A 75-year-old man presented in May 2003 with suspected drop attack (atonic seizure). He reported falling over and losing consciousness. He was a retired, single ex-smoker, who lived alone in an apartment that was in a poor state of repair with precarious hygienic conditions.
Over the course of 2 years he had unintentionally lost more than 10 kg (22 lbs) in weight. He had been diagnosed with diabetes approximately 10 years prior, and was receiving treatment with oral hypoglycemic therapy (fenformin/ glibenclamide, 25/2.5 mg, bid). He had been hospitalized for pneumonia in 2000.
In recent months, he had gone to the emergency department several times (about once every 2 weeks) due to his weight loss and asthenia, without obtaining a definite diagnosis.
On physical examination, his cognitive status was normal, but his nutritional status was deteriorated. Other clinical findings were negative. Blood chemistry tests revealed hypoalbuminemia (26.00 g/L). His personal hygiene was precarious and the apartment was completely neglected despite assistance by social support networks.
In conversation with the social support worker, it was revealed that the patient was homosexual; with the patient's informed consent, he was tested and found positive for HIV. He was consequently transferred to the Infectious Diseases Department, where further biochemical tests revealed:
* HIV-RNA Quantitative > 100.000 copies/ML COBAS Amplicor
* antibodies anti-HIV 1-2 reactive sample (Enzygnost HIV Integral and Axsym HIV 11/42 G0 [Abbott] EIA method)
* antibodies anti-HIV 1 positive (Western Blot).
The patient's serum also tested positive for syphilis (TPHA positive 1:320). The patient refused any specific treatment, left the hospital, and was lost to follow-up.
Key words: AIDS infection * sexuality * elderly
Infection with the human immunodeficiency virus (HIV) and its result acquired immunodeficiency syndrome (AIDS) is a worldwide problem affecting individuals of all ages and backgrounds. (1) More than 10% of HIV infection is found in adults age 50 and older; (2) it is difficult to determine rates of HIV infection among older adults, however, because few people over age 50 at risk for HIV routinely get tested. (3)
In 1991, nearly 1 million homosexuals were over age 65. (4) It is estimated that there are more than 60,000 people age 50 or older living with AIDS in the United States; more than 50,000 AIDS carriers in this age group have died since the epidemic began. (5)
The clinical manifestations of HIV infection in elderly patients are similar to those in younger patients. Certain symptoms of HIV infection (eg, fatigue, anorexia, weight loss, memory problems) are nonspecific and may be attributed to other diseases that are common in old age. As a result, appropriate diagnostic evaluation is often delayed (typically up to 10 months). (6)
HIV is diagnosed in older adults as in young people, by the detection of HIV itself, antibodies to HIV, or one of HIV's components. Antibodies anti-HIV generally appear in the circulation 4 to 8 weeks after infection. The standard screening test for HIV is the enzyme-linked immunosorbent assay (ELISA-sensitivity > 99.5 %). A positive ELISA result must be confirmed by the Western Blot test, a more specific assay.
AIDS is diagnosed by a positive serology for the HIV-1 virus and a CD4+ T-lymphocyte count < 200 [micro]L (< 0.2 x 109/l), or by the presence of an AIDS-indicator disease. There is little difference in the initial AIDS-defining diagnosis between younger and older patients. (6) The most predominant AIDS indicator diseases across all age groups are:
* Pneumocystis carinii pneumonia (in 75% of all cases) and
* candidal esophagitis (in 15% of all cases). (6)
Other AIDS-indicator diseases in older adults include:
* extrapulmonary cryptococcosis
* toxoplasmosis of the brain
* cytomegalovirus disease
* recurrent bacterial pneumonia
* Mycobacterium avium complex infection, and
* Kaposi's sarcoma. (6)
Age per se is an important predictor of progression in HIV infections.7 Numerous studies conducted before the era of antiretroviral therapy showed that older individuals have a more severe course of disease in HIV and a shorter survival. (6) More people are acquiring HIV infection later in life, rather than just being diagnosed later, but their survival is still shorter, possibly because of the compounding effect of co-morbidities. (8) In fact, early HIV symptoms--such as weight loss, fatigue, and declining physical and mental activity--are often mistaken for other diseases common in older adults (eg, Parkinson's, Alzheimer's, and respiratory diseases). As individuals age, any symptoms of HIV are often more readily attributed to "normal" aging. (8) This misinterpretation of HIV symptoms can lead to a delay in seeking medical care. (9)
The first article on older adults with AIDS appeared as a case report in 1984. (10) Three cases of AIDS in patients over age 60 were presented and were characterized by late diagnosis (because AIDS was not suspected) leading to a fatal short-term evolution in all cases. (11) In a recent case report, an 83-year-old heterosexual man with malaise tested positive for HIV infection. (12) A major finding of the latter study was that survival among older patients with AIDS was substantially longer than had previously been claimed in the literature. (13) The authors also observed a significantly better survival among patients given antiretroviral therapy; antiretroviral therapy was the only significant predictor of survival after AIDS had been diagnosed, just as it is a survival predictor in younger adults. (13) Older age may not necessarily be associated with more rapid disease progression and reduced survival times in persons with HIV infection or AIDS. (13)
Whereas blood transfusion was thought to be the primary mode of transmission in the past, (2) the primary mode of HIV transmission for older adults today is sexual contact. (14) Although Keitz et al (15) suggested that patients age 50 or older were less likely to acquire HIV via homosexual contact, male-to-male unprotected sex with an infected partner accounts for about 60% of all AIDS infection among older adults, and it is the main risk behavior associated with HIV infection among older adult Americans. (16) In fact, the highest risk of infection is anal (anorectal, oral-anal and digital-anal) sexual intercourse, where the virus is transmitted through contact with infected bowel epidural cells and breaks in the anal mucosa, enabling access to the bloodstream. Kingsley et al (17) showed that anal receptive intercourse accounted for nearly all new HIV infections among homosexual men. This finding was recently confirmed by Chen et al. (18)
Injection drug use is another mode of HIV transmission in older adults, although the specifics are in question. In fact, Keitz et al (15) showed that older patients are less likely to acquire HIV from intravenous drug use. Late middle-aged and older adults are seldom considered serious substance abusers. As with sexual habits, physicians tend not to ask older patients about drug abuse. It is commonly assumed that, even if patients ever were substance abusers, it was so long ago that it no longer matters.
Sexuality in older adults
Despite the dominant stereotype of the "asexual older person," studies on sexual activity among older adults showed that a high percentage (81.5%) of subjects over age 50 were involved in one or more sexual relationships, (14) including unprotected sex with prostitutes. In men, sexual activity is reported to decline with increasing age: of those living with a partner, sexual intimacy decreases from over 90% under age 60 to 61% over age 60. (19) The decline of sexual activity, however, occurs much earlier and in a more pronounced way in men who do not live with a partner: their sexual activity declines substantially between ages 41 and 60 (from 74% to 56%) and is further reduced to 17% after age 60. (20) Twenty percent to 30% of aging men complain of decreased libido, difficulties in sexual excitability, and loss of orgasm intensity. (20)
With the use of clinically effective oral medications for erectile dysfunction, levels of sexual activity in the older population have increased, however, (14) and have also facilitated the spread of HIV infection. Gender differences have been observed with regard to sexual activity. Starr and Weiner (22) questioned 800 adults over age 60 about key aspects of their sexual behavior and found that 92.7% of men and 70.4% of women were still sexually active. But it is well known that talking about the sexual needs of women, and older women in particular, is still taboo. Men are more likely to report multiple sexual partnerships than women, irrespective of marital status, for all age groups. (22) These results go against the common conviction that married older men have only one sexual partner.
Older adult women are consequently at risk of HIV infection during intercourse--even moreso than younger women due to age-related reductions in vaginal lubrication and thinning of the vaginal walls caused by estrogen loss compounded by a deterioration of the immune system. (23) As a result, the vaginal mucosa more likely sustains micro-tearing during intercourse, affording easier access for the virus.
Western society's views on sexuality in older adults are dominated by stereotypical thinking, ignorance, and prejudice, which can negatively influence the clinical interview process. We believe that physicians rarely consider their older patients to be at risk for HIV. This is because most doctors consider older adults "asexual," and thus rarely--or never--ask patients over age 50 questions about sexual activity, sexual satisfaction, or HIV/AIDS, or discuss risk factor reduction. Keeping in mind that all humans, regardless of age, need love, physical contact, companionship, and intimacy, (24) primary care physicians need to discuss sexual activity with all patients, but especially with those individuals at high risk (lesbian, gay, bisexual, and transgender). Older adults continue to have sexual contact and studies show that sexual satisfaction with partner relationships even increases with age. (19)
The majority of people over age 50 with AIDS reported that they received "not much" or "hardly any" information about HIV; for information they did receive, the most common source was the media (magazines and television). (14) This lack of information may be related to the fact that physicians often do not mention sexuality with older patients, so sexual histories are not routinely included in patient assessments in this age group. (14)
Only a small minority of individuals over age 70 said that they consistently used condoms even though they reported having more than two partners in the past five years. (25) This is partly because condom use, being historically linked to pregnancy prevention, is often ignored by heterosexual older adults. Stall and Catania3 reported overall low preventive measures during sexual intercourse for Americans older than age 50, as compared with the younger population; 92% of responders never used condoms, and 95% never had HIV testing. Many physicians do not suspect HIV in their older patients and miss the opportunity to suggest testing. Further education may be needed for professionals working with older people to encourage them to acknowledge the sexual health needs of their older patients, and perhaps overcome their own prejudices and stereotypes about later-life sexuality. (14)
Controlling and reducing the growing HIV/AIDS pandemic is one of the biggest challenges the world faces in the 21st century. Particularly, little attention has been given to the impact of the HIV epidemic on the geriatric population. This neglect has occurred despite the continually rising incidence of HIV infection among older adults (although it is obviously neither the most widespread disease, nor the greatest cause of death or disability in this age group).
HIV/AIDS has traditionally been seen as a disease of the younger generation, but now people are growing older with HIV. Given long-term treatments, HIV is now a chronic disease in an aging population with related and unrelated co-morbid conditions. Primary care physicians across the country, not just those in large metropolitan areas, can expect to see older adults in their practices with HIV/AIDS.
Primary care physicians who treat older adults need to be more proactive and broach the topic of sexual activity; they must recognize that individuals may be sexually active despite perceived age, illness, or disability. Sexual activity is a component of individual well-being, and sexuality is a part of self-identity at any age. Sexual activity is a primary basis for human relations, and a fundamental right of every adult in society. For older adults, a satisfying sex life is one way to feel "normal" when so much else about life has changed. Sexual activity can be a powerful source of comfort, pleasure, and intimacy. Particularly lesbian, gay, bisexual, and transgender older adults require a comprehensive medical, behavioral, mental health, and social support evaluation, as do all seniors.
Ultimately, we need to be less shy in approaching the sexual life of our older patients and establish an open, calm atmosphere of communication.
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Dr. Inelmen is a researcher in geriatrics in the Department of Medical and Surgical Sciences, Geriatrics Section, University of Padua, Italy.
Dr. Gasparini is a researcher in geriatrics in the Department of Medical and Surgical Sciences, Geriatrics Section, University of Padua, Italy.
Dr. Enzi is professor of geriatrics, Department of Medical and Surgical Sciences, Geriatrics Section, University of Padua, Italy.
Disclosure: The authors report no disclosures related to the content under discussion.
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