Rapid aging, frailty common in older HIV

Prevalence is 9% in one study

Frailty is not a diagnosis that typically comes to mind when clinicians examine HIV patients, but with increasing numbers of older people being diagnosed or younger patients growing old with the disease, it should be on HIV clinicians' radar.

"HIV infection is really a disease of accelerated aging," says Nur Onen, MBChB, an instructor in internal medicine in the infectious diseases division of Washington University School of Medicine in St. Louis, MO.

"A new concept we're looking at is the concept of frailty in HIV-infected individuals, and this is occurring in individuals who are under 50 years of age," Onen says.

Onen's research reported a frailty prevalence of 9% among 445 persons attending Washington University HIV Clinics between June and December, 2008.1

The study identified these independent predictors of frailty: unemployment, higher number of comorbid conditions, past opportunistic infections (OIs), higher depression severity score, receipt of antidepressants, and lower serum albumin.

Interestingly, the study did not find that age was an independent predictor.

"Our HIV outpatient population had a mean age of 42 years," Onen says. "Patients became prematurely frail."

Clinicians who observe frailty in HIV patients should be on the look out for higher blood pressure and bone density loss, she notes.

In fact, bone density screening should be routine for HIV patients older than 50 years of age, as recommended by the National Osteoporosis Foundation of Washington, DC, Onen says.

Patients can be screened for frailty with the Health Status Form (HSF), which notes four variables that best predict elderly members of the general population who are most at risk of frailty. These variables are age, indicating that health conditions interfered with daily activities, needing assistance for bathing, and needing assistance for taking medications.2

Onen also suggests clinicians use criteria for physical frailty diagnosis published by researcher Linda Fried, MD, who looked at weight loss, low physical activity, and exhaustion as signs of frailty.

Fried's work, published in the Cardiovascular Health Study, has associated frailty with these characteristics: diminished energy, systems dysfunction, such as diminished heart rate variability and immune function, low testosterone and IGF-1 levels, elevated cortisol, insulin, and glucose levels, and multi-system dysregulation.3

"What we have done is look at her criteria in HIV-infected population, and, yes, typically these patients don't have a lot of muscle mass, are thinner, and look frail," Onen says.

"We looked at a mixture of people and found that these characteristics predict frailty: a greater number of premorbid conditions, distinct from comorbidity, a history of OIs, higher depression scores, being on an antidepressant, and higher unemployment."

Onen's frailty and HIV patients study also found a high prevalence of neuropsychiatric comorbidity among frail patients and the suggestion that these increase with age.

Frailty also was associated with adverse socioeconomic and clinical outcomes. The study concludes that HIV clinicians likely will see increasing numbers of frail patients in coming years as the nation's HIV patient population ages.1

Frail patients cost more to treat, Onen says. "They have greater hospitalization rates for nonelective admissions, and five-fold longer inpatient stays."

References

  1. Onen NF, Agbebi A, Shacham E, et al. Frailty among HIV-infected persons in an urban outpatient care setting. J of Infection. 2009;59:346-352.
  2. Brody KK, Johnson RE, Ried LD. Evaluation of a Self-Report Screening Instrument to Predict Frailty Outcomes in Aging Populations. The Gerontologist. 1997;37(2):182-191.
  3. Newman AB, Gottdiener JS, McBurnie MA, et al. Associations of subclinical cardiovascular disease with Frailty. J Gerontol Med Sci. 2001;56:M1158-1166.