Doctors alarmed by complex needs of elderly people living with HIV

While HIV is often described as a chronic, manageable condition and the growing number of people ageing with HIV as a success, this does not describe the complete picture, Dr Frederico Duarte told the recent 19th European AIDS Conference (EACS 2023) in Warsaw. “The real scenario in clinical practice is much more complex and can be a bumpy road,” he said.

While people over the age of 70 make up only 5% of the patient cohort (65 people) in the town of Matosinhos, Portugal where Dr Duarte practices, their medical histories are complex. They have been on HIV treatment for an average of 10 years (but some have been treated for 25 years), most have several co-morbidities and as a result, need to take multiple medications. Four in ten of those over 70 are taking ten or more pills a day, with some taking as many as 18 pills.

Duarte said this ‘polypharmacy’ was a particular concern. Older people often need support to help them to remember all their medication (his oldest patient is aged 88), but many live alone or have concerns about stigma or disclosure, which may limit the support they get from family. The more medication a person takes, the greater the potential for drug interactions.

A more comprehensive picture comes from a French cohort of people living with HIV aged over 70. With around 500 study participants, this may be the largest cohort of people living with HIV over 70 in the world, even if those taking part represent a fraction of the several thousand HIV-positive people in this age group in France.

As reported earlier this year, 60% have three or more co-morbidities, with the most common being high blood pressure (67%), dyslipidaemia (67%), cognitive impairment (58%), kidney disease (39%), depression (33%) and diabetes (21%).

But geriatrician Dr Fatima Brañas of the Hospital Universitario Infanta Leonor in Madrid said that clinicians need to broaden their focus from HIV and co-morbidities to consider frailty and functional impairment. This should prompt more attention to problems which affect people’s day to day lives and their quality of life.

Even if there is disagreement about the definition of frailty and the best way to assess it, Brañas said clinicians should not wait for the perfect screening tool to be developed. Any assessment which suggests frailty can be a prompt for clinicians to take some basic but valuable actions – check that all co-morbidities are being appropriately managed, conduct a medicines review to deal with polypharmacy and check that the person is getting the dietary nutrients they need (loss of muscle mass often contributes to frailty, so eating enough protein is important).

She stressed that a key difference between frailty and disability is that frailty is reversible. But the sole intervention which has been proven to be effective in reversing frailty is physical activity, so supporting people to be more active may be the most important thing healthcare professionals can do.

In the French cohort of people over 70, frailty was assessed with the five-item FRAIL scale. When joining the cohort 10% of participants reported three or more of the following problems so were classified as frail: unintentional weight loss, low levels of physical activity, slow walking speed, exhaustion (“I felt that everything I did was an effort in the past week” or “I could not get going in the past week”) and low grip strength (a simple measure of muscle strength).

But 66% of the cohort had one or two of the problems, so were classified as ‘pre-frail’. There was also 24% who had no problems and are described as robust.

As Dr Clotilde Allavena described in a poster at EACS, 12 months later the proportions of people in each category were pretty similar (12%, 65% and 23%, respectively). But that is to hide substantial movements between the categories, suggesting that people are often able to move on from frailty and become more resilient.

Of those initially classified as frail, 47% had improved and were pre-frail a year later. Of those initially classified as pre-frail, 11% became robust while 14% worsened and were described as frail.  Unfortunately, the poster doesn’t have any details of the interventions that patients received and there weren’t any patient characteristics that were clearly associated with improvements.

Professor Jaime Vera reported on how frailty screening had been introduced in the English city of Brighton. Screening all people over the age of 50 for frailty – as recommended in EACS guidelines – was beyond the capacity of the Brighton HIV clinic, given that 64% of their patients are over 50. It was more achievable to screen those over the age of 60, who make up 23% of the cohort. Brighton chose the same five-item FRAIL scale as the French researchers and to include screening in annual nurse-led health checks – again, for reasons of simplicity and practicality. So far over three-quarters of those over 60 have been screened.

When a person is assessed as pre-frail, their GP is informed and they are given recommendations on healthy living and are referred to non-clinical services to help with exercise, diet and social connections, as needed. If someone is pre-frail and also has cognitive impairment, falls, depression, polypharmacy or functional impairment – or if they are classified as frail – they are referred for more in-depth assessment at the combined HIV and geriatrics clinic. The individualised care plan that is developed typically involves input from social care services, hospital doctors managing co-morbidities and the person’s GP.

Vera said the next step is research assessing clinical outcomes. The French cohort will be followed for five years to further assess how frailty evolves and whether it really does predict adverse health outcomes in the long term.