Thanks to the many benefits of combining potent anti-HIV therapy (commonly called art or HAART) more HIV-positive people in Canada and similar countries are living longer. The power of the art is so deep that researchers increasingly expect that some HIV-positive patients to people will have almost normal life.
As people with HIV enter their last years, changes will be needed in the care they receive; they and their health care providers will need to be more attentive to the issues of aging. For the average young adult HIV positive patients starting today, goals probably include a simple scheme with minimal side effects so that a low viral load in the blood can be achieved and maintained. As people age, goals can increase or change to include maintaining a good quality of life as well as physical, mental and emotional health. To enable successful aging, elements of gerontological care will need to be incorporated into regular medical care.
Doctors use the term geriatric syndromes to look at the common conditions seen in older people that can have several underlying causes. Examples of symptoms found in geriatric syndromes include the following:
- Which gives
- Fragile feeling
- Urinary incontinence
- Delirium– a disruption of consciousness with various resources, including problems with attention and awareness; memory difficulties; perception problems such as seeing or hearing things that are not true (hallucinations); being certain about the physical location; disorders of speech and language. In cases of delirium a person's mental state may change suddenly over hours or days. Delirium can make people confused and disoriented. Some people can also become violent and upsetting. The delirium not the same as dementia.
In general, the underlying cause (s) of problems in geriatric syndromes may involve multiple organ systems and each element of geriatric syndrome increases the vulnerability of older people more problems.
Aging and HIV
Understanding that HIV-positive people will need age-appropriate care, a team of researchers studying aging and infectious diseases at the University of Connecticut has proposed that doctors caring prematurely for the aging of HIV-positive people have incorporated the "Geriatric Assessment" in regular care. Such procedures assess whether patients for whom the researchers called "specific conditions that may predispose patients to become less functional," such as the following:
- Visual impairments - problems in this area could have impact on falls and adherence to medication
- Inner ear infections and hearing difficulties - problems in this area could affect balance, falls, ability to understand instructions and communication with health care providers
- Problems with balance and walking - this could increase a person's likelihood of falling
In San Francisco
A team of researchers in San Francisco began trying to understand the effect of aging on HIV-positive people. The team specifically sought to assess the presence of geriatric syndromes in people over 50 years old who had been on HAART and who had a low viral load for several years.
The study of 155 people found geriatric syndromes present. Participants with a greater number of existing co-conditions of health were at increased risk for the development of geriatric syndromes.
Study Details of Geriatric Syndromes
The researchers recruited participants from two major infectious disease clinical centers in San Francisco. Participants completed questionnaires, underwent physical examination, and blood samples were collected. All of these data were analyzed in conjunction with your medical records.
Researchers focused on the following issues:
- Urinary incontinence
- Ability to perform certain daily activities (including domestic work, medication administration, bathing, dressing, shopping) impaired
- Problems with hearing and vision
- Difficulty thinking clearly and memory problems
- Fragility (see below)
The research team defined fragility and pre-fragility by evaluating the presence of the following symptoms:
- The loss of unintentional weight
- Self-report of exhaustion
- Low physical activity
- Slow walking speed
- Physical weakness (assessed by hand pre-mill strength had three or more of these issues and pre-frailty was present in one or two.
Data from 155 people were available for review. The average profile of these participants was as follows:
- Age - 57 years
- 94% male, 6% female
- Duration of HIV infection - 21 years
- CD4 + count - 537 cells / mm3
On average, the participants had four existing co-conditions of health (comorbidities). The most common were as follows:
- Abnormal levels of cholesterol and triglycerides in the blood
- Higher blood pressure than normal
- Injured and painful nerves in hands, arms, legs or feet (peripheral neuropathy)
Participants had an average of nine drugs unrelated to the treatment of HIV infection as part of their daily regimen and medication.
The researchers found that 54% of participants had at least two geriatric syndromes, such as the following:
- Pre-fragility - 56%
- Difficulty with one or more activities of daily living - 47%
- Forgetfulness and trouble trying to think clearly - 47%
Other problems were as follows:
- Qudos - 26% reported that had fallen last year; on average there were two falls per person per year. In about 13% of such cases medical care was sought.
- Urinary incontinence - 25%
- Hearing impairment - 41%
- Visual impairment - 50%
- The disease - 22% of participants presented mild depression and 18% moderate to severe depression
Keep in mind that the study was observational and cross-sectional in nature. Since the data were captured to a large extent at one point in time and participants were not recruited randomly. Such studies are good at finding associations between a potential risk factor and an outcome (one of the geriatric syndromes mentioned earlier), but can not prove that a so-called risk factor causes a specific outcome. Its conclusions must be taken with caution.
In the study, the researchers found that people who had low CD4 + Pre-HAART counts were at greater risk for the future development of geriatric syndromes. They also found that people of darker-colored skin were at increased risk for these syndromes.
It is likely that participants who reported cases of peripheral neuropathy were exposed to a group of old anti-HIV drugs-commonly called "d-drugs" -that may be toxic to nerve cells:
- DdI (didanosine, Videx) Translator's Note: I took
- D4T (stavudine Zerit) Translator's Note - I took
- DdC (zalcitabine, Hivid)
Cross-sectional studies such as the present are good first steps and can be used to establish what is not a health problem that requires more research in a larger, more expensive study and of more robust statistical conceptions.
Such studies could investigate other potential risk factors for geriatric syndromes. Based on the findings obtained in the present study, the researchers recommended that the early initiation of ART may be a way to delay or prevent the development of care of these geriatric syndromes. However, since counseling services in treatment guidelines and clinical practice in high-income countries are generally moving early ART to be initiated early in the course of HIV infection, a researcher's recommendation may not be as important in the era current.
Researchers in San Francisco should be commended for doing the preliminary work needed to document that geriatric syndromes are REALLY occurring in HIV positive middle-aged people. A future study should enroll HIV-positive people e negative - including more women of similar types and really relevant socioeconomic backgrounds that can be made as valid comparisons. Such a study needs to explore a combination of other potential risk factors for geriatric syndromes, including the following (as well mentioned by the researchers):
- Psychosocial factors (social isolation, substance use)
- The presence of several comorbidities
- The burden of multiple medications for various conditions
- Chronic inflammation