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MORE INFORMATION ABOUT BONE HEALTH
The health of the bones of many older persons with HIV is known to be less when compared to others of the same age without HIV. The comparison of the frequency of problems has been estimated to be 3 times higher. The technical terms are low Bone Mineral Density (BMD), osteopenia, and osteoporosis. The lower BMD means that there are extra spaces inside the bone that result in less strength of the bone. If this is somewhat less it is called osteopenia and if it is even lower then osteoporosis. A separate designation is made for “Osteonecrosis” of the hip where the blood supply has been damaged and may lead to a fracture, even without a fall.
The bones of the body continually go through remodeling with resorption of bone parts followed by re-formation of the structure. This process requires calcium and vitamin D in the body. Usually, these steps are in balance, so the bones stay strong. However, in older persons with HIV the restructuring falls behind and reduces the BMD. Also, the HIV virus may cause excessive inflammation that slows this process.
There are other factors in the body that can play a role. These are low testosterone, low calcium, smoking, as well as general health factors such as stress, lean body mass, and sedentary life style.
There have been reports of certain ART medications being associated with lower BMD, especially at the beginning of therapy. In particular tenofovir has been implicated in lowering the BMD, but it appears that this negative process is short lived and within a year has not progressed.
A panel of experts has recommended screening for reduced BMD in older adults with HIV who are post-menopausal women or men 50 years or older. The preferred method is “DXA” or dual-X-ray absorptiometry. This approach is pain free and does not use excessive radiation. Usually, measurements are made in the area of the hip (femoral neck) and the spine. The machine generates a “T-score” that is compared to the average score of a healthy young adult taking the same test. The comparison is made in units called standard deviations. If the bone density test of the patient is between 1 unit and 2.5 units lower than the normal then a diagnosis of osteopenia is made. A score of 2.5 or more below normal means osteoporosis. Even without the test, a fracture in these areas without trauma (Fragility fracture) is consistent with osteoporosis
Because of the known association between HIV in older persons and bone softening, if your doctor agrees, it may be a good idea to increase the intake of calcium and vitamin D. This could be in foods or dietary supplements. Also, it is recommended that more exercise, including muscle strengthening, be done. In addition the elimination of smoking and less alcohol intake is encouraged. Avoidance of falls is an obvious suggestion. This may take training in balance and strength building. It is an important part of staying well.
The best treatment approaches for you should be discussed with your health care provider. Therapy might include a review of current medications being taken for possible adverse effects and the need to make changes. In more extreme cases specific medications for osteopenia or osteoporosis may be necessary. Further discussion of these issues is available by finding “osteoporosis” at “Recommended Treatment Strategies”:
MORE INFORMATION ABOUT FRAILTY
The concept of frailty has been used for years by clinicians to describe older adults who are seen as vulnerable to more disease and disability. This state is thought to be the result of a loss of reserve to meet the challenges to the body of the older person. Since this diagnosis was usually subjective in nature, there was an attempt to standardize the diagnosis by developing a series of criteria to be evaluated with a score. Subsequently, this same approach was applied to older persons with HIV. The frequency of frailty has been reported in studies to be from 5-30% depending on the population with HIV. A recent longitudinal study identified frailty at 12% of patient visits (without HIV).
The reasons for frailty in older persons with HIV vary by each individual and in many cases cannot be totally explained. Besides HIV itself, indirect predictors of frailty include older age, low CD4 count, presence of multiple comorbidities, especially depression, cognitive impairment, diabetes, and low body mass index. HIV, even if well treated, has a negative effect on the body. The principle mechanism is by persistent inflammation caused by the HIV infection. This results in various chemicals in the body being elevated and causing damage. In addition, separate from the inflammation, there can be direct negative effects on the energy metabolism of cells and the way the body handles the stress from excess oxygen from body metabolism. All these problems may combine to lead to frailty in older persons as well as older adults with HIV.
There are four approaches that have been used to make a diagnosis of frailty. First, in the hands of an experienced clinician, especially one trained in geriatrics, a history and physical examination plus the negative finding of a causal underlying disease may be enough to classify an older person with HIV as “frail”. Second, the symptoms that include unexplained weight loss, loss of energy, slow walking speed, low physical activity, and weakness measured by grip strength have been standardized into a more precise measurements and an index generated. Frailty is identified from having 3 out of 5 deficits for the various measurements. This is the most frequently used measure of frailty in various studies. The third approach is to add up the total number of diseases and conditions from a long list and give a score to the individual. The higher the score the more likely that frailty is present. Finally, there is an indirect measure of frailty called the VACS (Veterans Aging Cohort Study) Index. The index includes a number of variables from age and race to CD4 count and viral load, presence of hepatitis C, liver problems, anemia, and kidney function. It has been found to predict a number of serious outcomes, including hospitalization and death. Interestingly, in studies done over time with the same individuals, the frequency of frailty can change, suggesting that the measurements are not final, and individual behavior can change and influence the diagnosis or even occurrence of frailty.
If management of ART is inadequate to optimize CD4 levels, then there will need to be adjustments. If weight loss is unexplained, then work with a dietician to identify dietary changes is in order. If the main problem is weak and deteriorating muscles (sarcopenia), the assistance from a physical therapist is required. Balance exercises may be crucial in reducing falls with resulting fractures. Certainly, more exercise is needed. Start with walking and then increasing the activity. Better management of comorbidities paired with possible pill use reduction may help. Finally, the psychological aspect of frailty in an individual needs to be addressed. The most common associated condition is likely to be depression. In addition, loneliness may contribute to that depression. This aspect of the treatment of frailty will need the coordinated efforts of the managing medical team, social worker, psychologist and psychiatrist. With all of these efforts, some improvement in frailty should be possible.
MORE INFORMATION ABOUT KIDNEY DISEASE
Diseases of the kidney or renal disease are more common in older adults with HIV than in those without HIV. Fortunately, the frequency has decreased because better and earlier treatment with ART has reduced but not eliminated the effect of HIV virus on the kidneys. Also, the negative effect of the virus appears to be stronger in African American men. A study using a large data set of veterans followed over time has suggested that such renal disease may even occur somewhat earlier than a comparison group. Infectious disease doctors and nephrologists are teaming up to prevent and diagnose renal problems earlier and arrange for appropriate treatments.
Early on, when the HIV infection starts, the virus enters the covering of the kidney and subsequently causes damage to the deeper structures of the kidney (glomeruli and tubules). It is these parts of the kidney that participate in the cleansing of the body of harmful products and the controlling of the balance of necessary chemicals in the body. Usually, the disease process is a slow one, but there can also be acute kidney problems. This process can be made worse by various factors. It appears that in African Americans there may be some genetic factors that make those with HIV more prone to chronic kidney disease. It is still controversial as to how much could be genetic and how much related to other co-existing conditions, such as hypertension and diabetes that are not being adequately treated. Hepatitis C infection can also involve the kidneys.
There are ART drugs that can adversely affect the kidneys, especially atazanavir and ritonavir. Also, the PrEP drug called Truvada has in it tenofovir that has been associated with decreased renal function. However, there is a new variant of the same drug called TAF or tenofovir alafenamide that does not have this side effect. Over the counter pain meds, such as ibuprofen and aspirin, can also have adverse effects on the kidneys. The above-mentioned medications can also cause acute kidney disease.
For early diagnosis of kidney problems, it is important that a pattern of regular testing of the blood and urine for abnormalities be done to detect any early changes. The creatinine in the blood is a good indicator of kidney function and increasing levels suggest a developing kidney problem. Also, the value is used in determining creatinine clearance by the kidneys. Sometimes it is called the glomerular filtration rate. A number is generated with a normal value being 100 ml/minute or greater, and a value of 60 suggests a problem. A value of 30 is serious and requires the consultation from a nephrologist. It is recommended that urine be checked twice a year for the amount of albumin, a type of protein, or the total protein amount in the urine. If elevated it means that the kidney is damaged and leaking protein. It also would require a consultation.
At this point to be sure both about the cause and the seriousness of the condition a biopsy of the kidney may be indicated. This is done under local anesthesia and a piece of tissue is removed, and checked under the microscope. Certain patterns can tell for sure what is going on and clarify the best course of action.
If kidney problems are developing, it will be important to have optimal viral suppression, with ART medications. Your physician will make sure that the blood pressure is not elevated (below 140/90 but better to be closer to 120/80) and, if elevated, be addressed by weight loss and medications. Also, if there is any elevation of blood sugar (glucose) or indirectly indicated by the blood test HbA1c, the potential of diabetes will need attention. In some cases weight loss will be sufficient to correct the glucose elevation, but medications may be necessary to control the condition.
To avoid kidney failure (the technical term is “end-stage renal disease”) sometimes a diet of low protein and low salt will be helpful. However, it may be necessary to move to regular cleansing of the body by renal dialysis. Finally, if all things fail, kidney transplantation is now becoming more common. Recently, it has been shown that it is possible to obtain a matched kidney from another patient with HIV and successfully complete the transplant.
Prevention of kidney disease, where possible, is becoming more common, and is of course the best strategy. However, other more complicated treatments, even if appearing extreme, are becoming quite successful in prolonging a satisfactory life style.
MORE INFORMATION ABOUT LUNG DISEASE
Lung Disease or COPD (Chronic Obstructive Pulmonary Disease) is quite common in older adults with HIV. Its technical definition is: “a disease state characterized by airflow limitation that is not fully reversible”. COPD is a general term for a number of different lung problems. Common ones are “Chronic Bronchitis” characterized by symptoms of recurrent and chronic cough accompanied by phlegm. These symptoms involve damage to the upper air tubes of the lung. “Emphysema” presents with increasing shortness of breath with exertion. This problem involves disease of the small sacs or alveoli at the end of the breathing tube. As a result not enough oxygen can be transferred to the blood for normal physical functioning. Because asthma (an allergic reaction) is reversible with treatment, it is not included with COPD. Unfortunately, these conditions affect not only quality of life, but they make one more prone to pneumonia and increased risk of death.
A long history of chronic smoking cigarettes is a major culprit for causing COPD. Because older adults with HIV have tended to smoke more than adults without HIV, this reason is the likely cause of the excess of lung disease in this group. However, other causes are the recurrent lung infections that may have plagued older adults with HIV before adequate treatment was available. Other less common factors are related to occupational exposure to dusty conditions and mining. Poor control of HIV with a high viral load and or a low CD4 count can contribute to an increased risk of COPD.
You should report to your doctor if you are having recurrent bouts of shortness of breath, chronic cough with phlegm, or extreme tiredness. Then a series of relatively simple tests can be done to clarify the possible cause of your problem, including both lung and heart issues. A simple chest X-Ray can reveal the status of your lungs and heart as well as making sure that there is a not a growth present.
A COPD diagnosis is made using a “Spirometer”. This is a machine that requires one to breathe into a tube leading to a sensor. There are usually two or more different measurements in the testing. One will be asked to breathe in and then exhale as much air out as is possible. A calculation is made using the amount of air exhaled in one second, and then this is compared to the total amount of air exhaled called a forced vital capacity. If there is the possibility of asthma being the major problem, then a bronchodilator will be administered and the test repeated. Your doctor will use this information in a diagnosis of COPD.
WHAT CAN BE DONE
If a diagnosis of COPD is made, what can be done? Even with early symptoms it is never too late to quite smoking. An approach for stopping smoking recommended by the American Lung Association: https://www.lung.org/stop-smoking.
There are some medications, similar to those used with asthma, that can increase the size of the bronchi and decrease the respiratory symptoms. However, there may be some interactions with antiretroviral drugs that must be considered when using these medications. Your doctor and pharmacist can help resolve this problem. Steroids are usually not used in this situation because of long-term negative effects.
In some cases pulmonary rehabilitation can be helpful. This approach is to build up the muscles that assist with breathing and to increase the efficiency of how the heart circulates oxygenated blood.
Of course, since if one has COPD you may be vulnerable to infections, regular immunization against flu is indicated. This should be the stronger version of the flu vaccine given to those 65 years because of compromised immune function. In terms of preventing bacterial pneumonia, because there are a number of different bacteria that can cause pneumonia, it is necessary to receive two separate injections to assure the widest coverage against pneumonia.
MORE INFORMATION ABOUT MEMORY AND BRAIN FUNCTION
Probably the greatest fear we all have is that we lose the ability to think, including memory and being able to put together verbal language and written words into understandable statements. Alzheimer’s Disease is among the greatest concerns because of the total loss of these skills. The older person with HIV has these same concerns but especially the early loss of cognition (thinking). These concerns circulate widely among the community. The reality is that the data on cognition are variable and depend on the population studied. Importantly, the comparison population (the controls) must have similar characteristics to make any conclusions valid. However, testing does suggest that there may be some decrease in cognitive functioning, but much may be below the detectable level and not enough to affect daily functioning. There are no data to suggest that Alzheimer’s Disease is more frequent in the older adult with HIV. However, it must be recognized that most older persons with HIV have not reached the very old ages when the disease would be expected to be more frequent.
The older adult with HIV has various risk factors for neuropsychological impairment. These include a history of a very low CD4 level in the past, current low CD4 count, and a detectable viral load. Researchers have found that HIV can enter the brain and cause direct damage to cerebral tissues. In addition the presence of various comorbidities, such as diabetes, hypertension, hepatitis C, as well as substance use disorder, can also affect the brain. This can occur as direct effects on brain tissues or indirectly through affecting the blood vessels.
Neuropsychological testing is necessary for determining the presence and level of cognitive problems. There are various versions of these tests, but most include a memory test of words that need to be remembered after a few minutes, attention to a numbers list, subtracting a number multiple times, etc. Normal values have been established for performance comparison. These tests are used to establish a diagnosis of “HAND” (HIV-Associated Neurocognitive Disorder). Although one study found that about 50% of those tested had an indication of the diagnosis only a small number had any symptoms. In a study of women with HIV under observation in a long-term research protocol which used similar women without HIV for comparison, a comprehensive neuropsychological test battery was administered. The effect of HIV on cognition was found to be very small except for women with low reading skills and HIV-related comorbidities. In another approach to diagnosis, various studies using MRI (Magnetic Resonance Imaging) techniques have been done. Small blood vessel disease of the brain can be diagnosed by this method. In one study there was an increased number of white spots (white matter lesions) indicative of blood vessel problems in the older adults with HIV than in the comparison group. These changes may predict future cognitive decline. In another study of those receiving MRI’s and followed for 4 years, there was no difference in the brain tissue between those with HIV and controls, although there was some reduction in cognitive functioning. This sampling of data suggests the uncertainty in determining how much effect HIV has on the brain. More studies are needed, and those older adults with HIV can be reassured that a reason for major concern has not been established.
The older persons with HIV need to maintain an open dialogue with their medical provider about concerns relative to cognitive functioning. At some point the provider may have new information relevant to the current status of research on the issue. If the patient feels that there has been a major change in memory or other neurological functions, then it will be appropriate to request testing with referral for neuropsychological consultation. If there are specific neurological complaints, then referral to a neurologist with the possibility of receiving an MRI is appropriate. In terms of what the older person with HIV can do for brain health, there is some information from reviews of Alzheimer’s Disease prevention. Of the various approaches reviewed, there was some consensus that increased physical activity was one of the few activities that might be beneficial. This is a difficult area for older persons with HIV and for all older persons. But there are major research efforts under way to clarify the causes of cognitive decline and what might be done to treat it.
MORE INFORMATION ABOUT POLYPHARMACY
Older persons with HIV must face the reality of having to take a number of medications every day. First, this is the result of having to take the all important antiretroviral therapy (ART). On top of this is the increased frequency of other diseases in older persons, such as heart disease, kidney disease and lung disease, that require medications. In addition there are intermittent conditions, such as allergies or pain, that require over the counter pills. These circumstances can result in the daily need to take a large number of pills. The technical name of this is “polypharmacy”. There are various definitions of what is too many pills, but usually this is 5 or more pills each day. Fortunately, the average daily number of pills has been dropping over the last decade as ART is involving more single dose regimens. Still, estimates from various studies suggest averages of 3 to 7 pills per day.
This typical polypharmacy in older adults with HIV can result in unwanted consequences. A common adverse effect of having to take too many pills is that the person may become confused about the number and type of medication to be taken. This situation might result in too few or too many pills being taken. Also, the daily ritual of taking the pills may become enough of a burden that there is “burnout” in following the regimen. This situation can result in pills being missed resulting in poor adherence. And in HIV there is a loss of viral suppression and a drop in CD4 levels.
A major risk of taking a number of drugs is the possibility that there is an adverse relationship between them. This is especially important with ART. There can be an interaction between the HIV drugs and the other drugs causing either too much or too little of the ART being available in the body. This situation can occur when more than one physician is prescribing medications for the patient. Without coordinated communication between the physicians, there is an increased risk of a negative interaction. For example, an interaction could cause a lowering of blood pressure that could result in a fall and a fracture.
Other things that can complicate drug-drug interactions are use of occasional non- prescribed substances that can cause increases or decreases in medication effectiveness. For example, the use of St John’s Wort for self-treatment of depression can decrease the effect of certain ART drugs
First and foremost, in dealing with polypharmacy there must be a close relationship with your medical provider team so that an open and full discussion of medications can occur. You should openly discuss concerns as well as problems with pill regimen. The health team needs to know prescriptions received from other physicians as well as what over the counter medications you are taking. This information needs to be carefully updated at each visit.
Periodically there should be a broader review of which medications are absolutely necessary for the patient and which might be considered for discontinuation. In some cases, it might be appropriate for one to a have a partner, relative or friend (caregiver) participate in this discussion since it is easy to forget issues you want to raise. Such a discussion might include the pluses and minuses of changing to a single per day ART medication.. Also, there might be need for communication with other specialists who are managing other diseases and conditions about reduction in medications. Coordinated care is a need that must be addressed by the health care system.
Of course there are patient responsibilities in keeping track of medications, including ordering drugs and using one of the weekly divided pill boxes to make sure that there is no slip up. Regular discussions with a pharmacist familiar with ART medications and your situation will be beneficial. In addition there is the broader aspect of maintaining a healthy life style including diet, achieving sufficient physical activity, and keeping up contacts in the community.
The availability of various medications for the older person with HIV has had a major effect on improving health and extending life span. However, quality of life is an important issue. The number of daily medications needs to be kept in the right balance so that life style and quality of life can be as satisfying as possible.
MORE INFORMATION ABOUT HEART DISEASE
Cardiovascular Diseases: Heart Disease, Heart Attack, Stroke, Peripheral Vascular Disease
As all of us age, whether older adults with or without HIV, the frequency of cardiovascular diseases increases. However, a number of studies have shown that in older adults with HIV, the frequency of heart attacks may be even 50% higher than in comparison groups. Fortunately, a great deal of this increased frequency in cardiovascular diseases can be reduced by modifying known risk factors. Those factors are high blood pressure, elevated cholesterol, and smoking. On top of this, the presence of elevated HIV virus (increased viral load) can cause inflammation which directly affects the vascular system. However, early and adequate treatment can minimize this adverse effect.
More information follows for you to understand better the issues related to cardiovascular diseases and enable you to discuss possible interventions with your health care team.
DISEASES AND CONDITIONS
Cardiovascular Diseases including Heart Disease:
The general term of cardiovascular diseases covers injury of blood vessels from head to toe. These changes usually occur because of arteriosclerosis or atherosclerosis (the narrowing of blood vessels due to the collection of thickened debris on the inner side of blood vessels) that narrows the normal blood flow in arteries in the heart, and this compromises the function of the pumping muscle. This can lead to a heart attack, if there is too much sudden narrowing. Other related names are myocardial infarction, coronary artery disease, and coronary heart disease. Angina pectoris causes intermittent pain in the chest, often related to exercise, and results because of long term and gradual narrowing of blood vessels in the heart.
Stroke: There are large arteries in the neck that go from the heart up to the brain as well as smaller vessels in the brain that can be clogged or break open and cause a stroke with loss of body functions. There can be more slow changes in the blood vessels that can result in lose of brain tissue which may be manifested by changes in the size of the brain and reduce the speed of thinking or memory.
Peripheral Vascular Disease: This narrowing process can also occur in the blood vessels going to the legs and cause damage that results in pain with walking or affects the tissues in the legs causing symptoms of burning pain, or open sores. However, the HIV virus itself and some of the earlier drugs used to treat the HIV virus can have adverse effects on the nerves of the legs and cause pain. Again, adequate HIV treatment is necessary to minimize this adverse effect.
Hypertension: High blood pressure (BP) is a major problem leading to heart disease and stroke as well as chronic kidney disease, if untreated. The BP is measured with both an upper and lower value (systolic and diastolic BP). In the past doctors have accepted any measurement of 140/90 or less as normal but recent research indicates that 120/80 or below is the right level to prevent complications. There are a number of things that can be done to lower ones BP level:
- Weight reduction, if one is overweight using one of the indicators such as body mass index, can be a valuable tool for BP reduction as well as controlling blood fats and diabetes.
- Decreasing salt intake’s effect on BP is somewhat controversial, but some individuals are quite sensitive to salt reduction lowering BP.
- Finding the proper blend of medications to reduce BP is almost always possible. Because of the need to reduce the large number of medications taken by many individuals, the least number of additional meds taken for achieving satisfactory BP levels is preferred to avoid “polypharmacy”.
Blood Lipids (Fats): There are four kinds of blood lipids that can affect cardiovascular health and are commonly measured and treated.
1.The total cholesterol is a summation of three of these fats and is the most common measure used. A value less than 200 is felt to be optimal.
2.LDL (Low Density Lipoprotein) or bad cholesterol is the most potent predictor of heart attacks. Because of recent research the acceptable levels in the blood have reduced from140 to 100.
3.HDL (High Density Lipoprotein) or good cholesterol is believed to be a protective factor so the higher the better. However, over 50 is thought to be adequate.
- Triglycerides at high levels of 500 or more can be associated with cardiovascular diseases but also pancreatitis (inflammation of the pancreas). The ideal value is considered to be 150 or less.
In the last few years there has been a move to combine blood lipid values with other relevant measurements to develop an indicator of longer-term risk, . Such formulas are derived from large population studies, but most have not used older adults with HIV. So, the direct applicability is not so clear, but your doctor may use these indictors as an assist to treatment choices.
Elevated blood lipid levels, especially LDL and triglycerides, are very responsive to appropriate treatment. The American Heart Association has information at:
https://www.heart.org/en/health-topics/cholesterol. It is possible that weight loss can be paired with a low fat diet. Increased physical activity may lead to an increase in HDL level. If such maneuvers are not successful a class of drugs called statins may be prescribed. They both lower lipids and work against inflammation in the body. A major clinical trial is underway to determine if this therapy is beneficial in older adults with HIV.
Among the major predictors of cardiovascular disease, as well as chronic lung disease and cancer, is chronic smoking. The frequency of smoking among older adults with HIV is substantially higher than in comparison populations. It is recognized by both therapists and patients that it very difficult to achieve reduction or cessation of smoking. However, the payoff in better health is so high that repeat efforts at stopping are justified.
Besides participating in self-help groups, various treatment strategies can be used. First, the use of nicotine patches can gradually reduce nicotine dependence. Also, non-nicotine medications can be prescribed and have a good success rate for smoking cessation. (See information on how to stop smoking at: https://www.lung.org/stop-smoking/
The bottom line is that smoking reduction or cessation is the major approach to reducing risk for cardiovascular diseases.
By addressing cardiovascular risk factors the older person with HIV can make a substantial contribution to improving his or her long-term health, well-being and life expectancy while continuing to maintain HIV treatment at optimal levels.
If you would like to learn more, go to “New Journal Articles of Interest” A recent published report supports the rationale for addressing smoking, elevated blood pressure and high cholesterol to lower risk of heart disease.
Another source of information is available by finding “Cardiovascular Disease and Prevention in Older Adults with HIV at “Recommended Treatment Strategies”:
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