Older age exacerbates the deleterious
effect of HIV on daily functioning, investigators from the US report in the
online edition of the Journal of Acquired
Immune Deficiency Syndromes. Investigators compared ability to perform
daily tasks, cognitive function and quality of life between patients according
to their age and HIV infection status.
“For each of the functional outcomes, the
older HIV+ group demonstrated poorer everyday functioning relative to other
study groups,” comment the authors. “These findings suggest that older age may
exacerbate HIV-associated disability in daily life.”
The investigators believe their findings
have important implications for HIV care, which should focus on the early
detection of functional problems and their causes.
Thanks in part to the success of
antiretroviral therapy, the population living with HIV in the US and other
industrialised countries is ageing. Data from the US Centers for Disease
Control (CDC) suggest that a quarter of all people with HIV are now aged over
50. As they age, they become more vulnerable to age-related disorders
such as cardiovascular disease, changes in bone mineral density and
Investigators hypothesised that HIV
infection would exacerbate the declines in daily function that are associated
with these diseases of old age and ageing generally.
They therefore designed a cross-sectional
study involving 103 people living with HIV and 87 HIV-negative controls. They examined the
factors associated with everyday functioning and quality of life between those
aged under 40 and those aged over 50.
A wide spectrum of tests was used to assess
- Instrumental activities of
daily living (IADL): financial management, purchase of groceries, cooking,
using transport, shopping, managing medication and planning social activities.
- Basic activities of daily
living (BADL): cleaning, laundry, home repairs, dressing and bathing.
- Karnofsky score on a range of
100 (able to carry out normal activities) to zero (death).
- Questionnaires assessing both
physical and mental health-related quality of life.
- Medical evaluation: assessment
of co-morbidities common in older people living with HIV, including
diabetes, cardiovascular disease, respiratory disease and hepatitis C
- Neuropsychiatric assessment:
monitoring for HIV-related neurocognitive impairment.
- Psychiatric evaluation:
assessment of current mood and history of major depression and substance abuse.
The older group of people with HIV had an
average age of 55 years and 71% were male. They had been living with HIV for
a median of 18 years. Their median nadir CD4 cell count was 148 cells/mm3.
All were taking antiretroviral therapy and 90% had an undetectable viral load.
This group had a high prevalence of co-morbid conditions. A quarter
had a current major depression and half had a lifetime history of depression.
Over a third were co-infected with hepatitis C, 10% had cardiovascular disease,
15% had been diagnosed with diabetes and 5% had a respiratory complaint.
There was a significant interaction between
ageing and HIV regarding IADL scores (p = 0.025), BADL scores (p = 0.043) and
Karnofsky score (p = 0.001).
Factors associated with lower IADL scores
for older people with HIV included cognitive impairment (p = 0.043),
current major depression (p = 0.002), nadir CD4 cell count (p = 0.023) and lack
of “cognitive reserve”
– engagement with
intellectual and social activities (p = 0.028).
BADL severity was associated with current
depression (p = 0.007). A lower Karnofsky score for elderly people with HIV was also related to current depression (p = 0.016), as were having
other serious health problems (p = 0.008) and lack of cognitive reserve (p =
Poorer self-rated mental health-related
quality of life in older people with HIV was also attributed to the
additive effects of age and HIV.
“Several of these predictors are highly
amenable to proper screening and treatment,” note the researchers. “For
example, major depression was arguably the most reliable predictor of adverse
functional outcomes in our older HIV+ cohort…these findings highlight the need
to regularly screen older HIV+ adults for symptoms of depression given that
major depression can disrupt performance of important daily activities and are
potentially remediable.” They note that the best outcomes are seen in people
who are treated with both antidepressants and psychotherapy.
The investigators also highlight the
association between cognitive reserve and daily function. “This evidence
suggests that in older HIV-infected adults, lower cognitive reserve may
interfere with the adaptive ability to engage alternate brain networks and/or
initiate alternate brain networks and/or initiate use of compensatory
strategies when they encounter problems in their daily life, resulting in