Middle-aged people with HIV have a high risk of falls

Falls are common among middle-aged people with HIV, US investigators report in the online edition of the Journal of Acquired Immune Deficiency Syndromes. Over twelve months, almost a third of people in the study (30%) experienced a fall.

“We found that the fall rate in middle-aged adults…with HIV-1 infection, is as common as in uninfected persons aged 65 years or older,” comment the authors. “Falls in our cohort were associated with several previously reported risk factors such as hypertension, diabetes, impaired balance, and pain, as well as medications used in the treatment of these comorbidities.”

Falls are common among older adults, occurring in a third of over-65s each year. They are a frequent cause of emergency hospital admission and can result in loss of independence.

HIV infection appears to be a risk factor for a number of diseases of ageing. Moreover, there is also a high prevalence of traditional risk factors for falls such as diabetes, pain, depression, neuropathy and use of psychoactive medications among people living with HIV.

“We hypothesized that a greater number of fall risk factors would result in a higher than expected fall rate among middle-aged HIV-1-infected adults,” write the investigators.

They therefore designed a study involving 359 people who received care in Colorado between early 2009 and early 2010. All were aged between 45 and 65 and were taking antiretroviral therapy with an undetectable or low viral load (at least one undetectable measurement and no measurement above 200 copies/ml).

Most of the study participants (85%) were men, 74% were white, 65% were gay men and 21% had a history of injecting drug use. The mean age was 52 years, mean CD4 cell count was 594 cells/mm³ and 95% had an undetectable viral load.

A total of 109 people (30%) reported at least one fall in the previous year. Almost two-thirds (61%) of those experiencing a fall had multiple falls. Women and smokers were more likely to have recurrent falls (p < 0.05).

The investigators believe these figures underestimate the incidence of falls in people with HIV who are doing less well on antiretroviral therapy, as well as those “with advanced immunodeficiency, or with greater intravenous drug abuse.”

No HIV-related factor was associated with an increased risk of fall. Analysis failed to find any association with either nadir and current CD4 cell count or viral load. There was a weak association with longer duration of HIV infection, but this failed to reach significance.

However, the presence of other health problems did increase the risk of falls. Each additional co-morbidity increased the risk of falling by 70% (OR = 1.7; 95% CI, 1.5-2.1, p < 0.001).

Use of medication was also associated with the risk of falling. Each additional medication increased the risk of falls by 40% (OR = 1.4; 95% CI, 1.3-1.6, p < 0.001). Medications associated with a risk of falling included beta-blockers, antidepressants, sedatives and opiates (p < 0.01). The investigators also found evidence of an association with falls and the older anti-HIV drugs d4T (stavudine, Zerit) and ddI (didanosine, Videx). A recognised side-effect of these drugs is neuropathy, a known risk factor for falls.

Frailty and disability were also associated with an increased risk of falls (p < 0.001). In addition, people who had recurrent falls had a significantly slower walking pace compared to people who didn't fall (p < 0.001).

After controlling for potential confounders, the researchers found that a number of factors were associated with falls. These included female gender, diabetes, antidepressants, treatment with sedatives, opiates, HIV therapy that included ddI, exhaustion, weight loss and difficulty with balance. All more than doubled the risk of falls (p < 0.05).

“Ultimately, the best predictors of fall risk were those factors known to be associated with fall risk in geriatric populations,” write the investigators.

“Given that multiple factors lead to increased fall risk, it is expected that successful interventions to reduce falls in HIV-infected persons will require a multipronged approach including medication adjustment, behavioural modifications, vitamin D supplementation, physical therapy, and exercise or balance programmes,” the authors suggest.

They recommend “providers caring for HIV-infected persons should routinely inquire about falls, assess fall risk factors for those at risk for falling, and when high risk is identified, intervene to reduce risk.”

Erlandson KM et al. Risk factors for falls in HIV-infected persons. J Acquir Immune Defic Synr, online edition. DOI. 10. 1097/QAI.0b013e3182716e38, 2012.