A long and lonely walk of an elderly

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					A long and lonely walk of an

    WK Wong/KY Sha
    Inter-hospital Geriatric Meeting
   Madam C
   69 year old
   Lives alone in a public housing estate in Lam
   One daughter , lives in Shatin, calls patient
    every month, financially supports
   ADL independent , walk unaided
   Retired secondary school teacher
           Poor social support
   Born and grown up in Shanghai
   Came to Hong Kong 5 years ago, after
    husband’s death
   Husband died of pneumonia in Shanghai in
   No other relative nor close friend in Hong
   Hypertension for 2 years
       FU GOPD on Metoprolol
   Epigastric pain with OGD 1.2010
       HP –ve gastritis, normal esophagus
   R herpes zoster ophthalmicus 3.2010
       Given oral and gutt acyclovir
       CBP LRFT normal
              Admitted 29.7.2010
   Attended AED alone
   Complained of non-exertional chest pain for 1
    week, precipitated by meals
   Also odynophagia, malaise, loss of appetite,
    weight loss of 5 kg within 2 months (50 ->45kg)
   Fell in toilet
   Odd behavior in ward
       Sit on the chair/bed of co-patient, mutter to herself
       Speak loudly and yell sometimes
       Not confused
   No dysphagia / no symptom of GIB / no change
    of bowel habit
   No fever / no rash / no flu-like symptom
   No muscle weakness / no numbness
   Denies delusion / hallucination

   Daughter only noticed patient ‘talked slowly’
    and complained of ‘tiredness’ in recent 2
       No other abnormality noted in telephone
          Physical examination
   Afebrile
   BMI 16 kg/m2
   Hstix 4.2 mmol/L
   GCS 15, orientated and coherent speech
   Neck soft, Kernig’s sign negative
   Diffuse and severe oral thrush
   No lymph node palpable
   Chest / CVS / abdominal exam : normal
            CNS examination
   walk freehanded, normal gait but rather
    slow pace
   Cranial nerves intact, no dysphasia
   4 limbs proximal and distal power full
   Sensation (light touch, pin prick,
    proprioception) intact
   Tone and reflex normal, Babinski negative
   No cerebellar sign
                   Cognition test
   MMSE 23
       Orientation 9/10
       Registration 3/3
       Attention and calculation 1/5
       Recall 3/3
       Language 7/9 , failed to follow a steps in ‘3-
        staged command ‘and ‘copy a polygon’
   Oral candidiasis with odynophagia and weight
   mild cognitive impairment

   ?Ca esophagus
   ?HIV infection

   Investigations to look for any GI malignancy
    and rule out HIV infection
           Baseline investigations
   Normal WBC and hemoglobin
       WBC differential count normal
       Lymphocyte 1.3 x 10^9/ L
   LRFT Calcium normal
   TSH / vitamin B12/ folate level normal
   CXR clear
   Throat swab : Candida albicans
   Esophageal ulcer
   Histology
      viral inclusions seen

      Immuno-histochemical stain for CMV reveals positivity

      Cytomegalovirus (CMV) infection
                   HIV serology
   Anti-HIV antibody positive
   Confirmed by Western blot assay

   Syphilis serology negative
   HBsAg / anti- HCV negative

   Blood for Cryptococcus Ag
                    CT brain
Multiple cerebral infarcts
                  MRI brain
   No brain SOL seen
   Old lacunar infarcts in the right caudate
    nucleus and bilateral corona radiator
               Lumbar Puncture
   CSF clear and colorless
       WCC 1 / mm^3
       Protein 339 mg/L
       Glucose 3.8 mmol/L
   PCR for MTB complex negative
   No crytococcus seen
   Newly diagnosed AIDS in a 69 year old lady
   AIDS defining illnesses
       Oral candidiasis
       CMV infection
       HIV-associated mild neurocognitive disorder
        (MND)(HIV associated dementia)
             Transmission route?
   No history of sexually transmitted disease
   From husband ?
       Husband was the only sexual partner

   No history of major operation nor blood
   Denies any illicit intravenous drug use
 Started Cotrimoxazole
    Prophylaxis against opportunistic infections

 Valganciclovir

    CMV infection

 Fluconazole

    Candidiasis

 Referred Kowloon Bay

 Integrated Treatment Centre
                     Care plan
   Explained to patient about the diagnosis
   calm
   She keeps the diagnosis confidential to her
       Worried that daughter will evade her
   Decreased self care ability, prefers aged
    home placement
Social worker contacted OAH that patient chose
       Refused by several OAH
                      Care plan
   She was then discharged home
   Home care service arranged for meals and house
      volunteers (for escorting clinic follow up) from

       home care service said their appointment was
      Arranged volunteer from the Hong Kong Aids

       Foundation 伙伴義工
AIDS in Elderly
Increasing number of elderly living with HIV

  1.   Introduction of HAART in 1996 leads to a
       longer survival of HIV-infected patients
  2.   Increased HIV risk behaviors in older
          New infections

      Encounter greater numbers of older people
       living with HIV in clinical practice
                                   Data in USA
   From Center for Disease Control and
       In 2005, 15% of new HIV diagnoses
       24% of the entire HIV population across 33
        states are made up of people aged > 50
       8% increase in prevalence from 2001
       Underestimated, low rates of testing in this age
       mainly sexual transmission                    CDC
        Surveillance Report 2005
                  Aged > 50

 A ‘neglected’ diagnosis in elderly
  Lack of HIV                                  Health care
   prevention           Elderly not         workers are not
campaigns that                             alert about this
                       themselves at
   target the              risk               diagnosis in
     elderly                                     elderly

                 Delayed HIV testing

 Diagnosed only made
 at later stage (CD4                  Increased risk of
 <200/mm3)                         transmission to others
   Many elderly lead sexually active lives now
2010年 09月 09日 08:53 中國窗 香港商報
HIV risk behavior in elderly
    Introduction of potency drugs has extended the sex
     lives of males
    71% of men and 51% of women aged >60 continue
     to engage in sexual activity    Zablotsky J Acquir Immune Defic Syndr 2003

        Only a small minority of people aged >70 consistently
         use condoms Leigh Am J Public Health 1993
        Elderly not use it as contraception
    Post-menopausal women are especially at risk
     because of atropic vaginitis
        Tears in the vaginal wall
Other risk factors

   IV drug abuser accounts for about 16% of
    AIDS cases in those aged >50Linsk AIDS Reader 2000

   Blood transfusion prior to 1985
                     Clinical features
   Similar to those in younger patients

   Symptoms of AIDS may mimic diseases that
    are common in geriatric patients
       Weight loss, fatigue and anorexia
       Pneumocystis Jirovecii Pneumonia
          Insidious onset of SOB, not always with fever

       HIV-associated dementia
            age is a significant risk factor
Antiretroviral therapy in elderly
 Highly active antiretroviral therapies
 antiretroviral therapy (ART)

 Current guidelines recommend starting

   HARRT if
         1. AIDS diagnosis
         2. CD4 < 200

         3. Consider in patient with CD4 201 to 350

        No age specific difference in treatment regimen
        2008 guidelines for the treatment of HIV/AIDS of Dept of health and
        Human Services
                 Before HAART
   In the pre-HAART era (before 1996)
       Following HIV sero-conversion
       Patients aged >50 had a more rapid progression
        towards AIDS
          Shorter survival Goedert NEJM 1989
              Now, with HARRT
   Is elderly responding badly and having a
    lower survival rate?
                      Aging process
   Immunosenescence
      Less robust CD4 T-cell recovery

   T cell dysfunction
       Decreased production of IL-2 and IL-2 receptors
       Thymus involution
   Gastrointestinal immunity declines
       CD4 cells in the gut-associated lymphoid tissue
        (GALT) do not reconstitute
   Delayed immune reconstitution
     Baker J Acquir Immune Defic Syndr 2008
EuroSida cohort              Younger patients attain a CD4
Viard                        count >200 in a short time
J infect Dis 2001            period than the older

French prospective cohort    Rate of virologic suppression
Grabar                       better in the older (viral load
AIDS 2004                    <500 copies /ml)
                             Younger patients has faster
                             CD4 cell reconstitution
Italy prospective case       No difference in virologic and
control                      immunologic outcomes
Tumbarello                   based on age (>50 vs <50) in
BMC Infect Dis 2004          response to HARRT
                             Parallel profiles in terms of
Spanish prospective cohort
                             increased in CD4 counts and
                             reduction in viral load in >
BMC Infect Dis 2006
                             50 and <50 age group
1.   Limited data
        Elderly are often excluded from trials
        Few subgroup analysis in older patients
        no specific recommendations on the use of
         antiretroviral therapy in elderly
2.   Elderly subjects are often in later stage of
     disease in many of the studies
        delayed diagnosis in elderly patients
        lower CD4 counts
        higher plasma viral load
                 Shorter survival
   Overall, higher mortality and shorter
       Higher risk of clinical progression to AIDS
       Often from non-HIV causes
       Drug toxicities and interactions with drugs used
        for other conditions are more common in
                   Treatment safety
   Age-related decrease in renal and hepatic
   Together with co-morbidities, e.g. heart
    failure, liver cirrhosis
       Higher chance of drug toxicity and side effects
       e.g. Zidovudine in renal impairment
   Drug interactions
       e.g. Amiodarone with Kaletra
            Increased levels of anti-arrhythmics
       Warfarin with Ritonavir
            Increase warfarin level
CDC. HIV/AIDS Surveillance Reports, 2007
Social services for elderly with
HIV / AIDS - notoriously stigmatizing in HK

   Especially in elderly patients
   Hong Kong Council of Social Service (HKCSS)
    conducted a Knowledge, Attitudes, Behaviors and
    Practice (KABP) Study on AIDS among Social Welfare
    Personnel in Hong Kong, 2001
      ……從事「安老服務」人士,40.4%認同「我認為

   Hostel/ residential care for AIDS clients with self
    care deficit is nonexistent
   http://www.swd.gov.hk/tc/index/site_pubsvc/page_elderly/sub_resid
   入住條件
    (1) 年齡達65歲或以上*﹔ (2) 透過「安老服務統一評估機制」被評為適合入
    住護理安老院﹔ (3) 健康欠佳﹐或身體機能喪失或衰退﹐以致在個人照顧及
    起居活動方面需要別人提供協助﹔ (4) 可利用步行輔助器或輪椅走動﹔ (5) 沒
    有家屬可以提供必需的協助﹐或是照顧長者為家人帶來很大壓力﹔以及 (6)

   Private OAH can reject any case based on ‘Business
               In other countries
   Nursing homes / care homes catered for
    people with AIDS / HIV are available
   e.g. in UK
       Located in different parts of UK
       search by http://www.carehome.co.uk
       950 matches
       21 available in London area
       Self funding or entitled to State assistance
In New York, USA
   AIDS Home Care Program
       Part of the Long Term Home Health Care Program
       Joint program with Dept of Social Services and
        DSFHS (Dominican Sisters Family Health Service)
       frail elderly with HIV/AIDS can be maintained at
        home with appropriate services over a period of
       ‘Nursing Home Without Walls’
       Maintains persons at home at 75% of the cost of an
        area nursing home
       Skilled Nursing /Case Management /Physical, Speech and
        Occupational Therapies /Home Health Aides /Personal Care
        Aides/ Homemaking/Pastoral Care /Personal Emergency
        Response System /Social Adult Day Care /Home Delivered
        Meals /Home Maintenance/ Respite Care /Audiology
        /Respiratory Therapy
In Delaware, USA                             http://www.dhss.delaware.gov/dhss/dmma/

   AIDS/HIV Home and Community-Based Waiver
   enables individuals with HIV/AIDS to remain in the
   receive all regular Medicaid services and also
    additional Waiver services that Medicaid does not
   Case Management – helps to determine what services he needs
   Homemaker Services – bathing and dressing, light housekeeping and laundry.
   Respite Care - aide come to his home to take care of him for short periods of
    time when his primary caregiver has to be away from the home.
   Mental Health Services - receiving appropriate psychiatric and substance
    abuse treatment services.
   Supplemental Nutrition - ensure proper treatment in individuals
    experiencing weight loss, wasting, malabsorption and malnutrition.
In Ontario, Canada
   Ontario Ministry of Health and Long-Term Care
    funded programs
   Supportive housing for people with HIV/AIDS
       programs that provide volunteer-based in-home
        hospice care
       for people with HIV who have mental health concerns
   Casey House
       residence
       home hospice program for people with HIV/AIDS at the
        end stages of their lives
       medical and nursing care, counseling, nutrition,
        massage therapy and other services
                 Home care services
   Guideline targets for home helpers on
    caring for HIV infected patients is available
   Some organizations also provide home care

       nursing service similar to CNS
   Ride Concern, a free transportation service
    provided by AIDS Concern關懷愛滋
     Undeniably, it is not enough
   We will see more and more elderly living
    with HIV
   Failing to diagnose and thus deferring
    treatment is common
   A special group of HIV/AIDS patient that
    need special attention for their medical
    treatment and long term care
   She moved into OAH in HK Island with the
    help of social worker and with her diagnosis
    kept confidential to OAH
   Started ART
       Kaletra 200/50
       Lamivudine
       Stavudine
   Quite certain that elderly has a better
   Several studies suggested elder patients are
    more adherent to the treatment
       Wellons J Am Geriatr Soc 2002
       Wutoh J Natl med Assoc 2001
       Wutoh J Acquir Immune Defic Syndr 2003
       Silverberg Arch intern Med 2007
         HIV- associated dementia
   Increasing age is a significant risk factor for
       Odds of having HIV-associated dementia in the
        older age group was 3x higher than younger age
        group Valcour Neurology 2004
   Subcortical dementia
       Memory deficit and psychomotor slowing
       Gait disturbance is common
       Often accompanied by myelopathy and
                              Funeral service
   Refusal based on ‘business ground’ is common
   Complaint of such has not been made to
    relevant organization e.g., Equal Opportunities
        difficult for family of the deceased to do so during
         the acute stage of bereavement
   On telephone surveillance to 12 parlours, 4
    rejected to provide services to PLHA
   Some may pose a higher charge
    Review on Social and Support Services to People with HIV/AIDS in Hong Kong   July 2006, Hong Kong
    Advisory Council on AIDS
        Cardiovascular risk factors
   Already higher prevalence of cardiovascular
    risk factors in elderly patients
   HIV-related disorder of DM, lipodystrophy,
    and dyslipidaemia
       From toxicities of antiretroviral therapies,
        especially protease inhibitors
       Or from endothelial disruption from the virus
Perez, JL, Moore, DR. Greater effect of highly active antiretroviral therapy the survival rate
No statistically significant differences in on survival in people aged 50 years compared
Perez. Clin Infect Dis 2003
               with younger people in an urban observational cohort. Clin Infect Dis 2003; 36:212.

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