There are new guidelines for treating and evaluating patients over 50 years of age as a result of a multi-year effort on the part of specialists in older patient s (gerontologists or geriatricians) and the American Academy of HIV Medicine, who published a summary in HIV Specialist magazine recently.
As with all patients, those 13 to 64 years of age should get routine HIV tests. Unfortunately many hospitals and most physicians have been slow to counsel and test patients; if this were performed, many would not get HIV and would be found at an early stage. We still have people walking into the hospital half dead, not knowing they were HIV positive, and should have been treated years ago. Please help get the word out: get tested and wear condoms. Obviously and sadly heterosexuals pay less attention to routine testing than gays, but some gays are in denial and I have had many of them suffer much and/or die. I think gays have no excuse for not testing regularly, they are aware of the risks. I know this shocks you, but many gays participate in unsafe sex.
Evidently those over 50 should start therapy when the CD4 is less than 500, whereas this is optional for the younger and a little less optional for CD4s between 350 and 500. There are still some diseases where we should start medication with a very high CD4 count; the quantity of the immune system is good but the quality is not. Also, if someone insists on unsafe sex, then getting their viral load to undetectable will lower the risk of transmission greatly.
If the CD4 is greater than 500 then treatment is optional but it should be taken if the viral load is more than 50,000 or the CD4 is dropping fast, or they have risk factors for cardiovascular disease (heart attacks, strokes), such as smoking, family history of the same, high cholesterol, diabetes or high blood pressure. Smoking is the worst of all the risk factors and if you quit, you drop your risk dramatically. Risk takers, are you smoking, using drugs, and having unsafe sex? Come out of your fantasy and please accept reality, you’lll live longer and suffer less.
We should pay close attention to weight gain (common as we age), as it may lead to cardiovascular disease through causing some of the risk factors above.
To diagnose and monitor diabetes we use the hemoglobin A1C level, which tells us how the sugar has been the last 2-3 months. We usually like it below 6.5, but in elderly that can be raised to 8.
HIV patient s in general must have their laboratories monitored periodically, and this group is at higher risk for problems, so we must not postpone the blood tests and watch them closely.
We must be careful to monitor drug doses and interactions in the older patient since they cannot break down or excrete the drugss well as younger people. Mild kidney disease is common and we must adjust the dosages of medications. Older people are many times on multiple medications so we must be vigilant to check also for interactions. This can be very tricky. For example a lower cost generic for high cholesterol, simvastatin, the blood levels can go sky high and cause terrible side effects when combined with a family of antivirals. The HMOs love this medication since its cost is so low.
Hypertension is very common as we get older and we must pay close attention to diagnosing it and treating it. Avoiding too much salt, eating 5 portions of fruits and vegetables a day, and getting sweaty or breathing hard for 15-30 minutes a day is great prevention of hypertension and great for health overall.
Cancer of the rectum and anus is more common in HIV patients so a yearly rectal exam is recommended. Some are doing pap smears of the anus as we do in the cervix of women (they should have a pap smear once a year; we can’t let them rest for 3 years as we do with HIV negatives.) Remember that HPV, viral warts cause the cancer, may not be seen or felt by you, and transmit outside the condom protection area as does herpes and syphilis.
We should double check that the older patient is up to date on the recommended vaccines.
Safe sex (condoms) should be discussed at each visit as with the younger, but vaginal dryness and poor erections are common in the older patients and we have medications for these. If the vagina is dry, then it can be irritated during sex, causing better HIV transmission. We know that having an undetectable viral load lowers the risk of transmission and that a condom is a good backup since transmission is still possible. Likewise, we tell younger females that they need a condom and a backup method of birth control since there are failures of each method at times.
Osteoporosis (weakening bones) is more common in older patients and in HIV so a double risk is present. It is recommended to screen for this and check vitamin D levels.
The older we get, the closer to dying we are. It is inescapable. Younger people could have a tragedy so this applies to them too. Don’t avoid this. Please schedule a meeting soon with those whom you love this Valentine’s Day. This shows you love someone. It is a great favor to yourself and your loved ones to make out a:
A Will, so that all know where your valuables are going when you die.
A durable power of attorney for health care letter so that all know who the spokesperson is when you are unable to speak or think well, and with whom you have discussed your end-of-life issues and health goals with.
A living will: this has wording on the document that will help you express how you would want to be treated for severe problems. Of course it can’t predict all future events, but it helps your loved ones to know how aggressive you want to be, e.g. do you want to be a vegetable in a nursing home for years, with a diaper on and a feeding tube in your stomach, while you stare at the wall. This happens frequently since the patient put off the work needed to prevent it. Take a walk through a nursing home someday. Better yet, walk through one that has many people on breathing machines. Many of them didn’t do the paperwork and would rather not be there, but are now unable to express this.
Mental changes should be looked for whether it is from substance abuse, confusion, depression, or anxiety. Older people can slip into one of these and suffer more when it is unrecognized.
Well, that was pleasant! We must talk about this since it is unavoidable. Be mature, express that higher love.
Daniel Pearce, D.O., FACOI, AAHIVS
Associate Clinical Professor of Internal Medicine, Loma Linda University
HIV Specialist, Riverside County Public Health Department