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

Nathan L. Linsk, PhD

Disclosures

AIDS Read. 2000;10(7) 

In This Article

Treatment

There are few published research studies about HIV treatment in older patients. Older people may have age-related losses of renal and/or liver function or changes in serum albumin levels, all of which can alter the metabolism of drugs and change their efficacy.[28] These common conditions frequently lead to the exclusion of older persons from clinical trials of new drugs. In the United States, people older than 60 have been admitted to drug trials since 1993; however, given health-related criteria specifically related to renal and/or liver function, exclusion criteria frequently limit the participation of older people based on symptoms rather than on age alone. Since immunologic and renal functions routinely show age-related declines in activity, provisions should be made to include older persons as part of the investigation of a new drug. Adler and Nagel[23] also note that clinical trials often focus on a single drug or drug combination, which makes it difficult to apply to older adults who have multiple medical problems and may be treated with multiple medications. Clearly, prophylactic therapies against opportunistic infections and possi- ble antiviral therapy may be needed. Interactions with other chronic or acute conditions need to be considered as well.

The issue of comorbidity is often a clinical concern and a personal issue for older people with HIV. For many, their HIV infection is often not regarded as the most problematic issue they have to cope with on a daily basis. Such medical conditions as arthritis, diabetes, and heart disorders present daily challenges that are often perceived by older adults to be greater threats to their health.[2,21] In this age group, it is increasingly difficult to tease out the symptoms that may be related to advancing age and other medical conditions and those that are related to HIV/AIDS.

A number of confounding issues complicate HIV care for older adults. These include neuropsychiatric complications and cognitive impairments, which appear more common in older than in younger AIDS patients.[29,30] Little is known about older persons who may have coexisting HIV disease and Alzheimer disease or other dementias. HIV-related dementia and neurologic symptoms may be overlooked in older per- sons because of assumed age-related changes; yet, HIV-related dementia may be more episodic and amenable to antiviral treatments than are other forms of dementia.

The geriatric caveat of "start low, and go slow" may also become confounded in the case of HIV, where the current recommended treatment approach is to "hit early, hit hard" to maximize virologic response and minimize risk of resistance. Nonetheless, medications often used in younger adults with HIV may require reduced dosages with elders.[31] There are few data that suggest the appropriate dosage reduction for older adults. The utility of antiretroviral drugs with the elderly is supported by the finding of Whitman and associates,[32] who showed the mortality rate among persons over 50 has declined since the introduction of potent antiretroviral drugs. In a Chicago study, those aged 50 and older showed a 51% decline in death rates since 1995, compared with 61% for all ages.

Siegel[21] noted that the choices faced by all persons with HIV/AIDS with respect to accepting and complying with complex antiviral regimens is more complicated for older HIV-positive people because they are often already taking medications for other health problems. Alternatively, older adults are often accustomed to taking multiple drugs, and some may have already developed ways to master adherence to multiple- drug regimens. However, because of the risk of developing drug resistance, HIV drug dosing and administration require a level of precision that exceeds many drug regimens for other conditions. Potentially, HIV drugs may overload the already very challenging set of medication needs of many older adults, and these people may need help planning need- ed lifestyle changes to achieve treatment adherence. In addition, the cost of drug therapy must be considered for persons in an age group that is often on a limited budget.

Psychosocial issues include fear, changes in self-image, depression, isolation, disclosure, homophobia, and other forms of discrimination. Attitudes about HIV may range from major concerns about the disease to viewing HIV as only a component of the individual's overall life issues. The patient may need assistance in coping with home care needs or developing daily activities. Depression and isolation are concerns, and the provider needs to screen for self-destructive thoughts and mental status and provide for support or referral as needed.

People with HIV disease must determine how open they plan to be about their infection and how it was acquired. HIV disease brings forward a number of social taboos, which the elderly patient may not have addressed openly. A major concern is for the HIV-positive elderly to decide with whom they should share the news of their serostatus. Partners who have shared risk behaviors (usual sexual partners) need to be informed. Spouses or primary partners need to be informed both for support needs and to determine their own risk. Laws vary from state to state regarding HIV confidentiality and providers' ability or obligation to inform partners. The older adult with adult children needs to determine when (or if) he plans to inform them. If symptoms of illness occur, the family may need to address HIV concerns together. The response of each member may be a set of crisis phases: shock, denial, bargaining, and a level of acceptance. Some family members who have poor or little information about HIV infection may be concerned that grandchildren or others are at risk by being near the infected person and will also require education and counseling.

The older person may be very reticent in talking about how he may have been infected, compounding emotional conflicts through unresolved guilt. He may be reluctant to talk about sexual activity, whether it is same-sex or opposite-sex activity. Older gay or bisexual men may have accommodated to a life of extreme secrecy ("in the closet"), and the disclosure of HIV status would bring this secret into the open for the first time. Referral to or development of support groups for HIV-positive persons may assist in this transition.

Almost all persons with HIV and those who provide care for them need to address issues of homophobia and reluctance to deal with substance abuse. Unfortunately, despite changes in HIV incidence indicating the prevalence of HIV throughout many groups, many people still associate the disease with gay men. To address these issues, the provider must first assess and begin to resolve his own fears and attitudes about homosexuality and then must help both the infected elder and his family to do the same. Linkage to AIDS service organizations will often lead to opportunities to know other persons with HIV infection and to address concerns and fears more openly. Creating a comfort zone about personal issues, including drug use and sexuality, requires training for and commitment by providers. With training, most providers become adept quickly.

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