Aging and AIDS: Special series on older patients
Experts offer this advice for improving care of older HIV patients
[Editor's note: This issue of AIDS Alert presents the second part of a series about the problem of HIV infection among Americans who are 50 years old and older. This story addresses how clinicians can improve care and treatment of older HIV patients. The February 2007 issue covered the increasing numbers of older people infected with HIV, screening issues, and the psychosocial problems and dual stigma older HIV patients experience.]
Clinicians caring for older HIV patients increasingly need specific experience and training to deal with the treatment issues that are more commonly seen in this group.
There are additional polypharmacy issues and screening needs, as well as additional comorbidities and opportunistic infections (OIs) that will require attention, experts say.
And there often are psychosocial issues that require some knowledge about the disease's impact on people who are age 50 and older.
Less than a decade ago, HIV clinicians did not need to give much thought to specific problems experienced by older HIV patients, because the population of such patients was so small. That has changed as people diagnosed with HIV in their 30s and 40s now are living into their 50s and 60s, and as increasing numbers of older people are being diagnosed with HIV.
"Now we have to manage an overlapping effect of the aging process itself and age-related comorbid conditions, says Kris Ann Oursler, MD, ScM, deputy director of the Infectious Disease Clinic at the VA Maryland Health Care System in Baltimore, MD. Oursler also is an assistant professor of medicine at the University of Maryland School of Medicine in Baltimore.
Older HIV patients tend to be treated with more medications for other conditions than younger HIV patients, and so the polypharmacy issues are challenging, says Kathleen Casey, MD, chief of infectious disease at Jersey Shore University Medical Center in Neptune, NJ.
HIV doctors treating older patients need to be on the same page as the other specialists who see the patient for comorbid conditions so there won't be dangerous drug interactions, Casey says.
"You can't say, 'I'll take care of the HIV, and you take care of the diabetes and blood pressure,'" Casey adds.
"A lot of these health conditions overlap, and that's why it will be difficult to tease out the pathogenesis and develop treatment guidelines for those who are HIV infected," Oursler says. "There are not a lot of older, HIV-infected individuals in clinical trials, and there just now are some longitudinal studies starting, such as the Veterans Aging Cohort Study."
Oursler collaborates with gerontologists on clinical research focused on older HIV patients.
"I found that as an infectious disease-trained specialist, working with gerontologists has allowed me to appreciate the complexity of caring for older individuals," Oursler says.
It's important for clinicians to screen older HIV patients for hypertension, diabetes, and high cholesterol, says Kelly A. Gebo, MD, MPH, an assistant professor of medicine, epidemiology, and director of the Public Health Studies Program and director of the infectious diseases, post-doctoral fellowship program at Johns Hopkins University in Baltimore, MD.
"They often have more cancers and other kinds of comorbid conditions that occur with age," Gebo says. "We suspect that those comorbidities are going to be part of the reason these older HIV patients are going to have long-term reduced longevity."
This is why HIV clinicians should not forget to screen for these common age-related conditions, as well as schedule older HIV patients for mammograms, PSAs, colonoscopy exams, and other procedures, Gebo adds.
Older HIV patients are at increased risk for osteoporosis, cardiovascular disease, and cancer, but the biggest challenge is managing the metabolic toxicity of antiretroviral (ARV) therapy, Oursler notes.
One study on HIV in the elderly found that 40 percent had hypertension, 15 percent had diabetes, 12 percent had cancer, and 9 percent had coronary artery disease.1
"We looked at comorbidities specific to HIV and found that 40 percent were co-infected with hepatitis C," says Daniel Hart, MD, an assistant professor of medicine at the Robert Wood Johnson Medical School in New Brunswick, NJ. Hart was a co-author of the study on HIV in the elderly.
Of 163 patients age 55 and older included in the study, nearly 50 percent had been diagnosed after age 50, Hart says.
One of the confounding factors is that older individuals still are diagnosed concurrently with an opportunistic infection, meaning they were found later in the disease progression.
"Clinicians are still not thinking of HIV when a 50-year-old person comes in with weight loss," Oursler says.
"An HIV diagnosis often isn't considered in the older population," Hart notes. "There's a tendency for physicians to attribute symptoms to other things."
Then when older patients are diagnosed, it's difficult for clinicians to determine whether some comorbid conditions are made worse by the disease or antiretroviral treatment.
"We need to conduct longitudinal research to determine if older individuals on antiretrovirals in the long term are at increased risk for age-related diseases or more severe forms of age-related diseases," Oursler says. "Teasing out the pathogenesis of these overlapping problems will be a challenge, but will be necessary to create age-specific HIV care guidelines, which we are going to need."
Oursler, Casey, Gebo, and Hart offer these suggestions for caring for older HIV patients:
1. Metabolic problems are a chief concern.
"What is most studied so far is metabolic toxicity associated with lipodystrophy syndrome, specifically, glucose intolerance and diabetes, dyslipidemia, and fat redistribution," Oursler says.
Older age is one of the independent risk factors associated with lipoatrophy.2,3
"It's fair to assume that older individuals are at increased risk for lipodystrophy syndrome," Oursler says. "The problem you have in studying this question is there's so much overlap between ARV metabolic toxicity, comorbidity, and older age."
For instance, suppose an HIV clinician is presented with a 60-year-old patient who has no obvious health problems other than the HIV infection and being a little overweight, Oursler says.
"Then you give him antiretrovirals and get his HIV under control, and he gains 20 pounds — all in his midsection," Oursler says. "His fasting glucose is 200 and total cholesterol is 250, and so the question is how that individual got to this point in two years' time."
Was the individual's metabolic decline due to the antiretroviral therapy, or was it because of his advancing age combined with being at higher risk for obesity, diabetes, and high cholesterol?
"There's no way to tease out cause and effect," Oursler says.
2. Older HIV patients may have some unique psychosocial problems.
"Having HIV is not something you talk about at the family dinner table when you're an older person," Casey says. "You can talk about your blood pressure and heart attack, but not about HIV."
As a result, older HIV patients are much more private about their HIV status, and they often do not share this information with their adult children, Casey says.
"This makes it more difficult for them to find support," Casey adds. "And they can't just assume their children know what's wrong with them when they're hospitalized."
For instance, Casey says she doesn't even acknowledge her patients when she's in the grocery store or elsewhere in public because unless they approach her first, she assumes they want to keep the fact that they know an HIV doctor private.
"HIV is a different animal altogether," Casey says. "It's more difficult to cope with when the elderly person is surrounded by caring children who want to know what's wrong with mom or dad, and the parent cannot tell them."
Older HIV patients often deal with feeling isolated from their peers, friends, and families, Gebo says.
"They feel like they're the only ones who have the disease, and they worry that if they tell their children they might not be allowed to see their grandchildren," Gebo adds.
"We have a support group for older HIV patients, and we've found it to be very helpful because then patients feel that they're not the only ones at their age with the disease," Gebo explains. "There also is a National Association of HIV over 50 that has many resources and will speak at meetings, providing help to older patients."
Another issue that has arisen lately has to do with the way HIV medication is funded under the new Medicare prescription formulary, Casey notes.
"All of the HIV patients who have had their prescriptions rolled over to Medicare Part B have had their medication interrupted," Casey says. "No one has been denied their petition, but they aren't allowed to have their drugs until the petition is heard."
This type of treatment interruption is not safe for any disease, but it's especially dangerous with HIV when increasing evidence shows treatment interruption can result in a resurging viral load and other problems, she adds.
3. There's greater potential for adverse drug interactions and side effects.
In the recent study of HIV and the elderly, investigators found that older HIV patients use multiple drugs to treat a variety of conditions, including many associated with aging, Hart says.
"We found this cohort of patients were on an average of nine daily prescription drugs," Hart says. "So it's reflective of not only their comorbidities, but also the potential for drug interactions and issues along those lines."
Interestingly, the study found that one of the most common side effects among the older HIV patients was neuropathy, which impacted 31 percent of the group, Hart says.
"That's reflective of having older people who started on nucleosides in the early to mid-1990s," Hart says. "This finding was more of a result of the type of nucleoside reverse transcriptase inhibitors [NRTIs] they were started on, and these [initial ones] carried a risk of neuropathy."
4. There is an increase in age-related disorders.
Recent research has shown that older HIV-infected patients are more likely to have neuro-cognitive problems, including dementia and depression, and Parkinson's disease may be more common among the older HIV cohort.4-7
"The cause of death in HIV-infected individuals has changed, and we're seeing deaths now due to non-AIDS-related illnesses," Oursler says.
"The older HIV-infected individuals may be at increased risk for non-HIV conditions compared to younger patients, partly because they've been infected for a longer time," Oursler says. "That's why I believe that a key management strategy will involve prevention and treatment of comorbid conditions in the older HIV-infected individual."
Findings from the Veterans Aging Cohort Study (VACS-5) show that HIV-infected veterans with common comorbid conditions, such as hypertension and lung disease, have limited physical functioning that is similar to age-matched HIV-negative veterans.8
Clinicians also should screen older HIV patients for osteoarthritis and avascular necrosis when patients present with hip pain, and they should check for pneumonia when these patients have shortness of breath, Gebo suggests.
Oursler led a study that looked at physical functioning among older HIV-infected patients.9
The research team, including gerontologists and exercise physiologists, took patients into an exercise lab at the Baltimore VA Geriatric Research, Education and Clinical Center, and tested functional performance, Oursler says.
They found that patients had a 41 percent reduced aerobic capacity when compared with the expected values of healthy age- and gender-matched individuals. However, ambulatory function and strength were relatively intact, reduced only eight to 10 percent when compared to healthy individuals of that age.
"The reason this is important is because we need to figure out what's causing their severe impairment in aerobic capacity," she adds.
We hypothesize that older patients have a combination of effects from aging, ARV toxicity, and comorbidities that combine to hinder their bodies' ability to use oxygen, Oursler says.
Knowing that exercise and physical activity improve many comorbid conditions in older non-HIV patients, Oursler's team at the Baltimore VA is focusing on developing exercise interventions for older HIV patients.
References:
- Mathur AN, Hart D, Spooner LM, et al. HIV in the elderly: a suburban community clinic's experience. Presented at the 44th Annual Meeting of the Infectious Diseases Society of America, held Oct. 12-15, 2006, in Toronto, Canada. Abstract: 927.
- Wohl DA, McComsey G, Tebas P, et al. Current concepts in the diagnosis and management of metabolic complications of HIV infection and its therapy. Clin Iinfect Dis 2006;43:645-653.
- Grinspoon S, Carr A. Cardiovascular risk and body-fat abnormalities in HIV-infected adults. N Engl J Med 2005;352(1):48-62.
- Gebo KA. HIV and aging: implications for patient management. Drugs Aging 2006;23(11):897-913.
- Justice AC, McGinnis KA, Atkinson JH, et al. Psychiatric and neurocognitive disorders among HIV-positive and negative veterans in care: Veterans Aging Cohort Five-Site Study. AIDS 2004;18(Suppl 1):S49-59.
- Valcour V, Skikuma C, Shiramizu B, et al. Higher frequency of dementia in older HIV-1 individuals: the Hawaii aging with HIV-1 cohort. Neurology 2004;63(5):822-827.
- Vargas D, Nascimbene C, Lee A, et al. Chemokine and cytokine profiling by protein array technology shows the basal ganglia as the most affected area in HIV dementia [abstract], 12th Conference on Retroviruses and Opportunistic Infections; 2005 Feb. 22-25;Boston, MA.
- Oursler KK, Goulet JL, Leaf DA, et al. Association of comorbidity with physical disability in older HIV-infected adults. AIDS Patient Care STDS 2006 Nov;20(11):782-791.
- Oursler KK, Sorkin JD, Smith BA, Katzel LI. Reduced aerobic capacity and physical functioning in older HIV-infected men. AIDS Res Hum Retroviruses 2006 Nov;22(11):1113-1121.
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