HIV Among Older Adults: Age-Specific Issues in Prevention and Treatment

Nathan L. Linsk, PhD

Disclosures

AIDS Read. 2000;10(7) 

In This Article

Disease Course, Care, and Management

HIV disease involves many body systems, including respiratory and skin, as well as neurologic aspects of health and illness. A crucial issue regarding HIV infection in older adults is to distinguish among those conditions that are age-related, those that are HIV-related, those that are not distinguishable, and those related to both. Differential diagnosis in older adults is a complex process, because many diseases may resemble others and many elders may have multiple diagnoses. Symptoms may be correctly identified and treated without identifying HIV as a causative or related factor. Bacterial infections; pneumonias; herpesvirus infections, including herpes zoster; and other infections may be identified as diseases of the old and treated without a connection to HIV disease. For example, pneumocystis pneumonia can be mistaken for congestive heart failure in persons with chronic heart diseases. Kaplan[22] states that HIV dementia may mimic Alzheimer or Parkinson disease. Adler and Nagel[23] point out that while HIV-positive individuals may develop peripheral neuropathy and myelopathy, which is uncharacteristic of Alzheimer disease, some older AIDS patients present with altered mental status, impaired recent memory, or diminished intellect that may be incorrectly diagnosed as Alzheimer disease. Even though the manifestations of HIV infection resemble other diseases of aging, it is important to understand that HIV may be responsible for such symptoms as fatigue, shortness of breath, chronic pain, weight loss, and rashes. These symptoms may be episodic rather than constant.

A number of studies have demonstrated that the course of illness appears to be more rapid with increased age not only among older people but also across the life span.[24] Phillips and colleagues[25] investigated 2 possible explanations for more rapid progression to AIDS in older people: (1) CD4+ T-cell counts fall to lower levels more rapidly in older infected persons, and/or (2) there is greater risk of progression to AIDS among older infected people at low CD4+ T-cell counts. Phillips and coworkers studied 111 HIV-positive hemophiliacs (age range, 2 to 77 years) who had been followed for up to 10 years. These patients had been treated with zidovudine monotherapy and given Pneumocystis carinii pneumonia prophylaxis (an approach no longer considered the standard of care). These patients were compared with 137 HIV-negative hemophiliacs (age range, 20 to 79 years) followed from 1982 to 1989. This study found that increased age was associated with the fastest disease progression; those patients in their teens were the slowest progressors, and those in their 20s were in between. The investigators concluded that as people age, they are at higher risk for progression to AIDS than are their younger counterparts, even if their CD4+ T-cell counts are similar; therefore, they suggested that older HIV-infected persons may need prophylaxis for opportunistic infections earlier in the course of disease.

Ferro and Salit[26] compared disease progression in a sample of 21 older patients who did not have AIDS at the time of diagnosis of HIV infection with the disease progression in younger patients with HIV infection. Progression to AIDS was found in 13 (62%) of 21 older patients and in 9 (21%) of 42 younger patients. This difference persisted after excluding those patients who acquired infection via blood transfusion or blood products. However, no significant differences were found between the 2 groups in the frequency of distribution of different AIDS-defining conditions at presentation. There was a tendency for more HIV encephalopathy and less Kaposi sarcoma in the older group. By the end of the study period, 19 of 25 of older patients had died, compared with 18 of 47 patients in the younger sample (76% versus 38%, P < .002). Mean time from diagnosis to death was 6.3 (± 5.3) months for older persons versus 16.5 (± 8.7) months for younger ones (P < .001).

These investigators also noted that older patients more frequently presented with AIDS at the time of diagnosis with HIV infection than did younger patients (36% versus 5%, P < .001). This may be due, in part, to the lack of suspicion of HIV infection in older persons, but it also may be due to a shorter and/or less symptomatic pre-AIDS phase. A significantly higher proportion of old- er patients with a non-AIDS diagnosis had disease that progressed to AIDS compared with younger patients, and a significant difference was also found in the comparison of the AIDS-free survival curves. Some of the differences could be ascribed to differences in prescribing, because older patients were less likely to be receiving antiretroviral therapies.

Adler and Nagel[23] noted that clinical deterioration is more rapid among elderly HIV-infected persons than among younger adults, which is common in many other diseases, such as influenza. In their review of studies at Johns Hopkins University and the NIH, the researchers found that there were neither age-related differences in cell phenotypes nor differences in the degree of lymphocyte dysfunction between young (under 30 years) and old (over 70 years) HIV-positive individuals.[23] These researchers suggest that the difference between young and old HIV-infected persons in disease progression is not due to the degree or loss of specific immune function but rather to the faster loss of CD4+ helper cells in the older persons compared with the loss rate in the younger persons.

Justice and Weissman[27] point out that there are 2 sets of mediators that affect disease progression for older adults: mutable and immutable. Likely mutable mediators include delayed diagnosis, appropriateness of therapy, and socioeconomic factors. Immutable mediators include deficits in organ function, immune function, nutritional status, mental status, bone marrow function, kidney function, cardiac function, and psychiatric disease.

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