Extraordinary Concerns About HIV Infection in the Older Adult

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´╗┐Exceptional Concerns About HIV Infection in the Older Adult Joseph S. Cervia, M.D., FACP, FAAP Director, The Comprehensive HIV Care and Research Center, Long Island Jewish Medical Center Associate Professor of Clinical Medicine and Pediatrics, Albert Einstein College of Medicine

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The Problem Prevalence of HIV contamination and AIDS in more seasoned people (those over age 50) keeps on developing This marvel is felt to be identified with both: 1. The more drawn out survival of more youthful HIV-tainted people, and 2. New diseases of more established people who don't value their hazard.

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Epidemiology The total number of patients over age 50 with AIDS quintupled from 16,288 in 1990 to 90,513 before the end of December 2001. As of now more than 60,000 people more than 50 living with AIDS in the U.S. More than 50,000 have kicked the bucket in this age aggregate since the start of the pandemic. Mack, K. et al. JAIDS 2003; 33(2):S68-S75

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Why the Concern? Despite taking part in conduct which puts them at hazard for HIV, more seasoned grown-ups are less inclined to see themselves at hazard and to receive more secure sexual and needle-sharing conduct. More seasoned grown-ups will probably be analyzed late in ailment, encounter movement all the more rapidly, and get by for a shorter period than more youthful partners. Goodroad, B. J Gerontol Nurs. 2003; 29(4):18-24

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What is the degree of the issue? 11-15% of AIDS cases in the U.S. are in people >50

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Risk Behaviors Despite myths and generalizations, numerous more established people remain sexually dynamic, and gay person contact remains the most widely recognized reported hazard conduct in those more than 50. Intravenous medication utilize is the second most normal hazard variable, and receipt of blood items is third. Numerous more established people report no distinguished hazard. This may reflect hetero transmission from at hazard accomplices.

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Sexual Risk Americans more than 50 are 1/6 as prone to utilize condoms amid sex, and 1/5 as liable to have been tried for HIV as a correlation gathering of people in their 20's. Postmenopausal ladies are seen to be at more serious hazard because of the improved probability of diminishing and dryness of vaginal mucosa.

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HIV Among Older MSM HIV prevalence=19% for men in their 50's and 3% for men in their 60's Prevalence for more seasoned African-American men=30% High-hazard sex between serodiscordant partners=4-5%

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Immunological Risk Naïve CD8+ cell exhaustion, Diminished CD28 expression on CD8+ cells, and Reduced thymic volumes are conceivable corresponds of the cooperation of age and HIV sickness. Kalayjian, R. J Infect Dis. 2003;187(12):1924-33

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Natural History HIV contamination advances all the more quickly in more established people, and survival times are shorter. 37% of people >80 bite the dust inside a month of AIDS analysis. Zaidi, S. Cervia, J. NY Chapter ACP-ASIM Newsletter 2002;2(2):4

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Reasons for Poor Outcomes Comorbid ailment Immunosenescence Delay in conclusion by clueless suppliers and patients

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Causes of Diagnostic Delay Older people may not concede or even be gotten some information about hazard practices HIV may go undiscovered as the assessment for more normal conditions creating comparative side effects, (for example, disease, contamination, or natural cerebrum disorder) are sought after.

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Immunological Factors CD4+ cell considers decay all the more quickly as a real part of people >40 than among more youthful people. Thymic movement starts to decay from about the fourth decade maybe representing a more continuous recuperation of CD4+ lymphocytes saw in some more seasoned people. Nutritious inadequacies are likewise more normal in more established people, maybe adding to immunosuppression.

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HAART in Older Adults Recent studies show that age might not significantly affect the result of HAART. This would unequivocally contend for an approach in which treatment in the more established grown-up ought to be individualized by patient's wellbeing status instead of age, in essence.

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Opportunistic Infections in Older Adults The trademark AIDS-characterizing sharp contaminations have comparative pervasiveness rates paying little mind to age.

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HIV-Related Metabolic Abnormalities in Older Adults Higher danger of lipodystrophy, maybe mirroring the part of age ward alterations of lipid digestion system and insulin affectability in light of HAART.

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Clinical Events More Common in the Older HIV-Infected Adult Older age has been recognized as an autonomous hazard figure for extreme hepatic damage in guileless patients starting HAART. HIV contamination has been distinguished as a noteworthy hazard figure for CVA, and is more successive among more seasoned people. Subjective decay connected with HIV disease may likewise be noted all the more as often as possible in more established patients.

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Neurocognitive Morbidity Most regular is a diffuse, subacute encephalitis that causes dynamic dementia (AIDS Dementia Complex, ADC) ADC is showed in 8.5% of those >50 contrasted with 5.2% of those 13-49 ADC in the more seasoned individual must be separated from Alzheimer Disease or Parkinson Disease

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ADC: Rapidly dynamic Subcortical dementia Cognitive debilitation may enhance with HAART Alzheimer Disease: More slow movement Cortical dementia No change with HAART ADC versus Alzheimer Disease

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Case Presentation 52 year-old PC technologist is hospitalized with dynamic shortcoming and perplexity in the course of recent weeks 2 weeks back went by a neighborhood ER and was analyzed as "sickly" Yesterday, he appeared for work on his three day weekend. He has been afebrile, and without migraine, photophobia, or neck solidness. No history of travel, pets or creepy crawly nibbles He is situated to individual and place, yet trusts that it is "February" in June. Examination is noteworthy just for 3 very much characterized perianal ulcerations.

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Laboratory Data MRI of head uncovered numerous white matter flag variations from the norm CD4+=17

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Diagnosis HIV disease with Progressive Multifocal Leuko-encephalopathy (PML)

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Denouement The appraisal of a recently unhinged patient or a patient with a clinical course that more quick or less run of the mill of a perceived essential neurodegenerative issue may warrant serological testing for HIV. Zaidi, S. Cervia, J. NY Chapter ACP-ASIM Newsletter. 2002; 2(2):4

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Clinical Pharmacology Drug treatment for HIV contamination is all the more difficult in more seasoned people because of: Polypharmacy/Drug-tranquilize communications Higher occurrence of unfriendly impacts Altered pharmacokinetics with age

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Addressing the Needs of the Older HIV-Infected Patient Characteristics and care needs of the more seasoned HIV-tainted populace are extremely various and shift by introduction course: Older gay men: Predominantly white, more prone to have medical coverage, 38% utilized, 48% with wages >$25,000, great physical working and passionate bolster Older IDUs: Predominantly African-American, 11% utilized, 74% with salary <10,000, low physical working and enthusiastic bolster Crystal, S. JAIDS 2003; 33:S76-S83

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Addressing Emerging Risk Factors Finding sex accomplices on-line (34 million more established web clients) Late-onset split utilize Increasing travel and tourism among more seasoned grown-ups

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Resources Seniors in a Gay Environment (SAGE) gives data and referrals AARP Social Outreach and Support (SOS) offers programs on HIV/AIDS Social Security Administration gives advantage programs

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Recommendations Providers must get to be instructed on HIV hazard practices and related indications, and ought to offer HIV advising and testing regardless of a patient's age. Arrangement creators may need to consider development of suggestions for HIV directing and testing to incorporate elderly hospitalized patients, particularly in high seroprevalence territories.

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Recommendations (Continued) Outreach workshops and preparing ought to ought to be actualized for more established people and their guardians so as to educate them about transmission hazard and anticipation of HIV. Media and social showcasing effort might be useful in bringing issues to light and fortifying the requirement for instructive projects.

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Recommendations (Continued) Further research on HIV in more established grown-ups ought to be upheld.

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