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Teach staff about older HIV/AIDS patients
As the epidemic of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) matures in this country, health care providers are seeing new populations threatened by the disease. Among them are older patients, infected through long-ago blood transfusions or more recent sexual activity or IV drug use.
Patients ages 50 and older make up only a small portion of the total AIDS population — 72,161, or a little more than 10% of the total 688,200 U.S. cases reported to the Centers for Disease Control and Prevention through 1998. But the number appears to be growing, particularly in areas that serve a large geriatric population. Because home health workers deal with a largely older client population, they should be alert to the possibility of geriatric AIDS patients and the special needs of older clients with the disease.
In Broward County, FL, health providers are dealing with a relatively recent increase in AIDS cases among seniors, local experts say.
"It’s estimated that five to 6% of the hospice population here locally is geriatric and HIV-positive," says Bart Strang, PhD, clinical gerontologist, and director of the Center for Gerontology in Fort Lauderdale, FL. "There is a study being conducted now that indicates that other than black women, the elderly population is fastest growing [infected] population locally."
And that’s not taking into account the many older patients who do not realize they have HIV, because no one has thought to screen them. This is a particularly crucial point because the earlier HIV infection is detected, the more likely it is that the newest medicines can help retard the progression of AIDS.
AIDS and HIV are "absolutely not diagnosed as soon in the older population," says Martha Harrop, ARN, MSN, MBA, director of client services for Broward House Inc., a Fort Lauderdale facility that provides a wide range of services to AIDS and HIV-infected patients. "The biggest problem is that physicians, especially private physicians, do not think to put HIV in the differential diagnosis, so a lot of the cases are not caught until late."
The most common illnesses associated with AIDS, including a form of pneumonia, are similar to conditions often found among noninfected seniors. Strang says a particular form of AIDS-related dementia often isn’t diagnosed properly in older patients because it is assumed to be Alzheimer’s disease.
Home health workers should keep in mind the following issues as they care for their clients:
• Infection control: "They’ve got to use universal precautions at all times, period," Harrop says. "I know especially as they get very familiar with a certain client, they may become lax. They shouldn’t."
• Assessment questions: Home health nurses can help call attention to high-risk seniors by asking direct questions in assessments about risk factors for HIV. Items to check for include past blood transfusions, unprotected sexual activity (particularly with multiple partners), and drug use.
"One of the most overlooked things in seniors is drug and alcohol abuse," Harrop says. "That includes legal and illegal drugs. I’ve had several folks over 50 who were crack addicts."
Strang has rarely found elderly patients who have used illegal intravenous drugs, but he points out that certain forms of dementia can result in a decrease in social control in both men and women and can lead to increased sexual promiscuity.
Now that the incidence of infection through heterosexual sex is increasing, heterosexual seniors, like anyone else having sex, should use protection such as condoms to prevent the spread of AIDS or other sexually transmitted diseases. Strang said an education program now is under way in the Broward area to educate seniors about AIDS prevention.
AIDS is an immune system disorder brought about by infection with HIV. The disease leaves the patient susceptible to a host of debilitating illnesses, often called opportunistic infections. Many of the most common AIDS-related infections, such as Pneumo cystis carinii pneumonia and Kaposi’s sarcoma, are extremely rare among people who do not have AIDS. As the body becomes weaker, the patient eventually dies from one of these opportunistic infections.
Proper dose, proper time
Although no cure has been discovered for AIDS, recent advances have led to a successful drug cocktail that, when used by an infected patient, can lower the measurable level of HIV in the blood. The drugs are taken on a strict schedule; missed doses can help the virus become resistant.
"Unfortunately with geriatric patients, I think you’ve got more of a problem of forgetting to take medication," Strang says. He cites a study that showed seniors taking eye drops for glaucoma would often forget to take it for two or three days, then take a large dose to compensate.
Home health workers should emphasize to patients how important it is to take the medications at the proper times, and they should monitor medication use.
One of the hallmarks of AIDS is a wasting of the body, related to a host of factors that include diarrhea, vomiting, and malabsorption. Harrop says a proper diet is vital, one high in calories but low in fat. "It’s kind of like everything your mother ever taught you: Eat your vegetables, get plenty of rest, get a moderate amount of exercise, take your medicine, see your doctor regularly," she says. "But if you have a senior population that is not caring for their nutritional needs, it’s going to compound their HIV." She suggests making sure seniors have access to Meals on Wheels or another service that helps them eat a balanced diet.
In general, Strang says, the progression of AIDS among seniors does not appear to be significantly different than it is for other patients. Older patients do not appear more likely to be infected by exposure to HIV and don’t seem to progress more quickly from HIV infection to AIDS. However, their battle against the disease is often complicated by other illnesses. For example, he points out that a common drug for AIDS, stavudine, can be neurotoxic and so could affect a person who already suffers from Alzheimer’s disease.
AIDS can cause its own form of dementia as the disease attacks nerve cells in the brain. Strang estimates that 20% to 30% of all people with AIDS develop AIDS dementia complex. "It’s a little harder to get an estimate in the elderly population directly, because obviously you’ve got the incidence of Alzheimer’s dementia in the elderly that can mask the AIDS dementia," he says. The only way to discern the difference between the two is through sophisticated testing or an MRI.
But home health nurses can be alert for signs of dementia and report them quickly so a patient can be screened as soon as possible. AIDS-related dementia can be lessened significantly by another AIDS drug, zidovudine.
Strang suggests providers regularly administer the Folstein Mini-Mental State Examination. "It’s a cognitive screen for dementia in the elderly," he says. "It gives baseline estimates as to cognitive functioning in memory, language, visual/spatial capabilities, speech, that type of thing." He says it’s important to establish a baseline for those functions so they can be tracked over time.
Strang also suggests administering another test, the Geriatric Depression Scale, which gives a quantitative score for degree of depression in a patient. He notes that even without the introduction of an incurable, fatal illness, seniors are at risk for depression. "Aging is a depressing experience for just about everybody. It’s characterized by loss of capabilities, loss of social status, loss of memory, loss of friends and family."
Harrop says that in her experience, older clients deal with a diagnosis of HIV or AIDS with more maturity than younger ones, but they often lack the support network that younger clients have. They may feel uncomfortable discussing their illness with friends their own age or their family.
"There’s a measure of isolation and, also with this population, a lot of shame and guilt that you don’t see in the younger population," she says. "Certainly, younger people are sorry they got HIV, but there’s a certain bravado about being very sexual that you don’t find in older people."
Older patients with HIV may not realize how much help there is, particularly in larger cities, to assist them in coping with the disease, Harrop says. "They have access to a large network of support specifically aimed at HIV and AIDS patients in virtually every metropolitan area. They can get everything from mental health to chiropractic services to massage therapy."
She encourages home health workers to become knowledgeable about what agencies provide help to AIDS patients and to inform their clients. "If seniors are not in the system at all, they may lose out on the services completely."