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HIV+ Falls, Fractures & Death...."impending epidemic of bone fractures".....federal officials & others continue & persist to ignore this problem
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Download the PDF here
Download the PDF here
from Jules: I predict an explosive & devastating disaster in aging older HIV+.....we will see a higher death rate in HIV+ vs HIV-negative due to falls & fractures but this is only one condition, we will see in older HIV+ also explosions in heart disease, cognitive & neurologic & brain disorders, cancers, kidney disease, and other comorbidities, including increased depression, suicide ideation, worsening housing & income problems. This 1st HIV-infected generation of older aging is being ignored....http://www.natap.org/2016/CROI/croi_138.htm.....Researchers reported HIV+ at only an average age of 57 had a median of 4 (IQR: 3-6) comorbidities and were taking a median of 9 (6-12) nonantiretroviral medications......(53.6%) had 2 or more geriatric syndromes.....The most frequent conditions were prefrailty (n = 87, 56.1%), difficulty with 1 or more IADLs (72, 46.5%), and cognitive impairment (72, 46.5%). Prefrailty (1 or 2 of the Fried criteria) was found in 56.1%.....http://www.natap.org/2015/HIV/052015_04.htm....then researchers reported in HIV+ over 40 years old "independent activities of daily living (IADLs)" occurred much more frequently in HIV+ vs HIV-negatives with 52% between 50-59 having 2 or more IADLs, of course frailty was associated with this, so was cognitive impairment, history of smoking, liver disease, diabetes, less exercise, and heart disease...20-60% of study participants were unable to do laundry, shopping, take transportation, do housekeeping & had limited cooking & finances capacity......http://www.natap.org/2016/CROI/croi_58.htm
there are 3 reports herein: first a link to article by HIV bone researchers where they predict an epidemic of bone fractures in HIV+ although the article is a scientific report BUT there is NO QUESTION that across the board everyone in HIV agrees, that we will experience an epidemic of falls & fractures which will lead to as it does in the general population increased risk for severe mortality as it says in the 3rd article below but is widely known "Falls are a leading cause of morbidity and mortality in older adults". The 2nd article/study below outlines risk factors for falls in middle-aged HIV+ and reporting "We found that the fall rate in middle-aged adults (mean age 52.0 years) with HIV-1 infection is as common as in uninfected persons aged 65 years". The third article below discusses an intervention used in the general population of older adults that reduced falls - treadmill training and virtual reality (VR) intervention - falls were reduced by 42% in the treadmill training plus VR group - and mentioned: "roughly a third of community-living people aged 65 years or older fall at least once per year, with half of this number having multiple falls in this period".
Of note I have been talking with federal officials regarding aging problems trying to raise their awareness about what I see as an emerging explosion of disastrous outcomes for the aging HIV+ population, however I have been pushed back rather abruptly at every attempt I make requesting that these concerns get more attention & a national discussion. At this point in time I see as perhaps the most important issue is developing a program of special support services for the older increasingly disabled & unable to function aging HIV+ which would include providing education & tools for both clinicians, patients and service providers. Also important is as there are so many issues related to aging/HIV including the subject of this report from me regarding falls, fractures, death & an intervention - we need a national discussion to raise awareness & focus attention so we can with federal & state officials begin to address this quickly emerging what will be a devastating & explosive problem.
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impending epidemic of bone fractures.....HIV infection causes significant bone loss and skeletal deterioration, leading to fractures that are often devastating and incur significant financial burden on patients and their families. HIV-infected individuals have up to a five-fold higher risk of bone fractures, and the increasing average age of people living with HIV/AIDS has triggered fears of an impending epidemic of bone fractures in this population. Antiretroviral therapy, used to manage HIV infection, fails to prevent, but rather paradoxically accelerates skeletal decline.....http://journals.plos.org/plospathogens/article?id=10.1371/journal.ppat.1004497
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Risk factors for falls in HIV-infected persons.
JAIDS 2012
Erlandson, Kristine M. MD*,; Allshouse, Amanda A. MS; Jankowski, Catherine M. PhD; Duong, Syki MD; MaWhinney, Samantha ScD; Kohrt, Wendy M. PhD; Campbell, Thomas B. MD*
Available data suggest that HIV-infected persons have low bone density, increased fracture risk, and premature frailty.5,6,13,14,24,25 Thus, in addition to increased risk of falls, aging HIV-infected persons are likely to be at increased risk of morbidity when falls occur.....Providers caring for HIV-infected persons should routinely inquire about falls; assess fall risk factors in those at risk for falling; and when high fall risk is identified, intervene to reduce risk. Interventions such as discontinuation of psychotropic or other high-risk medications, balance training, home safety evaluations, and exercise programs decrease fall risk in elderly, non-HIV-infected persons.2,22,23 Future research is needed to investigate the effectiveness of interventions to reduce fall risk in middle-aged and older HIV-infected persons.
We found that the fall rate in middle-aged adults (mean age 52.0 years) with HIV-1 infection is as common as in uninfected persons aged 65 years.....Falls in our cohort were associated with several previously reported risk factors such as hypertension, diabetes, impaired balance, and pain and medications used in the treatment of these comorbidities....Ultimately, the best predictors of fall risk were those factors known to be associated with fall risk in geriatric populations.....it is expected that successful interventions to reduce falls in HIV-infected persons will require a multipronged approach including medication adjustment, behavioral modifications, vitamin D supplementation, physical therapy, and exercise or balance programs
no prior studies have evaluated the rate or risk factors for falls among HIV-1-infected adults.....Comorbidity was associated with increased odds of recurrent falls, with each additional comorbid condition associated with 1.7 greater odds of falls.....A one point worsening on Fried frailty score increased the odds of falls by 3.1....Recurrent fallers had a significantly slower pace on the 400-m walk (1.33 ± 0.04 m/sec) than nonfallers (1.52 ± 0.02 m/sec, P < 0.001).....Polypharmacy was associated with increased odds of falls, with each additional prescribed medication associated with an incremental increase of 1.4 in the odds of falls
As a geriatric syndrome, falls are the consequence of multiple interrelated factors including comorbidities (arthritis, diabetes, pain, depression among many others), physical impairments (vision, cognition, neuropathy, strength, gait), and polypharmacy (especially psychoactive medications).4
Persons aging with HIV-1 infection are thought to manifest "accelerated aging" with an earlier than expected occurrence of many diseases of aging.5 Similarly, persons with HIV infection have a high prevalence of several comorbidities and physical impairments associated with an elevated fall risk.6 Approximately, 75% of HIV-infected persons receive at least 1 prescription medication in addition to antiretroviral therapy, and prescriptions associated with high fall risk (cardiovascular and psychoactive medications) are among the most common.7
Despite heightened awareness of aging complications in the HIV-infected population, the rate of falls and risk factors for falls among HIV-1-infected adults are unknown. We hypothesized that a greater number of fall risk factors would result in a higher than expected fall rate among middle-aged HIV-1-infected adults.
BACKGROUND: The incidence of and risk factors for falls in HIV-1-infected persons are unknown.
METHODS: Fall history during the prior 12 months, medical diagnoses, and functional assessments were collected on HIV-infected persons 45-65 years of age receiving effective antiretroviral therapy. Fall risk was evaluated using univariate and multivariate regression analyses.
RESULTS: Of 359 subjects, 250 persons (70%) reported no falls, 109 (30%) had ≥1 fall; and 66 (18%) were recurrent fallers. Females, whites, and smokers were more likely to be recurrent fallers (P ≤ 0.05). HIV-related characteristics including current and nadir CD4 T-cell count, estimated HIV duration, and Veterans Aging Cohort Study Index scores were not predictors of falls (all P ≥ 0.09); didanosine recipients were more likely to be recurrent fallers (P = 0.04). The odds of falling increased 1.7 for each comorbidity and 1.4 for each medication (P < 0.001) and were higher in persons with cardiovascular disease, hypertension, dementia, neuropathy, arthritis, chronic pain, psychiatric disease, frailty, or disability [all odds ratio (OR) ≥ 1.8; P ≤ 0.05]. Beta-blockers, antidepressants, antipsychotics, sedatives, and opiates were independently associated with falling (all OR ≥ 2.7; P ≤ 0.01). Female gender, diabetes, antidepressants, sedatives, opiates, didanosine, exhaustion, weight loss, and difficulty with balance were the most significant predictors of falls in logistic regression (all OR ≥ 2.5; P ≤ 0.05).
CONCLUSIONS: Middle-aged HIV-infected adults have high fall risk. Multiple comorbidities, medications, and functional impairment were predictive of falls, but surrogate markers of HIV infection or an HIV-specific multimorbidity index were not. Fall risk should be assessed routinely as part of the care of HIV-infected persons.
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Virtual reality and the prevention of falls in the real world
Falls are a leading cause of morbidity and mortality in older adults.1, 2 Studies conducted in Europe, the USA, and Australia show that roughly a third of community-living people aged 65 years or older fall at least once per year, with half of this number having multiple falls in this period.2 Falls impose major social and economic burdens for individuals, their families, health services, and the economy. With the number of older people increasing across the world, the costs associated with falls will increase substantially in the coming decades,3 making the prevention of falls an urgent public health challenge.
The Article by Anat Mirelman and colleagues4 reported in The Lancet presents positive findings of an innovative fall prevention strategy. Their study was a multicentre, randomised controlled trial that compared a combined treadmill training and virtual reality (VR) intervention with treadmill training alone in 302 participants aged 60-90 years at high risk of falls. The VR component consisted of motion capture of the participants' feet, which was then projected onto a screen, with challenges in the form of obstacles, pathways, and distractors that required continual adjustment of steps.
The groups were well matched at baseline, and the incident rate of falls was similar in both groups before training, with 10⋅7 (SD 35⋅6) falls per 6 months in the treadmill training group and 11⋅9 (39⋅5) falls per 6 months for the treadmill training plus VR group. The main finding, assessed in a modified intention-to-treat sample of 282 (93%) participants, was that falls were reduced by 42% in the treadmill training plus VR group compared with the treadmill training group in the 6 month period following the end of training (incident rate ratio 0⋅58, 95% CI 0⋅36-0⋅96; p=0⋅033). Furthermore, important secondary outcome measures, including gait variability during obstacle negotiation, functional balance and gait, and quality of life were significantly improved in the treadmill training plus VR group after training compared with the treadmill training group, with some gains retained at the 6 month follow-up.
The finding of a 42% reduction in falls is in line with the most effective fall preventions that have assessed more traditional group-based and homed-based exercise interventions in older people and well above the average reduction of 17% for exercise interventions reported in systematic reviews.5 It is also notable that the reduction in falls reported in the current trial is made in comparison to a treadmill walking intervention of similar intensity, as opposed to no intervention or usual care.
Unlike traditional exercise where the principle of "use it or lose it" is assumed, the intervention was of short duration (ie, 6 weeks). The 6 month retention of improved functional balance and gait and improved obstacle negotiation suggests that task-specific learning relevant for negotiating hazards and avoiding trips in the real world might have contributed to the reduction of falls seen in the treadmill training plus VR group. This mechanism is consistent with complementary research that has shown short-term trip and slip training can have lasting benefits for fall prevention in older people.6, 7
A major difference in the two interventions compared in this trial was the cognitive component included in the treadmill training plus VR group, yet no differential improvement in executive function was detected in participants assigned to this group (p=0⋅40 for executive function index, p=0⋅61 for attention index score). It could be that pen-and-paper cognitive tests are not sensitive enough to detect differences, but might also suggest that the intervention effects were quite specific and restricted to improved gait adaptability in situations requiring focused attention and planning.
Participants with Parkinson's disease (who represented more than 40% of the study population) benefited the most from the combined intervention (incident rate ratio 0⋅45, 95% CI 0⋅24-0⋅86; p=0⋅015). This finding is encouraging because, despite evidence for remediation of physical fall risk factors, there is little evidence of translation of these improvements into the prevention of falls in this group.8 Notably, secondary analyses of a recent trial examining the effects of the cholinesterase inhibitor rivastigmine on falls in people with Parkinson's disease suggest the beneficial effect may also have been related more to reducing gait variability than to improving cognition.9
Mirelman and colleagues' findings have important implications for clinical practice. No serious adverse events occurred and adherence was good. A health economic analysis was not presented, and although it is the case that VR training is not substantially more resource-intensive than treadmill training, one-on-one supervision was used in this study. It is conceivable, however, that treadmill training with a VR component could be administered in community gyms and rehabilitation clinics, and since the intervention is relatively short term in nature, throughput of many people would be possible.
As with all studies, the findings need confirmation in additional populations. It also needs to be established whether beneficial effects are retained beyond 6 months and whether older people with a history of multiple falls and those with mild cognitive impairment benefit from this intervention approach (subgroup analysis suggested that this was not the case in this trial). Finally, related research has shown the importance of gait adaptability in ageing and fall risk10, 11 and the incorporation of such adaptive stepping responses along with other exergame attributes such as brain training, engaging recreation, and performance feedback12 require further research and application more generally to exercise programmes for older people.
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