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Burden of Aging with HIV: "better Care Systems Needed" UCSF
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....an urgent need remains to develop systems of care that better address the holistic needs of older adults living with HIV despite optimal management of HIV itself. [the entire HIV healthcare system needs to be changed to meet this changing epidemiology that the entire population is aging, soon 75% will be >50 & 50% >60. Jules]....We recruited participants from the HIV Elders Study at the University of California, San Francisco. To meet inclusion into the parent study, participants were HIV infected, virally suppressed (<50 HIV copies/mL), 60 years or older, and clinically diagnosed with MND based on 2007 criteria, as previously described
26 June 2019 JNl of the Amer. Geriatric Assoc.
Kalei R.J. Hosaka, BA,* Meredith Greene, MD, Thomas A. Premeaux, BBA,*
Shireen Javandel, BA, Isabel E. Allen, PhD, Lishomwa C. Ndhlovu, MD, PhD,* and
Victor Valcour, MD, PhD
The burden of depressive symptoms was also quite high, at 39%, and similar to prior reports.15, 16 We identified a mean VACS index score of 33, supportive of a higher risk for mortality. This mortality risk should be considered in the context of our selection with all participants having well-controlled HIV with suppressed HIV RNA in plasma, and most had CD4 counts higher than 200 cells (n = 133/139). The risk in those who are unsuppressed and, particularly those with lower CD4 counts, is expected to be higher.
A little more than half of participants live alone (56%), raising concerns for the availability of social support of older adults with HIV. Older adults with HIV tend to have higher rates of social isolation than younger adults.19 Social isolation in combination with difficulty with performing ADLs contributes to feelings of social loneliness and was associated with depressive symptoms.20 The combination of cognitive impairment, social isolation, and other geriatric syndromes highlights the substantial vulnerability of this aging group of individuals. Early and accurate identification of geriatric syndromes may aid clinicians in focusing resources on assisting the most vulnerable patients.
In an era of HIV and aging, multimorbidity, polypharmacy, and functional decline are primary concerns.1 A geriatrics-focused approach of functional preservation will become increasingly important in caring for older adults with HIV living in the community.5
Taken together, an urgent need remains to develop systems of care that better address the holistic needs of older adults living with HIV despite optimal management of HIV itself.
Participants were HIV infected, virally suppressed, 60 years or older, and clinically diagnosed with mild neurocognitive disorder (MND). We conducted standardized assessment of geriatric conditions and everyday function and investigated multimorbidity burden using the Veterans Aging Cohort Study (VACS) index.
We found that 32% indicated difficulty with mobility, and 41% reported a fall in the last year. Mild to moderate depression was present in 39%....The mean VACS index score is 33 (standard deviation = 14), suggesting a 13.8% 5-year all-cause mortality risk.
Results: Among 141 older PLWH with MND, 58% report incontinence, 55% meet criteria for pre-frailty, and a substantial proportion report dependence with instrumental activities of daily living (52%) or activities of daily living (41%). The mean VACS index score is 33 (standard deviation = 14), suggesting a 13.8% 5-year all-cause mortality risk.
Conclusions: Older PLWH with symptomatic cognitive impairment carry a substantial burden of other geriatric conditions. Our work supports the need for comprehensive geriatric systems of care for cognitively impaired individuals aging with HIV.
Frequency of Geriatric Conditions
Among participants studied, 58% reported incontinence, 55% reported pre-frailty, and 52% reported IADL difficulties (Figure 1). Frailty was noted in 7%. We found that 32% indicated difficulty with mobility, and 41% reported a fall in the last year. Mild to moderate depression was present in 39%. In the overall cohort, the mean VACS score was 33 with an SD of 14 (n = 138).
Geriatric Syndromes in Older Adults Living with HIV and Cognitive Impairment
26 June 2019 JNl of the Amer. Geriatric Assoc.
Kalei R.J. Hosaka, BA,* Meredith Greene, MD, Thomas A. Premeaux, BBA,*
Shireen Javandel, BA, Isabel E. Allen, PhD, Lishomwa C. Ndhlovu, MD, PhD,* and
Victor Valcour, MD, PhD
Abstract
Objectives
Nearly half of the population living with human immunodeficiency virus (HIV) in the United States is now older than 50 years with at least 6% over age 65.
Between 35% and 50% live with mild to moderate cognitive impairment.
Older persons living with HIV (PLWH) also have a substantial burden of HIV-associated non-acquired immunodeficiency syndrome medical conditions and are at risk for frailty, geriatric syndromes, and early mortality compared with HIV-uninfected peers.
We sought to define the magnitude of geriatric conditions and multimorbidity in PLWH older than 60 years who are living with symptomatic cognitive impairment. In a subset of participants, we examined associations between these geriatric conditions.
Design
Retrospective cohort study.
Setting
HIV Elders Study at the University of California, San Francisco, Memory and Aging Center.
Participants
Participants were HIV infected, virally suppressed, 60 years or older, and clinically diagnosed with mild neurocognitive disorder (MND).
Measurements
We conducted standardized assessment of geriatric conditions and everyday function and investigated multimorbidity burden using the Veterans Aging Cohort Study (VACS) index.
Results
Among 141 older PLWH with MND, 58% report incontinence, 55% meet criteria for pre-frailty, and a substantial proportion report dependence with instrumental activities of daily living (52%) or activities of daily living (41%). The mean VACS index score is 33 (standard deviation = 14), suggesting a 13.8% 5-year all-cause mortality risk.
Conclusions
Older PLWH with symptomatic cognitive impairment carry a substantial burden of other geriatric conditions. Our work supports the need for comprehensive geriatric systems of care for cognitively impaired individuals aging with HIV.
J Am Geriatr Soc 67:1913–1916, 2019
Nearly half of the population living with human immunodeficiency virus (HIV) in the United States is now older than 50 years with at least 6% over age 65.1, 2 People with HIV are living longer due to effective antiretroviral therapy (ART), a trend also seen in resource-limited settings.3 Particularly concerning for older adults with HIV is their increased risk for cognitive impairment. HIV-associated neurocognitive disorder persists in older adults with HIV despite combination ART and is associated with overall morbidity.4 It is estimated that between 35% and 50% of older adults living with HIV experience mild to moderate cognitive impairment.4
Frailty and geriatric syndromes may occur at a younger age in individuals with HIV than they do in those who are not infected with HIV.5 Older persons living with HIV (PLWH) also have a greater burden of comorbidities, termed HIV-associated non-acquired immunodeficiency syndrome medical conditions,6 and multimorbidity as measured by the Veterans Aging Cohort Study (VACS) index.7
Past work indicates that the VACS index better predicts hospitalization and all-cause mortality than typical severity measures like CD4 T-lymphocyte counts, HIV RNA levels, and age.7 One group identified direct correlations between the VACS index and cognitive impairment.8
In PLWH or without ART, geriatric conditions, such as decreased instrumental activities of daily living (IADLs) and poor medication adherence, are associated with a higher VACS score.9 It is thought that inflammation, particularly monocyte activation, is a key predictor of increased morbidity and all-cause mortality even in the context of viral suppression.1, 10, 11
In this study, we sought to define the frequency of geriatric conditions and burden of multimorbidity in adults older than age 60 with virally suppressed HIV and diagnosed with mild neurocognitive disorder (MND). We also investigated multimorbidity burden using the VACS index.
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