Interdisciplinary topics in gerontology and geriatrics最新文献

With increasing success in treating HIV, infected persons are living longer, and a new challenge has emerged - the need to understand how HIV-infected adults are aging. What are the similarities with typical aging and what are the unique aspects that may have resulted from HIV infection, interacting with characteristic life style factors and other comorbid conditions? Are specific diseases and conditions (comorbidities), typically seen as part of the aging process, occurring at accelerated rates or with higher frequency (accentuated) in HIV-infected adults? At this juncture, conclusions should be tentative. Certainly, biological processes that correlate with aging occur earlier in the older adult HIV population. Clinical manifestations of these biological processes are age-associated illnesses occurring in greater numbers (multimorbidity), but they are not accelerated. Specifically cardiovascular disease, certain cancers, and renal disease are more common with other comorbidities less certain. Management of this elevated risk for developing multimorbidity is a major concern for patients and their health care teams. The medical system must respond to the evolving needs of this aging and growing older adult population who will dominate the epidemic. Adopting a more holistic approach to their health care management is needed to achieve optimal health and well-being in the HIV-infected older adult. Geriatric care principles best embody this approach.

With effective antiretroviral therapy, HIV has become a chronic disease, and life expectancy among HIV-infected persons is approaching that of HIV-uninfected persons. Despite this success, epidemiologic evidence suggests that the burden of multiple aging-related diseases, including cardiovascular disease, liver disease, metabolic abnormalities, chronic kidney disease, cognitive dysfunction, and osteoporosis, is higher in HIV-infected persons compared to their HIV-uninfected peers. These comorbid diseases tend to cluster in a single person, leading to multimorbidity and polypharmacy. Emerging evidence suggests that multimorbidity among HIV-infected persons results in functional decline, reduced quality of life, and increased mortality. In this review, we examine the epidemiology, risk factors, etiologies, and potential consequences of multimorbidity in aging HIV-infected persons. With aggressive risk factor management for comorbidities and less toxic antiretroviral medications, the burden of multimorbidity in HIV-infected persons can be reduced.

Both the Joint United Nations Program on HIV/AIDS and the US National HIV/AIDS Strategy identify HIV stigma as a barrier to care, a barrier to service access, and deleterious to personal and social well-being. This chapter discusses the topic of HIV stigma from a conceptual basis, including the mechanisms of prejudice and discrimination, and defining anticipated, enacted, and internalized stigma. Stigma is then placed in a historical context of HIV and AIDS, and events exacerbating HIV stigma are discussed. The components of HIV stigma are then applied to the population of older adults (age 50 years and older) who are at-risk of or living with HIV infection. The importance of intersectionality is discussed with regard to race, ethnicity, gender, sexual orientation, gender identity, and in particular, age. Drawing upon the HIV and gerontological literature, the chapter outlines characteristics found to be protective against stigma and placing older adults at greater risk for HIV stigma. Stigma management strategies are outlined and finally, implications of working with older adults related to HIV stigma are provided.

HIV infection may potentiate specific biomarkers that influence the development of premature clinical indices commonly associated with aging. Therefore, predicting mortality outcomes in people living with HIV is extremely important as this population ages. This chapter describes biomarkers associated with inflammation, coagulation, and immune activation in HIV, and reviews the association between specific biomarkers and the development of co-morbid conditions in individuals with HIV. Measures that incorporate specific biomarkers related to HIV infection, designed to predict mortality outcomes in individuals with HIV, are also discussed.

People aging with HIV present a unique challenge for providers. HIV-infected patients experience accentuated aging and multimorbidity, but are typically disconnected from geriatric care, which is limited by a shortage of geriatric providers worldwide. Consequently, HIV providers are tasked with managing multiple age-related illnesses, within service networks that are historically not designed to care for aging patients. While comfortable with the management of antiretroviral therapy, HIV providers may have limited training on how to recognize or manage geriatric syndromes, especially in the context of multimorbidity. The result is an emerging, vulnerable population, and the question is how to best care for them. As part of the answer, we offer examples of how providers can use geriatric principles to improve the care of aging HIV-infected patients. We begin by describing basic geriatric concepts and examples of care models, and subsequently use a patient case to illustrate their applications at the patient level. At the system level, we discuss how HIV service networks can use components of geriatric care models to meet the needs of aging HIV-infected patients. Lastly, we identify aging-specific guidelines and service integration as important areas for future endeavors.

This introduction serves to foreground current patterns associated with HIV and aging, globally. We highlight key trends by World Health Organization sub-region, and identify gaps in existing knowledge. HIV and aging is insufficiently documented, as prevalence data for those over age 49 have not generally been captured by many countries, or by UNAIDS. Despite limited data and data systems, several dominant trends among adults aged 50 and older are discernible, including: growing HIV risk and prevalence is increasingly evident among maturing adults, worldwide; older individuals at risk of or living with HIV, and their health providers, fail to recognize risk and symptoms, leading to disease progression and delayed treatment. Cross-sectoral strategies will be needed to mount responses; public health campaigns will be essential in educating and informing individuals about HIV risk, prevention and care; and special efforts to tailor interventions to key populations most vulnerable or stigmatized in countries will be critical.

In addition to physical health challenges, older people living with HIV/AIDS (PLWHA) experience mental health burdens and challenges to their social well-being that diminish their overall health. These health states are synergistic and are driven by HIV and HIV treatments, the aging process itself, and psychosocial and structural conditions of their lives. However, resilience, which we understand as both a trait and a process, may serve to buffer the effects that HIV/HIV treatments, aging, and social/structural conditions may have on the overall well-being of the individual. In this chapter, we examine the extant literate on the mental health and psychosocial challenges experienced by older PLWHA as elements of the total health of the individual. We also provide a contextualization and conceptualization for understanding the significant role that resilience may play in empowering individuals to enact processes which buffer health from the stressors. In this perspective, the health of older PLWHA must be viewed through a lens of power and strength rather than one of deficit. We conclude by outlining a theoretical paradigm for the role of resilience in the health of older HIV-positive adults, which may serve as a guide to clinicians, public health practitioners, and researchers working with this population.

Nearly 50% of HIV patients in the US are now over 50, and the problem of comorbidities associated with the aging process is becoming increasingly complicated. In this chapter, we will review the challenge of polypharmacy and suggest ways of minimizing drug-drug interactions. Newer medications and combinations that reduce the pill burden, and allow the healthcare provider to customize HIV treatment while remaining mindful of other medical issues will be addressed. Adherence to medication schedules and possible future alternative drug delivery systems will also be presented.

Aging is a complex biological process that leads to several physiological changes. Among these changes, the most striking are those involving the innate and adaptive parts of the immune system. Furthermore, these changes are associated with a low-grade inflammation called inflamm-aging, which is the result of several lifelong antigenic stimulations, including chronic viral infections such as cytomegalovirus. Immunosenescence, concomitantly with inflamm-aging, is considered as the leading cause of age-related diseases including cardiovascular, neurodegenerative and metabolic diseases, and cancer. HIV infection, once considered a unique deadly infectious disease, has now become a chronic disease with efficacious highly active antiretroviral therapy. This signifies that the treatment transforms HIV infection from a chronic infection to a chronic inflammatory disease. Most people with HIV infection become aged, and older adults have been contracting HIV infection. Thus, there is a great interest to study HIV infection in relation to immunosenescence and inflamm-aging to determine whether immunosenescence contributes to HIV infection, or if HIV is causing immunosenescence and, as such, represents a premature immunosenescence and accelerated aging. Although there are many similarities in the immune and inflammatory changes and the occurrence of age-related chronic diseases between normal aging and HIV infection, the interaction between these processes is not well understood, and consequently the concept that HIV infection is an accelerated aging model is questioned. Future studies are needed to effectively answer this question for the better care of HIV-infected elderly patients.

Over 50% of adults with HIV exhibit some form of HIV-associated neurocognitive disorder, ranging from mild asymptomatic neurocognitive impairment to HIV-associated dementia. As adults age with HIV and become susceptible to cardiovascular and metabolic comorbidities, the prevalence and severity of such neurocognitive disorders are likely to increase. With compromised renal and hepatic functioning often accompanying HIV, pharmaceutical interventions to address such neurocognitive disorders may not be the best strategy and are not without risks. Fortunately, as noted in the geriatric literature, cognitive training strategies have been shown to improve targeted neurocognitive domains and everyday functioning. A review of some of these cognitive training strategies, especially as they relate to aging with HIV, are highlighted and explained in the context of neuroAIDS, aging, and neurocognitive reserve. Implications for practice and research are provided.