Infection with HIV and subsequent development of AIDS in the population of older adults in the United States needs to be explored in greater depth. Current literature, including research-based investigations of HIV/ AIDS in the elderly population is limited. McCormick and Wood (1992) relate that descriptions and details of AIDS cases in the elderly population are predominantly in the form of case reports in the medical literature.
Reports from the Centers for Disease Control and Prevention (CDC) (1996) reveal that 10% of all AIDS cases reported in the United States are in individuals older than age 50. Table 1 delineates cases of diagnosed AIDS by exposure category in people of this age group. Hinkle (1991) recognizes that there really is no accurate way to assess the extent of HIV infection in this population because the number of infected people cannot be identified accurately. Underreporting is likely to occur, which may discount the total number of elderly people identified. In addition, it is likely that a number of older adults die without ever having been diagnosed as HIV positive.
INCIDENCE OF INFECTION WITH AIDS BY AGE AND EXPOSURE CATEGORY
Many articles and epidemiological data related to AIDS in elderlyindividuals unfortunately combine all individuals age 50 and older in one age category for identification of infection with HIV/ AIDS. The current clustered age ranges for older adults with HIV/AIDS includes: 50 to 54, 55 to 59, 60 to 64, and 65 and older (CDC, 1996). Dividing the age cohort into further separate and distinct categories would help identify the epidemiology, risk factors, disease progression, and symptoms in middle age and older adults.
The purpose of this review of the literature is to increase knowledge and awareness of gerontological nurses related to older adults and HIV/AIDS. The related intent is the potential improvement of the provision of care to older adults with HIV/AIDS. Understanding the unique issues of infection with HIV in the elderly population will allow health care providers to better meet the needs of those who are ill or who may be at risk.
SOURCES OF INFECTION
The sources of infection with the HIV/ AIDS virus need to be identified clearly and delineated for older adults so there is greater awareness among health care providers of potential risk factors and interventions so prevention and control can be implemented more easily. Adler and Nagel (1994) noted that initially older adults with HIV/AIDS most often became infected with the AIDS virus through a tainted blood transfusion. This pattern has changed since 1985 when the blood supply in the United States began to be routinely tested for antibodies to the virus. After mandatory testing began, the number of transfusionacquired AIDS cases began to decline in all age groups.
Schuerman (1994) sutes that sexual contact currently is the leading cause of transmission of the AIDS virus in all age groups except for individuals older than age 65. Research completed by Gordon and Thompson (1995) found that 38% of infected older adults in their study acquired HIV/AIDS through sexual contact, 16% via intravenous drug use, and only 9% from transfusions.
Although research into risk factors for the development of HIV/AIDS has been an important issue for the younger population, very little effort has been focused on identifying risk factors applicable to older adults. It is necessary to identify risk factors for individual age groups because specific interventions are essential to prevent transmission of the virus in various cohorts. A risk factor for older adults, as well as many younger adults, is that they often do not view themselves at risk for developing HIV/AIDS (Nocera, 1997). Specifically, older adults often do not use condoms as a safety measure when engaging in sexual activity because they are past their childbearing years and do not fear the potential of an unwanted of pregnancy (Luggen, 1996). The elderly population also does not consider the potential for acquiring other forms of sexually transmitted diseases routinely (Stall & Catania, 1994). In essence, the majority of older adults do not feel that they can, or will, be affected by HIV/AIDS. They do not see themselves at risk, and they may lack knowledge of the risk factors that make them vulnerable to infection. Stall and Catania (1994) present data from the National AIDS Behavior Surveys conducted between 1990 and 1991 which suggest that high-risk individuals who are older than age 50 are much less likely than individuals of the younger population to employ AIDS prevention strategies.
Wallace, Paauw, and Spach (1993), cite that homosexual or bisexual behavior is the predominant risk factor for infection with HIV in men up to age 70. In older adults who remain sexually active, it cannot be assumed that all sexual relations are heterosexual in nature. Older men who are homosexual or bisexual are much more likely than younger adults to hide their sexual preferences related to the fear of being exposed and the potential stigma associated with the disease (Lavick, 1994). This in itself may be a risk factor related to a potential lack of knowledge of the transmission of the virus during sexual contact.
It is essential to consider that it is not just older homosexual or bisexual men who may be infected with HIV. Heterosexual contact among older adults also is a risk factor that cannot be ignored. Although sexual functioning may diminish as people age, many older adults remain sexually active. Women who are past menopause are at greater risk for developing infection with HIV during intercourse because of thinning of the vaginal mucosa (Hinkle, 1991). Age-related vaginal thinning may lead to increased disruption of the mucosa during sexual activity and, thus, a greater chance of transmission of the virus through this disturbed tissue (Gordon & Thompson, 1995).
Intravenous drug use also may be a factor in the development of HIV/AIDS in the elderly population (Wallace et al., 1993). Transmission of HIV/AIDS occurs via the use of contaminated needles in all age categories (CDC, 1996), although the number of younger adults infected with HIV through contact with used needles is higher than the population of older adults who contract HIV/AIDS via intravenous drug use. The issue remains that older adults can be infected by intravenous drug use and by sharing contaminated needles (Nocera, 1997). Further research is essential to determine specific cohorts of older adults who are at risk for HIV/AIDS related to the use of intravenous drugs.
An additional risk factor specific to older adults is related to age-related decline in immune function (Scura & Whipple, 1990). Thymic involution occurs with aging, which leads to an increase in immature Tlymphocytes. Normal immune responses thus are reduced in older adults. In essence, the functional capacity of the immune system deteriorates with age, and this leads to a greater potential for various types of infections. This is a risk factor for older adults because their immune systems may not be able to combat potential infection with HIV or the resulting opportunistic infections (Hinkle, 1991).
DIAGNOSIS AND PROGRESSION
Older adults often do not obtain testing for HIV unless they are convinced by their own personal physicians that testing may be necessary (Ship, Wolff, & Selik, 1991). The questions then become:
* How many physicians are willing to suggest testing for older adults with identifiable risk factors?
* Do health care providers see the elderly population at risk for developing HIV/AIDS?
If testing is not performed, then the actual incidence of HIV/AIDS in older adults is inaccurate, and older adults who are infected with HIV/AIDS may not be identified.
Diagnosis of HIV/AIDS in the elderly population often is delayed. There is a decreased life expectancy and an increased severity of the disease process after the infection is clinically diagnosed as AIDS (Nocera, 1997). The first dilemma in diagnosis of HIV/AIDS in older adults is that members of the health care team often do not recognize signs and symptoms of HIV/AIDS in the elderly population (Hinkle, 1991). Second, older adults in this society often are not perceived to be at risk for developing AIDS. These obstacles lead to delayed diagnosis and a poorer prognosis for elderly individuals infected with HIV. ElSadr and Gettler (1995) relate that serovprevalence studies have been targeted mainly at younger populations, and very little effort has been made to assess the extent of infection with HIV in the elderly population.
Delayed diagnosis often leads to a poorer prognosis in older adults. Current data suggest there is a shorter time between infection with HIV/AIDS and the onset of clinical symptomatology, namely opportunistic infections (McCormick & Wood, 1992). When elderly individuals are diagnosed with HIV/ AIDS they most often present with advanced disease and experience a shorter length of life (Wallace et al., 1993). This shortened life span is related both to delayed diagnosis and a more rapid clinical deterioration. Skiest, Rubinstien, Carley, Gioiella, and Lyons (1996) found that because older adults were diagnosed later, the time between actual identification of AIDS and death from the disease was shorter.
SIGNS AND SYMPTOMS OF COMMON OPPORTUNISTIC INFECTIONS
One cause of the more rapid clinical deterioration is related to the decreased immune function normally found in older adults and their inability to replace T-helper cells at a rate comparable to that of the younger age groups. An increase in comorbidity also may be related to a more rapid course of the disease process and a decreased survival rate in older adults. Scura and Whipple (1990) found that among older adults who were infected with HIV, the mean time from potential exposure to the virus to testing as HIV positive was 4.2 years, with a range from 1 to 7 years. Thus, early diagnosis and treatment may be essential for improved quality of life in older adults.
COMMON OPPORTUNISTIC INFECTIONS
Opportunistic infections associated with AIDS often are misdiagnosed as other chronic conditions that typically affect older adults (McCormick & Wood, 1992). Signs and symptoms of opportunistic infections related to HIV/AIDS may look similar to those associated with chronic diseases commonly found in older adults. Comorbidity often masks the problem when older adults present to various health care providers with a multitude of vague symptoms, some of which may be related to an unknown infection with HIV.
Health care providers should be aware of opportunistic infections that are recognized as AIDS-defining. Wallace et al. (1993) list the five most common opportunistic infections as:
* Pneumocystis carinii pneumonia (PCP).
* Mycobacterium tuberculosis (TB).
* Mycobacterium avium complex (MAC).
* Herpes zoster.
* Cytomegalovirus (CMV).
Signs and symptoms of these infections are listed in Table 2. Older adults who present with symptoms suggestive of these opportunistic infections need to undergo appropriate diagnostic testing, including a differential diagnosis for chronic conditions commonly found in older adults versus those diseases which may be indicative of infection with HIV. Risk factors, possible sources of infection, and potentially unsafe behaviors should be assessed in any older adult who exhibits symptoms of any of these opportunistic infections.
AIDS DEMENTIA COMPLEX
AIDS has been referred to in much of the literature as the "new great imitator" (Nocera, 1997, p. 76). AIDS dementia complex (ADC) often is misdiagnosed as Alzheimer's disease when older adults develop symptoms distinctive for dementia. Neurological symptoms commonly found in individuals with Alzheimer's disease sometimes are recognized in individuals infected with HIV. Therefore, it is crucial to include testing for HIV in the differential diagnosis of dementia, as well as accurate evaluation of behavioral and functional changes in older adults who exhibit signs and symptoms of dementia (Scarnhorst, 1992).
Late diagnosis of infection with HIV in elderly individuals leads to a variety of treatment challenges. For example, a greater number and severity of opportunistic infections may be present when the disease has progressed to an advanced stage. This, in itself, makes treatment a formidable task. Treatment is complicated further when other disease processes or comorbidity may be affecting the older individuals.
Even if the diagnosis is made early in the course of the disease, drug therapies create their own difficulties. Many older adults suffer from other conditions that require use of various medications. Drug interactions are a real concern when older adults are using drugs to treat chronic conditions and then must add other medications to treat HIV/AIDS and related opportunistic infections.
Further, drug trials of antiretroviral medications in elderly individuals currently are not available, and there are only anecdotal reports of the effects of these drugs when used by older adults. Adler and Nagel (1994) note that older adults are much less likely to tolerate the side effects of the major antiretroviral drug zidovudine (AZT). This may be because older adults metabolize many drugs differently, which may change the ability of antiretroviral agents to maintain their intended actions. Wallace et al. (1993) suggest that the use of antiretroviral agents in elderly individuals is warranted but that therapy should begin with smaller doses, and older adults should be monitored closely for any adverse effects that may occur.
NURSING CARE OF OLDER ADULTS INFECTED WITH HIV
Nursing care of older adults infected with HIV/AIDS can be challenging. In addition to addressing issues related to chronic conditions and problems commonly found in older adults, emphasis must be placed on the uncertainties associated with advanced infection with HIV. Older adults who are infected with HIV often experience anxiety, depression, social isolation, weakness, activity intolerance, inability to care for themselves, and issues related to loss and grieving, as well as other individualized dilemmas and obstacles.
Symptom control must be addressed as the course of the disease progresses for any individual infected with AIDS, but this is an area of specific concern for older adults who may have an ambiguous pattern of distressing symptoms. Acute symptoms must be identified and managed along with more chronic symptomatology, while continuously striving for quality of life that is acceptable to the older individuals.
Older adults with AIDS also may reach a point in the progression of the disease in which palliative care issues need to be addressed in a timely manner. As noted earlier, older adults infected with HIV/AIDS presumably will reach the end-stage of the disease process sooner than younger adults because of delayed diagnosis and treatment, as well as other health problems that complicate the clinical picture. Therefore, it is essential that all members of the health care team be experienced in the treatment of common symptoms seen in older adults with HIV/AIDS. These symptoms include:
* Weight loss.
* Decreased physical stamina.
* Diminished mental abilities.
Adequate patient education, health teaching, support, and guidance of both older and younger adults infected with HIV cannot be neglected. Concerns related to progression of the disease as well as acquired opportunistic infections should be communicated both to the individuals as well as appropriate significant others. Issues associated with sexuality and transmission of the virus also should be addressed with older adults who remain sexually active. Teaching related to current treatment measures, drug regimens, and potential side effects need to be reinforced continually. Families and significant others who are involved in the care of the individuals with AIDS should be included in the teaching process because these caregivers can reinforce what the nurses have taught.
Psychosocial aspects of being infected with HIV/ AIDS frequently are similar for both older and younger people. The stigma associated with being HIV positive, fear of telling family members, lack of support from the community and family, dwindling financial resources, and quality of life issues affect all people with AIDS. In addition, older adults often feel they may become a burden to their families and fear disclosing their sexual preferences at a late age because of rejection from family and friends. There also are a number of distinct and separate issues that are faced by older adults.
Lavick (1994) recognized the paucity of literature related to psychotherapeutic issues specifically focused on older adults. Her research identified the following psychosocial issues that may be encountered in older adults infected with HIV:
* Stage of life.
* Issues of entitlement.
* Disclosure of status to adult children.
* Historical perspective and community ties.
* Sexual issues.
Lavick (1994) also recommended the formation of a support group for older people infected with HIV. All members of her study group stated that it was beneficial to meet with other people their own age who also were infected with HIV.
The American Association of Retired Persons (1988) reported that older people with AIDS often feel isolated and lack a support network. Education, community resources, and treatment options have not been focused on the elderly population. Garvey (1994) similarly noted that older adults infected with HIV often do not use community services because they feel these services are primarily for the younger population. Reasons for lack of connection with community resources include the fear of being stigmatized and the possible lack of stamina or energy required to reveal their diagnosis at an advanced age.
Early diagnosis and proper treatment of HIV/AIDS is essential for the elderly population. Health care providers must assess for risk factors pertinent to the development of HIV/AIDS in all age groups of individuals they may treat. Thorough risk assessment is essential in the elderly population. Testing, education, and counseling must be offered to any individual potentially infected with the AIDS virus, regardless of age. The use of a multidisciplinary health care team approach is essential to meet goals for treatment and control of symptoms in older adults infected with HIV. Education of all staff involved in meeting the physical and emotional care needs of older adults should include a component related to older adults and HIV/AIDS.
The public health arena in the United States needs to confront the issue of HIV/AIDS in older adults. Public health measures need to be focused on educating older adults regarding their risk for infection with HIV, and community resources should be developed that will benefit this age group. Further research on issues that older adults' face when infected with HIV/AIDS is critical.
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INCIDENCE OF INFECTION WITH AIDS BY AGE AND EXPOSURE CATEGORY
SIGNS AND SYMPTOMS OF COMMON OPPORTUNISTIC INFECTIONS