Considering_the_Impact_of_Agin.pdf

Considering the Impact of Aging When Caring For and Treating Adults With HIVJudy Frain, PhD, RN

ABSTRACTThe current study investigates how age impacts factors associated with success-fully managing HIV. One hundred thirty adults with HIV were recruited for the study. Participants were divided into two groups, those age ≥50 and those age <50. Cog-nitive impairment and depressive symptoms were seen at higher rates in older adults, and the severity of depressive symptoms was also higher in older adults. Depressive symptoms impacted cognitive function to a higher degree in older adults compared to younger adults (r = –0.293, p = 0.018 vs. r = –0.109, p = 0.387). Polypharmacy was a greater concern in older adults, with 88% having polypharma-cy compared with 60% of younger adults. Similarly, the prevalence of comorbidities was more than double in older adults compared to younger adults. Factors associ-ated with aging complicate management of HIV. Gaining insight into the challenges of caring for this population will furnish nurses with information necessary to pro-vide the best possible care for this growing population. [Journal of Gerontological Nursing, 46(4), 31-40.]

S ince the start of the HIV epi-demic, tremendous advances have been made in the care and

treatment of persons living with this disease. Th ese successes have trans-formed HIV from a fatal to a chronic disease and have also contributed to the demographic shift now seen in the

HIV population. Th e majority of new infections are still found in younger adults, but now more than one half of all persons with HIV are older than 50 (Centers for Disease Control and Prevention, 2017), and it is expected that this aging population will con-tinue to grow.

As is true with many other chronic diseases, aging has led to an increase in the number of comorbid condi-tions. Comorbidities complicate HIV treatment, decrease quality of life, in-crease morbidity and mortality, and increase the cost of health care (Cahill & Valadéz, 2013; Rodriguez-Penney et al., 2013). Several studies have found that the number of comorbidi-ties experienced by people with HIV was greater when compared to HIV-

negative adults, including those with other chronic conditions (Maciel et al., 2018; Mayer et al., 2018; Ruzicka et al., 2019). Although the number of comorbid conditions was greater in persons with HIV, the types of co-morbidities are typical of aging adults in general, with hypertension, lipid/metabolism, respiratory, and psycho-logical disorders common in persons with and without HIV, suggesting that aging, rather than HIV, is respon-sible (Kong et al., 2019; Serrão et al., 2019; Smith & Wrobel, 2014).

One corollary of the high num-ber of comorbidities is the increase in pill burden for many adults with HIV (Moore et al., 2015). In a re-cent study, overall prevalence of poly-pharmacy (fi ve or more medications) was 25% among persons with HIV, compared to 18.7% in HIV-negative adults. Signifi cantly, polypharmacy was approximately 50% in adults 50 and older with HIV (Ware et al., 2018). In another study, polyphar-macy was an issue for 66% of older adults with HIV, and 48% of younger adults with HIV, compared to just 13% of HIV-negative adults. Even when HIV medications were exclud-ed from pill counts, 30% of older and 14% of younger adults with HIV had polypharmacy (Halloran et al., 2019).

Due to its importance in suppress-ing the virus, adherence to antiretro-

Dr. Frain is Associate Professor, Goldfarb School of Nursing at Barnes-Jewish College, St. Louis, Missouri.

The author has disclosed no potential confl icts of interest, fi nancial or otherwise.

Address correspondence to Judy Frain, PhD, RN, Associate Professor, Goldfarb School of Nursing at Barnes-Jewish College, 4483 Duncan Avenue, St. Louis, MO 63110; e-mail: Judith.frain@bjc.edu.

Received: August 30, 2019Accepted: November 11, 2019doi:10.3928/00989134-20200304-02

31Journal of Gerontological Nursing | Vol 46 | No 4 | 2020

viral therapy (ART) remains a vital component in the successful manage-ment of HIV. Common advice from providers has been that patients need to take their HIV medications cor-rectly 95% of the time to achieve and maintain viral suppression. Although newer drugs may be more forgiving of missed doses, non-adherence remains a primary cause of virologic failure for persons with HIV (Denison et al., 2015; Dunn et al., 2018; Glass et al., 2015). Studies have shown polyphar-macy and multi-comorbidities, along with other factors, contributed to non-adherence (Bogart et al., 2016; Cantudo-Cuenca et al., 2014; Corless et al., 2017; Manzano-García et al., 2018).

Depression is one of the most common mental health comorbidities found in persons with HIV. Th e prev-alence of depression in adults with HIV is more than three times that of the general adult population (Brody et al., 2018; Do et al., 2014; Nanni et al., 2015). Depressive disorders have been associated with faster HIV progression, increased morbidity and mortality, slower immune response, reduced adherence to ART, and a decrease in cognitive function and quality of life (Gonzalez et al., 2011; Wagner et al., 2011). Depressive symptoms have been shown to nega-tively impact HIV self-management, including daily health practices, and were positively correlated with per-ceived stress (Webel et al., 2016). Studies are mixed as to the eff ect of aging on the prevalence of depression in adults with HIV; however, there is some evidence that depressive symp-toms have a greater impact on qual-ity of life and health outcomes as this population ages (Millar et al., 2017; Th omas et al., 2009).

Th e connection between psychiat-ric symptoms and cognitive function has been examined in previous HIV studies with mixed results. Evidence from studies of older adults with HIV found that although psychiatric symptom burden was high, it did not result in an increase in HIV-associated

neurocognitive disorders, and comor-bid psychiatric symptoms were not associated with cognitive impairment (Bourgeois et al., 2019; Milanini et al., 2017). However, in other stud-ies that included older and younger adults with HIV, results indicated that depressive symptoms impact cog-nitive function (Laverick et al., 2017; Rubin & Maki, 2019; Schouten et al., 2016).

Th e current study explores the im-pact of aging on successfully treating and managing HIV in adults age 50 and older. Age 50 was chosen because that is the age defi ned by the Centers for Disease Control and Prevention (Blanco et al., 2012) as older adult in the study of persons with HIV. How aging impacts psychosocial, cogni-tive, and quality of life measures is ex-plored, in addition to aging’s impact on medication adherence, as measured by a 3-day medication recall. Th is re-search fi lls a gap by giving health care providers and their patients informa-tion they can use to better understand how aging can impact successfully liv-ing with and managing HIV.

METHODDesign and Sample

A descriptive, correlational design was used in this study. Participants were recruited from an outpatient infectious disease clinic of an ur-ban medical center in the Midwest, and from the AIDS Clinical Trials Unit (ACTU), which shares a build-ing with the clinic. Persons were ap-proached during their appointment to discuss the trial. Informational fl yers were also placed in the waiting rooms of the clinic and clinical trials unit. Data were collected as part of a study assessing medication manage-ment in adults with HIV.

A convenience sample of 130 adults between ages 20 and 76 with HIV were enrolled and divided into two groups, those 50 and older, and those younger than 50. Inclusion criteria were having documented HIV, taking ART for at least 16 consecutive weeks prior to study entry, and ability

to read and understand English. After giving informed consent, participants completed instruments that included the Montreal Cognitive Assessment (MoCA), Center for Epidemiologic Studies Depression Scale (CES-D), Self-Effi cacy for Managing Chronic Disease Scale, and a medication ad-herence instrument. Data included demographic information; alcohol, drug, and tobacco history; current medications; current viral load and current and nadir CD4 count; years since HIV diagnosis; and additional comorbidities. HIV viral load and CD4 counts were documented in this study as measures of HIV. A low or un-detectable viral load indicates ART is eff ectively controlling the HIV. When uncontrolled, HIV attacks the body’s CD4 cells, causing a decrease in num-ber and resulting in an increased risk for opportunistic infections. A nor-mal CD4 count ranges from 500 to 1,500 cells/mm3 of blood. Generally, if CD4 counts >500 cells/mm3 can be maintained, the risk for opportunistic infections is decreased.

ProcedureTh e study was approved by the

University’s Institutional Review Board. All participants provided written informed consent prior to completing any study-related activi-ties. Study procedures took place in a quiet, private room conveniently located near the clinic and ACTU. Participants completed a demograph-ic form, which included medical and social histories, the CES-D, the MoCA, the Self-Effi cacy for Man-aging Chronic Disease Scale, and a medication management test. Trained research staff administered the MoCA and the medication management test and were available to assist if ques-tions arose when participants were completing the other instruments. Medical records were also used to complete information on the demo-graphic form, including number of comorbidities, medications, and CD4 counts and viral load. HIV health care providers were notifi ed of participants

32 Copyright © SLACK Incorporated

scoring ≥16 on the CES-D, indicating clinically signifi cant depressive symp-tomology.

InstrumentsBrevity and adaptability to the clin-

ical setting were considerations when choosing the instruments for this study. Th e CES-D and MoCA have been used in previous HIV research and have been shown to be valid and reliable instruments (Nasreddine et al., 2005; Radloff , 1977). Concise-ness and ease of administration make these instruments ideally suited for use in the clinical setting, where time and resources are often limited.

Th e CES-D is a 20-item, self-administered questionnaire used to measure depressive symptoms over the past 1 week (Radloff , 1977). A sum-mary score is calculated, with total possible scores ranging from 0 to 60. Scoring for each item is on a 4-point scale ranging from 0 (rarely or none of the time) to 3 (most or all of the time). Responses are based on frequency of occurrence during the past 1 week. A higher score indicates a higher level of depressive symptomology. A score ≥16 indicates a clinically signifi cant level of depressive symptomology. Less than 20% of the general popu-lation would be expected to score in this range. Th e CES-D has been used in many large-scale HIV research tri-als, and its reliability and validity have been well-established. Cronbach’s al-pha is 0.94 (Radloff , 1977). In a re-cent study focused on persons with HIV, Cronbach’s alpha ranged from 0.92 to 0.94 (Mueses-Marín et al., 2019). Another study comparing men with HIV with uninfected men found specifi city of 99.9% and sensitivity of 75% in the HIV group (Armstrong et al., 2019).

Th e MoCA is designed as a quick screening tool for assessing mild cog-nitive impairment (MCI) and is not recommended as a stand-alone diag-nostic tool. It is a 30-item instrument that takes approximately 10 minutes to complete and can be administered with minimal training. Th e MoCA

assesses diff erent cognitive domains, including attention, concentration, executive function, memory, lan-guage, visuoconstructional skills, con-ceptual thinking, calculations, and orientation (Nasreddine et al., 2005). Th e highest possible score is 30, and a person scoring ≥26 is considered to have normal cognitive function. Th e MoCA has been used to measure HIV–associated MCI (Bourgeois et al., 2019; Overton et al., 2013). Over-all reliability of this instrument has been shown to be 0.83 (Nasreddine et al., 2005). Studies focused on adults with HIV have reported sensitivities ranging from 59% to 85% (Hasbun et al., 2012).

Th e Self-Effi cacy for Managing Chronic Disease Scale is a six-item scale that is designed to measure how confi dent a person is in managing symptoms of his/her disease. Respons-es can range from 1 (not at all) to 10 (totally confi dent). Th e scale score is the mean of the six items. When orig-inally tested on a sample of 605 adults with chronic disease, the mean score was 5.17 (SD = 2.2), and reliability was 0.91 (Lorig et al., 2001).

Data Management and AnalysisData were analyzed using SPSS

version 22. Data were stored on a hard drive and backed up on a secured server. Hard copies of completed study questionnaires were stored in a locked fi le cabinet in a secured offi ce. All stored data were de-identifi ed. Descriptive statistics were used to summarize the demographic charac-teristics and other information from the demographic form. Independent t tests, analysis of variance (ANOVA), and regression analysis were used to analyze data.

RESULTSTable 1 summarizes participant de-

mographic data. All participants were seen in care at least once within the past 1 year and were prescribed ART. Th us, this was a relatively healthy group, with three quarters of partici-pants having undetectable viral loads

(n = 97), and a mean CD4 count of 558 cells/mm3, with counts rang-ing from 5 to 1,649 cells/mm3. CD4 counts were similar between groups, with older adults having a mean CD4 count of 549 (SD = 291) cells/mm3, and younger adults 567 (SD = 318) cells/mm3. Viral load, however, dif-fered signifi cantly between groups. Whereas 81.5% of older adults had an undetectable viral load, only 67.7% of younger adults were un-detectable. Th e median viral load was undetectable for both groups; however, the mean for older adults was 1,303 (SD = 7,507) cells/mm3, whereas the mean for younger adults was 6,600 (SD = 27,956) cells/mm3, primarily due to approximately 10% of younger adults having viral loads >10,000 cells/mm3, compared to <2% of older adults.

Cognitive function did not dif-fer signifi cantly between groups. Th e mean overall score for all participants was 24.23 (SD = 3.67). Older adults had a mean score on the MoCA of 23.62 (SD = 4.04) compared to a slightly higher score of 24.85 (SD = 3.17) in the younger group. Overall, 36% (n = 47) of participants were classifi ed as having normal cog-nitive function and 64% (n = 83) had scores suggesting MCI. Separately, 66% (n = 43) of older adults and 61% (n = 40) of younger adults exhibited MCI.

Depressive symptoms were com-mon in both groups, with 55 (42%) participants exhibiting clinically sig-nifi cant depressive symptoms (≥16 on the CES-D). Higher scores indicate a greater number of depressive symp-toms overall. Th ere was no signifi cant diff erence in depressive symptoms between older and younger adults. Forty-three percent of older adults and 42% of younger adults expe-rienced depressive symptoms clas-sifi ed as clinically signifi cant. Th e mean score on the CES-D was 15.85 (SD = 12.8) for older adults and 14.98 (SD = 10.2) for younger adults. Diff erences were noted in the severity of depressive symptoms, with older

33Journal of Gerontological Nursing | Vol 46 | No 4 | 2020

adults experiencing severe depressive symptoms (CES-D >24) at a higher rate than younger adults (i.e., 23% compared to 14%, respectively).

Self-effi cacy for managing chronic disease was high for older and young-er participants. In participants 50 and older, the mean score was 7.67 (SD = 2.1), and in the younger group, the mean was 7.83 (SD = 1.9). Both groups scored signifi cantly higher than the original testing group, where >600 patients with chronic disease had a mean score of 5.17 (SD = 2.2) (Lorig et al., 2001).

Multiple regression analysis was used in each group to test pre-

dictors of depressive symptoms (Table 2). Th e results of the regres-sion indicated that self-effi cacy in managing symptoms and education explained 43% of the variance in old-er adults (R2 = 0.43, F[2,62] = 23.45, p < 0.001), considered to be a mod-erate to large eff ect size. Self-effi cacy and education signifi cantly predicted depressive symptoms (� = –0.534, p < 0.001 and � = –0.296, p = 0.004, respectively). However, in younger adults, these same variables explained only 11% of the variance (R2 = 0.11, F[2,62] = 3.75, p = 0.029), which was considered to be a small to negligible eff ect size. In the younger age group,

education level remained a signifi cant predictor (� = –0.290, p < 0.02); however, self-effi cacy was no longer signifi cant (� = –0.120, p = 0.324).

Th e correlation between depres-sive symptoms and cognitive func-tion was signifi cant for older adults (r = –0.293, p = 0.018), indicating that as depressive symptom scores in-creased, cognitive function scores de-creased. Th is correlation was not sig-nifi cant in younger adults (r = –0.109, p = 0.387). Cognitive function and depressive symptoms were predictors of medication management ability in older adults (R2 = 0.45, p < 0.001), which was considered a moderate to

TABLE 1Participant Demographics

Older Group (n = 65)

Younger Group (n = 65)

Total (N = 130)

Variable n (%)

Identifi es as male 51 (78) 44 (68) 95 (73)

Identifi es as female 14 (22) 21 (32) 35 (27)

Undetectable viral load 55 (86) 44 (68) 99 (76)

Alcohol (current/past use) 58 (89) 60 (92) 118 (91)

Tobacco (current/past use) 50 (77) 49 (76) 99 (76)

Drugs (current/past use) 35 (54) 44 (68) 79 (61)

Mean (SD) (Range)

Age (years) 56.2 (6.01) (50 to 76) 37.7 (8.02) (20 to 49) 46.9 (11.67) (20 to 76)

Years of education 12.88 (2.66) (8 to 20) 12.95 (2.43) (8 to 22) 12.9 (2.54) (8 to 22)

Nadir CD4 count (cells/mm3) 161.51 (147.67) (0 to 600)

261.36 (218.15) (0 to 1,289)

211.4 (192.20) (0 to 1,289)

Current CD4 count (cells/mm3) 548.94 (290.87) (5 to 1,417)

566.75 (317.85) (8 to 1,649)

558 (303.60) (5 to 1,649)

Years since diagnosis 17.8 (7.62) (5 to 32) 13.68 (6.6) (3 to 30) 15.74 (7.93) (3 to 32)

No. of medications 8.75 (4.13) (1 to 22) 5.83 (3.17) (1 to 14) 7.29 (3.95) (1 to 22)

No. of comorbidities 4.55 (2.61) (0 to 12) 2.15 (1.78) (0 to 7) 3.35 (2.54) (0 to 12)

CES-D scorea 15.89 (1.28) (0 to 50) 14.98 (10.17) (0 to 41) 15.44 (11.52) (0 to 50)

MoCA scoreb 23.62 (4.04) (13 to 30) 24.85 (3.17) (16 to 30) 24.23 (3.67) (13 to 30)

Note. CES-D = Center for Epidemiologic Studies Depression scale; MoCA = Montreal Cognitive Assessment.a Scores range from 0 to 60, with higher scores indicating higher level of depressive symptomology.b Scores range from 0 to 30, with scores ≥26 considered normal cognitive function.

34 Copyright © SLACK Incorporated

large eff ect size. Cognitive function and depressive symptoms also pre-dicted medication management in younger adults, although the eff ect size was small (R2 = 0.27, p < 0.001). Table 3 provides more information about correlations found in the cur-rent study. Correlations, and the strength of those correlations, diff ered between older and younger adults.

Even greater diff erences were seen when examining comorbidities. Older adults had a mean number of comor-bidities more than twice that of persons younger than 50 (4.55 [SD = 2.61] vs. 2.14 [SD = 1.78], p < 0.001). Number of medications was also approximately twice as high for older adults compared to younger adults (mean = 6.4 [SD = 3.9] vs. mean = 3.4 [SD = 2.7], p < 0.001).

DISCUSSION Th e current study found a num-

ber of similarities between older and

younger adults with HIV; however, signifi cant diff erences were noted that could impact how care is provided for older adults. Depressive symptoms remain a common problem for many adults with HIV, but the impact of depressive symptoms may be greater for older adults. A stronger correla-tion was found between depressive symptoms and cognitive function in older adults than in younger adults, and depressive symptoms, along with cognitive function, were stronger pre-dictors of medication management in older adults than younger adults. Approximately 42% of participants had clinically signifi cant levels of de-pressive symptomology. Th ese rates are similar to rates found in previous studies that measured depression in persons with HIV. Signifi cantly, these rates are approximately three times the rates found in the general adult popu-lation (Bhatia & Munjal, 2014). It is

also noteworthy that an additional 22% of current participants scored at a subclinical level of depressive symp-tomology. Prior research has found that there is an incremental relation-ship between depressive symptomolo-gy and treatment non-adherence, and that this incremental relationship has been identifi ed in high and low levels of depression severity, indicating even at subclinical levels depressive symp-toms can aff ect treatment adherence (Magidson et al., 2015; Uthman et al., 2014).

Cognitive impairment was also prev-alent, with 64% of participants scoring in the MCI range, with a mean MoCA score of 24.23 (SD = 3.67). Th ese re-sults are similar to a recent study that found 63.8% of participants scoring at the impairment level (mean = 25.4 [SD = 2.7]), and similar to the current study, found these results independent of age (Herrmann et al., 2019).

TABLE 2Depressive Symptoms: Model Summaries for Older and Younger Adults

Regression Model 1 (ANOVAa) Summary for Older Adults

R R2 Adj. R2 F df p Value

0.656b 0.431 0.412 23.45 2,62 0.001

Model Sum of Squares df Mean Square F p Value

Regression 4503.72 2 2251.86 23.45 0.001

Residual 5954.52 62 96.04

Total 10458.25 64

Regression Model 1 (ANOVAa) Summary for Younger Adults

R R2 Adj. R2 F df p Value

0.329b 0.108 0.079 3.75 2,62 0.029

Model Sum of Squares df Mean Square F p Value

Regression 714.842 2 357.42 3.75 0.029

Residual 5904.14 62 95.23

Total 6618.99 64

Note. ANOVA = analysis of variance.a Predictors (constant), education level, self-effi cacy.b Dependent variable: depressive symptoms.

35Journal of Gerontological Nursing | Vol 46 | No 4 | 2020

TAB

LE 3

Corr

elat

ions

Am

ong

Varia

bles

: Old

er a

nd Y

oung

er A

dults

Old

er A

dult

Mea

sure

sA

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olTo

bacc

oDr

ugs

Com

orbi

ditie

sN

on-H

IV

Med

sCo

gniti

ve

Func

tion

Depr

essi

ve

Sym

ptom

sM

edic

atio

n Te

stSe

lf-Effi

cac

y

Alco

hol

Toba

cco

0.

35**

Drug

s

0.34

**

0.45

**

Com

orbi

ditie

s

–0.0

3

–0.1

4

0.00

Non

-HIV

med

s

0.09

–0

.04

0.

11

0.43

**

Cogn

itive

func

tion

–0

.20

0.

25*

0.

08

0.01

–0

.06

Depr

essi

ve s

ympt

oms

–0

.09

–0

.37*

*

–0.2

7*

0.18

0.

18

–0.2

9*

Med

icat

ion

test

—

0.10

0.

28*

0.

00

0.02

–0

.06

0.

59**

–0

.38*

*

Self-

effi c

acy

0.

13

0.10

0.

04

–0.2

4*

–0.1

6

0.06

–0

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11

Tim

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0.11

0.

34**

0.

08

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6

0.01

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0.

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0.

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Drug

s

0.31

*

0.63

**

Com

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s

0.18

–0

.05

–0

.01

Non

-HIV

med

s

0.24

*

–0.0

2

–0.0

7

0.80

**

Cogn

itive

func

tion

–0

.19

0.

01

–0.0

6

–0.1

3

–0.1

7

Depr

essi

ve s

ympt

oms

–0

.09

–0

.18

–0

.24

0.

14

0.13

–0

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Med

icat

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test

–0

.23

0.00

0.07

–0

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–0.2

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effi c

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–0

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0.

180.

22

–0.4

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0.

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0.41

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at 0

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tail)

.

36 Copyright © SLACK Incorporated

Th e current study also identifi ed a correlation between depressive symp-toms and cognitive function in older adults. It is understood that cognition plays an important role in medication adherence, and that adherence is the primary predictor of eff ectively man-aging HIV. In addition, research has shown that adherence to ART leads to undetectable viral loads, which can signifi cantly reduce the risk of HIV transmission (Yah, 2017). Th us, early identifi cation and implementation of treatment for depressive symptoms may increase medication adherence for older adults, leading not only to an improved state of health for individu-al patients, but also a decrease in risk for new infections. Although phar-macological treatment may be con-sidered, counseling, support groups, and cognitive-behavioral therapy are also options for patients coping with depressive symptoms.

Interestingly, although cur-rent CD4 counts were similar be-tween groups, nadir CD4 counts were signifi cantly lower for older adults compared to younger adults (mean = 162 [SD = 147.68] cells/mm3 vs. 261.35 [SD = 218.15] cells/mm3, respectively, p = 0.003). Th ere is evi-dence that nadir CD4 count is predic-tive of neurological outcomes, making it important for health care providers to be aware of the health history of their patients, including historical CD4 counts (McCombe et al., 2013; Valcour et al., 2006). Th e diff erences in nadir CD4 counts between groups are a refl ection of increased HIV test-ing in younger adults, and historical changes in recommendations of when to start ART (Th ompson et al., 2012). Unfortunately, these counts also re-fl ect the reality that older adults are still getting diagnosed much later in the disease process, where their CD4 count has already dropped to a dan-gerous level (Roberson, 2018).

Although the number of medica-tions and number of comorbidities were signifi cantly higher for older adults than for younger adults in the current study, the only signifi cant cor-

relation was with self-effi cacy in the younger group (r = –0.48, p < 0.001), indicating that as the number of medications increased, self-effi cacy decreased. Th e same correlation was not signifi cant for older adults (r = –0.159, p = 0.21), indicating that the number of medications taken did not aff ect self-effi cacy.

Self-effi cacy for managing chronic disease symptoms was high for older and younger adults. It was hypoth-esized that this was due to the sample having lived with HIV for many years (mean = 15.74 [SD = 7.93] years). Self-effi cacy was negatively correlated with number of other diagnoses in older and younger adults, indicating that as the number of diagnoses in-creased, self-effi cacy decreased. Th is fi nding may signal that as comorbidi-ties make managing HIV more com-plicated, there is less confi dence that individuals can successfully manage their disease.

Identifying depressive symptoms early can increase treatment options and optimize treatment strategies. Th e importance of talking with and educating patients with HIV about the signs and symptoms of depression cannot be overstated. Adults with HIV are living every day with the stigma of this diagnosis. Th e aversion to stacking a mental health diagnosis, with its own perceived stigma, on top of an HIV diagnosis may lead these patients to ignore or minimize depres-sive symptoms, muting meaningful discussion and erecting an impenetra-ble barrier to diagnosis and treatment. Health care providers who initiate conversations about and screenings for depression at the initial visit and continue those practices as a routine part of each health care visit may de-crease the stigma surrounding mental health and lay the groundwork for the early recognition and discussion of depressive symptoms in persons with HIV, particularly older adults who are less likely to discuss psychological is-sues with their provider.

MCI was also a problem for the majority of older adults in the current

study, with 66% exhibiting MCI as measured by the MoCA (score <26), possibly leading to problems manag-ing medications. As patients are now seen as infrequently as once per year, poor medication management can have a detrimental eff ect on morbid-ity and quality of life. Early detection of cognitive changes off ers the op-portunity to intervene with strategies to improve adherence prior to expe-riencing the negative consequences of missed medications. Off ering sug-gestions such as pill boxes, alarms, or help in setting up pills, could benefi t patients who may be at risk for poor adherence.

Recognizing the diffi culties of managing multiple chronic condi-tions and the medications used to treat them, providers must be vigilant to any medication changes that could impact HIV medications. Single pill ART options, when available, can de-crease the risks associated with poly-pharmacy, a common problem for older adults with HIV.

Poor healthy lifestyle choices were found for older and younger adults. Tobacco use was prevalent in older and younger adults with HIV, with 77% of older adults and 75% of younger adults being past or current smokers. Correlations between smok-ing and cognitive function, depressive symptoms, and medication manage-ment were all seen in older adults, but not in younger adults. Encourag-ing healthy choices, such as smoking cessation, could provide benefi ts be-yond the health benefi ts of not smok-ing. Alcohol and drug use were also prevalent in both groups (Table 1). However, the only correlation found was the negative correlation between drug use and depressive symptoms (Table 3).

IMPLICATIONS AND CONCLUSION

Providing comprehensive, integra-tive care for the health of body and mind off ers persons with HIV a better quality of life and a better chance for longevity. Early identifi cation of at-

37Journal of Gerontological Nursing | Vol 46 | No 4 | 2020

risk patients using objective measures such as the MoCA and CES-D can help identify problems before they be-come clinically signifi cant. Th ese are quick, objective assessment tools that can be used to detect small changes in cognition and depressive symptoms that may not be apparent using sub-jective measures. Implementing de-pression and cognition assessments as a regular part of every health care visit aff ords health care professionals the opportunity to open a dialogue with their patients, discussing the emotion-al and mental health aspects of living with HIV, and about implementing eff ective treatment and coping strate-gies to combat the adverse eff ects of these comorbidities. Th ere have been tremendous advances in treatment and care of persons with HIV over the past three decades, yet health care providers face new challenges in car-ing for older adults with HIV. Holistic care can best be achieved by focusing on both the physical and psychologi-cal symptoms of HIV.

Finally, when caring for adults with HIV, nurses should keep in mind that age 50 is considered the marker for identifying “older” in per-sons with HIV (Blanco et al., 2012). Nurses should be alert for comorbidi-ties, polypharmacy issues, and other cognitive problems that typically arise decades later in patients without HIV. Th is awareness can help guide the health care visit and will contribute to improved care, increased patient satis-faction, and better outcomes.

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