HIV infection in the elderly

In the US, an estimated 1 million people are infected with HIV, although one-third of this population are unaware of their diagnosis. While HIV infection is commonly thought to affect younger adults, there are an increasing number of patients over 50 years of age living with the condition. UNAIDS and WHO estimate that of the 40 million people living with HIV/AIDS in the world, approximately 2.8 million are 50 years and older. With the introduction of highly active antiretroviral therapy (HAART) in the mid-1990s, survival following HIV diagnosis has risen dramatically and HIV infection has evolved from an acute disease process to being managed as a chronic medical condition. As treated HIV-infected patients live longer and the number of new HIV diagnoses in older patients rise, clinicians need to be aware of these trends and become familiar with the management of HIV infection in the older patient. This article is intended for the general clinician, including geriatricians, and will review epidemiologic data and HIV treatment as well as provide a discussion on medical management issues affecting the older HIV-infected patient.     

Quality of life in elderly heart failure patients

Quality of life(QOL),as a relevant area of research in the understanding of heart failure(HF)patient outcomes,has been increasingly studied during the last two decades.The purposes of this review article are to (1)describe QOL in older adults with HF,(2) identify and critique research designed to test interventions to improve QOL,(3)identify gaps in the literature,and (4)provide recommendations for future research.Seventeen studies describing QOL in older adults with HF were identified.Elderly HF patient QOL has been reported to be fair to poor and is worse as compared to a healthy control group.Furthermore,there is some evidence that suggests that QOL is better in older adults than younger adults and worse in women(both older and younger)than in men,although these findings are not consistent across studies.Predictors of QOL and its dimensions in older HF patients included demographic,clinical,and psychosocial variables.Sixteen interventional studies were identified that reported QOL as an outcome in older adults.Findings among randomized clinical trials(RCTs)to improve QOL outcomes in elderly HF patients do not allow strong conclusions about the benefits of the interventions.It must be noted,though,that while not all studies reported improvements in QOL(either significant or as a trend), no studies reported deterioration in QOL with randomization to an intervention versus control.These studies were limited by several methodological issues.While there has been some research of QOL in this elderly cohort,it is paramount that we address methodological issues and thereby improve the scientific rigor of our research,continue to explore QOL in elderly HF patients,and design intervention trials for elders at risk for poor QOL.     

Heart failure in the oldest patients: the impact of comorbid conditions

Heart failure (HF) is the leading cause of hospitalization in older adults; it is also an important cause of death and chronic disability. HF in the elderly differs in many respects from HF occurring during middle age; in particular, the diagnosis and treatment of HF in the elderly are often complicated by the presence of multiple cardiac and noncardiac comorbid conditions, many of which have important implications for the care of the older HF patient. This article reviews the effects of common noncardiac comorbidities on the management of HF in older adults and discusses the impact of noncardiac comorbid conditions on clinical outcomes in the geriatric HF patient.     

AIDS and the elderly.

Individuals 50 years of age or older continue to account for at least 10% of AIDS cases reported to the Centers for Disease Control and Prevention in recent years. Little research is devoted to addressing the specific issues affecting diagnosis, treatment, and prevention of AIDS in older Americans. Survival rates among elderly individuals infected with human immunodeficiency virus (HIV) are consistently decreased in comparison with those for younger patients. Elderly individuals also are less likely to use a condom during sexual intercourse or to participate in routine HIV testing. This article reviews the current literature concerning the changing epidemiology of AIDS among older Americans. The article also addresses AIDS-related morbidity and mortality, treatment issues, and HIV-prevention behaviors among the elderly. Enhanced clinician awareness of HIV in the elderly, along with further research concerning HIV treatment and prevention, is necessary to improve survival and outcome for those patients.     

Microscopic polyangiitis in an adolescent presenting as severe anemia and syncope

Microscopic polyangiitis (MPA) is an autoimmune systemic vasculitis of small vessels. The condition has been best characterized in older adults and little is known of the natural history of this disease in children and adolescents. In this report, a case of an adolescent presenting with symptomatic anemia and syncopal episodes is described. An extensive evaluation ultimately led to the diagnosis of MPA. The unique findings in this case and review of the literature are presented, outlining the variable clinical presentations and challenge of diagnosing this condition in pediatric patients.     

HIV infection in older adults

The incidence and prevalence of HIV infection in older adults is rising, with disproportionate increases in women and minorities. Compared with younger adults, older patients who have HIV often are diagnosed later in the course of the disease and may have an accelerated decline in immune function. Although the prognosis for older adults has improved with the initiation of highly active antiretroviral therapy, there remains a higher risk for comorbid illness. Additional efforts to diagnose and prevent HIV infection in this older age group are necessary to decrease the transmission of HIV and to reduce the morbidity and mortality associated with this infection.     

Policy-maker attitudes to the ageing of the HIV cohort in Botswana

Background: The roll out of antiretroviral therapy in Botswana, as in many countries with near universal access to treatment, has transformed HIV into a complex yet manageable chronic condition and has led to the emergence of a population aging with HIV. Although there has been some realization of this development at international level, no clear defined intervention strategy has been established in many highly affected countries. Therefore we explored attitudes of policy-makers and service providers towards HIV among older adults (50 years or older) in Botswana. Methods: We conducted qualitative face-to-face interviews with 15 consenting personnel from the Ministry of Health, medical practitioners and non-governmental organizations involved in the administration of medical services, planning, strategies and policies that govern social, physical and medical intervention aimed at people living with HIV and health in general. The Shiffman and Smith Framework of how health issues become a priority was used as a guide for our analysis. Results: Amidst an HIV prevalence of 25% among those aged 50–64 years, the respondents passively recognized the predicament posed by a population aging with HIV but exhibited a lack of comprehension and acknowledgement of the extent of the issue. An underlying persistent ageist stigma regarding sexual behaviour existed among a number of interviewees. Respondents also noted the lack of defined geriatric care within the provision of the national health care system. There seemed, however, to be a debate among the policy strategists and care providers as to whether the appropriate response should be specifically towards older adults living with HIV or rather to improve health services for older adults more generally. Respondents acknowledged that health systems in Botswana are still configured for individual diseases rather than coexisting chronic diseases even though it has become increasingly common for patients, particularly the aged, to have two or more medical conditions at the same time. Conclusions: HIV among older adults remains a low priority among policy-makers in Botswana but is at least now on the agenda. Action will require more concerted efforts to recognize HIV as a lifelong infection and putting greater emphasis on targeted care for older adults, focussing on multimorbidity.     

Anemia in older adults as a geriatric syndrome: A review

Anemia, a frequently occurring condition in older patients, has no standard definition; however, in most studies, it is defined as hemoglobin level <12 and <13 g/dL in women and men, respectively. Approximately 10% of older adults living in the community have anemia. The prevalence of anemia is significantly correlated with advanced age and male sex. Anemia is associated with falls, frailty and other negative outcomes, including early mortality. However, there remains little consensus regarding whether anemia treatment favorably affects these adverse outcomes. Therefore, this article reviews the prevalence of anemia, and provides updates on its common causes and treatments in older adults. While excluding well-established hematopoietic diseases, the etiology of anemia in older adults has been grouped into four categories: (i) nutritional deficiency; (ii) inflammation; (iii) clonal hematopoiesis; and (iv) “unexplained anemia,” when there is no clear mechanism to account for the anemia. Recently, clonal leukocytes were detected in a considerable number of older individuals. The number of somatic mutations in blood leukocytes increases with age; however, single mutations of DNMT3A, TET2 and ASXL1 are not correlated with the presence of unexplained anemia in older adults. With an increased understanding of anemia etiology and the availability of innovative anti-anemic drugs, future studies that evaluate the causes and benefits of treatment are required. Geriatr Gerontol Int 2021; 21: 549–554 .     

Failing to Focus on Healthy Aging: A Frailty of Our Discipline?

The academic geriatrics community has provided outstanding leadership in addressing frailty and complexity in older adults, but a minority of older adults are frail. Although resources to treat older adults are limited, and it is appropriate to focus clinical efforts on those with frailty and multimorbidity, there is also important expertise that can be brought to bear on the health of ALL older adults. A review of the literature suggests that attention to healthy or successful aging has failed to keep pace with the focus on frailty. By providing leadership to promote successful aging, the quality of life of older adults across the spectrum can be improved and transitions to frailty reduced. The template that leaders have established in understanding frailty—defining and operationalizing it, understanding outcomes, identifying pathophysiology—can be used as an approach to successful aging. Several community‐based programs have been successful in promoting successful aging. These are potentially highly scalable and could have a substantial effect on the aging population, but their essential components need to be better understood. The geriatrics community is uniquely positioned to take on this role. This is a critical time to work together to make the lives of all older adults as healthy and fulfilling as possible.     

Group Therapy with Older Alcoholics

Group therapy for elderly alcoholics is discussed using examples from the author's clinical experience in an outpatient alcoholism program for older alcoholics. Included in the discussion are perspectives from literature on group treatment with the elderly and group treatment with alcoholics; very little has been written specifically on elderly alcoholics in groups The paper explores several aspects of group work with older problem drinkers: accessibility of treatment in terms of group location and setting; the various functions that a therapy group serves for older alcoholics; and issues in the role of the group leader.     

Knowledge Gaps in Cardiovascular Care of Older Adults: A Scientific Statement from the American Heart Association,American College of Cardiology,and American Geriatrics Society: Executive Summary

The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease (CVD) is the leading cause of death and major disability in adults aged 75 and older. Despite the effect of CVD on quality of life, morbidity, and mortality in older adults, individuals aged 75 and older have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older adults with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in nursing homes and assisted living facilities. As a result, current guidelines are unable to provide evidence‐based recommendations for diagnosis and treatment of older adults typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence‐based decision‐making, and recommend future research to close existing knowledge gaps. To achieve these objectives, a detailed review was conducted of current American College of Cardiology/American Heart Association (ACC/AHA) and American Stroke Association (ASA) guidelines to identify content and recommendations that explicitly targeted older adults. A pervasive lack of evidence to guide clinical decision‐making in older adults with CVD was found, as well as a paucity of data on the effect of diagnostic and therapeutic interventions on outcomes that are particularly important to older adults, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population‐based studies and clinical trials that include a broad spectrum of older adults representative of those seen in clinical practice and that incorporate relevant outcomes important to older adults in the study design. The results of these studies will provide the foundation for future evidence‐based guidelines applicable to older adults and enhance person‐centered care of older individuals with CVD in the United States and around the world.     

Providers not diagnosing HIV in older women

Females over the age of fifty are the invisible victims of the HIV epidemic. The Federal Centers for Disease Control and Prevention (CDC) reported that ten percent of all women diagnosed with AIDS by June 1994 were over fifty years of age. Midlife-and-older women with AIDS are not being diagnosed until late in the disease process, sometimes after death. CDC statistics show that the mode of transmission is changing. Women in these age groups are acquiring the disease through heterosexual contact, rather than transfusions. The difficulty remains with the health care providers who are often not adequately prepared to diagnose and treat midlife-and-older women with HIV/AIDS. A seminar, co-sponsored by the American Association of Retired Persons (AARP) and the Center for Women's Policy Studies (CWPS), has raised several issues regarding HIV in older women. Many behavioral and physiological risk factors are overlooked. In addition, diagnosis and treatment of HIV infection in older women is complicated by other aging factors, and socioeconomic and cultural factors limit access to care and treatment. The AARP and CWPS recommend developing programs to educate physicians about primary and secondary HIV prevention counseling. They also recommend developing partnerships with institutions that have access to older women in order to transmit prevention messages.     

Acute myeloid leukemia in older adults

Acute myeloid leukemia (AML) is predominantly a disease of older adults, with a median age at diagnosis of over 65?years. AML in older adults differs biologically and clinically from that in younger ones, and is characterized by stronger intrinsic resistance and lower tolerance to chemotherapy. The effects of age on both patient- and disease-related factors result in a higher incidence of early death during chemotherapy, a lower rate of complete remission, and a reduced chance of long-term survival. Treatment options for older adults with AML include intensive chemotherapy, less-intensive chemotherapy, best supportive care, or enrolment in clinical trials. Given the heterogeneous nature of AML in older adults, therapeutic decisions need to be individualized after systematic assessment of disease biology and patient characteristics. Regardless of treatment, however, outcomes for older AML patients remain in general unsatisfactory. In contrast with the progress made for younger adults, the treatment of AML in older adults has not improved significantly in recent decades. Development of less toxic and more targeted agents may well provide treatment alternatives for a majority of these patients. The overall dismal outcome with currently available treatment approaches has encouraged older AML patients to participate in prospective clinical trials.     

A comparison of HIV stigma and disclosure patterns between older and younger adults living with HIV/AIDS

The purpose of this study was to examine the relationships between age, HIV-related stigma, and patterns of disclosure. Previous literature has suggested that older age is associated with increased HIV stigma and less disclosure of HIV status. Eighty-eight individuals, 44 between the ages of 20-39 and 44 aged 50 and over were recruited for the study through an AIDS service organization in the Pacific Northwest. Subjects in each group were matched as closely as possible by gender, ethnicity, HIV exposure and diagnosis. In a comparison of sociodemographic characteristics, older adults (50+) were significantly more likely to live alone, and to be retired. Younger adults were significantly more likely to be never married/ partnered, unemployed and be recipients of Medicaid. Bivariate analysis revealed no significant differences in overall stigma scores between groups; however, younger adults were more likely to fear losing their job because of HIV. Older adults were less likely to disclose HIV to relatives, partners, mental health workers, neighbors, and church members than those 20-39 years of age. Pearson product moment correlations found disclosure to be significantly associated with time since diagnosis, heterosexual exposure, ethnicity, use of HIV services, and having a confidant. Stigma was associated with ethnicity, having a confidant, and instrumental social support. In a multiple regressions analysis, 48.4% of the variance in disclosure accounted for by time since first diagnosis, service use, and having a confidant. Service use was the only independent variable significantly associated with stigma, accounting for 21.6% of the variance.     

HIV, Sexual Health, and Psychosocial Issues Among Older Adults Living with HIV in North America

It is estimated that by the year 2015, at least half of those living with HIV disease in the United States will be 50?years of age or older. Older adults with HIV disease are living longer than ever before and are living healthier and more normal lives. They continue to be involved in intimate and sexual relationships. This paper provides an overview of some epidemiological trends among older adults living with and at risk for HIV in North America and discusses the current and emerging needs and behaviours related to their sexual health. Included are issues of sexual orientation, sexual behaviour, sexual dysfunction, and sexual risk. In addition, a number of the important psychosocial needs of older adults who are living with HIV are discussed, along with recommendations for future practice, policy, and research. Given that increasingly more people living with HIV are aging, the issues of aging and HIV disease can no longer be seen as unrelated. Gerontological providers, researchers, and policy makers must begin to address the needs of this increasingly common, yet vulnerable population of older people.