1
Didactic Series
HIV and Aging
Daniel Lee, MD UCSD Medical Center – Owen Clinic
July 12th, 2018
Special thanks to Meredith Greene, MD, AAHIVS for her permission for me to use her
many slides
3
Learning Objectives
1) To review how aging affects the HIV community (from a geriatric perspective)
2) To discuss the concepts of multimorbidity and polypharmacy in the aging population
3) To discuss various screening tools that may be useful in evaluating aging persons living with HIV
Increasing Numbers of Older Adults Living with HIV
50% of PLWH by 2017 will be age 50+ – in VA since 2003 – in NYC since 2014 – in San Francisco since 2010 (63% > age 50)
5
Question #1: In aging HIV patients, what do you think is true? A. Aging is accelerated B. Aging is accentuated C. Aging is both accelerated and accentuated D. Aging is similar to non-HIV population E. What is the difference between accelerated and
accentuated?
PresenterPresentation NotesNo correct answer
Why Age 50? Accelerated vs. Accentuated Aging
Pathai S J Gerontol A Biol Sci Med Sci 2014
PresenterPresentation NotesSummarize conclusions of this article
What Is Aging?
Gradual change in an organism that leads to increased risk of weakness, disease, and
death
Aging is not a disease!
There is more heterogeneity among older people than any other age group
Heterogeneity in Older HIV+ Adults
Aging with HIV Infected with HIV at older
age
The New York Times 2007 The Honolulu Advertiser 2003
Slide courtesy of Victor Valcour
How are older adults different?
• Common physiologic changes: – Decreased GFR – Decreased lean body mass – Decreased bone density – Decreased cardiac output and increased
myocardial and arterial stiffness – Decreased vision and hearing
PresenterPresentation NotesPoint out similarities with HIV, be more specific
How are older adults different?
• Diseases often present atypically: – May not have the
“usual” signs and symptoms
– Delirium/altered mental status may be the primary presenting sign and is not always a UTI
• Less reserve—small insults can cause significant problems
• Occam’s razor - one unifying diagnosis may not apply
PresenterPresentation NotesEven small insults on a weakened physiologic system can result in significant failureAcute renal failure with a new medicationRespiratory failure with pneumoniaDelirium with minor illness or dehydrationFalls and incontinence with CHF exacerbation
It can also result in marked improvements with small interventionsReversal of lethargy with 500cc of IV fluidsCure of “dementia” with medication adjustmentRestored independence with the right assistive device
Geriatric Perspective • Focus on function
– How do diseases impact social, emotional, and physical functioning?
– How can the environment (physical, social) support function?
• Focus on quality of life and goals of care
• Working across different settings – Home, Residential Care Facility for Elderly (RCFE),
Clinic, Hospital, Skilled Nursing Facilities (SNF)
PresenterPresentation NotesMr. B in the article
Similarities with HIV Care
• Dealing with Complexity – multimorbidity, polypharmacy, complex social
situations
• Working in interdisciplinary teams
• Emphasis on social context of care
PresenterPresentation NotesAlso the
How Geriatric Perspective Can Help
PresenterPresentation NotesHolistic approach; not just medical issues; function is the same
HIV Associated Non AIDS Conditions (HANA)
Slide courtesy Steven Deeks
PresenterPresentation NotesDefinition: HIV contributes to but non AIDS defining; add coinfections
Multimorbidity Higher in PLWH
• CAD / MI, HTN, PAD, CVD / Stroke, COPD • T2DM, Renal Dz, Non-AIDS CA, Osteoporosis
Schouten, CID, 2014 Slide Courtesy of Peter Hunt
Multimorbidity
• Not just individual problems on a problem list
• Individual disease guidelines and screening
guidelines that focus on Dx and Rx – Result: adding medications for each individual
disease state
PresenterPresentation NotesBoyd, Lucas Curr Opin HIV/AIDS 2014Tinnetti M,N Engl J Med, 2004 Boyd C. JAMA 2005
Time Medications Non-pharmacologic Therapy
All Day Periodic
7 AM
Ipratropium MDI Alendronate 70mg weekly
Check feet Sit upright 30 min. Check blood sugar
Joint protection
Energy conservation
Exercise (non-weight bearing if severe foot disease, weight bearing for osteoporosis) Muscle strengthening exercises, Aerobic Exercise ROM exercises
Avoid environmental exposures that might exacerbate COPD
Wear appropriate footwear
Albuterol MDI prn
Limit Alcohol
Maintain normal body weight
Pneumonia vaccine, Yearly influenza vaccine
All provider visits:Evaluate Self-monitoring blood glucose, foot exam and BP
Quarterly HbA1c, biannual LFTs
Yearly creatinine, electrolytes, microalbuminuria, cholesterol
Referrals: Pulmonary rehabilitation
Physical Therapy
DEXA scan every 2 years
Yearly eye exam
Medical nutrition therapy Patient Education: High-risk foot conditions, foot care, foot wear Osteoarthritis COPD medication and delivery system training Diabetes Mellitus
8 AM Eat Breakfast HCTZ 12.5 mg Lisinopril 40mg Glyburide 10 mg ECASA 81 mg Metformin 850mg Naproxen 250mg Omeprazole 20mg Calcium + Vit D 500mg
2.4gm Na, 90mm K, Adequate Mg, ↓ cholesterol & saturated fat, medical nutrition therapy for diabetes, DASH
12 PM Eat Lunch Ipratropium MDI Calcium+ Vit D 500 mg
Diet as above
5 PM Eat Dinner Diet as above
7 PM Ipratropium MDI Metformin 850mg Naproxen 250mg Calcium 500mg Lovastatin 40mg
11 PM Ipratropium MDI
It’s Not Easy Living with Multimorbidity
Boyd, JAMA 2005;294:716-724
PresenterPresentation NotesWe constructed a hypothetical patient with 5 chronic conditions of moderate severityWe generated an aggregate treatment regimen for this hypothetical patient by combining the relevant CPGs. We constructed a hypothetical patient with 5 chronic conditions of moderate severityWe generated an aggregate treatment regimen for this hypothetical patient by combining the relevant CPGs. We :Followed explicit instructions when availableAssumed once a day drug dosing when availableAssumed generic drugs when availableTook advantage of potential synergies between CPGsChose medicines with least adverse effects / interactionsCalculated cost to patient from prices from low-cost internet store (drugstore.com)Calculated complexity of medication regimen
Polypharmacy
19
Question #2: What is the most commonly accepted definition of polypharmacy? A. 2 or more medications daily B. 3 or more medications daily C. 5 or more medications daily D. 7 or more medications daily E. 10 or more medications daily
PresenterPresentation NotesC is correct answer
Polypharmacy: Prescribing Issues
Greene M. JAGS 2014.
PresenterPresentation Notes% meeting criteria polypharmacy, % with at least 1 drug-drug interaction, % potentially inappr med (describe), ARS scale scoreWhen compared to age and sex matched HIV- HIV+ had more of each prescribing issue
Chart1
0
0
0
0
0
Percentage of Participants
0
0
0
0
0
Aging affects pharmacology
Pharmacokinetic (PK) changes: -Elimination (renal and liver) -Distribution (changes with body fat/water) -Metabolism: possible cytochrome p450
Pharmacodynamic (PD) changes:
-Increased sensitivity to medications at standard doses -Sedation with certain meds: benzodiazepines
PresenterPresentation NotesNot much change absorption: achlorydia, distribution, decreased lean body water and mass- lipophilic stick around longer;Metabolism- possibly decreased hepatic metabolism; conflicting results with cytochrome p450
Prescribing Cascade
PresenterPresentation NotesCould move this to case discussion instead
Addressing Multimorbidity: Geriatric Assessment Can Help!
Hazzard’s Principles of Geriatric Medicine 6th edition
PresenterPresentation NotesHolistic approach; not just medical issues; function is the same
Functional Status Activities of Daily Living (ADLs) • Bathing • Dressing • Toileting • Transferring • Feeding
Instrumental Activities of Daily Living (IADLs) • Telephone • Finances • Transportation • Laundry • Housekeeping • Shopping • Meal preparation • Medications
Functional Status Important in HIV+
*Adjusted for gender, race/ethnicity, age, comorbidities SPPB: Short Physical Performance Battery
Greene M. AIDS. 2014
Short Physical Performance Battery (SPPB) • Predictive validity showing a gradient of risk for mortality,
nursing home admission, and disability • Balance Tests
• Side-by-Side Stand – feet together side-by-side x 10 sec • Semi-Tandem Stand – heel of 1 foot touching big toe of other foot x
10 sec • Tandem Stand – heel of 1 foot in front of and touching the toes of
other foot x 10 sec
• Gait Speed Test - timed • 3 or 4-meter walk – repeat twice, record shorter of the two times
• Chair Stand Test - timed • Single Chair Stand – stand up from a chair without using arms • Repeated Chair Stand – same as above, but repeat x 5
http://geriatrictoolkit.missouri.edu/SPPB-Score-Tool.pdf
PresenterPresentation NotesIn 359 HIV+; 30% of 45-65 y/o had ≥1 fall, 18% recurrent fallsHIV factors not associated except hx d4T30% of 45-65 y/o had ≥1 fall, 18% recurrent falls
Comorbidities and medications importantBalance problems common>=10 is low risk
Geriatric Syndromes in Older HIV+ Adults
56.1%
46.5%
46.5%
40.0%
34.8%
25.8%
25.2%
25.2%
21.9%
14.2%
9.0%
0% 10% 20% 30% 40% 50% 60%
Pre-frailty
Difficulty ≥1 IADL
Cognitive Impairment
Depression
Visual Impairment
Falls
Incontinence
Difficulty ≥1 ADL
Mobility
Hearing Impairment
Frailty
Greene M, JAIDS, 2015
Screening for Falls
CDC STEADI: 1) Have you fallen in past year? 2) Do you feel unsteady when standing or walking? 3) Do you worry about falling?
https://www.cdc.gov/steadi/index.html https://www.cdc.gov/steadi/pdf/Stay_Independent_brochure-print.pdf
CDC STEADI https://www.cdc.gov/steadi/pdf/Stay_Independent_brochure-print.pdf
Approach to Falls
PresenterPresentation NotesMore than one out of four people 65 and older falls each year, and over 3 million are treated in emergency departments annually for fall injuries.
Lack of Support, Isolation, Loneliness in HIV+
• Medication adherence
• Sexual risk taking behaviors
• Tobacco and other substance use
• Mood symptoms - depression Johnson CJ AIDS Care. 2009, Bianco AIDS Behavior 2011, Golub STD 2010, Hubach IAS 2015; Grov AIDS Care 2010; Stanton AIDS Care 2010
How to Screen for Loneliness
Support Networks Loneliness
Perception of Support
https://www.campaigntoendloneliness.org/
Loneliness Screening
Question Hardly Ever
Some of the Time
Often
1. I feel left out 1 2 3
2. I feel isolated 1 2 3
3. I lack companionship
1 2 3
3-item Loneliness Scale:
Max score 9: higher score=more lonely
http://psychcentral.com/quizzes/loneliness.htm
Not just Loneliness
• Traumatic Loss and Complicated Grief
• Stigma -- & often multiple stigmas
• Depression
34
Conclusions • Aging (whether accelerated, accentuated, or both) will be
an ongoing issue as people live longer with HIV/AIDS
• Awareness of the complexity of management of multimorbidities and the concern for preventing unnecessary polypharmacy is key in providing excellent care to those living with HIV/AIDS
• Screening tools can be used in the aging HIV population to assess for a variety of parameters including – Functional Status – Fall Risk – Loneliness
Resources
Resources: Aging Specific • Adult Day Health Centers
• Senior Centers
• Friendly Visitor Programs:
https://www.coasc.org/programs/friendly-visitor/
• Institute on Aging (IOA) Friendship Line: https://www.ioaging.org/services/all-inclusive-health-care/friendship-line
• Village Movement: https://villagemovementcalifornia.org/
Didactic SeriesSlide Number 2Learning ObjectivesIncreasing Numbers of Older Adults Living with HIVQuestion #1:Why Age 50? �Accelerated vs. Accentuated AgingWhat Is Aging?Heterogeneity in Older HIV+ AdultsHow are older adults different?How are older adults different?Geriatric PerspectiveSimilarities with HIV CareHow Geriatric Perspective Can HelpHIV Associated Non AIDS Conditions (HANA)Multimorbidity Higher in PLWHMultimorbiditySlide Number 17PolypharmacyQuestion #2:Polypharmacy: Prescribing IssuesAging affects pharmacologyPrescribing CascadeAddressing Multimorbidity: Geriatric Assessment Can Help!Functional StatusFunctional Status Important in HIV+Short Physical Performance Battery (SPPB)Geriatric Syndromes in Older HIV+ AdultsScreening for FallsSlide Number 29Lack of Support, Isolation, Loneliness in HIV+How to Screen for LonelinessLoneliness ScreeningNot just LonelinessConclusionsResourcesResources: Aging Specific