An Emerging Concern-High Rates of Frailty among Middle-aged and Older Individuals Living with HIV

Cardiometabolic Diseases and Quality-of-Life Outcomes in Adults With HIV in the Deep South: A Cross-sectional Study

ABSTRACT

The role of cardiometabolic diseases (CMDs) on physical health-related quality of life (P-HRQoL) and quality of sleep was examined among 261 PLWH ≥40 years, recruited from a university-affiliated HIV clinic in the Deep U.S. South. Using a cross-sectional study design, participants completed the Medical Outcomes Study HIV Health Survey (MOS-HIV; P-HRQoL) and Pittsburgh Sleep Quality Index. The overall prevalence of self-reporting ≥1 CMD was 64.4%. P-HRQoL scores were lower in PLWH with ≥1 CMD compared with those with no CMDs (45.53 ± 11.54 vs. 49.67 ± 10.77, p <.01). Poor sleep quality was higher among participants with ≥1 CMD compared with those with no CMDs (9.28 ± 4.42 vs. 7.26 ± 4.17, p <.01). Each additional CMD resulted in a 1.83-point decrease in P-HRQoL and 0.74-point increase in poor sleep quality scores. Interventions that focus on targeting these quality-of-life domains in PLWH with CMDs are needed.

Ageing with HIV: Medicine Optimisation Challenges and Support Needs for Older People Living with HIV: A Systematic Review

BACKGROUND

Older people living with HIV (PLWH) are at increased risks of co-morbidities and polypharmacy. However, little is known about factors affecting their needs and concerns about medicines. This systematic review aims to describe these and to identify interventions to improve medicine optimisation outcomes in older PLWH.

METHODS AND DATA SOURCES

Multiple databases and grey literature were searched from inception to February 2022 including MEDLINE, CINAHL, PsycInfo, PsychArticles, the Cochrane Database of Systematic Reviews and the Cochrane Controlled Register of Trials, Abstracts in Social Gerontology, and Academic Search Complete.

ELIGIBILITY CRITERIA

Studies reporting interventions/issues affecting older PLWH (sample populations with mean/median age ≥ 50 years; any aspect of medicine optimisation, or concerns). Quality assessments were completed by means of critical appraisal checklists for each study design. Title and abstract screening was led by one reviewer and a sample reviewed independently by two reviewers. Full-paper reviews were completed by one author and a 20% sample was reviewed independently by two reviewers.

SYNTHESIS

Data were extracted by three independent reviewers using standardised data extraction forms and synthesised according to outcomes or interventions reported. Data were summarised to include key themes, outcomes or concerns, and summary of intervention.

RESULTS

Seventy-nine (n = 79) studies met the eligibility criteria, most of which originated from the USA (n = 36). A few studies originated from Australia (n = 5), Canada (n = 5), Spain (n = 9), and the UK (n = 5). Ten studies originated from Sub-Saharan Africa (Kenya n = 1, South Africa n = 6, Tanzania n = 1, Uganda n = 1, Zimbabwe n = 1). The rest of the studies were from China (n = 1), France (n = 1), Germany (n = 1), Italy (n = 1), the Netherlands (n = 1), Pakistan (n = 1), Switzerland (n = 1), Saudi Arabia (n = 1) and Ukraine (n = 1). Publication dates ranged from 2002 to 2022. Sample sizes ranged from 10 to 15,602 across studies. The factors affecting older PLWH's experience of and issues with medicines were co-morbidities, health-related quality of life, polypharmacy, drug interactions, adverse drug reactions, adherence, medicine burden, treatment burden, stigma, social support, and patient-healthcare provider relationships. Nine interventions were identified to target older persons, five aimed at improving medication adherence, two to reduce drug interactions, and two for medicine self-management initiatives.

CONCLUSION

Further in-depth research is needed to understand older PLWH's experiences of medicines and their priority issues. Adherence-focused interventions are predominant, but there is a scarcity of interventions aimed at improving medicine experiences for this population. Multi-faceted interventions are needed to achieve medicine optimisation outcomes for PLWH.

TRIAL REGISTRATION

This study is registered with PROSPERO registration number: CRD42020188448.

Frailty in older people living with HIV: current status and clinical management

This paper will update care providers on the clinical and scientific aspects of frailty which affects an increasing proportion of older people living with HIV (PLWH). The successful use of combination antiretroviral therapy has improved long-term survival in PLWH. This has increased the proportion of PLWH older than 50 to more than 50% of the HIV population. Concurrently, there has been an increase in the premature development of age-related comorbidities as well as geriatric syndromes, especially frailty, which affects an important minority of older PLWH. As the number of frail older PLWH increases, this will have an important impact on their health care delivery. Frailty negatively affects a PLWH's clinical status, and increases their risk of adverse outcomes, impacting quality of life and health-span. The biologic constructs underlying the development of frailty integrate interrelated pathways which are affected by the process of aging and those factors which accelerate aging. The negative impact of sarcopenia in maintaining musculoskeletal integrity and thereby functional status may represent a bidirectional interaction with frailty in PLWH. Furthermore, there is a growing body of literature that frailty states may be transitional. The recognition and management of related risk factors will help to mitigate the development of frailty. The application of interdisciplinary geriatric management principles to the care of older PLWH allows reliable screening and care practices for frailty. Insight into frailty, increasingly recognized as an important marker of biologic age, will help to understand the diversity of clinical status occurring in PLWH, which therefore represents a fundamentally new and important aspect to be evaluated in their health care.

Correlation Between Polypharmacy and Frailty Among Thai Older Persons Living with HIV

Polypharmacy and frailty are correlated in Persons Living with HIV (PLWH) in the United States, but little is known about their correlation in resource-limited settings. Our cross-section study evaluated the correlation between polypharmacy and frailty among Thai 324 virally suppressed PLWH and 132 uninfected patients aged ≥50 between March 2016 and April 2017. The primary predictor was the number of patient-reported non-antiretroviral therapy (ART) medications. The outcome was having additional domain of the five Fried frailty phenotype domains (0 = normal, 1-2 = prefrail, >3 = frail). Most participants were male (63% PLWH, 67% uninfected) with few comorbidities (1.4 PLWH, 0.9 uninfected) and small median number of non-ART medications (2 PLWH, 1 uninfected). Frailty was uncommon (8.6% PLWH, 3.8% uninfected). Each additional non-ART medication correlated with 6% increased likelihood of having additional frailty domain among PLWH (95% CI: 0.002-0.11, p = .04) but not statistically significant among the uninfected. The association between polypharmacy and frailty is more pronounced in Thai PLWH than in participants without HIV. Further study is warranted to confirm this association in other resource-limited settings and explore potential deprescribing practices.

Muscle mass, strength, bone mineral density and vascular function in middle-aged people living with HIV vs. age-matched and older controls

Introduction

Combination antiretroviral therapy (cART) substantially extended the life of people living with HIV (PLHIV). However, prolonged HIV infection and cART increase the risk of comorbidities accelerating age-related muscle, bone, and vascular disorders. This cross-sectional study compared muscle mass and strength, bone mineral density (BMD), and vascular function in middle-aged PLHIV treated with cART vs. non-infected age-matched and older controls.

Methods

After careful screening for secondary diseases and medications, body composition, muscular and vascular function were assessed in 12 PLHIV (43.9±8.7 yrs old; HIV-infection for 16.2±8.6 yrs; on cART for 11.6±9.2 yrs), 12 age-matched (CONT, 43.2±8.5 yrs old), and 12 older (OLDER, 74.4±8.3 yrs old) controls through dual x-ray absorptiometry, isokinetic dynamometry, and venous occlusion plethysmography, respectively.

Results

PLHIV and CONT showed similar relative muscle mass (65.3±8.0 vs. 66.9±7.3%, respectively; P= 0.88) and strength (160.7±53.9 vs. 152.0±52.9 N.m⁻¹, respectively; P= 0.90), which were greater than OLDER (80.6±18.8 N.m^−1; P= 0.001). Total BMD was similar in PLHIV (1.04±0.13 g.cm⁻²) and OLDER (1.00±0.15 g.cm⁻², P= 0.86), and both groups presented lower values than CONT (1.20±0.13 g.cm⁻², P< 0.01). No significant difference across groups was detected for macrovascular reactivity (P= 0.32).

Conclusion

Age-related osteopenia might be accelerated in middle-aged PLHIV on prolonged cART, as their BMD approached values found in older adults. On the other hand, muscle mass, isokinetic strength, and vasodilation capacity were similar in PLHIV and age-matched uninfected controls.

Construct and Criterion-Related Validity of the Clinical Frailty Scale in Persons With HIV

BACKGROUND

The co-occurrence of frailty and cognitive impairment in older (50+ years) persons with HIV (PWH) is common and increases the risk of poor outcomes. In HIV clinics, the most commonly used frailty measures are the frailty phenotype (FP), which requires measuring grip strength and gait speed to implement, and the frailty index (FI) based on comprehensive health data collected on patients. We examined construct and criterion-related validity (as it predicts cognition) of the Clinical Frailty Scale (CFS), a less resource-intensive approach for assessing frailty, in relation to these more commonly used frailty assessments (FP and FI).

SETTING/METHODS

A total of 143 older (age 50+) PWH (mean age 57 years; 88% male) seen at the Southern Alberta Clinic underwent both frailty screening with the FP, CFS, and FI and neuropsychological testing. Mixed-effects regressions examined the associations between frailty status and cognition.

RESULTS

Concordance with the FP was slightly superior for the CFS than the FI. The FP and CFS had similar associations with domain-specific cognitive performance with frail PWH performing worse than nonfrail individuals on tests requiring manual dexterity (Trail Making Part A and B; Symbol Digit; and Grooved Pegboard; P values <0.05). Neither were associated with executive function, learning, or memory performance. The FI was associated with worse fluency, fine motor skills (Grooved Pegboard), and Trail Making Part A.

CONCLUSION

The CFS is a simple screening tool with good construct and criterion-related validity. It was associated with a similar pattern of cognitive deficits as the FP. If confirmed and the associations are extended to other clinically significant characteristics and outcomes, the CFS can be considered as an alternative to the FP and FI in assessing frailty in older PWH.

Cross-sectional study of correlates and prevalence of functional and high-risk multimorbidity in an academic HIV practice in New York City

OBJECTIVES

People with HIV have high levels of multimorbidity, but studies often focus on high-risk comorbidities such as hypertension or coronary artery disease. We examined both high-risk and functional comorbidities in an ethnically diverse clinic population to compare the prevalence of comorbidities and different patterns of multimorbidity.

DESIGN

Retrospective cross-sectional study.

SETTING

University-based primary care HIV clinic with two locations in New York City.

PARTICIPANTS

Patients who had been seen by a physician at least once between 1 June 2016 and 31 May 2017.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data regarding demographics, diagnoses and lab values were downloaded in a one-time data import from the electronic medical record. Comorbidities were classified as high-risk (with major impact on mortality) or functional (with major impact on function), and multimorbidity was determined for both classes in the total sample of 2751. Factors associated with high-risk and functional multimorbidity were determined first through bivariate analysis and then through multivariable median regression in 2013 patients with complete data.

RESULTS

Median age was 52 years (IQR 43-59). Cisgendered women comprised 24.6% of the sample, and 31.7% were African-American. Both functional and high-risk comorbidities were common and risk increased with age. Among those 75 and older, median number of both functional and high-risk comorbidities was 3 (IQR 2-4). High-risk comorbidities were associated with age (p<0.001), more years with an HIV diagnosis (p<0.001) and being an African-American (p<0.001). Associated with a higher number of functional comorbidities were age (p<0.001), being a cisgender female (p<0.001), being Hispanic (p=0.01) and more years with an HIV diagnosis (p<0.001).

CONCLUSIONS

Comorbidities with functional impact increase with age in parallel to those with a more direct impact on mortality and should be assessed and monitored, especially as the population with HIV ages.