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Essay topic: The Effects of Aging on HIV Care and Treatment for Adults
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Considering the Impact of Aging When
Caring For and Treating Adults With HIV
Judy Frain, PhD, RN

ABSTRACT
The 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, 2019
Accepted: November 11, 2019
doi: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.

METHOD
Design 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.

Procedure
Th 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

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

Instruments
Brevity 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 Analysis
Data 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.

RESULTS
Table 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 1
Participant 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.

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 2
Depressive 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

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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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