DALLAS – HIV adds to the typical health concerns that affect people as they age, and with fewer people dying of AIDS, healthcare providers are facing more complicated geriatric cases.
By 2030, 73% of people with HIV will be older than 50 years, according to one report (Lancet Infect Dis. 2015;15:753-754). But despite advances in antiretroviral therapy, life expectancies are still lower for people with HIV than for those without, according to a population-based study (J Acquir Immune Defic Syndr. 2016;71:213-218).
One of the key issues of concern for people with HIV is that they will develop more comorbidities as they age than uninfected people, said Kristine Erlandson, MD, from the Divisions of Infectious Diseases and Geriatric Medicine at the University of Colorado Hospital in Aurora.
Polypharmacy, which is already common in older patients, is an even greater issue in people with HIV because of their added comorbidities. And it can lead to a host of health problems.
The Problem of Polypharmacy
“We know that more medications are associated with decreased drug adherence, an increased risk of drug side effects, increased drug-to-drug interactions, and a risk for geriatric syndromes, including falls, cognitive impairment, and frailty,” Dr Erlandson said here at the Association of Nurses in AIDS Care (ANAC) 2017.
The use of five or more medications is associated with increased mortality in older adults, but the association is stronger in people with HIV, according to data from one cohort of veterans (Drugs Aging. 2013;30:613-628).
And a recent review of 248 older San Franciscans with HIV – presented by Meredith Greene, MD, from the UCSF School of Medicine in San Francisco at the 8th International Workshop on HIV & Aging in October – showed that patients were taking a mean of 14 medications, 11 of which were not related to HIV.
Alarmingly, 16% of the patients were taking more than 20 medications, and 63% were taking at least one potentially inappropriate medication, Dr Erlandson reported.
“This is clearly a huge problem in the geriatric population of HIV-positive patients,” she pointed out.
The best strategy to address polypharmacy is to enlist the help of the pharmacist.
“Have your patients take all of their medications, including supplements, over-the-counter medications, ointments, nasal sprays, eye drops – everything – to the pharmacist, who can help sort things out,” she advised. And, she added, recommend that patients use a single pharmacy for their HIV care.
When a patient presents with a complaint, clinicians should explore whether the symptoms are an adverse drug effect, a drug-drug interaction, or an underlying medical problem, Dr Erlandson said.
One resource for the latest information on drug interactions is the Beers Criteria for Inappropriate Medication Use in the Elderly, from the American Geriatrics Society, she added.
Bone loss is a common problem in older patients with HIV. The risk for osteoporosis that can be up to 3.7 times higher in infected than uninfected people, she reported.
Clinicians might want to avoid antiretroviral regimens that contain tenofovir disoproxil fumarate and instead use a combination of abacavir and lamivudine or tenofovir alafenamide and emtricitabine, she said.
Patients should also be evaluated for other possible contributors to osteoporosis, such as low testosterone level, low vitamin D level, phosphate wasting, hyperparathyroidism, substance use, and smoking.
Because of the increased risk for osteoporosis in older people with HIV, the risk for fracture is also elevated. The Partners HealthCare System study, which included 8525 people infected with HIV and more than 2 million uninfected people, showed that after the age of 50, fractures are significantly more common in women (P = .002) and men (P < .0001) with HIV than in those without ( J Clin Endocrinol Metab. 2008;93:3499-3504).
Falls are the cause of many, if not most, fractures. In a study of 359 HIV-positive patients conducted by Dr Erlandson and her colleagues, 30% had fallen at least once in the previous year, and 18% had fallen more than once (J Acquir Immune Defic Syndr. 2012;61:484-489).
The key risk factors for falls were difficulty completing a tandem stand, defined as standing with one foot directly in front of the other, heel to toe, for 10 seconds without stumbling (odds ratio [OR], 13.5), antidepressant use (OR, 3.7), exhaustion (OR, 3.7), diabetes (OR, 3.6), and being female (OR, 3.5).
Fall prevention measures – including discontinuing medications that contribute to dizziness and exercising to improve balance and strength – can make a difference. “Tai chi has been shown to have particular benefit in some studies,” Dr Erlandson noted.
Exercise can also help manage the weight gain that is associated with antiretroviral therapy and that may contribute to comorbidities such as fatty liver and diabetes, she explained.
Adults with HIV can also experience muscle loss accompanied by generalized weight gain, leading to sarcopenic obesity. “Treatment should focus on reducing weight through dietary change and increasing muscle mass through exercise and adequate protein to maximize function,” she said.
Clinicians are probably used to resistance from patients when it comes to exercise recommendations, but they should keep in mind that older patients with HIV face unique challenges, such as greater perceived or actual fatigue, said Dr Erlandson.
Patients can feel stigmatized by their HIV status and have difficulty adopting a long-term perspective on health and wellness. And they might be in various stages of frailty, which often is “easy to recognize but hard to define,” she pointed out.
The Rockwood Index and other tools can help identify frailty, but it is important to remember that it is a “multisystem clinical syndrome that reflects biologic rather than chronologic age and a vulnerability to stressors,” she said.
The recent observational HAILO study showed that 6% of HIV-positive men and women aged 40 years and older were frail (AIDS. 2017;31:2287-2294). The risk for recurrent falls was more than 17 times greater in frail than in nonfrail patients.
“Knowing frailty status can provide an excellent assessment of fall risk,” Dr Erlandson said.
Other research has shown that early intervention can significantly help frail patients.
In general, frail patients tend to have greater responses to multidomain interventions that include elements such as exercise, nutritional counseling, and ― as some studies suggest ― vitamin D supplementation and hormone replacement.
The care of HIV patients needs to be better coordinated, said Veronica Njie-Carr, PhD, from the University of Maryland School of Nursing in Baltimore.
In a focus group conducted at her center, patients discussed the fact that HIV practitioners should be trained in geriatric medicine, Dr Njie-Carr reported.
“This presentation validates that at the patient level,” she noted.
“The patients also expressed how they have to go to one practitioner for their renal problem and another for arthritis, etc. So there clearly is the need for better coordination of care,” she added.
Dr Erlandson reports receiving funding from the National Institutes of Health National Institute on Aging and research funding or speaker fees, paid to the University of Colorado, from Gilead Sciences and Theratechnologies. Dr Njie-Carr reports no relevant financial relationships.
Association of Nurses in AIDS Care (ANAC) 2017. Presented November 3, 2017.
By Nancy A. Melville