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HIV-infected patients aged above 75 years in France:
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A descriptive study of HIV-infected patients aged over 75 years was conducted in six hospitals of the Pays de la Loire region, France. Socio-demographic, immuno-virological, and therapeutic characteristics were collected via an electronic medical record software (Nadis® ). To assess frailty, a simplified geriatric assessment was conducted during an HIV routine visit.
1. In our study, frailty was significantly higher among women. This finding is concordant with data from the general population
2. From an epidemiological standpoint, only female sex was significantly associated with frailty (53.8% in the frailty group or at risk of frailty versus 15.8% in the non-frailty group, P = 0.0066).
3. Screening for these cognitive disorders [discussed below] is crucial as they might be a risk factor for poor compliance with ART
4. As for comorbidities: seven patients (13.7%) were managed for diabetes, 25 (49.0%) for high blood pressure, seven (13.7%) for cardiovascular disease, six (11.8%) had a history of stroke, 25.5% had renal insufficiency, 18 (35.3%) had a history of neoplasia. Vitamin D low level (25 OHD3 < 30 ng/mL) was observed in almost half of patients (insufficiency: 18.9%, deficiency [25 OHD3 < 10 ng/mL]: 27.0%).
5. The mini-GDS test contributed to detecting depression in 35.3% of included patients. Depression is probably underestimated and undertreated among HIV-infected individuals [27]. The prevalence of depression in the ambulatory general geriatric population is 15% to 30% [28].
6. The prevalence of undernourishment and vitamin D low levels in HIV-infected individuals (25.5% and 45.9%, respectively, in our study) is higher than in the general geriatric population living at home, with a prevalence of approximately 4% for undernourishment [11,29].
7. Our study also confirms the high rate of polypharmacy in this geriatric population, with a median number of six drugs (including ART).
8. These evaluations could also help in implementing an individualized plan for care and assistance, especially as access
9. to medical/social facilities for elderly HIV-infected people may be difficult because of institutional obstacles as highlighted by the French Directorate-General for Health [33].
Overall, 21.6% of our patients were at risk of frailty and 3.9% were frail patients. These figures may be underestimated as some of the patients with the highest degree of frailty could not come to consultation during this period (hospitalization, transportation difficulties, etc.). Another study assessing frailty in a younger population of patients and using a different scale (VAS score) reported a frailty prevalence of 2% in virologically-controlled HIV-infected patients of a median age of 47.6 years (7.1% > 60 years) [17]. A case-control study of 520 HIV-infected individuals (mean age: 52 years; 10.8% > 65 years) reported a significantly higher incidence of frailty and pre-frailty in HIV-infected individuals (1.6% vs. 2.7% and 50.7% vs. 36.3%, respectively, P < 0.001) [18]. The authors of another study of female HIV-infected patients only, reported a frailty prevalence of 8%, using Fried's criteria [19]. In our study, frailty was significantly higher among women. This finding is concordant with data from the general population. We did not observe any relation between frailty and low CD4 nadir, unlike other authors who reported a correlation between low CD4 nadir and an increased risk of geriatric syndromes [20-22].
The adequate immunological restoration of HIV-infected individuals included in our study and the duration of undetectable viral load (median of more than 3 years), might have had a "compensatory" effect, thus avoiding the occurrence of frailty. We also did not observe any relation between the HIV infection duration and frailty, unlike findings from the pre-cART era [23].
Patients from our study had been living with HIV for a median of 18.8 years, but they were also receiving ART for a median of 15.4 years. The high immuno-virological efficacy of these treatments probably has a protective effect on some components of the frailty syndrome.
The high frequency (60.8%) of cognitive disorders, assessed by the three-word tests, was certainly overestimated as this score is not the most adequate with HIV-infected individuals. This test can nevertheless be used as a guiding test in studies of this type. Other studies already reported a high prevalence of cognitive disorders, although to a lower extent and in a younger HIV-infected population (50-60 years) [20]. Tests such as MOCA [24], TMT A-TMT B, or the clock-drawing test, would have probably been more adequate, but are time-consuming in routine practice. To confirm cognitive disorders and define their nature, all HIV-infected patients with a positive Three-Word Test, should undergo complete neurocognitive assessment or even brain imaging (CT scan or brain MRI). Screening for these cognitive disorders is crucial as they might be a risk factor for poor compliance with ART [25]. Most study patients maintained mobility and autonomy. The GIR test was sometimes difficult to administer during the consultation (when no caregiver or member of the multidisciplinary team was present) and results may have been overestimated. Greene et al. reported physical dependence in 10% of HIV-infected patients aged 65 years or above [20]. Sarcopenia screening, which was not performed in our study, also seems important [26]. The mini-GDS test contributed to detecting depression in 35.3% of included patients.
Overall, 100% of patients were receiving ART and 98.0% had an undetectable plasma viral load. By way of comparison, over the same period 94.0% of HIV-infected patients - all ages - in the Pays de la Loire region were receiving ART and 92.8% had an undetectable viral load [13].
Despite restoration of a good immunological status and a sustained virological control with treatments, HIV-infected individuals remain more vulnerable than the general population.
They are at higher risk of non-infectious comorbidities related to aging such as cardiovascular diseases, high blood pressure, diabetes, renal insufficiency, osteoporosis, and cancer [3-5]. Over the past years, several studies assessed HIV-infected individuals aged above 50 years in terms of morbidity, fatality, and iatrogenic events. The 50-year threshold was selected based on epidemiological criteria (age pyramid of HIV-infected people) and not on clinical criteria. Yet, the geriatric population of developed countries usually refers to people aged above 75 years as, irrespective of comorbidities, frailty syndrome may be observed from this age onwards. Frailty is defined as a clinical syndrome indicative of a reduction in reserve physical capacities impairing the stress adaptation mechanisms. Little data is available on the geriatric HIV-infected population in western Europe. We aimed to better characterize HIV-infected individuals aged above 75 years and to assess their vulnerability to comprehend the complexity of the aging process and to adequately adapt their management.
We performed an observational, epidemiological, multi center, regional, and cross-sectional study in the six centers of the Regional coordination for the management of HIV (French acronym COREVIH) of the Pays de la Loire region (Angers, Laval, La Roche-sur-Yon, Le Mans, Nantes, Saint-Nazaire) from January to May 2016.
Alongside data collected in Nadis®, a simplified geriatric evaluation was performed using a standardized questionnaire (used by the mobile geriatric team of Angers). The geriatric evaluation assessed eight health items among the following: cognition using a Three-Word Test [7], mood using the mini-Geriatric Depression Scale (GDS) [8], mobility using the ADTM scale (sitting-standing-changing position-walking), autonomy using the AGGIR grid (autonomy-gerontologygroup-iso-resources) [9], pain using a Numeric Verbal Scale [10], nutrition with BMI measurement and albumin level [11], comorbidity burden by counting the number of drugs taken by the patient, environmental status using the socio-family evaluation.
The geriatric evaluation was assessed out of 24 points; patients were considered "frail" with a score higher than 16 and "at risk of frailty" with a score between 8 and 16. Undernourishment was defined by an albumin level between 35-30 g/L or a BMI < 21, and severe undernourishment by an albumin level < 30 g/L or a BMI < 18. Vitamin D deficiency was defined as a vitamin D level < 10 ng/mL, and vitamin D insufficiency as a level between 10 and 30 ng/mL. Renal insufficiency was defined by a glomerular filtration rate estimate < 60 mL/min/1.73 m2 with the MDRD formula.
Results
Sixty-five (1.6%) of the 3965 patients of the Pays de la Loire COREVIH were aged 75 years or above. Fifty-one of the 65 HIV-infected patients aged 75 years or above, followed up in the Pays de la Loire region, consulted and agreed to take part in the study.
Epidemiological and immuno-virological characteristics of the studied population as well as ART distribution at the study visit are detailed in Table 1.
Of the 42 patients treated with a triple therapy, 14 (33%) were treated with a single-tablet triple therapy; 28 (67%) with a combination of two nucleoside reverse transcriptase inhibitors (NRTIs) + one non-nucleoside reverse transcriptase inhibitor (NNRTI), nine (21%) with two NRTIs + one integrase inhibitor (II), four (10%) with a combination of two NRTIs + one boosted protease inhibitor (bPI) and one (2%) with a combination of one NNRTI + one II + one bPI. Overall, seven patients were treated with a two-drug combination therapy, including four patients with a combination with one NNRTI and one II, without any NRTI nor bPI. Two patients were treated with a four-drug combination therapy.
As for comorbidities: seven patients (13.7%) were managed for diabetes, 25 (49.0%) for high blood pressure, seven (13.7%) for cardiovascular disease, six (11.8%) had a history of stroke, 25.5% had renal insufficiency, 18 (35.3%) had a history of neoplasia. Vitamin D low level (25 OHD3 < 30 ng/mL) was observed in almost half of patients (insufficiency: 18.9%, deficiency [25 OHD3 < 10 ng/mL]: 27.0%).
Results of the simplified geriatric evaluation are detailed in Table 2 (all 51 patients were assessed using all tools): 84.3% of patients had a GIR score of 6 and 86.3% had an ADTM score of 5. The median number of different treatments per day were six. Three-quarters of patients were considered non-frail patients, 11 (21.6%) were at risk of frailty, and two (3.9%) were considered frail.
The comparison between the group of non-frail patients and the group of frail patients or patients at risk of frailty did not reveal any significant difference between both groups, neither in terms of immuno-virological parameters (Nadir CD4, CDC stage, current CD4, viral load, CD4/CD8 ratio, CMV serological status) nor in terms of treatment characteristics (age at treatment initiation, number of ART lines received, number of ARTs received). From an epidemiological standpoint, only female sex was significantly associated with frailty (53.8% in the frailty group or at risk of frailty versus 15.8% in the non-frailty group, P = 0.0066).
HIV-infected patients aged above 75 years
Highlights
• We performed a multicenter observational study of HIV-infected individuals aged 75 years and above, i.e. a poorly studied population. The study assessed immuno-virological and therapeutic data, and highlighted the excellent follow-up of these patients. We also suggested a simplified geriatric evaluation to screen for frailty in these patients, and we underlined underdiagnosed and poorly treated frailty factors such as depression, cognitive disorders, undernourishment, vitamin D deficiency, and pain.
Abstract
Background
Little data is available on HIV-infected patients aged over 75 years.
Methods
A descriptive study of HIV-infected patients aged over 75 years was conducted in six hospitals of the Pays de la Loire region, France. Socio-demographic, immuno-virological, and therapeutic characteristics were collected via an electronic medical record software (Nadis®). To assess frailty, a simplified geriatric assessment was conducted during an HIV routine visit.
Results
Among the 3965 patients followed in the six centers, 65 (1.6%) were aged over 75 years. From January to May 2016, 51 patients were included in the study: median age 78.7 years, male patients 74.5%, homosexual transmission 41.2%, living at home 98% and single in 54.5% of cases, median duration of HIV infection 18.8 years, median CD4 nadir 181 cells/mm3; CDC stage C 36.4%. All patients were on antiretroviral therapy and 98% of them had an HIV RNA < 50 c/mL; 82% of patients had at least one comorbidity and 58% at least two comorbidities. Eleven of 51 patients (21.6%) were diagnosed as at risk of frailty and 2/51 (3.9%) were considered frail. Cognitive disorders were diagnosed in 60.8%, depression in 35.3%, malnutrition in 25.5%, and vitamin D deficiency in 45.9%.
Conclusions
HIV-infected patients aged above 75 years are well-managed, but the prevalence of geriatric comorbidities is high.
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