What Problems Associated With Ageing Are Seen in a Specialist Service for Older People Living With HIV?

Howell T. Jones; Alim Samji; Nigel Cope; Joanne Williams; Leonie Swaden; Abhishek Katiyar; Fiona Burns; Aisha McClintock-Tiongco; Margaret Johnson; Tristan J. Barber

Disclosures

HIV Medicine. 2022;23(3):259-267. 

In This Article

Materials and Methods

The Ian Charleson Day Centre (ICDC) was established at the Royal Free Hospital in 1990 as the first open-access clinic for people with HIV in the UK and currently coordinates the care of 3200 people, just over half of whom are older than 50. Many service users were presenting with problems related to ageing, so a dedicated monthly multidisciplinary clinic, 'The Sage Clinic' (non-acronymous), was formed with the aim of identifying and managing these problems.

Clinic Design

The monthly 4-h multidisciplinary clinic allowed for six patients to be seen in a carousel format made up of three 30-min assessments, with each patient assessed for 90 min in total. The multidisciplinary team (MDT) consisted of the following members: HIV physician, geriatrician, physiotherapist, occupational therapist, HIV specialist pharmacist and HIV specialist nurse. Dietetics, speech and language therapy, psychology and social work professionals were not available to attend and were referred onto as needed.

Prior to the clinic the referral and patients' existing medical records were reviewed to formulate a summary highlighting potential issues including possible barriers to engagement or interventions. The first of the three assessments comprised a medical review led by a geriatrician focusing on the physical and psychological domains of the CGA.[10] The assessment was performed alongside a consultant HIV physician to provide a point of reference to the relevance of an HIV diagnosis and to ensure that there were no contraindications for any suggestions. The functional and social domains of the CGA were explored by a physiotherapist and occupational therapist who reviewed mobility and function while providing patient education, onward referral to therapy or social services and delivery of equipment. The final part of the CGA included a medication review by a HIV specialist pharmacist to evaluate concordance, tolerability and drug–drug interactions. Prior to the clinic patients were sent questionnaires to ascertain information to help guide the reviews; as these were often not completed, the final part of this session involved a HIV specialist nurse assisting with this.

At each stage attendees were provided with a summary of the professionals' findings and suggestions and were invited to ask any questions. The MDT reconvened at the end of the clinic to construct an MDT report summarizing their findings, providing information on how best to support the patient who was then sent to the referring HIV clinician plus the primary care physician when permitted.

Patient Identification

Table 1 demonstrates the referral criteria for the Sage Clinic with patients identified by their regular HIV clinician or HIV specialist nurse.[13]

Objective Outcome Measures

The outcome measures collected during the Sage Clinic are summarized in Table 2.

The Fried Frailty Phenotype assesses five criteria (weight loss, exhaustion, low physical activity, slowness and weakness) to determine the degree of frailty, with a score of 0 indicating a person as robust, 1–2 as pre-frail and 3 or more as frail.[13] Table 2 illustrates the adapted version used within our service using subjective questions rather than the objective measures required in traditional Fried scoring to facilitate ease of use.[13]

Fried scoring is limited as it does not account for the psychological or neurocognitive aspects of frailty so depression was screened for using the Patient Health Questionnaire-9 (PHQ-9), a nine question tool where a score of 10 or more is suggestive of depression (range 0–27).[14,15] Anxiety was assessed for using the General Anxiety Disorder-7 (GAD-7) tool comprising seven questions again where a score of 10 or more is diagnostic (range 0–21).[16] Cognitive screening was performed using the Montreal Cognitive Assessment (MoCA), a one-page 30-point test of seven domains where a score of 26 or more is considered normal.[17]

Quality of life (QOL) was assessed using the World Health Organization Quality of Life-HIV BREF (WHOQOL-HIV-BREF) which comprises thirty-one questions on the patient's perceptions of their well-being over the preceding 2 weeks.[18] Responses are given via a 1–5 Likert scale where 1 represents 'disagree' or 'not at all' and 5 represents 'completely agree' or 'extremely'.[18] Questions cover six domains: physical, psychological, level of independence, social, environmental and spiritual.[18] Finally, disability was assessed using the World Health Organization Disability Assessment Schedule (WHODAS 2.0), a 36-question tool which covers six areas: cognition, mobility, self-care, getting along, life activities and participation, using a 1–5 Likert scale, with 1 representing 'none' and 5 'extreme or cannot do'.[19]

Costings

HIV clinician, pharmacist and nursing time was provided directly from within the existing HIV departmental budget. The time of the geriatrician, physiotherapist and occupational therapist was paid for on a sessional basis, supported by an external grant.

Statistical Analysis

Data were summarized using descriptive statistics including frequency, median or with corresponding percentages or interquartile ranges.

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