Meredith Greene

Management of human immunodeficiency virus infection in advanced age.

IMPORTANCE Human immunodeficiency virus (HIV)-positive patients treated with antiretroviral therapy now have increased life expectancy and develop chronic illnesses that are often seen in older HIV-negative patients. OBJECTIVE To address emerging issues related to aging with HIV. Screening older adults for HIV, diagnosis of concomitant diseases, management of multiple comorbid medical illnesses, social isolation, polypharmacy, and factors associated with end-of-life care are reviewed. EVIDENCE ACQUISITION Published guidelines and consensus statements were reviewed. PubMed and PsycINFO were searched between January 2000 and February 2013. Articles not appearing in the search that were referenced by reviewed articles were also evaluated. FINDINGS The population of older HIV-positive patients is rapidly expanding. It is estimated that by 2015 one-half of the individuals in the United States with HIV will be older than age 50. Older HIV-infected patients are prone to having similar chronic diseases as their HIV-negative counterparts, as well as illnesses associated with co-infections. Medical treatments associated with these conditions, when added to an antiretroviral regimen, increase risk for polypharmacy. Care of aging HIV-infected patients involves a need to balance a number of concurrent comorbid medical conditions. CONCLUSIONS AND RELEVANCE HIV is no longer a fatal disease. Management of multiple comorbid diseases is a common feature associated with longer life expectancy in HIV-positive patients. There is a need to better understand how to optimize the care of these patients.

Geriatric Syndromes in Older HIV-Infected Adults.

Background: Geriatric syndromes such as falls, frailty, and functional impairment are multifactorial conditions used to identify vulnerable older adults. Limited data exist on these conditions in older HIV-infected adults, and no studies have comprehensively examined these conditions. Methods: Geriatric syndromes including falls, urinary incontinence, functional impairment, frailty, sensory impairment, depression, and cognitive impairment were measured in a cross-sectional study of HIV-infected adults aged 50 years and older who had an undetectable viral load on antiretroviral therapy. We examined both HIV and non–HIV-related predictors of geriatric syndromes including sociodemographics, number of comorbidities and nonantiretroviral medications, and HIV-specific variables in multivariate analyses. Results: We studied 155 participants with a median age of 57 (interquartile range: 54–62) and 94% were men. Prefrailty (56%), difficulty with instrumental activities of daily living (46%), and cognitive impairment (47%) were the most frequent geriatric syndromes. Lower CD4 nadir incidence rate ratio [IRR: 1.16, 95% (confidence interval) CI: 1.06 to 1.26], non-white race (IRR: 1.38, 95% CI: 1.10 to 1.74), and increasing number of comorbidities (IRR: 1.09, 95% CI: 1.03 to 1.15) were associated with increased risk of having more geriatric syndromes. Conclusions: Geriatric syndromes are common in older HIV-infected adults. Treatment of comorbidities and early initiation of antiretroviral therapy may help to prevent development of these age-related complications. Clinical care of older HIV-infected adults should consider incorporation of geriatric principles.

Polypharmacy, Drug–Drug Interactions, and Potentially Inappropriate Medications in Older Adults with Human Immunodeficiency Virus Infection

To describe the frequency of medication‐related problems in older adults with human immunodeficiency virus (HIV) infection.

The relationship of physical performance with HIV disease and mortality.

Objective:To evaluate whether HIV infection was associated with reduced physical performance, and to examine if reduced physical performance predicted mortality in our aging cohort of HIV-infected and HIV-uninfected persons. Design:Prospective, observational cohort of current and former injection drug users in the AIDS Linked to the IntraVenous Experience study in Baltimore, Maryland, USA. Methods:The Short Physical Performance Battery (SPPB) was used as an objective measure of physical performance and measured semiannually along with behavioral and demographic data. Correlates of reduced physical performance (SPPB score ⩽10) were identified and the relationship between reduced physical performance, HIV infection and mortality was analyzed by Cox regression. Results:Among 12 270 person-visits contributed by 1627 participants, the median age was 51, 30.3% were HIV-infected and 32.6% had an SPPB score 10 or less. In multivariable models, HIV infection was independently associated with 30% increased odds of reduced physical performance [odds ratio 1.30; 95% confidence interval (CI):1.12–1.52]. Reduced physical performance predicted mortality in a dose-response manner and within all HIV disease strata. Whereas reduced physical performance alone (hazard ratio 2.52, 95% CI: 1.59–4.00) and HIV infection alone (hazard ratio 2.78, 95% CI: 1.70–4.54) increased mortality, HIV-infected participants with reduced physical performance had a six-fold increased mortality risk (hazard ratio 6.03, 95% CI: 3.80–10.0) compared with HIV-uninfected participants with higher physical performance. Conclusion:HIV infection was independently associated with reduced physical performance. HIV and reduced physical performance have independent and joint effects on mortality. Physical performance measurement may be an important research and clinical tool to predict adverse outcomes among aging HIV-infected persons.

Geriatric Assessments and Association With VACS Index Among HIV-Infected Older Adults in San Francisco.

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 to 2014 among HIV-infected patients ≥50 years at 2 San Francisco-based HIV clinics. We evaluated 4 health domains: (1) physical health and function (activities of daily living), instrumental activities of daily living (IADL), falls, gait speed, (2) social support (physical and perceived support, loneliness), (3) mental health (depression, anxiety, posttraumatic 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:Three hundred fifty-nine patients completed assessments (median age 57; 85% male; 57% white; 72% >high school education). On functional assessment, 39% reported dependence with ≥1 IADL, and 40% reported falls in the previous year. Fifty-eight percent experienced loneliness, 60% the lowest levels of perceived social support, 55% depression, and 12% posttraumatic stress disorder. Forty percent had possible mild cognitive impairment. Thirty percent 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.

Psychiatric symptom burden in older people living with HIV with and without cognitive impairment: the UCSF HIV over 60 cohort study

ABSTRACT Psychiatric comorbidities are common in people living with HIV (PLWH) and adversely affect life satisfaction, treatment adherence and disease progression. There are few data to inform the burden of psychiatric symptoms in older PLWH, a rapidly growing demographic in the U.S. We performed a cross-sectional analysis to understand the degree to which symptom burden was associated with cognitive disorders in PLWH over age 60. Participants completed a standardized neuropsychological battery and were assigned cognitive diagnoses using Frascati criteria. We captured psychiatric symptom burden using the Geriatric Depression Scale (GDS) and proxy-informed Neuropsychiatric Inventory-Questionnaire (NPI-Q). Those diagnosed with HIV-associated neurocognitive disorders (HAND, n = 39) were similar to those without HAND (n = 35) by age (median = 67 years for each group, p = 0.696), education (mean = 16 years vs. 17 years, p = 0.096), CD4+ T-lymphocyte counts (mean = 520 vs. 579, p = 0.240), duration of HIV (median = 21 years for each group, p = 0.911) and sex (92% male in HAND vs. 97% in non-HAND, p = 0.617). Our findings showed similarities in HAND and non-HAND groups on both NPI-Q (items and clusters) and GDS scores. However, there was a greater overall symptom burden in HIV compared to healthy elder controls (n = 236, p < 0.05), with more frequent agitation, depression, anxiety, apathy, irritability and nighttime behavior disturbances (p < 0.05). Our findings demonstrate no differences in psychiatric comorbidity by HAND status in older HIV participants; but confirm a substantial neurobehavioral burden in this older HIV-infected population.

It's Academic: Public Policy Activities Among Faculty Members in a Department of Medicine

PROBLEM To investigate whether and how faculty members in a department of medicine are engaged in public policy activities. APPROACH Between February and April 2011, the authors conducted a cross-sectional, Web-based survey of all active Department of Medicine faculty members at the University of California, San Francisco. Survey questions covered demographics, academic role, academic rank, and participation in three specific public policy activities during the past five years: (1) policy-related research, (2) expert advice to government officials, and (3) public policy advocacy in collaboration with organizations outside government. OUTCOMES Two hundred twenty of 553 faculty (40%) responded to the survey. One hundred twenty-four faculty members (56% of respondents and 22% of total active faculty) reported that they were engaged in at least one of the three types of policy-related activities: 51 (23%) conducted policy-related research, 67 (30%) provided expert advice to government officials, and 93 (42%) collaborated with organizations to advocate for public policy. Higher faculty rank was significantly associated with faculty members reporting that they were involved in one or more of the three policy activities (P = .04). NEXT STEPS Academic departments should identify public policy expertise among their faculty and leverage this expertise by facilitating opportunities to develop a shared faculty awareness of their public policy activities, by supporting the establishment of mentoring relationships for less experienced faculty in the area of public policy, and by incorporating standards of excellence for work in public policy into the promotions process.

Assessment of geriatric syndromes and physical function in people living with HIV

ABSTRACT As the number of older adults living with HIV continues to increase, understanding how to incorporate geriatric assessments within HIV care will be critical. Assessment of geriatric syndromes and physical function can be useful tools for HIV clinicians and researchers to help identify the most vulnerable older adults and to better understand the aging process in people living with HIV (PLWH). This review focuses on the assessment of falls, frailty, and physical function, first in the general population of older adults, and includes a specific focus on use of these assessments in older adults living with HIV.

Older adults in jail: high rates and early onset of geriatric conditions

BackgroundThe number of older adults in the criminal justice system is rapidly increasing. While this population is thought to experience an early onset of aging-related health conditions (“accelerated aging”), studies have not directly compared rates of geriatric conditions in this population to those found in the general population. The aims of this study were to compare the burden of geriatric conditions among older adults in jail to rates found in an age-matched nationally representative sample of community dwelling older adults.MethodsThis cross sectional study compared 238 older jail inmates age 55 or older to 6871 older adults in the national Health and Retirement Study (HRS). We used an age-adjusted analysis, accounting for the difference in age distributions between the two groups, to compare sociodemographics, chronic conditions, and geriatric conditions (functional, sensory, and mobility impairment). A second age-adjusted analysis compared those in jail to HRS participants in the lowest quintile of wealth.ResultsAll geriatric conditions were significantly more common in jail-based participants than in HRS participants overall and HRS participants in the lowest quintile of net worth. Jail-based participants (average age of 59) experienced four out of six geriatric conditions at rates similar to those found in HRS participants age 75 or older.ConclusionsGeriatric conditions are prevalent in older adults in jail at significantly younger ages than non-incarcerated older adults suggesting that geriatric assessment and geriatric-focused care are needed for older adults cycling through jail in their 50s and that correctional clinicians require knowledge about geriatric assessment and care.

A Pharmacist‐Led Program to Evaluate and Reduce Polypharmacy and Potentially Inappropriate Prescribing in Older HIV‐Positive Patients

The goal of this pharmacist‐led study was to utilize two validated instruments, Beers Criteria and Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP), to assess potentially inappropriate prescribing (PIP) in older patients infected with the human immunodeficiency virus (HIV) and evaluate pharmacist interventions.