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