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Caring for Older Adults Living with HIV Infection: policy needed
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- high rates of comorbidities, polypharmacy & dangerous drug-drug interactions, social isolation - social support needed - "We need to address Local, National and International Policies, we need provision of healthcare and social services."......our aging HIV+ are the new silent majority, its a hidden worsening epidemic
Jules Levin
NATAP
www.natap.org
The problems for those aging with HIV has been discussed now for 15 years and more with little change occurring in terms of support services for older aging HIV+ who need them and for their clinics and for staff at ASOs, community based organizations. 15 years ago we started discussing the increased medical and health concerns for aging HIV+ but its now 15 years later and the population is older and the need now is for support services to address worsening self-stigma and external stigma, social isolation, cognitive impairment, worsened physical and mental decline causing impaired functioning and performance of normal daily independent living activities. As well navigating the health care system is very challenging for a group that needs the healthcare system more with greater referrals to specialists, yet suffer from cognitive & physical impairment. Primary HIV care providers are squeezed for time in these days where reimbursement is more limited yet these older HIV+ need more time and attention, and better care coordination. It us in this context that this problem is being ignored by local, state and federal US government officials, as well as globally this is a great problem that will worsen. Yet its being swept under the carpet. The advocacy community has also done little to address the problem in the sense of making changes in the provision of services for this group by government officials. Researchers need to be more vocal. Policies are needed, funding for services must be provided by government officials including the RWCA, CDC, HRSA OAR and HHS. Large scale discussions are needed at the highest levels of local, state and federal HIV government leadership, yet this is not occurring. One day we will wake up and it will be a major problem, right now 75% in 5 major US cities are over 45, 50$ over 50, 25% over 65, but soon 50% will be over 60. The HIV population is quickly aging. Young advocates fail to understand this problem, and older advocates as well. Its a complicated situation where I believe ageism and bias persists in our HIV community just as it does in the broader human community. Some not well understanding advocates & younger HIV+ not yet suffering the worst ravages of aging with HIV say - one can deal with this, but that's not true, most over 65 who suffer cognitive & mental & physical decline and impaired independent living functioning will not be able to deal with this regardless of having greater access and health literacy - they all will have similar difficulty in dealing with this problem. Some suggest go to industry and foundations for services funding instead of directly demanding this from our federal and local HIV government funding resources but this is what federal tax-payer funded resources are for I say. There is a lack of understanding by many about actually living with aging & HIV includes not just not appreciating the real impact of mental & physical decline and functioning but also does not understand that along with this comes incapacity to navigate the healthcare system due to these mental & physical impairments along with greater fatigue, depression and isolation. As well following up with as many as 5-10 specialists plus your primary HIV care provider and trying to negotiate that your primary care provider is communicating adequately with you and the specialists is an enormous task not many are up to. Minority populations (poor, African American, Latino) will suffer the greater brunt of this for many reasons. But all will suffer from this. Those who are older started HAART late when CD4 were low, a low nadir CD4 is a major contributor to the depleted immunity causing accelerated or premature aging in HIV despite high or even normal CD4 after years on ART with undetectable viral load. Do we not owe a greeter respect and dignity to the first older surviving aging generation of HIV+, its a high insult to our community not appreciated by many.
the NATAP HIV & Aging dedicated website:
http://www.natap.org/age.htm
Aging with HIV is medically complex.
HIV infection may synergistically interact with age to contribute to functional decline. HIV+ are at increased risk compared to HIV-negative for heart disease (50% increased heart attack risk), cancer, bone disease (osteoporosis, liver, disease, kidney disease, cognitive disorders. In a study highlighted below HIV+ also have high rates of polypharmacy often taking 13 medications daily vs 6 for older HIV-neg , 52% were taking potentially inappropriate medications, and 17% were taking nticholinergic medications: Anticholinergic properties of medications have been associated with delirium, cognitive impairment, dry mouth and constipation; the term anticholinergic burden refers to the cumulative effect of multiple anticholinergic medications. In San Francisco research from Meredith Greene's group reported in 2014 so by now the situation is likely worsened http://www.natap.org/2014/CROI/croi_66.htm- where they have 1 of the only 2 Geriatric HIV Clinics in the USA - Greene reports among older HIV+ generally older than 55 to 60, which is still young: 9% had frailty, 14% hearing impairment, 21% mobility difficulty, 46% had problems with performing independent daily living activities functioning, 25% had 1 or greater numbers of falls, 34% had visual impairment, 40% depression, 56% had pre-frailty, 57% report mild loneliness. In a VA study by Greene from 2013 where veterans were over 55 so its a different population than the SF study HIV+ had greater rates of social isolation - 59% suffered social isolation but being HIV+ and over 75 tripled social isolation rates - 82% suffered social isolation among HIV+ over 75 years old compared to only 28% among HIV-negtive. In addition non-whites had a 44% higher risk for social isolation highlighting that marginalized minority populations including African Americans and Latinos suffer aging worse and need attention for support services. In this study 68% were non-white or Hispanic, 25% suffered depression, 38% of HIV+ suffered hypertension, 21% hyperlipidemia, 17% diabetes, 27% hepatitis C, 8% coronary heart disease, and 76% had less than $25k annual income. - Only now getting increased attention is the comorbidity of non-viral (no HCV, HBV) liver disease among HIV+. HIV+ have all the ingredients for liver disease not caused by HCV or HBV which can lead to liver disease as one ages. Although social isolation has similar effects on hospitalization and death for HIV+ and uninfected individuals, those with HIV are at substantially higher risk of being socially isolated. Although the effects of social isolation on mortality have been well documented in older adults. The authors say: HIV+ individuals are frequently admitted for (and die from) chronic conditions that characterize the aging population as a whole.35 Rather than focusing on HIV‐related comorbidities, our findings suggest a need to understand aging HIV+ individuals' risks for hospitalization and mortality in the broader context of their social lives and to increase preventative efforts for those with low social support. Although it was found that social isolation affected these outcomes for HIV+ and uninfected individuals in the cohort, the finding that the prevalence of social isolation is higher in HIV+ older adults, particularly at older ages, underscores the need to prioritize such efforts for this population. http://natap.org/2018/HIV/090518_04.htm
Additional symptoms reported among older HIV+ are: 20% severe fatigue, 20% severe sadness, 20% severe neuropathy, 20% severe sleeping disorders, 10% severe headaches, 10% severe diarrhea, 10% severe sobbing - Slide talk: http://www.giaging.org/documents/Greene_GIA_Fellows_10-13_final_(2).pdf
Two experimental projects are ongoing of a Geriatric Clinic at Cornell in NYC & in SF at UCSF. We do not know why is the best model of care for the older HIV+.
http://www.natap.org/2017/AGE/AGE_11.htm
NY Cornell Aging / Geriatric Clinic - Current Reality: The New York Experience - - (10/06/17)
Current Reality: The San Francisco Experience / SF Aging Clinic: reality switch from 1990 to 2018 / a crisis ignored by many - (10/06/17)
There is a Changing Demographics of Older Adults-more Minority groups and LGBT older adults. We need to address National and International Policies, we need provision of healthcare and social services.
Lessons from HIV+ adults may inform aging and lessons from aging may inform HIV care. Aging organizations will come into contact with older adults living with HIV, they Need to understand relevant issues. But HIV+ is such a unique group suffering stigmas that do we need support services provided selectively for them? I say yes. AIDS service organizations know very little about the aging problem, agency leadership and staff need education about aging, and funding to support work. Linkages to existing community services for aging is low. Services provisions are non-existent in most cities and areas. Aging related issues may occur earlier than age 65.
Polypharmacy and Drug-Drug Interactions Occur in Aging Older HIV+, taking inappropriate
As one example of a study looking at polypharmacy: Participants were enrollees in the University of California, San Francisco HIV Over 60 Cohort, a study of community‐dwelling adults aged 60 and older living in the greater San Francisco area. Most were Caucasian (91%) and male (94%), and they had a median age of 63 (range 60-82) and were highly educated. The majority reported HIV risk as having sex with another man (MSM), and the median estimated duration of HIV infection (since known diagnosis of HIV) was 20 years (range 1-28 years). Participants had well‐controlled HIV infection, with a median reported CD4 T‐lymphocyte cell count of 513 (interquartile range (IQR) 350-700) cells/μL, and 84% of participants reported an undetectable viral load. Hyperlipidemia (61%), hypertension (43%), and depression (37%) were the most frequently reported comorbidities. a median 13 medications (IQR 9-17) per participant.
A total of 1,198 medications were reported, with a median 13 medications (IQR 9-17) per participant. Four of these 13 medications (IQR 3-5) were antiretroviral medications, and eight (IQR 4-14) were nonantiretroviral medications. Of the nonantiretroviral medications, two‐thirds were prescription medications, most commonly nervous system (27%), cardiovascular (23%), and gastrointestinal medications (11%), and the remaining one‐third were vitamins or supplements.HIV‐negative participants were taking a median of 6 (IQR 3-10) medications (P = .03), with a median of 1 vitamin or herbal medication per participant.
Taking into account all medications, 85 (96%) participants were taking five or more medications, and 68 (76%) were taking nine or more. Even when taking into account only nonantiretroviral medications, 66 (74%) participants met the criteria for polypharmacy by taking five or more medications, and 43 (48%) were taking nine or more medications. Sixty‐two participants (70%) had at least one Category D (consider therapy modification) drug-drug interaction, with a median of 1 (range 0-15, IQR 0-3) interaction per participant. Ten participants (11%) also had a Category X interaction (avoid combination). Two hundred eighty‐three interactions (171 different drug-drug interaction pairs) were identified, with 267 (94%) classified as Category D and 16 (6%) as Category X. Most interactions were between an antiretroviral medication and a nonantiretroviral medication (152, 54%), although 99 of the interactions (35%) occurred between two nonantiretroviral agents. Fewer interactions (32, 11%) occurred between two antiretroviral medications. Of the different drug-drug interaction pairs, the clinical pharmacist deemed 101 (60%) to be clinically significant.
Potentially Inappropriate Medications and Anticholinergic Burden
At least one potentially inappropriate medication based on Beer's criteria was detected in 46 (52%) of HIV-infected participants, most frequently testosterone (n=20), ibuprofen (n=15), zolpidem (n=9), and lorazepam (n=5). As we did not have information about hypogonadism or chronicity of medications we performed sensitivity analyses. When androgens were excluded from the analysis, the number of participants with at least one potentially inappropriate medication decreased to 39 (44%); with non-steroidal anti-inflammatories and nonbenzodiazepine hypnotics excluded the number of participants decreased to 36 (40%); and with all three classes excluded the number of participants with a potentially inappropriate medication decreased to 24 (30%).
Fifteen (17%) of participants had an Anticholinergic Risk Scale (ARS) Score of ≥ 3. The most frequent medications with anticholinergic burden were mirtazapine (n=5, 1 point on ARS), diphenhydramine (n=4, 3 points on ARS), and cetirizine (n=3, 2 points on ARS). Figure 2 shows the percentage of HIV-infected participants with polypharmacy, drug-drug interactions, potentially inappropriate medications, and a clinically significant Anticholinergic Risk Scale Score of ≥3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4043391/
Managing HIV Infection
in Older Adults....Aging Clinic at UCSF
"there's still a lot of work to be done to figure out how we are really going to support the health and care for older adults who are dealing with HIV"
How should clinicians address the risk for social isolation in older HIV-positive adults?
First, they have to ask about it. There may be a few patients who would openly talk about that, but I think just being aware that "especially people who have aged [with] HIV and survived the 80s and 90s--they may have lost a lot of friends and partners so there may be isolation or loneliness from that. Additionally, people may be estranged from family "whether through past drug use or because their family did not accept that they were gay. "there are many reasons people might be at increased risk for social isolation. There is also still a lot of stigma from HIV infection. There are some studies to suggest that older adults [in general] may be at increased risk of stigma. So the first point for providers is just being aware and asking about isolation or stigma.
As far as what to do, there have been a few studies that have shown that a telephone intervention to help improve coping strategies can help decrease loneliness and isolation. Even an online support group--there was a study that looked at that and showed that that had positive impact.
Here in San Francisco and in other places, there are support groups for people who are 50 and over living with HIV where they can come together and discuss issues. Sometimes there are social activities that occur in that context, and people are able to create new relationships and help decrease some of the isolation that they might be feeling. 8. How should clinical care of older HIV-infected adults incorporate geriatric principles? A lot of the things we've talked about "just thinking about polypharmacy, thinking about multi-morbidity (meaning people who have more than two or three different medical conditions) are areas in which geriatricians have expertise. When you are dealing with increased medical complexity or complex chronic illness "taking a geriatrics approach can be useful. When I say that, it means specific things like asking about someone's functional ability "how well are they managing daily activities? Are they having limitations with walking? Do they need help managing medications?
I think what HIV care does very well is taking a holistic approach to care, which geriatrics does as well. Thinking through functional status. Looking at all the medications and looking for drug interactions. I think we are still trying to understand what are the geriatric assessments that are going to be most useful for older, HIV positive adults. That's one of the projects we are working on now--trying to create a more formalized geriatric HIV clinic here at San Francisco General to try to understand how we can be doing this and what it should look like.....http://www.natap.org/2016/HIV/040616_05.htm
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