SEATTLE,

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February 13–16, 2017

 
 

 

HIV Infection and the Occurrence of Medically Significant Falls: Accelerated or Accentuated Aging?
CROI | Feb 13-16, 2017


Mark Mascolini

Age, Weight, Being a Woman Tied to Falls in Veterans With/Without HIV

from Jules: bear in mind the comparison of HIV+ Vets vs HIV-neg Vets uses a comparison group, Vets, that is not a healthy comparator group so they too have probably elevated risk for falls; many of all Vets have a history of IDU & substance abuse which in and of itself likely raises risk for falls; look at Table 1 below, Demographics, and you will see about 40% in both HIV+ & HIV-negative groups have a history of alcohol use/abuse & opioids with 10-11% with a history of opioids. Also in Table 1 dementia (vascular & Alzheimers is 3 times higher in the HIV+  group. And HCV is more than 2 times greater in the HIV+ group, any viral disease affects overall systemic integrity including vascularity. I speak to lots of clinicians and many older HIV+ patients are increasingly experiencing multiple falls, this is not good. In Table 2- Multivariate Analysis- you see HIV+ >50 years old have an 18% greater risk for a fall compared to HIV-negative <50 and again put this in the context of that this comparator group is not a healthy group of people. Its noteworthy that falls incidence doubled in HIV+ from age 35 to age 65, and increased for HIV-negatives from 20 to only 30, a much larger increase in HIV; you can see this in Figure 1 where age 35-44 the numbers of falls increase much more for HIV+ vs HIV-negatives & the differences between the HIV+ vs HIV -neg continues to expand further with advancing age such that by age 65 the difference is about double for HIV+ vs HIV-negative. Falls are associated with cognitive impairment, neuropathy and fractures, this is a hallmark of the HIV+ Aging Patient Population. Many studies report increased falls & fractures in all HIV+ patient populations. The burden for this on patients, doctors & the healthcare system will worsen quite a to & increase much with time. Regarding accelerated or accentuated, I strongly that HIV accelerates aging. The reason VA researchers may say accentuation is I think because only some comorbidities appear to them to be accelerated perhaps & others don’t but I do not disagree that some comorbidities have different progression rates, for example, cancers do not appear to be necessarily accelerated but CVD & bone disease do. The authors in this study conclude based on reported falls in HIV+ vets vs HIV-neg vets that this proves accentuation & not acceleration is frankly ridiculous. These are reported falls, the number of falls do not necessarily reflect underlying immune senescence.

Veterans with HIV had a higher incidence of medically significant falls than veterans without HIV in a 130,000-person study [1]. Age over 50 independently predicted falls in veterans both with and without HIV. Other independent fall predictors were female sex, white race, and being underweight.

Veterans Aging Cohort Study (VACS) investigators set out to explore links between HIV status, age, race, and other variables and medically significant falls. This longitudinal cohort analysis included 130,107 HIV-positive and negative veterans in care between 1996 and 2009. The VACS team identified medically significant falls by injury codes and by a machine learning algorithm that identifies falls in radiology reports. To pinpoint fall predictors they used generalized estimating equations with autoregression correlation. 

The analysis included 43,615 veterans with HIV and 86,492 HIV-negative veterans (34% and 66%). Both groups had a baseline age of 47 years. The HIV group had a lower proportion of whites (38% vs 40%) and a higher proportion of blacks (49% versus 47%) (P < 0.0001), a lower average body mass index (25 versus 30 kg/m2, P < 0.0001), and higher proportions with HCV infection (27% vs 11%, P < 0.0001), anemia (29% versus 14%, P < 0.0001), and dementia (0.7% versus 0.2%, P < 0.0001). Women made up 2% of each group. 

Both groups took an average of 4 medications with higher proportions of the HIV group taking opioids (13% vs 11%) and lower proportions taking muscle relaxants (3% vs 5%) and anticonvulsants (2% versus 3%) (P < 0.0001 for all medication differences).

Age at first fall averaged 48 overall, and fall incidence was significantly higher in the HIV group (30 vs 27 per 1000 person-years, P < 0.0001). Fall incidence rose faster with age in HIV-positive veterans (about 20 to 45 per 1000 person-years from age 35 to 65) than in HIV-negative veterans (about 20 to 30 per 1000 from age 35 to 65). 

Multivariable analysis adjusted for demographics, comorbidities, and medications determined that, compared with HIV-negative veterans under age 50, older HIV-positive veterans and older HIV-negative veterans both had higher odds of a medically significant fall (adjusted odds ratio [aOR] 1.18, 95% confidence interval [CI] 1.12 to 1.25, P < 0.0001, with HIV; aOR 1.13, 95% CI 1.09 to 1.16, P < 0.0001, without HIV). HIV-positive veterans younger than 50 had lower odds of a significant fall than HIV-negative veterans younger than 50 (aOR 0.89, 95% CI 0.85 to 0.93, P < 0.0001).

Compared with men, women had 40% higher odds of a medically significant fall (aOR 1.40, 95% CI 1.30 to 1.51, P < 0.0001). Compared with whites, blacks had almost a 20% lower chance of a fall (aOR 0.82, 95% CI 0.80 to 0.85, P < 0.0001). Compared with normal-weight veterans, underweight veterans had 35% higher odds of a fall (aOR 1.35, 95% CI 1.26 to 1.44, P < 0.0001), while overweight veterans and obese veterans both had lower odds of a fall (aOR 0.85, 95% CI 0.83 to 0.88, P < 0.0001, for overweight; aOR 0.81, 95% CI 0.78 to 0.84, P < 0.0001, for obese). 

Given the significantly greater fall incidence in veterans with HIV, the researchers recommend that HIV-positive people over age 50 should be assessed for fall risk.

Reference

Womack JA, Murphy TE, Bathulapalli H, et al. longitudinal association between HIV status and medically significant falls. Conference on Retroviruses and Opportunistic Infections (CROI), February 13-16, 2017, Seattle. Abstract 930. http://www.croiconference.org/sites/default/files/posters-2017/930_Womack.pdf 

 
 
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