Managing HIV in the Aging Patient
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Transcript of Managing HIV in the Aging Patient
Managing HIV in Managing HIV in the Aging the Aging
PatientPatient
Donna Gallagher,Donna Gallagher,
RNCS,MS,ANP,FAAN,MARNCS,MS,ANP,FAAN,MA
PI/Director NEAETCPI/Director NEAETC
HelenHelen
• 60 year old widow60 year old widow• Lives in a retirement communityLives in a retirement community• HTN, new Diabetes, skin rashes, HTN, new Diabetes, skin rashes,
some neuropathysome neuropathy• No history of operations, accidents, No history of operations, accidents,
blood transfusionsblood transfusions• Smokes 1/2 ppdSmokes 1/2 ppd• Drinks 1 bottle of “good wine” a weekDrinks 1 bottle of “good wine” a week
Helen con’tHelen con’t
• Married for 40 years, 5 sons grownMarried for 40 years, 5 sons grown• Husband died 3 months ago in ? Overdose Husband died 3 months ago in ? Overdose
sleeping pillssleeping pills• Feeling depressed and weak since thenFeeling depressed and weak since then• Seen regularly by LMDSeen regularly by LMD• Mild anemia, 21 lb weight lossMild anemia, 21 lb weight loss• Reports only 1 sexual partner in her Reports only 1 sexual partner in her
lifetimelifetime• Tested 2 months ago for HIV+ for change Tested 2 months ago for HIV+ for change
in insurancein insurance
Persons Older than 45 are at Persons Older than 45 are at Increasing Risk of HIV, AIDS and Increasing Risk of HIV, AIDS and
DeathDeath
0
5
10
15
20
25
HIV
AIDS
Deaths
Estimated HIV diagnoses, AIDS diagnoses and deaths of persons with AIDS, by age group in 2004
More than 11% of People Living More than 11% of People Living with AIDS are Older than 55 Yearswith AIDS are Older than 55 Years
0
10
20
30
40
50
13 13-19 20-34 35-44 45-54 55-64 65+
PA
USA
Estimated proportion of persons living with AIDSAnd the US by age group
The proportion of persons with The proportion of persons with HIV/AIDS over 55 years old HIV/AIDS over 55 years old
continues to increasecontinues to increase
10
15
20
1997 1998 1999 2000 2001
Estimated proportion of persons living with AIDSby age group
AIDS cases by age and sex AIDS cases by age and sex reported from 1981 reported from 1981
through 2000 through 2000
http://www.cdc.gov/hiv/graphics/surveill.htm.
OutlineOutline• EpidemiologyEpidemiology• Treatment IssuesTreatment Issues
– AdherenceAdherence– Virologic SuppressionVirologic Suppression– CD4 ResponseCD4 Response– Morbidity/ MortalityMorbidity/ Mortality– ToxicityToxicity– Drug-Drug InteractionsDrug-Drug Interactions
• Co-morbiditiesCo-morbidities• General Health MaintenanceGeneral Health Maintenance• Psychosocial IssuesPsychosocial Issues• Future Research NeedsFuture Research Needs
Older patients are getting Older patients are getting infected!infected!
• Seniors not considered at risk: don’t ask, don’t Seniors not considered at risk: don’t ask, don’t telltell
• Patient lack of awareness of HIV risk factors Patient lack of awareness of HIV risk factors – Many older people are newly single Many older people are newly single – Belief that HIV only affects younger people Belief that HIV only affects younger people
• Unprotected sexual activityUnprotected sexual activity– Use of Viagra and other ED drugs may Use of Viagra and other ED drugs may
contribute to increased rates of sexual activity contribute to increased rates of sexual activity – Menopause= No risk for pregnancy=No Menopause= No risk for pregnancy=No
condomcondom– No training in safer sexual activities No No training in safer sexual activities No
sexual negotiation skillssexual negotiation skills• Lack of HIV prevention education targeted at Lack of HIV prevention education targeted at
older peopleolder people
Demographics of Older vs. Demographics of Older vs. Younger HIV+ PatientsYounger HIV+ Patients
<50<50N=8,609N=8,609
>>5050N=1,664N=1,664
OverallOverallN=10,723N=10,723
Median Median AgeAge
39 (18 – 39 (18 – 49)49)
54 (50 – 54 (50 – 82)82)
42 (18 – 42 (18 – 82)82)
Male SexMale Sex 70.270.2 73.473.4 70.870.8
CaucasiaCaucasiann
BlackBlack
Hispanic Hispanic
29.529.541.741.726.626.6
27.827.844.244.226.126.1
29.229.242.142.126.626.6
IDUIDU 20.220.2 27.227.2 21.521.5
Clinical Outcomes in Older Clinical Outcomes in Older Patients Treated with Patients Treated with
HAARTHAART
• Adherence Adherence • Virologic SuppressionVirologic Suppression• Immunologic ResponseImmunologic Response• Morbidity and MortalityMorbidity and Mortality
Adherence: Adherence: Some things do get better Some things do get better
with Agewith Age
0102030405060708090
Overall 95% Adherence
<50 >50
Hinkin AIDS 2004
HIV-1 RNA <500 at 6 HIV-1 RNA <500 at 6 months: months: by Ageby Age
6768697071727374757677
Percent Undetectable
<50 >50 Grabar AIDS 2004
Treatment Issues in Treatment Issues in Older HIV PatientsOlder HIV Patients
• Older people may have age-Older people may have age-related losses of kidney related losses of kidney and/or liver function which and/or liver function which may change metabolism of may change metabolism of drugs drugs
• Drug-drug interactionsDrug-drug interactions• Toxicities significantToxicities significant• Older people often Older people often
excluded from clinical excluded from clinical trials and few subgroup trials and few subgroup analysis in older patientsanalysis in older patients
• Little pharmacokinetic Little pharmacokinetic data at extremes of agedata at extremes of age
ToxicitiesToxicities
• CardiovascularCardiovascular• Lipid AbnormalitiesLipid Abnormalities• Lipid/Glucose metabolismLipid/Glucose metabolism• Renal FunctionRenal Function• Hepatic InsufficiencyHepatic Insufficiency• Peripheral NeuropathyPeripheral Neuropathy• PancreatitisPancreatitis
Contraindicated Drug-Drug Contraindicated Drug-Drug CombinationsCombinations
• PI’sPI’s– Lipid Lowering Drugs: Lipid Lowering Drugs:
• Lovastatin and SimvastatinLovastatin and Simvastatin– Amiodarone: Ritonavir/lopinavir and Amiodarone: Ritonavir/lopinavir and
ritonavir (Kaletra)ritonavir (Kaletra)– Quinidine: RTV/IDVQuinidine: RTV/IDV– CisaprideCisapride– PPI’s (Atazanavir)PPI’s (Atazanavir)– St. John’s WortSt. John’s Wort
• NNRTI’s NNRTI’s – Cisapride with DLV or EFVCisapride with DLV or EFV
• NNRTIs and PI’sNNRTIs and PI’s• Benzos: triazolam, midazolamBenzos: triazolam, midazolam
Use with Caution Drug-Use with Caution Drug-Drug CombinationsDrug Combinations
• PI’sPI’s– Sildenafil and other Sildenafil and other
ED drugsED drugs– EchinaceaEchinacea– St John’s WortSt John’s Wort– EcstasyEcstasy– MethodoneMethodone
HIV vs. AgingHIV vs. Aging
• Aging process may hide or mimic age-Aging process may hide or mimic age-related diseasesrelated diseases
• Symptoms of SOB, fatigue, pain and Symptoms of SOB, fatigue, pain and weight loss treated as normalweight loss treated as normal
• Delay in diagnosisDelay in diagnosis– Bacterial Pneumonia or Bacterial Pneumonia or PCPPCP??
– Arthritis or Avascular Necrosis? Arthritis or Avascular Necrosis? – Alzheimer’s or AIDS Dementia?Alzheimer’s or AIDS Dementia?– Poor Circulation or Neuropathy?Poor Circulation or Neuropathy?
Multiple Comorbidities Kilbourne, et al. (2001)
Depressive Sx Only15%
Drug/AlcoholOnly: 6%
> Gen. Med.Conditions: 15%
12% 13%5%
7%
First Principles: Age May Exert its Effects Indirectly
HIV and Co MorbiditiesHIV and Co Morbidities
0
5
10
15
20
25
30
35
40
45
Comorbidities
HTNCOPDDMArthritisHCV+CADDepressionRenal Disease
Shah CID 2003
Co-Morbidities in HIVCo-Morbidities in HIV
• CancerCancer• DiabetesDiabetes• DepressionDepression• Substance AbuseSubstance Abuse• Memory ProblemsMemory Problems
Co-Morbidities in HIVCo-Morbidities in HIV
• CancerCancer• DiabetesDiabetes• DepressionDepression• Substance AbuseSubstance Abuse• Memory ProblemsMemory Problems
Increased Risk of Cancer In Increased Risk of Cancer In Elderly HIV PatientsElderly HIV Patients
ObserveObservedd
ExpecteExpectedd
RR (95% CI)RR (95% CI)
AllAll 548548 423.5423.5 1.3 (1.2-1.3 (1.2-1.4)1.4)
ProstateProstate 118118 153.1153.1 0.8 (0.6-0.8 (0.6-0.9)0.9)
LungLung 105105 54.554.5 1.9 (1.6-1.9 (1.6-2.3)2.3)
LeukemiLeukemiaa
1919 7.8 7.8 2.4 (1.5-2.4 (1.5-3.8)3.8)
Hodgkin’Hodgkin’ss
1515 1.11.1 13.1 (7.4-13.1 (7.4-21.6)21.6)
MyelomaMyeloma 1515 5.65.6 2.7 (1.5-2.7 (1.5-4.4)4.4)
LiverLiver 88 2.02.0 3.9 (1.7-3.9 (1.7-7.8)7.8)
AnusAnus 66 0.70.7 8.2 (3.0-8.2 (3.0-17.8)17.8)
Biggar JAIDS 2004
Co-Morbidities in HIVCo-Morbidities in HIV
• CancerCancer• DiabetesDiabetes• DepressionDepression• Substance AbuseSubstance Abuse• Memory ProblemsMemory Problems
Risk of diabetes in Risk of diabetes in HIV/HCV+ Veterans by age HIV/HCV+ Veterans by age
category category
Butt, Hepatology 2004
Co-Morbidities in HIVCo-Morbidities in HIV
• CancerCancer• DiabetesDiabetes• DepressionDepression• Substance AbuseSubstance Abuse• Memory ProblemsMemory Problems
Prevalence of Depression Prevalence of Depression in HIV+ vs. HIV- Veterans in HIV+ vs. HIV- Veterans
by Ageby Age
Justice AIDS 2004
Co-Morbidities in HIVCo-Morbidities in HIV
• CancerCancer• DiabetesDiabetes• DepressionDepression• Substance AbuseSubstance Abuse• Memory ProblemsMemory Problems
Prevalence of Drug Use Prevalence of Drug Use among Veterans: by HIV among Veterans: by HIV
status and age status and age
Justice AIDS 2004
Prevalence of ETOH Abuse Prevalence of ETOH Abuse among Veterans: by HIV among Veterans: by HIV
status and agestatus and age
Justice AIDS 2004
Co-Morbidities in HIVCo-Morbidities in HIV
• CancerCancer• DiabetesDiabetes• DepressionDepression• Substance AbuseSubstance Abuse• Memory ProblemsMemory Problems
Self-Reported Memory Self-Reported Memory Problems in HIV+ vs. HIV- Problems in HIV+ vs. HIV-
Veterans Free of Veterans Free of Depression by AgeDepression by Age
Justice AIDS 2004
Older Infected Individuals are More Older Infected Individuals are More Likely to Have Cognitive Impairment:Likely to Have Cognitive Impairment:
The Allegheny County Neuropsychiatric The Allegheny County Neuropsychiatric Survey (ACNS)Survey (ACNS)
0
10
20
30
40
<50 50+
Dementia
CIND
Older Infected Individuals are Older Infected Individuals are Also More Likely to Develop Mild Also More Likely to Develop Mild
Impairment over 12 MonthsImpairment over 12 Months
0
5
10
15
20
25
>40 40+
CIND
Older Infected Individuals are Older Infected Individuals are More Likely to Develop Peripheral More Likely to Develop Peripheral
Neuropathy Neuropathy
Lopez
HIV+ patients HIV+ patients >>55 years 55 years old with Adequate Health old with Adequate Health Maintenance ScreeningMaintenance Screening
0102030405060708090
100
Health Maintenance
PCP ProphylaxisAny CholesterolAnnual PPD Influenza vaxPneumo Vax ( 5 years)Mammo within 2 yearsAnnual Pap
Shah CID 2002
Medications for common Medications for common age related illnessesage related illnesses
10
15
20
25
Inhaled B-agonist Ca Channel BlockerNSAID’s Anti Peptic Ulcer DrugAce inhibitor DiureticOral Hypoglycemic Antidepressant Shah CID 2002
General Routine Health General Routine Health MaintenanceMaintenance
• All MedicationsAll Medications• Tobacco/ETOH/drug useTobacco/ETOH/drug use• NutritionNutrition• Injury Prevention: Burns/Falls/DrivingInjury Prevention: Burns/Falls/Driving• IncontinenceIncontinence• Sexuality including a review of HIV risk Sexuality including a review of HIV risk
behaviorsbehaviors• MobilityMobility• Mentation/DepressionMentation/Depression• Hearing/VisionHearing/Vision• Activities of daily livingActivities of daily living• Social supportSocial support• Advance directivesAdvance directives
General Routine Health General Routine Health ScreeningScreening
• Screening:Screening:– Lipids: Yearly, especially if on HAARTLipids: Yearly, especially if on HAART– Diabetes: Yearly, quarterly if on HAARTDiabetes: Yearly, quarterly if on HAART– Thyroid Disease: screen every 5 yearsThyroid Disease: screen every 5 years– Osteoporosis: women >65 densitometryOsteoporosis: women >65 densitometry– Colonoscopy every 5 yearsColonoscopy every 5 years– Prostate exam annuallyProstate exam annually
Psychosocial IssuesPsychosocial Issues
• DisclosureDisclosure• IsolationIsolation• Lack of supportLack of support• Financial Financial
issues/Povertyissues/Poverty• End of life End of life
suffering/Poor pain suffering/Poor pain managementmanagement
• SuicideSuicide
ConclusionsConclusions
• Increasing prevalence of HIV in patients Increasing prevalence of HIV in patients >50, Consider HIV in the differential >50, Consider HIV in the differential
• Ask ALL patients about sexual Ask ALL patients about sexual history/drug use, alcohol use, herbs, history/drug use, alcohol use, herbs, spices and recreational drugsspices and recreational drugs
• Older adults may still have worse HIV Older adults may still have worse HIV disease progression and shortened disease progression and shortened survival, even with HAARTsurvival, even with HAART
• The beneficial effects of HAART therapy The beneficial effects of HAART therapy may be less in older HIV patientsmay be less in older HIV patients
ConclusionsConclusions
• Toxicity from HAART is substantial Toxicity from HAART is substantial and may be exacerbated in older and may be exacerbated in older patientspatients
• Drug-drug interactions are commonDrug-drug interactions are common• Unclear what the “ideal” HIV regimen Unclear what the “ideal” HIV regimen
is for older patientsis for older patients• High rates of comorbidities in older High rates of comorbidities in older
HIV patients HIV patients • General routine health maintenance General routine health maintenance
and screening is importantand screening is important• Future research is essential for Future research is essential for
developing accurate treatment developing accurate treatment recommendations in older patientsrecommendations in older patients
Resources for the Older Resources for the Older HIV PatientHIV Patient
OrganizationsOrganizations• National Association on HIV Over Fifty National Association on HIV Over Fifty
(NAHOF)(NAHOF)www.hivoverfifty.orgwww.hivoverfifty.org (617) 233-7107 (617) 233-7107
• New York Association on HIV Over FiftyNew York Association on HIV Over Fiftywww.nyahof.orgwww.nyahof.org (212) 481-7594 (212) 481-7594
• HIV Wisdom for Older WomenHIV Wisdom for Older Womenwww.hivwisdom.orgwww.hivwisdom.org (913) 722-3100 (913) 722-3100
• National Institute On AgingNational Institute On Agingwww.nia.nih.gov/health/agepages/aids.htmwww.nia.nih.gov/health/agepages/aids.htm
• American Association of Retired American Association of Retired Persons (AARP)Persons (AARP)
www.aarp.orgwww.aarp.org
Resources for the Older Resources for the Older HIV PatientHIV Patient
BooksBooks• AIDS in an Aging Society: What We Need to AIDS in an Aging Society: What We Need to
KnowKnow; Riley, Ory & Zablotsky 1989 ; Riley, Ory & Zablotsky 1989 • HIV & AIDS and Older PeopleHIV & AIDS and Older People; Kaufmann 1995 ; Kaufmann 1995 • HIV/AIDS and the Older AdultHIV/AIDS and the Older Adult; Nokes 1996 ; Nokes 1996 • Aging with HIV: Psychological, Social, and Aging with HIV: Psychological, Social, and
Health IssuesHealth Issues; Nichols, et al. 2002 ; Nichols, et al. 2002 • HIV/AIDS and Older Adults: Challenges for HIV/AIDS and Older Adults: Challenges for
Individuals, Families, and CommunitiesIndividuals, Families, and Communities; Emlet ; Emlet 2004 2004
• Midlife and Older Adults and HIV: Midlife and Older Adults and HIV: Implications for Social Services Research, Implications for Social Services Research, Practice, and PolicyPractice, and Policy; Poindexter & Keigher ; Poindexter & Keigher 20042004
Resources for the Older Resources for the Older HIV PatientHIV Patient
VideosVideos• HIV/AIDS and Older Americans; HIV/AIDS and Older Americans;
videovideoproduced by the National Minority produced by the National Minority AIDS Council Sept. 2001AIDS Council Sept. 2001
• HIV and Older Adults: Age is No HIV and Older Adults: Age is No Barrier; videoBarrier; videoNew York State Department of New York State Department of Health/AIDS InstituteHealth/AIDS InstituteMay 2003May 2003