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AIDS May Escape Diagnosis in Older People

by Joyce Baldwin

Geriatric Times January/February 2001 Vol. II Issue 1

Of the AIDS-infected population, 10.4% are over 50 years old, yet health care professionals may not consider an HIV/AIDS diagnosis when examining an older patient. What's more, it may be difficult to determine if dementia is HIV-related or a sign of Alzheimer's disease (AD) and to discern that an infection is an opportunistic one linked to HIV, not an unrelated condition such as pneumonia or herpes zoster.

Experts believe AIDS might be misdiagnosed or underdiagnosed in elderly patients, perhaps because stereotypical thinking perpetuates the myth that seniors are not sexually active.

"If an older person presents with fatigue or illness, the symptoms are often attributed to age-related changes rather than indications of a sexually transmitted disease," Marcia Ory, Ph.D., M.P.H., told Geriatric Times. "The person who presents may have no idea they're infected [with HIV], and the health care provider looks at a 65-year-old woman, maybe a 70-year-old man, and they think of everything else before they think: Could this be a case of HIV/AIDS?"

"The assumption is that health care providers look at somebody 75 and don't think sex and don't think drugs," said Ory, chief of behavioral medicine and public health at the National Institute on Aging (NIA) of the National Institutes of Health. Although in most cases they are right, Ory said that clinicians would be surprised at what they would find out about some of their patients if they did an assessment.

In an interview with GT, Bradley S. Bender, M.D., noted the lack of research regarding HIV/AIDS and seniors, "I think [it] is a common notion to say that [HIV/AIDS] is misdiagnosed more frequently in older persons, but I don't think there are a lot of data that support it." Bender is professor of medicine at the Department of Veterans Affairs Medical Center in Gainesville, Fla.

While working in a nursing home, Katie Wooten-Bielski, M.S.N., C.R.N.P., noted that, although some people had infections such as herpes zoster, "no one ever addressed sexuality in older adults or the possibility of HIV infection in any of our patients." Wooten-Bielski, a lecturer at the University of Pennsylvania School of Nursing, believes it is important to "be open to the possibility that even an older person could have an infection that could have been sexually acquired." She reported in Geriatric Nursing (1999;20[5]) that older people with HIV may be mistakenly diagnosed with other conditions. She told GT that Pneumocystis carinii pneumonia, shingles, herpes zoster, tuberculosis, cytomegalovirus, oral thrush and dementia may all be HIV-related.

Another factor contributing to under-diagnosis is that older people are more likely to get diseases such as disseminated tuberculosis and lymphoma that mimic opportunistic infections, Merle A. Sande, M.D., told GT. "Therefore, the medical team may be less likely to think of these progressive lung diseases as being associated with AIDS. Just because older people get more things, and AIDS is not high on their radar screen, they're not going to think about [it], and they may make misdiagnoses."

In "AIDS and the Elderly," an article in Clinical Infectious Diseases (1999;28[4]:740-745), Chiao et al. stated:

Several case studies illustrate that older patients with AIDS who present with symptoms of opportunistic infection often undergo the workup and treatment for other disease processes such as cerebrovascular disease, Alzheimer's disease, bacterial or viral pneumonia, malnutrition, and occult malignancy. Thus, symptoms that would suggest HIV/AIDS in a younger patient may be overlooked in the older patient and, therefore, the diagnosis of an HIV infection is made late in the course of disease.

Sande, co-author of the article and chair of the department of internal medicine at the University of Utah in Salt Lake City, told GT that determining whether a patient has AD- or HIV-related dementia is sometimes a difficult distinction to make. Sande and his co-authors found that HIV-related dementia is associated with subacute encephalitis; progresses more rapidly than AD dementia; is more often associated with peripheral neuropathies, myelopathies, weight loss and fatigue; may show mildly elevated protein levels in the cerebrospinal fluid; and often may improve with administration of antiretroviral therapy.

The most prevalent mode of transmission of HIV in the senior population is now through sexual intercourse, not through contaminated blood products. (In 1996, only 2.4% of AIDS patients =50 years of age reported receipt of blood or blood products as the mode of transmission [Chiao et al., 1999]-Ed.) Yet, no longer concerned about contraception and not thinking of themselves as at risk for developing AIDS, the over-50 segment of the population is much less likely to use condoms or to seek HIV testing than are their younger counterparts. Of infected seniors, 84% are male; the largest exposure categories are men who have sex with men (36%), followed by no risk reported (26%), injection drug use (19%) and heterosexual contact (15%).

NIA's Ory said that a 60-year-old may need the same safe sex message and the same "be careful about drugs" message as a younger person. Commenting on the need to educate seniors and their health care providers, she told GT, "Most of the prevention messages are not targeted toward the middle-aged and older person at risk. They are not even targeted toward health care providers to understand that these people can be at risk.

"It is true that this population is engaging in less risky behavior, but I think the key is that those who are engaging in risky behaviors are just as likely, if exposed to the virus-and in some cases maybe even more likely-to be infected. So if you engage in risky behaviors, just because you are 65 doesn't mean you aren't going to get AIDS."

Stressing the need to broach the subject of HIV infection with patients during a routine visit, Wooten-Bielski told GT that health care workers should not make the topic taboo, but should approach the discussion very matter-of-factly, as part of a normal health history.

The importance of introducing the subject of HIV infection is underscored by statistics indicating that AIDS is a greater health concern for people over 50 than for youngsters. "There is a lot of emphasis on pediatric HIV; but, at least in the United States, there are at least 10 times as many seniors with HIV as there are children with the infection," said Bender. "Numbers alone do not tell the whole story, however. A 2-year-old with AIDS seems much more tragic than a 62-year-old with AIDS, but it still doesn't mean that the 62-year-old with AIDS doesn't require attention and care."

In "AIDS in Older Persons," a chapter in The Medical Management of AIDS, 6th ed. (1999; W.B. Saunders), Bender described a 66-year-old male who had experienced a 25 lb. weight loss and chronic diarrhea; was admitted and discharged from the hospital twice in a three-month period; then readmitted within several days for dehydration. It was only on the third admission that an infectious disease physician was consulted, and a recommended HIV test was found to be positive.

Bender told GT that the patient was a widower who visited a prostitute monthly and that he was alive and well three years after treatment for HIV was started.

"Old age is not a contraindication to therapy," Bender said. "Old people should be treated the same as younger people and they should be treated with the same drugs." Bender said that currently there are about 15 antiretroviral drugs approved by the U.S. Food and Drug Administration for treatment of HIV. The standard of care is a combination therapy that consists of a cocktail of three or more drugs. This therapy, known as HAART (highly active antiretroviral therapy), is aimed at restoring the effectiveness of the patient's immune system.

Bender said, "As best as we can tell, older people respond as well as younger people in regards to immune reconstitution."

He noted that older people have a more rapid progression of HIV infection, which suggests they might require a more aggressive approach to therapy with earlier use of combination therapies. Bender added, "Drug toxicities and drug interactions are more common in older persons," indicating the need to carefully monitor these patients.

Discussing the impact on an older person of an HIV diagnosis, Ory pointed out that the health care team can provide crucial assistance in helping patients cope.

"Older people who are infected feel very, very isolated and stigmatized," she said, explaining that they are less likely than younger patients to know others with the same condition. "There needs to be special sensitivity," Ory stressed, "because these people often feel as though they have no family support, no social support. Physicians can help patients not feel ashamed and can help them get in a track that is positive and set them up with appropriate networks."