Age-related problems dog older HIV-positive patients

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Older HIV-positive patients have a high prevalence of multiple age-related problems, investigators from the US report. The research involved patients aged 50 years and older receiving outpatient care in San Francisco. Overall, 40% reported difficulties with daily activities, most reported loneliness, many had mild cognitive impairment and 30% had only poor to fair quality of life.

“This is one of the first studies to have evaluated a wide range of geriatric assessments among HIV-infected individuals in an outpatient clinical setting and provides a comprehensive overview of the health needs faced by the aging HIV-positive population,” write the authors. “We observed a high burden of clinically-concerning deficits in older HIV-infected adults across multiple domains, including functional impairment, falls, depression and social isolation.”

The investigators believe their findings have implications for patient care, commenting “our results highlight the importance of systematically providing functional, social and mental health support for the aging HIV-infected population.”

Improvements in treatment and care mean that many patients with HIV are now living well into old age. Over half of HIV-positive adults in the US are now aged 50 years and over. Previous research has shown that these patients frequently have multiple health problems and develop conditions associated with old age earlier than the traditional cut-off for old age – 65 years.

The Veterans Aging Cohort (VACS) Index, a prognostic tool based on markers associated with HIV and other health conditions, can be used to identify older HIV-positive patients with a high risk of illness and death. VACS Index score has also been associated with risk of fragility fractures, cognitive impairment and exercise capacity. However, less is known about its association with geriatric conditions, such as functional status.

Investigators therefore designed a cross-sectional observational study assessing the physical, cognitive, social and behavioural health of a large sample of older HIV-positive adults receiving outpatient care in San Francisco. A combination of geriatric and other assessments were used to assess psycho-social issues observed in older patients with HIV. The investigators hypothesised that both age and VACS Index would be associated with the geriatric conditions identified in the assessments.

Recruitment was between December 2012 and December 2014 and English-speaking patients aged 50 years and older were eligible to participate. Assessments included questions on physical, social, mental and cognitive health. The investigators used a combination of assessments that addressed traditional geriatric conditions and also the issues faced by older HIV-positive patients.

Four broad areas of health were assessed: physical health and functioning; falls and walking speed (Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL]); social support, including physical and perceived support and loneliness; mental health, including depression, anxiety, post-traumatic stress disorder; and behavioural and general health, including adherence to HIV therapy and overall quality of life.

A total of 359 patients were assessed. Most (85%) identified as male, two-thirds were in the men who have sex with men (MSM) risk category, and approximately 60% were white. Approximately three-quarters had attended college. Half were receiving disability benefits and the majority had an annual income below $20,000. Most (85%) had been living with diagnosed HIV infection for ten years or over. As regards HIV-related markers, 82% had an undetectable viral load and over half had a CD4 cell count above 500 cells/mm3.

Median age was 56 years and two-thirds of patients were in their 50s. Patients aged 60 years and older were more likely to be white, college educated and to have a higher annual income when compared to younger participants. The patients had a high burden of conditions associated with older age, with 41% reporting a fall in the previous year, almost 60% reported loneliness, half reported receiving low levels of social support and over a third met the criteria for mild cognitive impairment.

Patients aged 60 years and older were more likely to report problems with balance than patients in their 50s (47% vs 33%). Prevalence of problems with physical health and functioning was similar in the two age groups (12%), but patients in their 60s had slower walking speed.

However, older patients reported less anxiety and had higher levels of adherence to their HIV treatment. Although older patients were more likely to rate their health-related quality of life as “good”, fewer reported that it was “very good” or “excellent”, compared to patients in their 50s (p = 0.04).

A higher VACS Index score – indicative of higher mortality risk – was associated with greater levels of dependence and IADL scores, ie falls and slower gait speed (p = 0.003).

“Our data add to the growing body of evidence that older HIV-infected adults are facing increasing medical, psychiatric and social complexity and help to provide insight into how this complexity varies in different age groups in older adults,” conclude the authors. “Our findings highlight the importance of taking a comprehensive approach to identify health issues facing older HIV-positive patients and the critical need to develop interventions to improve the quality of life and address the multifaceted needs of older HIV-infected patients.”

Abstract
Objectives: To perform geriatric assessments in older HIV-infected adults in San Francisco and examine the association with age and the Veterans Aging Cohort Study (VACS) index scores.
Methods: A cross-sectional study was conducted from 2012-2014 among HIV-infected patients > 50 years at two San Francisco-based HIV clinics. We evaluated four health domains: 1) physical health and function (Activities of Daily Living [ADL], Instrumental ADL [IADL], falls, gait speed, 2) social support (physical and perceived support, loneliness), 3) mental health (depression, anxiety, post-traumatic stress disorder) and cognition, and 4) behavioral and general health (antiretroviral adherence and quality of life). Contingency table and rank-sum analyses examined associations between these domains with age and VACS index scores.
Results: 359 patients completed assessments (median age 57; 85% male; 57% Caucasian; 72% >high school education). On functional assessment, 39% reported dependence with >=1 IADL, and 40% reported falls in the previous year. 58% experienced loneliness, 60% the lowest levels of perceived social support, 55% depression, and 12% PTSD. 40% had possible mild cognitive impairment. 30% reported poor or fair quality of life. Older age was associated with lower CD4 counts, balance problems, slower gait, lower anxiety, poorer general health, and higher antiretroviral adherence. VACS Index score was associated with dependence in >=1 IADL and antiretroviral adherence.
Conclusion: In a large sample of older HIV-infected adults, multiple significant aging-related conditions were identified. Integrating geriatric assessment tools into HIV/AIDS clinical care may help target interventions to optimize clinical care and quality of life for older HIV-infected individuals.

Aidsmap material
Journal of Acquired Immune Deficiencies abstract


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