Older patients especially prone to depression, stress
Older patients especially prone to depression, stress
Elderly often need targeted interventions
An estimated one in five people with AIDS are men age 45 or older, a rate that has doubled since 1995.1 Also, an estimated one in four women newly infected with HIV are between 35 and 44.1 This suggests the HIV population will shift more to the middle years, particularly with the long-term success of antiretroviral drugs. This population requires special attention because people with HIV who are middle-age or elderly have a variety of other health, social, and emotional concerns.
"Depressive symptoms are not uncommon among older adults, and this is particularly true of older adults with cognitive impairments," says Timothy Heckman, PhD, associate professor of psychology at Ohio University in Athens. He has been involved with two recent studies of depression among older persons living with HIV disease.
Older people commonly live alone and experience anxiety and social isolation in addition to feelings of depression. In addition, HIV-infected persons often suffer from multiple bereavements, loss of physical and financial independence, discrimination, and other HIV-related difficulties.2 That combination can lead to life distress and a greater risk for suicide, Heckman says.
People between 45 and 65 years of age have higher suicide rates than do other adults, and suicide is one of the 10 leading causes of death for this age group.1 Add HIV infection to the group’s other life stressors, and the danger is even higher. Investigators have found that one in four middle-age and older persons with HIV infection involved in a recent study reported having had thoughts about suicide within the past week.1
The study also found that men had higher rates of suicidal ideation, which were associated with physical symptoms related to HIV disease.1
Heckman and other investigators have studied how health care professionals can help this at-risk population, both preventing suicide and improving older HIV patients’ general quality of life. Here are some strategies the research suggests:
• Help improve social support. In a pilot intervention Heckman and other investigators tested, they found that older adults with HIV were very happy to get together in a group setting with other people like themselves.
Those who had attended support groups consisting of younger HIV-infected people said they couldn’t identify with the younger group members. On the other hand, the older adults often said they would love to participate in groups involving other older HIV-infected people. "They need a place where they can talk openly about difficulties they’ve had in the past and difficulties they’re having now," he says. "A support group is a good environment to share personal stories and access support they might not get other places."
• Teach coping effectiveness training. Such training can be done in a group setting. "We have them identify stressors in their lives, and then they talk with other group members about the ways they might more effectively deal with these stressors," he says. "They talk about maladaptive coping, such as high alcohol use."
Then the group creates goals for implementing adaptive coping strategies. For example, one event that can lead to stress is the loss of a friend or loved one, which is common among many older HIV-infected people; they were adults when the AIDS epidemic was new 20 years ago and often have lost friends and partners to the disease. Also, older people with HIV may have lost family members to other diseases, and they often have lost jobs and financial independence. Loss is a big issue and an easy stress trigger. "So we spend a lot of time talking about loss," Heckman says. "If people experience bereavements and don’t deal with them effectively, that can lead to greater stress."
HIV disclosure also is a major stressor
Another major stressor has to do with when to disclose one’s HIV status. "Older adults have to tell children and grandchildren and friends, who might never have known they were gay or bisexual," he explains. "We discuss who to tell, how to tell, and whether it is safe to tell this individual or this group." The support group creates a safe environment for practicing HIV disclosure. Members might talk about how a particular person will react to the news and whether this could be used against them in a job or housing situation.
"The nice thing about the group environment is that people who’ve been in similar situations can share with their peers how they handled it and what the response was," he adds.
• Reach rural HIV patients through phone groups. Older HIV patients, especially those in rural or small-town areas, often lack support groups of people in their own age bracket. "In rural areas, it’s complicated because you have HIV-infected people who live long distances from traditional sources of support, and they can’t make it to support groups because of geographical distances or physical limitations," he says. "Often these people will not have cars or driver’s licenses. Or they’ll have issues of confidentiality and may be concerned about meeting with other HIV-infected people in a small community because word spreads about what’s going on and who attends these groups."
A possible solution is a telephone support group in which several HIV-infected rural people are linked across the country, all on the same telephone line at the same time. "They can talk about life histories, perceptions of loneliness, discrimination, perceptions of isolation, and all the things that everybody talks about such as finances, relationship difficulties," Heckman says.
Telephone support groups can be similar to everyday conversations, only with strangers who share similar life circumstances.
Although it is not the same social dynamic as a face-to-face group encounter, the telephone support groups provide participants with the knowledge that other people are experiencing the same sort of difficulties they face. And they can discuss and identify strategies that will help them cope with their daily stressors.
This type of support also can be provided through the Internet in chat rooms and on message boards. But because computer technology is cost-prohibitive for low-income people, the telephone conference, supported by a grant or HIV clinic, may be a more realistic option.
Investigators are studying the outcomes of telephone support services when used to assist HIV-infected people in rural areas. This could be a relatively inexpensive way to provide services to a hard-to-reach population.
"If we find you can effectively disseminate services through the telephone, then others can make a stronger argument to do this and request money to support this type of program," says Heckman.
References
1. Kalichman SC, Heckman TG, Kochman A, et al. Depression and thoughts of suicide among middle-aged and older persons living with HIV-AIDS. Psychiatr Serv 2000; 51:903-907.
2. Heckman TG, Kochman A, Sikkema KJ, Kalichman SC. Depressive symptomatology, daily stressors, and ways of coping among middle-age and older adults living with HIV disease. J Ment Health Aging 1999; 5:311-322.
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