired Immune Deficiency Syndromes:
1 January 2012
Fumaz, Carmina R. PhD*,; Munoz-Moreno, Jose A. MS*,; Ferrer, Maria Jose MS*,; Gonzalez-Garcia, Marian MS*,; Negredo, Eugenia MD, PhD*,; Perez-Alvarez, Nuria MS*,; Clotet, Bonaventura MD, PhD,*Lluita contra la SIDA Foundation, Badalona, Barcelona, SpainHIV Unit-Germans Trias i Pujol University Hospital, Badalona, Barcelona, Spain- Universitat Autonoma de Barcelona, Barcelona, SpainStatistics and Operations Research Department-Universitat Politecnica de Catalunya, Barcelona, SpainAIDS Research Institute IrsiCaixa-HIVACAT, Badalona, Barcelona, Spain
" Almost three-quarters of the participants reported a limitation affecting daily life functioning, interpersonal relationships and work activity that was attributed to aging symptoms. .....In summary, our study shows that aging symptoms were related to more depressive symptoms and limitation in functioning areas in this sample of HIV-infected subjects diagnosed nearly 20 years ago, being women were more affected by these changes......Aging symptoms limited daily life functioning, interpersonal relationships, and work activity according to 74% of subjects (71% men versus 77% women; P = 0.51), 70% of subjects (63% men versus 82% women; P = 0.04), and 61% of subjects (53% men versus 77% women; P = 0.02), respectively......Depressive symptoms were evaluated through the Geriatric Depression Scale (GDS).... GDS is a self-report assessment used to identify depression in the elderly and has been used previously in other studies about depression and HIV infection.8 Scores are interpreted as follows: 0-4 absence of depressive symptoms, 5-8 mild, 8-11 moderate, and >12 severe depressive symptoms.....Participants had a median (IQR) in GDS of 6 (2.7-9). Eighteen subjects had severe depressive symptoms (9 men and 7 women). Gender differences were found regarding median GDS [men: 5 (2-9) versus women: 7 (3.2-10.5); P = 0.08].....Forty-three percent of the subjects reported to think they were suffering from premature aging (18% men versus 80% women; P < 0.0001) and 37% affirmed feeling older than HIV-negative similar-aged subjects (14% men versus 82% women; P < 0.0001).Women had more depressive symptoms, as consistent with previous studies,10 expressed more affectation of the symptoms in all the functioning areas assessed and perceived themselves more prematurely aged.....More than half of the subjects in our study reported to think they were suffering from premature aging, feeling also older than HIV-negative control-aged subjects. The lack of previous literature make difficult to interpret these data but, considering that our subjects were younger than 50 years, it may be thought that the clinical manifestations of aging imply a high emotional burden for these subjects......
The symptoms of depression observed in our study were mild. Mild depressive symptoms go unnoticed and consequently untreated when compared with severe symptoms.9 This lack of perception may lead to an increase of the intensity of the symptoms if support is not provided. However, it is important to emphasize that 18 individuals had severe depressive symptoms according to the questionnaire used and none of them were being treated with pharmacologic or psychotherapeutic treatment at the evaluation. These data alert about the need of assessment of the emotional status in the routine care to detect possible mood alterations that are not perceived in the clinical practice"
To the Editors:
Despite aging-related diseases seem to appear earlier in HIV-infected population, premature aging remains still unclear and undefined.1 Aging includes a number of diverse factors which may favor the impairment of quality of life and emotional status like functional decline, physical dependence, decrease of economic capacity, and changes in social activity and relationships among others.2 Physiological factors such as changes in brain structure and inflammatory processes may become factors of vulnerability as well.3 Different studies have pointed that HIV-infected subjects show higher levels of depressive symptoms than noninfected population.4,5 Multiple stressors such as the impact of the diagnosis or the uncertainty of the course of the disease contribute to increase grief in these subjects. It might be hypothesized that aging symptoms, especially those appearing prematurely, may be factors that contribute to worsen the emotional status of a population that appears per se emotionally vulnerable.
We performed a cross-sectional study to determine the impact of aging symptoms on emotional status and functioning in a sample of long-term diagnosed HIV-infected subjects, exploring the possible differences between genders as well. We hypothesized that the presence of aging symptoms would be related to more depressive symptoms together with a decrease in the functioning of all the areas assessed.
Preselection of the candidates that fulfilled the inclusion criteria was done in the data base of the HIV Unit of Germans Trias i Pujol University Hospital, Badalona, Spain. Eligible candidates were recruited between April 1, 2010, and July 1, 2010, and approached when they attended the hospital in their routine care visits. Inclusion criteria were as follows: (1) age ≥18 years, (2) time since confirmed diagnosis of HIV-1 infection ≥15 years. Subjects were excluded if at the study entry they had documented psychiatric diagnoses, were following a psychotherapeutic intervention, were using intravenous drugs, or were following an anti-hepatitis C virus (HCV) therapy to control their HCV infection.
The study was conducted in accordance with the Helsinki Declaration of 1964 (1996 revision) and Good Clinical Practice guidelines. The Institutional Review Board of our center approved the study (EO-10-102). All patients provided their written informed consent.
Information about subjects' characteristics and HIV-related data were obtained from medical records. Depressive symptoms were evaluated through the Geriatric Depression Scale (GDS) in its 15-item abbreviated form and validated in Spanish population.6,7 GDS is a self-report assessment used to identify depression in the elderly and has been used previously in other studies about depression and HIV infection.8 Scores are interpreted as follows: 0-4 absence of depressive symptoms, 5-8 mild, 8-11 moderate, and >12 severe depressive symptoms.
Participants were asked about limitations attributable to aging symptoms in several functioning areas as follows: daily life functioning, interpersonal relationships, and work activity with the use of yes/no answers items. They were also interviewed about their subjective impression of premature aging regarding their own evolution and compared with HIV-negative similar-aged subjects.
Statistical summaries for the main variables were prepared. The Kolmogorov-Smirnov test was used to explore the distribution of continuous variables. Because variables did not follow a normal distribution, they were described by medians and interquartile ranges (IQR) and were compared using a Mann-Whitney nonparametric test. For the discrete variables, number of patients and percentages were given and compared using the w2 or Fisher exact test (as appropriate). Logistic and ordinal regression analyses were performed to determine the relationship between the presence of depressive symptoms and aging symptoms, subjective impression of premature aging and limitations in daily life functioning, interpersonal relationships and work activity.
Statistical analyses were performed using SPSS 15.0 (SPSS Inc, Chicago, IL) and R 2.12.0 (http://cran.r-project.org/) software with univariate 2-tailed significance levels of 0.05.
A total of 124 subjects who met the inclusion criteria were approached and 100 (81%) agreed to participate. The reasons for not participating were lack of time to complete the questionnaires (18 subjects) and lack of interest in this issue (6 subjects).
Participants were 60 men and 40 women, diagnosed with HIV infection a median (IQR) of 18 (15.7-21) years ago, and had a nadir CD4 cell count and CD4 cell count at the study entry of 172 (95-272) and 543 (403-677), respectively. Eighty percent of the subjects had HIV-RNA viral load under 25 copies and 42% were HCV/HIV coinfected (31 subjects with low fibrosis stage). The infection route had been mainly injection drug use (37%) and men who have sex with men (32%). Sixty-two percent of the subjects were actively working, and 58% had a stable partner. Men and women had similar demographic and clinical characteristics, except for the work situation, because more men were employed (P = 0.04).
Participants had a median (IQR) in GDS of 6 (2.7-9). Eighteen subjects had severe depressive symptoms (9 men and 7 women). Gender differences were found regarding median GDS [men: 5 (2-9) versus women: 7 (3.2-10.5); P = 0.08].
Forty-three percent of the subjects reported to think they were suffering from premature aging (18% men versus 80% women; P < 0.0001) and 37% affirmed feeling older than HIV-negative similar-aged subjects (14% men versus 82% women; P < 0.0001). Aging symptoms limited daily life functioning, interpersonal relationships, and work activity according to 74% of subjects (71% men versus 77% women; P = 0.51), 70% of subjects (63% men versus 82% women; P = 0.04), and 61% of subjects (53% men versus 77% women; P = 0.02), respectively.
Higher scores in GDS were observed in subjects reporting a subjective impression of premature aging [P = 0.04; OR: 1.12; 95% confidence interval (CI): 1.003 to 1.260], feeling older than HIV-negative similar-aged subjects (P = 0.04; OR: 1.12; 95% CI: 1.003 to 1.260), limitation in daily life functioning (P < 0.001; OR: 1.47; 95% CI: 1.186 to 1.747), interpersonal relationships (P < 0.001; OR: 1.51; 95% CI: 1.252 to 1.834), work activity (P < 0.001; OR: 1.49; 95% CI: 1.197 to 1.856), and higher number of aging symptoms (P < 0.001; coefficient 0.0596; SD: 0.128) (Fig. 1).
The symptoms of depression observed in our study were mild. Mild depressive symptoms go unnoticed and consequently untreated when compared with severe symptoms.9 This lack of perception may lead to an increase of the intensity of the symptoms if support is not provided. However, it is important to emphasize that 18 individuals had severe depressive symptoms according to the questionnaire used and none of them were being treated with pharmacologic or psychotherapeutic treatment at the evaluation. These data alert about the need of assessment of the emotional status in the routine care to detect possible mood alterations that are not perceived in the clinical practice.
More than half of the subjects in our study reported to think they were suffering from premature aging, feeling also older than HIV-negative control-aged subjects. Almost three-quarters of the participants reported a limitation affecting daily life functioning, interpersonal relationships and work activity that was attributed to aging symptoms. The lack of previous literature make difficult to interpret these data but, considering that our subjects were younger than 50 years, it may be thought that the clinical manifestations of aging imply a high emotional burden for these subjects.
Women had more depressive symptoms, as consistent with previous studies,10 expressed more affectation of the symptoms in all the functioning areas assessed and perceived themselves more prematurely aged. Multiple causes may be considered to explain these results, among others, a higher cultural pressure regarding female body image and aging, or the fact that women usually explain more their concerns and emotions. Larger studies based on the research of how HIV-infected women and men face aging are needed to shed light on this issue.
In our study, factors that contributed to depression were perception of premature aging, perception of feeling older than negative subjects, limitations in all functioning areas, and more aging symptoms. This finding supports the importance of subjective beliefs about health and their impact on the emotional status and self-care of patients, as shown in a previous study.11
We acknowledge several limitations of this study. Considering that women expressed more emotional affectation it might be thought that factors like menopause might be influencing in these results. A third of our women had secondary amenorrhea, a percentage similar to the one described previously.12 However, the important differences observed between men and women cannot be explained isolated by this factor. Additionally, our study lacks for a control group to compare our data with the situation of noninfected population or younger HIV-infected population. Again, larger studies including matched HIV-negative controls will be necessary to clarify whether HIV-infected subjects are emotionally more vulnerable to the changes that aging brings, especially at a premature stage.
In summary, our study shows that aging symptoms were related to more depressive symptoms and limitation in functioning areas in this sample of HIV-infected subjects diagnosed nearly 20 years ago, being women were more affected by these changes.
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