One Doc's Advice for Caring for Elderly Patients With HIV
According to the Centers for Disease Control and Prevention (CDC), about 45% of all people living with HIV in the U.S. are over 50 years of age. Some of them are people who are living longer due to advances in treatment, but some of them are people who are either contracting HIV later in life or were not diagnosed for many years.
Providers need to consider many issues when treating older patients who are living with HIV, whether it's drug interactions with HIV medications and treatments for other illnesses a patient may have or what it means to be HIV positive and living in an assisted living facility. At the Association of Nurses in AIDS Care Conference in November 2017, Sony Salzman sat down with Kristine Erlandson, M.D., an assistant professor of medicine with the University of Colorado, to discuss significant issues related to caring for elderly HIV-positive patients.
Sony Salzman: I wanted to talk to you about what clinicians should keep in mind or know about caring for the elderly.
Kristine Erlandson: Yeah. I have my interest areas, so there are things that I think are more important that other people will disagree with. But I think probably one of the most important issues is polypharmacy.
We pile medications on people to try to treat every comorbidity they have and don't stop and think whether each medicine's adding additional benefit.
Patients are on so many different medications that they start to have all these side effects from their medications. And then, we get them more medications to treat the side effects from their medications -- and then they don't take any of them.
I think [we should] try to decrease medications, or come up with the priority medications, and eliminate medications that potentially are high risk in the older population.
SS: Right. Well, that's really interesting. When it comes to the HIV population, the one thing that you can't eliminate is the HIV med.
KE: This is your priority. And it automatically adds basically three more medications to everyone's regimen. We have polypharmacy in the geriatric population. I think, as people start to get older, trying to avoid the HIV meds that, like cobicistat [Tybost] or ritonavir [Norvir], have these huge drug interactions is probably more of an issue in that population.
SS: It's kind of twofold. As the HIV doc, you're doing the work to make sure that your patient is on the best regimen for his or her other conditions; but then, at the same time ...
KE: ... Trying to minimize harm with the treatment you're giving them.
SS: Right. And negotiating with their other clinicians. And by negotiating, it's like putting your foot down.
KE: Well, I think some of it's having a central provider, making sure that if you're the primary provider for your patient, that if you send them to a cardiologist, their cardiologist is discussing it with you before they add more medications, and empowering the patient to really say, "Hey, let me check with my [HIV] doc and make sure this is OK."
We get patients that get admitted for chest pain, and cardiology loves to stick people on 80 mg of atorvastatin, which in the HIV patient on a boosted PI, it's like 200 mg of atorvastatin. It's like whopping doses higher because of that drug interaction. But they're just -- that's kind of their protocol. You come in with chest pain; you get this drug. And they just don't necessarily think about those drug interactions.
So, trying to make sure the patients are really empowered to say, "No, I need to talk to my doc first," and then trying to minimize the potential that a drug interaction might even happen, so potentially avoiding some of those high drug interaction ART [antiretroviral treatment] regimens, if possible, in the older population.
SS: OK, polypharmacy is a big one.
KE: I think multimorbidity is kind of along that same line. It's the idea that people have multiple conditions, and they all kind of interact -- and the more you have, they probably build synergistically. So, you have diabetes and you have cardiovascular disease, and it's not just that you're treating one or the other; it's how they interact. It's a big concept in aging.
From my bias, I think one of the most important things to address is someone's physical function, and functional abilities.
Some things that might go into that might be nutrition. I think, particularly as people get older, they don't have a good system to get food.
SS: Oh, my gosh. I know. All my grandmother eats is peanut butter, literally.
KE: I know. Poor education about what they should eat, particularly as our nutrition knowledge has improved over the years; we realize how important some things are. But nutrition, I think, is huge.
And then, people can't get to the grocery store to get food. And then, along that same line for mobility is exercise and trying to get people active, whether or not it's just walking.
I think the other big issue is socialization.
SS: I was going to say loneliness.
KE: Yeah. I think, along that whole line of depression, loneliness, social isolation -- and probably fitting into that, cognition, too -- and how the more engaged people can stay in the community, the more it probably helps their cognition over time.
I think another important issue is advance directives and end-of-life planning. A lot of our patients tend to have fractured social networks. Depending on the state they live in, they maybe have a same-sex partner that is not recognized by their legal system if they aren't married.
And, unless they have an advanced directive, their family, who they haven't talked to in 30 years, gets called to handle the end-of-life decisions. So, I think making sure patients have a trusted decision maker that's going to help them make those decisions [is important].
And then, also, what are they going to do? Can they stay in their own home? Do they need to go to a facility? Can they utilize geriatric resources -- or home care, skilled care, stuff like that -- to help them get the services they need to stay out of a nursing home? Or do they need skilled care? But there's a lot of stigma, still, in the nursing homes.
SS: Around HIV?
KE: I think that -- somebody was just telling me a couple weeks that they had a patient who got sent to a nursing home, and the nursing care staff insisted the patient use plastic silverware, because they thought their HIV would be contagious.
SS: That's bonkers.
KE: I know. It's crazy what people don't know, still, about HIV. I was just at my husband's grandma's 90th birthday party in her little nursing home in rural Illinois. There's nobody gay in her nursing home. They would freak out if there were. It's just such a foreign concept, still, in these very conservative communities. So, I think people that need that care just struggle when they try to go into a community like that.
I think the other big issue is falls.
KE: Falls. I think that we under-recognize falls in our population. They have a high risk of falls.
SS: What do you mean, under-recognize falls? I mean, everybody's always talking about how old people fall.
KE: Old people fall. But I don't think we appreciate how much middle-aged HIV people fall and how they're starting to fall at an earlier age. We don't necessarily ask them about a fall unless they're getting injured. And then, I don't know that a lot of people know what to do if their patient is falling.
SS: What do people do?
KE: You can -- I mean, exercise is a big thing, to try to improve their muscle strength. You can send them for physical therapy and balance training. You could send out an occupational therapist to their home. Or there's this nice check sheet patients can download from the CDC website and go through.
SS: What do you mean that HIV patients fall more? Did you say they fall more often?
KE: They do -- we think. Most of the data with falls in the older population is in, like, 65 year olds. We looked in our clinic population. In the 65 year olds, there's around a 30% fall risk starting at about age 65. In our HIV clinic, of 45-to-65 year olds, we found that there was a 30% fall risk in that middle-aged population.
SS: Hmm. That seems young.
SS: Why? What's going on?
KE: It could be neuropathy, pain medications, substance use, sedatives, antidepressants that have a lot of those dizzy side effects, lack of muscle mass. People may have weak muscles; they don't control their balance, as well. Neurologic -- other neuro diseases -- from HIV.
SS: That's interesting. Yeah. I've never heard that before. Fascinating.
This transcript has been lightly edited for clarity.