Transcript Powerpoint - Aids 2012

Optimizing Health Care in the
Context of Multimorbidity,
Polypharmacy, and Decreasing
Physiologic Reserve
Amy C. Justice, MD, PhD
Section Chief, General Internal Medicine
VA Connecticut Healthcare System
Professor of Medicine and Public Health
Yale University
Multimorbidity
HIV Has Never Occurred in a Vacuum
• Irrespective of aging, HIV care complicated by:
– Multi drug regimens susceptible to non adherence,
resistance, and toxicity
– Co infections (HCV, TB, MDR-TB)
– Socio economic issues: stigma, substance addiction,
incarceration, homelessness, under nutrition
• Aging adds multiple chronic diseases
(multimorbidity) to mix
Multimorbidity and Age in HIV+ South Africans
% Prevalence
WHO Survey “Study of global AGEing and adult health (SAGE), South African subjects”
Data are restricted to those with HIV infection. Negin J. et al. AIDS 2012 26(S1):S55-63
Incident Chronic Disease: Swiss Cohort 2008-10
Of 1,189 events in 8,444 patients, only 16% were HIV events, 84% were Non HIV:
Hasse B. et al. Morbidity and Aging in HIV-Infected Persons: The Swiss HIV Cohort Study CID 2011 53:1130-1139
Limit of Silos:
Coordination
and
Communication
Accelerated or Accentuated?
A. Accelerated and Accentuated:
cancer occurs earlier among those
with HIV than uninfected
comparators and there are more
cancer events.
Shiels MS. Ann Intern Med 2010:153:452-460.
B. Accentuated risk: cancer occurs
at the same ages but more often
than among comparators.
Age at Onset of Cancer AIDS Patients and Age
Matched Uninfected Individuals
Cancer
AIDS
HIV-
Age Adjusted
HIV-
Apparent
Difference
Real
Difference
Rectal
46
69
51
-23 yrs
-5 yrs
Anal
50
62
54
-12 yrs
-4 yrs
Larynx
48
65
52
-17 yrs
-4 yrs
Lung
50
70
54
-20 yrs
-4 yrs
Ovarian
42
63
46
-21 yrs
-4 yrs
Testicular
35
34
38
+1 yr
-3 yrs
Hodgkin
lymphoma
42
37
40
+5yrs
+2 yrs
Myeloma
47
70
52
-23 yrs
-5 yrs
Looked at 26 different diagnoses, no difference (p>0.05) for 18 cancer.
Differences for remaining cancers were <5 years.
Shiels MS. Ann Intern Med 2010:153:452-460.
Age at Diagnosis in VACS
Comorbid
Disease
Source
HIV+
(yrs)
HIV- Difference
(yrs)
Lung
Cancer
Medapalli RK. AIDS
2012;26(8):1017-25
57
59
-2
Myocardial
Infarction
Kaku A. CROI 2012 oral # 120
56
56
0
Renal Failure
(eGFR<45)
J Acquir Immune Decif Syndr
2012; 60(4):393-9
59
63
-4
Fragility
Fracture
Womack J. PloS ONE
2011;6(2):e17217
IAC 2012: MOPE087, Womack J.
54
53
+1
Symptomatic
Liver Cirrhosis
IAC 2012: WEABO 102, Lore V.
57
58
-1
See also: IAC 2012 TUPE160 Shiels M. Age at Cancer Diagnosis
in HIV+ in North America Compared to General US Population
Polypharmacy
Polypharmacy
• Typically defined as >5 drugs
• Associated with diminished marginal benefit
from additional medication due to:
– Nonadherence
– Adverse drug events (confusion, falls, renal failure, etc.)
• Risk of adverse events increases approximately
10% with each additional medication
Salazar JA. Expert Opin Drug Saf (2007) 6(6):695-704
Gandhi TK. N Engl J Med 2003;348:1556-64
Decreasing Physiologic Reserve
Disability, Frailty, and Functional Status
• 3 geriatric concepts increasingly applicable to
those aging with HIV
• Each is a consequence of total physiologic injury
rather than of any particular diagnosis
• Of note, these concepts also relate to cognitive
dysfunction, especially delirium and dementia
VACS Index Thresholds and Weights
Age (years)
<50
50 to 64
> 65
0
23
44
0
12
27
CD4
cells/mm3
> 500
350 to 499
200 to 349
100 to 199
50 to 99
< 50
0
10
10
19
40
46
0
6
6
10
28
29
HIV-1 RNA
copies/ml
< 500
500 to 1x105
> 1x105
0
11
25
0
7
14
Hemoglobin
g/dL
> 14
12 to 13.9
10 to 11.9
< 10
0
10
22
38
FIB-4
< 1.45
1.45 to 3.25
> 3.25
0
6
25
eGFR mL/min
> 60
45 to 59.9
30 to 44.9
< 30
0
6
8
26
Age
HIV
Specific
Biomarkers
Biomarkers
of General
Organ
System
Injury
Index Score
Restricted
VACS
Hepatitis C Infection
VACS.MED.YALE.EDU
5
VACS Index
• Predicts mortality:
– All Cause, HIV, and non HIV (European Data)
– Risk of mortality over 5 years (North American Data)
• Predicts morbidity: hospitalization, MICU
admission, and fragility fractures
• Correlated with functional performance and
symptom burden
• Responsive to changes in risk after ART initiation,
intensification, and interruption
For more information and full documentation go to: www.vacohort.org
To use/comment on the VACS Index Calculator go to: HTTP://vacs.med.yale.edu
We Need a “Map” to Optimize Care
• A comprehensive outcome to compare
effectiveness of interventions and identify those
with the best benefit/harm ratio
• A means of combining interventions into a
strategy for medical patients with multimorbidity
• A means of motivating and guiding patients and
providers to pay attention to that which matters
most for patient outcomes
Health Risk Assessment:
A Means of Navigating Complexity
• Identify and prioritize modifiable risks among a
lengthening list of possibilities
• Motivate and map progress
• Quantify harm and benefit from interventions
– Level of susceptibility to adverse drug events
– Short term risk of hospitalization
– Risk of disability, assisted living requirements
• Identify end of life to signal change in priorities
We Have a Sense for 50-64 yrs,
But 65+ Remains Uncharacterized
Relative Risk (HR)
Relative Risk of Incident Disease at 5064 and 65+ Compared with <50 Yrs
Hasse B. et al. Morbidity and Aging in HIV-Infected Persons: The Swiss HIV Cohort Study CID 2011 53:1130-9
End of Life
• With aging inevitably comes end of life
• Aging patients want to know when
they are within 5 years of death to:1
– Prepare
– Make the most of remaining life
– Make medical/health-related decisions
1. Ahatt C. et al. “Knowing is Better”: Preferences of Diverse Older Adults for Discussing Prognosis.
J Gen Intern Med 2011, 27(5):568-75
Conclusions
• Multimorbidity is common for those aging with HIV and
requires a new approach to care and research
– Individual diagnoses less important than cumulative injury
– We need tools to assess injury and its impact
• In the context of polypharmacy and physiologic injury,
additional medication may cause more harm than good
– Need to consider what medications are most essential
• Ongoing risk assessment, evidence based prioritization,
and coordination of care must become the new bywords
Research Priorities
• Study mechanisms in multimorbidity:
– “Multi-hit” (cancer) and “cumulative frailty” (geriatrics)
– Develop a standard approach to measuring physiologic injury
– Compare HIV+/- to determine whether HIV has distinct
mechanisms of injury
• Compare harms and benefits of additional
treatment and of decreased treatment
• Consider alternative ways of organizing and
delivering care in the context of multimorbidity
• Test whether care prioritized based upon risk,
benefit, and preferences is more effective than UC
Two Studies in General Population
Illustrate the Tension in Studying
Aging and HIV
STOPP
Polycap
METHODS
Randomized 400 hospitalized
patients aged 65+ yrs. to receive
either usual care or screening with
STOPP/START criteria with follow up
recommendations to providers.
RESULTS
•Unnecessary drugs decreased 36%
•Underutilization of indicated drugs
decreased by 21%
•Improvements sustained for 6 mos.
•No significant differences in deaths,
falls, readmission, LOS, or f/u outpt
visits—all but readmissions less in
intervention arm (but not significant)
• 2007-2008
• 2,053 subjects; 50
centers in India
• 45-80 yrs; 1 risk factor
• Not on medication
• Aspirin, thiazide,
ramipril, atenolol, and
simvastatin
• Outcome: BP, LDL,
heart rate, urine
biomarker for plt. act.
• ADE: discontinuation
Yusuf S. Lancet 2009; 373:1341-51.
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