Interdisciplinary topics in gerontology and geriatrics最新文献

Ageism, in the form of prejudice, stereotyping, and discrimination targeting older adults, represents a barrier to addressing the graying of the HIV epidemic. There is widespread misperception on the part of older adults themselves, as well as service providers and society in general that HIV risk is low as one ages. In addition, internalized ageism may play a role in poorer physical and mental health outcomes, as the negative stereotypes associated with aging become a self-fulfilling prophecy. A number of steps can be taken to address HIV and aging in the context of ageism with regard to: prevention, education, and outreach; treatment guidelines for older adults with HIV; funding to address the aging of the epidemic; engagement of communities, health and social service organizations, and other providers around mental health and social support, and addressing the needs of special populations. Caring for an aging population with HIV represents a challenge, which is exacerbated in low and/or middle-income countries that typically lack the infrastructure of high resource settings. How we address the aging-related issues of the HIV epidemic across regions and settings could serve as a model in dealing with aging in our society in general regardless of HIV status.

Social networks of older adults with HIV have been characterized as fragile, with a greater reliance on friends as compared to family. However, we know little about the subgroup differences in the social network constellations of this population, how such characteristics are related to social support resources, and their relationship with psychosocial well-being. We developed a typology of social networks of older HIV-positive adults and examined if they would be related to receipt of informal assistance, perceptions of support sufficiency, and psychosocial well-being. Data were obtained from Research on Older Adults with HIV (n = 914). Participants were 50 years and older, HIV positive, and diverse in terms of race/ethnicity, gender, and sexual orientation. Cluster analysis identified Isolated, Friend-centered, and Integrated social network types. The Isolated reported significantly lower levels of assistance, lower perceptions of support availability and adequacy, greater stigma and psychological distress, and lower well-being compared to their peers. While friends dominate many social networks in this population, a more nuanced interpretation is needed; many have no friends and a substantial proportion receive significant family support. Those with Isolated network types will likely need to access a high volume of community-based services as they age as they lack informal support resources.

Older people living with HIV are increasingly requiring formal supportive community-based services. Supportive services are essential to medical care and treatment for older people living with HIV/AIDS. This chapter considers Andersen's behavioral model of health services, and explores the predisposing, enabling, and need factors that affect service utilization among the older HIV population. The Andersen model provides a lens to understand the need for supportive services to go beyond primary medical care. Examples of such services and referrals typically include medical and non-medical case management, clinical provider referrals, mental health and substance use treatment, housing assistance, legal services, nutrition, transportation, home care, emergency assistance, patient education support groups, and other programs such as the AIDS Drug Assistance Program and secondary prevention services. Barriers to assistance and support, and consequences and resources for caregivers are addressed. Aspects surrounding structural inequities, multiple-minority status, and HIV stigma are examined with the goal of offering insight and advocacy ideas for community-based providers and policy makers. In future, the healthcare and supportive services infrastructure must be better equipped to manage the distinctive treatment and care needs of HIV-positive older adults.

The previous chapter focused on the conceptualization and operationalization of the deficit accumulation and phenotypic approaches to the description of frailty. The purpose of this chapter is to summarize some studies that compared these most commonly used frailty definitions. We also discuss the strengths and limitations of using these two frailty assessments in clinical settings and how they might be usefully employed in future studies.

This chapter considers the pragmatic integration of frailty in primary care. While some patients present to primary care practitioners with relatively well-defined problems that can be managed by a single intervention and/or organ-specific specialist referral, others present with nonacute, poorly defined problems that are complex and rooted in multiple factors. The latter are often in need of a comprehensive geriatric assessment (CGA). CGA can have important positive impacts on the health of older people, but it is labor-intensive and costly. Therefore, patients at higher risk of adverse outcomes should have higher priority to publicly funded CGA services. Frailty is an age-independent marker of risk that fits the biopsychosocial model of primary care, and its use (as opposed to age alone) may promote equity of access to CGA services. A number of frailty assessment tools have been recommended for use in primary care. Some randomized controlled trials have shown that frailty screening in primary care, with subsequent CGA and intervention, can prevent adverse outcomes. However, this result has not been obtained with every screening tool, and comparative trials are ongoing. Meanwhile, primary care commissioners in the UK are establishing new frailty care pathways and developing frailty registers in primary care.

The increasing prevalence of frailty within the aging population poses challenges to current models of chronic disease management and end-of-life care delivery. As frailty progresses, individuals face an increasing frequency of acute health issues requiring medical attention. The ability of health care systems to recognize and respond to acute health issues in frail patients using a holistic understanding of health and prognosis will play a central role in ensuring their effective and appropriate care, including that at the end of their lives. This chapter reviews the history of palliative care and the elements of frailty that require the modification of current models of palliative care. In addition, tools and models for recognition of end of life in frailty and considerations for symptom management are introduced.

Although women live longer lives than men, they tend to have poorer health status. Here, we review the biological and socio-behavioral factors that may contribute to this sex-frailty paradox. The conceptual framework that frailty is a product of the environment and the recovery rate provides a new understanding of women's frailty burden. Even developed countries may present an environment more adverse for women, and lifestyle factors may increase women's vulnerability to stochastic subcellular events that increase recovery time. The frailty index does not reach the theoretical maximal value of 1; its limit is lower in men (0.61) compared to women (0.69). Perhaps deterministic characteristics omitted in current deficit counts, such as reduced emotional adaptability, are more prevalent in men. Alternatively, different limits may result from quantitative evolutionary design, such as a fitness-frailty pleiotropy in men or fertility-frailty pleiotropy in women. The engineering principle of safety factors (maximal capacity divided by routine functioning) may also be informative. If the human system has the same safety factor as its organs (approximately 2.5), men may be 'calibrated' around a frailty index of 0.244, compared to 0.276 for women. Because 0.25 represents the tipping point between functional independence and reliance on others, evolutionary design may have allowed for some limited dependence in women, perhaps motivated by the perinatal period.

In both demographic and clinical studies, frailty is understood as a multidimensional state of increased vulnerability compared with the status of others of the same age. Of the many theoretical definitions of frailty, two are commonly employed: the physical frailty/phenotypic approach and the deficit accumulation approach. The purpose of this chapter is to discuss how frailty is conceptualized and operationalized based on these two approaches.