Considering the Impact of Aging When Caring For and Treating Adults With HIV

Considering the Impact of Aging When Caring For and Treating Adults With HIV Judy Frain, PhD, RN

ABSTRACT The current study investigates how age impacts factors associated with success- fully managing HIV. One hundred thirty adults with HIV were recruited for the study. Participants were divided into two groups, those age ≥50 and those age <50. Cog- nitive impairment and depressive symptoms were seen at higher rates in older adults, and the severity of depressive symptoms was also higher in older adults. Depressive symptoms impacted cognitive function to a higher degree in older adults compared to younger adults (r = –0.293, p = 0.018 vs. r = –0.109, p = 0.387). Polypharmacy was a greater concern in older adults, with 88% having polypharma- cy compared with 60% of younger adults. Similarly, the prevalence of comorbidities was more than double in older adults compared to younger adults. Factors associ- ated with aging complicate management of HIV. Gaining insight into the challenges of caring for this population will furnish nurses with information necessary to pro- vide the best possible care for this growing population. [Journal of Gerontological Nursing, 46(4), 31-40.]

S ince the start of the HIV epi- demic, tremendous advances have been made in the care and

treatment of persons living with this disease. Th ese successes have trans- formed HIV from a fatal to a chronic disease and have also contributed to the demographic shift now seen in the

HIV population. Th e majority of new infections are still found in younger adults, but now more than one half of all persons with HIV are older than 50 (Centers for Disease Control and Prevention, 2017), and it is expected that this aging population will con- tinue to grow.

As is true with many other chronic diseases, aging has led to an increase in the number of comorbid condi- tions. Comorbidities complicate HIV treatment, decrease quality of life, in- crease morbidity and mortality, and increase the cost of health care (Cahill & Valadéz, 2013; Rodriguez-Penney et al., 2013). Several studies have found that the number of comorbidi- ties experienced by people with HIV was greater when compared to HIV-

negative adults, including those with other chronic conditions (Maciel et al., 2018; Mayer et al., 2018; Ruzicka et al., 2019). Although the number of comorbid conditions was greater in persons with HIV, the types of co- morbidities are typical of aging adults in general, with hypertension, lipid/ metabolism, respiratory, and psycho- logical disorders common in persons with and without HIV, suggesting that aging, rather than HIV, is respon- sible (Kong et al., 2019; Serrão et al., 2019; Smith & Wrobel, 2014).

One corollary of the high num- ber of comorbidities is the increase in pill burden for many adults with HIV (Moore et al., 2015). In a re- cent study, overall prevalence of poly- pharmacy (fi ve or more medications) was 25% among persons with HIV, compared to 18.7% in HIV-negative adults. Signifi cantly, polypharmacy was approximately 50% in adults 50 and older with HIV (Ware et al., 2018). In another study, polyphar- macy was an issue for 66% of older adults with HIV, and 48% of younger adults with HIV, compared to just 13% of HIV-negative adults. Even when HIV medications were exclud- ed from pill counts, 30% of older and 14% of younger adults with HIV had polypharmacy (Halloran et al., 2019).

Due to its importance in suppress- ing the virus, adherence to antiretro-

Dr. Frain is Associate Professor, Goldfarb School of Nursing at Barnes-Jewish College, St. Louis, Missouri.

The author has disclosed no potential confl icts of interest, fi nancial or otherwise.

Address correspondence to Judy Frain, PhD, RN, Associate Professor, Goldfarb School of Nursing at Barnes-Jewish College, 4483 Duncan Avenue, St. Louis, MO 63110; e-mail: Judith.frain@bjc.edu.

Received: August 30, 2019 Accepted: November 11, 2019 doi:10.3928/00989134-20200304-02

31Journal of Gerontological Nursing | Vol 46 | No 4 | 2020

viral therapy (ART) remains a vital component in the successful manage- ment of HIV. Common advice from providers has been that patients need to take their HIV medications cor- rectly 95% of the time to achieve and maintain viral suppression. Although newer drugs may be more forgiving of missed doses, non-adherence remains a primary cause of virologic failure for persons with HIV (Denison et al., 2015; Dunn et al., 2018; Glass et al., 2015). Studies have shown polyphar- macy and multi-comorbidities, along with other factors, contributed to non-adherence (Bogart et al., 2016; Cantudo-Cuenca et al., 2014; Corless et al., 2017; Manzano-García et al., 2018).

Depression is one of the most common mental health comorbidities found in persons with HIV. Th e prev- alence of depression in adults with HIV is more than three times that of the general adult population (Brody et al., 2018; Do et al., 2014; Nanni et al., 2015). Depressive disorders have been associated with faster HIV progression, increased morbidity and mortality, slower immune response, reduced adherence to ART, and a decrease in cognitive function and quality of life (Gonzalez et al., 2011; Wagner et al., 2011). Depressive symptoms have been shown to nega- tively impact HIV self-management, including daily health practices, and were positively correlated with per- ceived stress (Webel et al., 2016). Studies are mixed as to the eff ect of aging on the prevalence of depression in adults with HIV; however, there is some evidence that depressive symp- toms have a greater impact on qual- ity of life and health outcomes as this population ages (Millar et al., 2017; Th omas et al., 2009).

Th e connection between psychiat- ric symptoms and cognitive function has been examined in previous HIV studies with mixed results. Evidence from studies of older adults with HIV found that although psychiatric symptom burden was high, it did not result in an increase in HIV-associated

neurocognitive disorders, and comor- bid psychiatric symptoms were not associated with cognitive impairment (Bourgeois et al., 2019; Milanini et al., 2017). However, in other stud- ies that included older and younger adults with HIV, results indicated that depressive symptoms impact cog- nitive function (Laverick et al., 2017; Rubin & Maki, 2019; Schouten et al., 2016).

Th e current study explores the im- pact of aging on successfully treating and managing HIV in adults age 50 and older. Age 50 was chosen because that is the age defi ned by the Centers for Disease Control and Prevention (Blanco et al., 2012) as older adult in the study of persons with HIV. How aging impacts psychosocial, cogni- tive, and quality of life measures is ex- plored, in addition to aging’s impact on medication adherence, as measured by a 3-day medication recall. Th is re- search fi lls a gap by giving health care providers and their patients informa- tion they can use to better understand how aging can impact successfully liv- ing with and managing HIV.

METHOD Design and Sample

A descriptive, correlational design was used in this study. Participants were recruited from an outpatient infectious disease clinic of an ur- ban medical center in the Midwest, and from the AIDS Clinical Trials Unit (ACTU), which shares a build- ing with the clinic. Persons were ap- proached during their appointment to discuss the trial. Informational fl yers were also placed in the waiting rooms of the clinic and clinical trials unit. Data were collected as part of a study assessing medication manage- ment in adults with HIV.

A convenience sample of 130 adults between ages 20 and 76 with HIV were enrolled and divided into two groups, those 50 and older, and those younger than 50. Inclusion criteria were having documented HIV, taking ART for at least 16 consecutive weeks prior to study entry, and ability

to read and understand English. After giving informed consent, participants completed instruments that included the Montreal Cognitive Assessment (MoCA), Center for Epidemiologic Studies Depression Scale (CES-D), Self-Effi cacy for Managing Chronic Disease Scale, and a medication ad- herence instrument. Data included demographic information; alcohol, drug, and tobacco history; current medications; current viral load and current and nadir CD4 count; years since HIV diagnosis; and additional comorbidities. HIV viral load and CD4 counts were documented in this study as measures of HIV. A low or un- detectable viral load indicates ART is eff ectively controlling the HIV. When uncontrolled, HIV attacks the body’s CD4 cells, causing a decrease in num- ber and resulting in an increased risk for opportunistic infections. A nor- mal CD4 count ranges from 500 to 1,500 cells/mm3 of blood. Generally, if CD4 counts >500 cells/mm3 can be maintained, the risk for opportunistic infections is decreased.

Procedure Th e study was approved by the

University’s Institutional Review Board. All participants provided written informed consent prior to completing any study-related activi- ties. Study procedures took place in a quiet, private room conveniently located near the clinic and ACTU. Participants completed a demograph- ic form, which included medical and social histories, the CES-D, the MoCA, the Self-Effi cacy for Man- aging Chronic Disease Scale, and a medication management test. Trained research staff administered the MoCA and the medication management test and were available to assist if ques- tions arose when participants were completing the other instruments. Medical records were also used to complete information on the demo- graphic form, including number of comorbidities, medications, and CD4 counts and viral load. HIV health care providers were notifi ed of participants

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scoring ≥16 on the CES-D, indicating clinically signifi cant depressive symp- tomology.

Instruments Brevity and adaptability to the clin-

ical setting were considerations when choosing the instruments for this study. Th e CES-D and MoCA have been used in previous HIV research and have been shown to be valid and reliable instruments (Nasreddine et al., 2005; Radloff , 1977). Concise- ness and ease of administration make these instruments ideally suited for use in the clinical setting, where time and resources are often limited.

Th e CES-D is a 20-item, self- administered questionnaire used to measure depressive symptoms over the past 1 week (Radloff , 1977). A sum- mary score is calculated, with total possible scores ranging from 0 to 60. Scoring for each item is on a 4-point scale ranging from 0 (rarely or none of the time) to 3 (most or all of the time). Responses are based on frequency of occurrence during the past 1 week. A higher score indicates a higher level of depressive symptomology. A score ≥16 indicates a clinically signifi cant level of depressive symptomology. Less than 20% of the general popu- lation would be expected to score in this range. Th e CES-D has been used in many large-scale HIV research tri- als, and its reliability and validity have been well-established. Cronbach’s al- pha is 0.94 (Radloff , 1977). In a re- cent study focused on persons with HIV, Cronbach’s alpha ranged from 0.92 to 0.94 (Mueses-Marín et al., 2019). Another study comparing men with HIV with uninfected men found specifi city of 99.9% and sensitivity of 75% in the HIV group (Armstrong et al., 2019).

Th e MoCA is designed as a quick screening tool for assessing mild cog- nitive impairment (MCI) and is not recommended as a stand-alone diag- nostic tool. It is a 30-item instrument that takes approximately 10 minutes to complete and can be administered with minimal training. Th e MoCA

assesses diff erent cognitive domains, including attention, concentration, executive function, memory, lan- guage, visuoconstructional skills, con- ceptual thinking, calculations, and orientation (Nasreddine et al., 2005). Th e highest possible score is 30, and a person scoring ≥26 is considered to have normal cognitive function. Th e MoCA has been used to measure HIV–associated MCI (Bourgeois et al., 2019; Overton et al., 2013). Over- all reliability of this instrument has been shown to be 0.83 (Nasreddine et al., 2005). Studies focused on adults with HIV have reported sensitivities ranging from 59% to 85% (Hasbun et al., 2012).

Th e Self-Effi cacy for Managing Chronic Disease Scale is a six-item scale that is designed to measure how confi dent a person is in managing symptoms of his/her disease. Respons- es can range from 1 (not at all) to 10 (totally confi dent). Th e scale score is the mean of the six items. When orig- inally tested on a sample of 605 adults with chronic disease, the mean score was 5.17 (SD = 2.2), and reliability was 0.91 (Lorig et al., 2001).

Data Management and Analysis Data were analyzed using SPSS

version 22. Data were stored on a hard drive and backed up on a secured server. Hard copies of completed study questionnaires were stored in a locked fi le cabinet in a secured offi ce. All stored data were de-identifi ed. Descriptive statistics were used to summarize the demographic charac- teristics and other information from the demographic form. Independent t tests, analysis of variance (ANOVA), and regression analysis were used to analyze data.

RESULTS Table 1 summarizes participant de-

mographic data. All participants were seen in care at least once within the past 1 year and were prescribed ART. Th us, this was a relatively healthy group, with three quarters of partici- pants having undetectable viral loads

(n = 97), and a mean CD4 count of 558 cells/mm3, with counts rang- ing from 5 to 1,649 cells/mm3. CD4 counts were similar between groups, with older adults having a mean CD4 count of 549 (SD = 291) cells/mm3, and younger adults 567 (SD = 318) cells/mm3. Viral load, however, dif- fered signifi cantly between groups. Whereas 81.5% of older adults had an undetectable viral load, only 67.7% of younger adults were un- detectable. Th e median viral load was undetectable for both groups; however, the mean for older adults was 1,303 (SD = 7,507) cells/mm3, whereas the mean for younger adults was 6,600 (SD = 27,956) cells/mm3, primarily due to approximately 10% of younger adults having viral loads >10,000 cells/mm3, compared to <2% of older adults.