AIDS May Escape Diagnosis in Older People
by Joyce Baldwin
| Geriatric Times |
 |
January/February 2001 |
|
Vol. II |
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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."