Our next speaker is Dr. Howell.

Dr. Howell is an assistant

professor of medicine and

also a geriatrician.

She joined us in

community internal medicine last

year. And she comes from a very

prestigious background.

She trained at Harvard for

undergrad. She went to

residency and Yale

trained at Mt.

Sinai for her geriatric fellowship.

And we're very, very excited to

have her join staff.

She has a special interest in

HIV and aging,

and that's most of her research

interest.

She has worked in an all over the

world in Uganda and Thailand

to provide geriatric care to

HIV infected patients.

And today she will be sharing with

us her expertise in HIV

in the elderly.

Thank you, Dr. Hall.

Hi, everybody.

Thank you so much for joining me

today.

So imagine you at a

nursing home today and you're seeing

a patient for a post hospital

discharge follow up.

And this guy, he's a 67

year old male and he has dementia

and HIV.

And then the nurses are calling you

because he is refusing bloodwork.

Said you looked in the title a

little more and you saw that he did

the same thing in the hospital as

well.

And psychiatrist saw him and said

that he does not have capacity.

But they caution you that the

sister, who is a health care proxy

that was designated, does not

know that he has HIV.

So at this point, you're pulling

your hand a little bit and mumbling

to yourself, what am I supposed to

do with this guy?

So quick show of hands, who would

tell the sister that the patient

has HIV?

Off your hands there.

Who would not tell the sister

that the patient has HIV?

All right. Who who doesn't

know?

I'm not sure.

Depends on what happens.

All right.

Well, as a citizen

who have worked with HIV patients in

the past, I hope to share with you

over the next half hour or so how we

can approach this patient.

We say have financial disclosure

to report, but I don't have any.

All right.

So first, we can start with

looking at what the world looks like

now that we have antiretroviral

therapy art, and then we

going to talk about what we're going

to do.

So before

art became available,

are HIV patients look like

the guy on the left?

And that is Freddie Mercury.

He is the least in girl queen.

He was diagnosed with HIV in 1987,

and then he died soon after in 1991,

very quickly.

But now that art became available in

1996, our patients

dress look like the guy on the

right.

And that is Greg Louganis.

He's the American Olympic diver.

He was diagnosed in 1988

and he made it to 1996

when art became available.

And now he's 58 years old.

And he's probably stronger and much

fairer than I am.

But this is what our HIV

patients are going to start to look

like. They're going to age into

their 60s, 70s and 80s.

And if you have not come across

with one, the odds

are that you're going to start

seeing more and more of them because

the soldiers, an army, does not

apply only to the uninfected

patients.

They also apply to the HIV patients.

So let's start off with some

questions

based on the most recent CDC

HIV surveillance report in 2016.

Which of the following is true

regarding HIV in the post art

era?

All right.

So the correct answer is

C. And we're going to go

over the answers a little bit here.

So new infections are

really common in older adults,

as high as 17 percent.

So all people, tolis, still have

sex.

The largest increase in rates of

people living with HIV

was among older people,

people over 65 years old.

And that increase was 57

percent, which is very high.

Persons aged 50 to 54

years made up the largest percentage

of people living with HIV in

the U.S. at this time, which is 18

percent. So the correct answer is C.

So now that we have art,

mortality has decreased

significantly and

we have huge life expectancy

gain where death is no

longer imminent.

And most of the time is not from HIV

anymore.

What we have is more and more older

HIV patients who would die from

something else.

And the number one cause

right now is actually cardiovascular

disease.

And by 2015,

more than half of the patients

with HIV in the U.S.

were over 50 years old.

We also find that in the post

art era, HIV patients

have increased morbidity.

And this is probably from two main

reasons.

The first one is that on Parbo,

the traditional risk factors for

chronic conditions, HIV

patients have additional

HIV related risk factors.

There is also a theory that

chronic HIV infection can

cause either accelerated

or accentuated aging.

But both these two reasons combined

to result in what we call

multi morbidity, where

patients have multiple chronic

conditions that don't just co-exist

next to one another, but there

interact to make each other worse.

So what other traditional risk

factors among HIV patients that

we see?

A lot of them will have will have

had exposure to smoking,

alcohol or substance abuse,

but they also may have confection

with hepatitis C, which causes

an independent neurotoxic

effect on the brain.

And this is through

pro inflammatory cytokines that are

released by the hepatitis C core

protein.

It also has an independent

fracture risk on top of the

HIV and the system modulation

of the calcio terpene and the

gonadotropin hormone levels

in weight loss that results

from hepatitis C also contribute

to osteoporosis.

Now, your question to which

of the following is incorrect?

Regarding increased morbidity

from HIV related risk factors.

See what people say.

Yep, the correct answer is

a..

So we find that in patients

who are excellently suppressed

with zero viral load and

Excellency's, for they're still

sicker than people who don't have

HIV.

And we'll talk about why.

So on top of the traditional

risk factors that HIV

related risk factors

increase morbidity in HIV patients

and the first risk factor being

living for a long time with

chronic HIV infection,

we find that despite

excellent viral control, patients

still has chronic Tiso activation

that increased production approved

inflammatory cytokines.

And this low line for

inflammation causes multiple

and organ damage, including

increased risk for cardiovascular

disease.

Living with art for a long time

also has long term side effects

in people who have AIDS with HIV

over the years were exposed to all

those generations of art that are

not as good as the ones that we have

now.

For example, the older version

of Tarnoff Evere called T.D.

F, which stands for Turn-off

of Year, dies. Approx of human rate

has been shown to increase risk of

renal disease.

And so also there is a questionable

risk of osteoporosis as well.

Studies have shown that TGF

caused an initial but modest

decrease in bone density loss,

that thens as plateau's out.

So then we're not really sure how

much of an effect it has on the

actual fracture risk.

But there's a new version of Tarnoff

of the Air now called TAF

are turned off of the and amide,

which is less likely to cause

renal disease, osteoporosis.

So that's that's enough of year of

choice at this point.

There's also a question that a Black

Caviar may cause heart disease.

Multiple studies have shown

correlations.

But one large mirror analysis

did not find any link.

So there is still a debate there.

But most HIV providers will try

to avoid a bacteria.

They can if there's any risk of

heart disease.

Protease inhibitors are also

notorious at causing fat

redistribution, a condition

that we call I poor dystrophy.

And this increases 10 year high risk

for the patient as well.

Israeli patients are also likely

to be exposed to other

HIV related medications

that are used for opportunistic

infection or prevention.

For example, we found that Phos

Kurnit or contamination can cause

lower calcium level and

Kitto Kommissar can accelerate bone

loss as well.

The other reason why

older HIV patients may have

increased morbidity is

that we think that chronic HIV

infection can cause either

accelerated or accentuated

aging.

And what extend the

accelerator easing means is that

you have the same frequency of

disease. It is occurs earlier

in the age spectrum.

And you may see HIV

patients who are 55

years old on paper, but they look 70

years old.

So that's what accelerated aging may

look like.

Accentuated aging means that

the diseases happen at the same

age. But more often.

And right now, there's still a

debate back and forth about which

one is happening.

And it might be it might depend on

what diseases you're talking about.

But either way and Rizzle

wish we see that

HIV patients are more likely

to have more time morbidity.

If you look at this graph, you will

see that compared to the

uninfected patients,

HIV patients are more likely to have

more diseases.

If we say just focus on

the 65 plus age group,

you will see that there are just

higher proportions of HIV patients

with more than three diseases

compared to people who don't have

HIV.

So how do we help this

emerging and vulnerable population?

Let's go back to our patient case.

We're going to call him Mister.

Ah, he's sixty seven years

old. He has HIV and

he is on art.

He's in your nursing home today

after coming out of hospital.

He has a history of squamous

cell carcinoma of the lung.

And he was at home before he

went to the nursing home.

He had his last session

of radiation therapy

and he was just declining at home.

So much so that he was not

able to go through any more

surveillance imaging.

And they decided that they're not

going to pursue treatment for

squamous cell carcinoma of the lung

anymore.

While he was trying to recuperate at

home, he had pneumonia and he

had to go to hospital.

So in the hospital,

he was just getting our antibiotics

only because he consistently

refused I.V.

medications.

He refused other types of Keres as

well. But not consistently.

So they call psychiatrist to come

see him.

And they said that he had no

capacity because

he was inconsistent

and he was not able to provide

logical reasons why he does not

want some of these care.

They picked a sister who's the next

of kin as a health care proxy.

But of course, in the documentation,

they don't tell you why they picked

the sister or how that happened.

But you notice when you know the

sisters in the room with the patient

that they have difficult

relationship and they don't get

along very well.

And the note told you

that the sister does not know that

the patient has HIV.

Now, Mr Ares refusing blood work.

You have to deal with him.

So what are we supposed to do?

While we step back a little bit,

Mr. Ah is a lot like

our patients.

He has more morbidity

like our orders, geriatric patients.

He's medically complex.

He has deficits and function and

cognition.

He's vulnerable with many

psychosocial stressors.

Mr. Aziz has

family dynamics that we're dealing

with right now.

But a lot of other older HIV

patients will have other things

going on, like they may have

had HIV

related stigma that cause

social isolation,

that results in limited

family support, network support.

He may have limited access to

insurance or resources.

And there's a lot of mistrust and

fear regarding breach of

confidentiality with HIV

status for these patients

and most likely Mr. Ah

can benefit from comprehensive

patients and care and

multidisciplinary team the same

way that our geriatric patients can.

So how do we approach Mr. Ah.

Well, I think the first

step would be to figure out if we

can reverse this cognitive

impairment and if we can

then we can figure out who we need

to talk to about his goals of care.

In terms of cognitive impairment for

HIV patients,

the causes include the usual

culprits that the uninfected

patients would have.

They can have Alzheimer's or

vascular dementia.

They're not immune to these.

But there are also additional causes

that you need to look at.

And these include HIV related

secondary causes like lymphoma

or infection in the brain.

And the HIV virus can also

cause direct damage to their brain

tissue.

And that condition is called HIV

Associated Neurocognitive

Disorder or hand.

And interestingly, hand is

reversible.

Right, we'll try. Question three

now.

Every HIV infected patient

with cognitive impairment should get

all of the following.

Except what?

Huh? OK.

Lumbar puncture.

Well, the correct

answer is D.

Neuropsych testing.

And we don't really

recommend neuropsych testing

because it can be

time consuming, costly,

stressful to the patient,

and it may not add much more

than testing that you can do in

office, which will talk about.

So the work up that you would do

for HIV infected patients

who have cognitive impairment would

include the things that you would do

for the uninfected patients.

And those are things like making

sure they don't have V12 or folate

deficiency, checking their

electrolytes, checking their

thyroid, rule out depression.

And you can use appears Kunai or

the geriatric depression

scale at a G.D.

s.

But in contrast to

work out for the uninfected

patients, the two things that

you absolutely must do is

lumbar puncture to rule out

infection in the brain

and also the brain MRI to look for

lymphoma or abscess.

Interestingly,

the features of hand that you

may see on the MRI

include atrophy

of the basal ganglia in the frontal

white matter.

But this is not specific

or sensitive.

Are there things you should do is to

rule out for neurosyphilis and

then screen for hepatitis C?

Because, like we mentioned, that has

independent neurotoxic effect on

top of the HIV.

The other ways that you can

maybe distinguish Han from other

dementia is to look for certain

clinical features.

And there are three types that you

can look at.

The first one is mood disturbances.

And then they're motor symptoms and

cognitive deficits.

The mood disturbance symptoms are

separated into depressed

symptoms or activated symptoms.

Depressed symptoms include things

like apathy, lethargy,

loss of sexual drive, and

he donia activated

symptoms include irritability,

insomnia, weight loss,

restlessness and anxiety.

These symptoms can progress to

psychosis, where a patient has

paranoid ideation and

hallucinations.

And these symptoms can be an early

manifestation of the

more severe form of hand,

which is called HIV associated

dementia.

Or had you

can just distinguish these symptoms

from depression by noticing that

patients with hand usually would not

have lack of would not have sadness

or crying spells.

The motor symptoms that patients

with hand may have include

difficulties with smoothly

movements.

If this happens in the low

extremity, they might have unsteady

gait.

If this happened in the upper

extremity with fine motor movement

such as Tremor, Brady, Conesa

or Destry data cocaine easier,

it might result in limited activity

of daily loving's like they may

not be able to eat soup or comb

their hair.

They may also have abnormal reflexes

as well, where they're either hyper

reflex sick or they have abnormal

front or release signs.

And these are things like grass

reflex where if you put a finger

in their palm, they're going to try

to grab it, or the snout reflex

where you tap the middle of their

lip. They're going to pout

or the global a reflex where

you tap the middle of their four.

They won't be able to resist

blinking.

The cognitive deficit features that

can help distinguish hand from,

say, Alzheimer's.

Is that Hanwood have memory

loss and executive dysfunction.

But they usually would not have

higher cortical dysfunction,

like they would not have a fascia

agnosia or a apraxia.

And the other important thing is

that hand can fluctuate and is

reversible versus Alzheimer's

usually is not.

Now, there's no consensus on

what

tests would be the best at screening

for hand.

But we should always remember that

in real life, when you see these

patients, you're screening for all

causes of cognitive impairment,

not just hand.

So you want a test that is versatile

and because hand has

features of executive dysfunction.

We don't recommend that you use

the middle mini mental status

exam because it's not very

good at picking up executive

dysfunction.

The neurologist here at Mayle

would recommend that you use a

common test.

Other tests that have been used in

studies in HIV patients include

the Moka. You can use that one as

well.

There's also this test called the

HIV, HIV dementia

scale, which was developed

specifically to pick up the symptoms

and the features that we talked

about prior.

But it may not be as good at

screening for Alzheimer's

or other causes of dementia.

So I would be careful at using

this alone in HIV patients.

If you find that or if you have

a source suspicion that the patient

has hand, the next step

would be to contact the HIV

provider to see if they can start

art. If they're not already on a

regimen, if they already

on a regimen, you could potentially

switch to a regimen that

has higher sea CNS

penetration effectiveness score

or what we call the C.P.E.

score.

And this has been shown to

cost improvement in certain things

like neuropsych testing, score

their speed or processing

their concentration or mental

flexibility.

For Mr. R.

He was already on art with high

CNS penetration,

and he also had a very specific.

Resistance resistance pattern

that prevented us from

switching his art.

So.

What should we do with him next?

Well, right now, we need to approach

the goals of care discussion

and Mr. Archer has some of these

challenges.

But the common issues that we run

into with older HIV patients

is that the people that

they trust are usually

not legally or socially

recognized.

It could be their same sex partners

or friend with HIV.

Now, the family members who

are usually legally recognized

as the next of kin

may have been straight estranged

from the patient.

They may not have talked to the

patient for a while and they may not

know what the patient would want in

these cases anymore.

And a lot of them don't even

know that the patient has HIV.

So it can be really challenging.

Other issues that

add to the problem is that

it's difficult to

prognosticate in this population

because this is an emerging

population. There's a lot that we

don't know about what happens

in older HIV patients.

The other problem also is that

HIV tend to occur in

vulnerable population, people

who are non-white, people with

mental illness or substance users,

and they may have low health

literacy or high mistrust that make

goals of care discussion

challenging.

For Mr. R, it was very

challenging for us as well.

What happened is that.

The sisters really against anything

that's related to hospice,

so she won't let us use any morphine

or opiate or anything like that.

Luckily, Mr. R has been

taking out a van throughout his life

for anxiety.

So we were able to continue that.

And as he declined, he became really

sensitive to Adriano that we didn't

need to use much to calm him down.

And the sister wants us to

basically do everything.

And what that means is, you know,

checking his INR and giving him

Coumadin until the day he died.

But if

you guys remember anything from

this talk today, I hope that

you remember these next three

points.

HIV patients who are older

has increased small time morbidity.

They're similar to geriatric

patients in any way.

And they can benefit from what we

do. Best wishes, multidisciplinary

and patient centered care.