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  Conference on Retroviruses
and Opportunistic Infections (CROI)
February 13-16, 2017, Seattle WA
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Frailty Stronger Than Neurocognitive Impairment in
Predicting Falls-Disability-Death
  Conference on Retroviruses and Opportunistic Infections (CROI), February 13-16, 2017, Seattle
[ from Jules: of note this study did not break out outcomes by IDU history or age, only that the study looked at people over 40, and patients were in the ACTG which I think indicates perhaps higher functioning than perhaps more marginalized patient populations. 49% were white and we know health disparities persist among Blacks & Hispanics in the US and among HIV+.
...... the outcome that frailty is worse than neurocognitive impairment (NCI) in terms of this study outcome - falls, disability and death - is not surprising to me because frailty includes affects on balance and walking ability. But this study found having frailty+NCI is worse than frailty or NCI alone. Both frailty & NCI are problems in the older aging population, frailty worsens with aging & a significant percent, more than many might expect or appreciate have cognitive or neurologic impairment, and all too often patients been at younger ages do not realize they have cognitive impairment, and of course there is no evaluation by doctors or providers for NCI or frailty. Its only in older age when NCI might worsen and when frailty worsens & becomes a factor that when you combine both, as they saw in this study that frailty+NCI had the worst outcome for falls, disability & death, and this will certainly worsen with time as the aging population grows even older. The DOHs in these locales - SF, Boston, NY, Florida - report 80% over 45, 50% over 50 and 20% over 60, so most people in the US are over 50 or very close to be over 50, this IS the most important problem for patients with HIV in the US ! But the issues related to daily function & activities for patients - that lead to falls, disability & death - receives no attention & is not recognized hardly at all in terms of a federal program providing special support services for patients & education for clinicians, except for 2 Aging clinics recently opened and funded privately, no funding from the federal, state or city government in NY at Cornell [http://www.natap.org/2016/AGE/AGE_13.htm] and in SF at SF General, Golden Compass Aging Clinic / program launches at SF General - "one-stop shop for HIV-positive people age 50 and older" - (02/13/17).
When will the NYC HIV & DOH and Ryan White Council wake up and begin to address the problem, And of course more important is when will the federal government begin to address this. I have called for a National Discussion on aging with HHS, NIH. And when will we stop getting these poorly done survival studies misleading people into thinking HIV+ or more particularly HIV+ aging, older frail patients with multicomorbidities & polypharmacy may have near normal survival, because these published studies are unable to consider the affects of multicomorbidities & polypharmacy on older aging patients, none of the studies have factored this in. Here is an exception showing HIV+ over 50 - "we detected a 1.6-fold increased risk of death of among HIV-infected individuals ≥ 50 years without comorbidity compared with population controls without comorbidity: ...http://www.natap.org/2016/HIV/020816_05.htm]
Mark Mascolini
Frailty and neurocognitive impairment (NCI) each independently predicted falls, disability, and death in an 897-person AIDS Clinical Trials Group (ACTG) cohort [1]. But frailty proved the stronger predictor, about as strong as frailty and NCI combined.
ACTG investigators who conducted this study observe that frailty and NCI are closely related, and their previous work identified NCI as one of the strongest frailty predictors in people with HIV. They conducted the new study to explore associations between frailty and NCI--alone and together--and three serious outcomes: falls, disability, and death.
Study participants were HIV-infected adults 40 or older who received their first antiretroviral regimen in an ACTG trial. Each completed a standard frailty assessment incorporating a 4-meter walk, grip strength, and self-reported weight loss, exhaustion, and low physical activity. Participants completed three neurocognitive tests and researchers used results to define NCI. Every 24 weeks participants reported falls, and every 48 weeks they reported disability (an increase from baseline in 1 or more Instrumental Activities of Daily Living). The investigators tabulated these outcomes and mortality over 96 weeks.
Of the 954 study participants, 44% were 40 to 49, 41% were 50 to 59, and 15% were 60 or older. Most participants, 81%, were men, 49% were white, 31% black, and 20% Hispanic. People had been taking antiretrovirals for a median of 7.7 years, and 76% had a viral load below 200 copies on more than 75% of visits.
Among 897 participants with outcome data, 4% were frail, 14% had NCI, 2% had both frailty and NCI, and 80% had neither. Proportions with at least one of the three outcomes (falls, disability, death) were 28 of 37 (76%) with frailty, 59 of 123 (48%) with NCI, 15 of 17 (88%) with both frailty and NCI, and 261 of 720 (36%) with neither frailty nor NCI.
In an age-adjusted log-binomial model, frailty plus NCI (vs no frailty and no NCI) proved the strongest predictor of the three outcomes (risk ratio [RR] 2.11, 95% confidence interval [CI] 1.70 to 2.60). But frailty alone predicted the three outcomes almost as strongly (RR 1.96, 95% CI 1.59 to 2.41). NCI alone also predicted the three outcomes, but less robustly than frailty alone (RR 1.33, 95% CI 1.09 to 1.61) (P < 0.001 for all associations). Results of an insurance-adjusted analysis were similar. But in an education-adjusted analysis, NCI alone was a stronger outcome predictor (RR 2.14, P < 0.001) than frailty plus NCI (RR 2.09, P < 0.001) or NCI alone (RR 1.24, P = 0.05).
"Although frailty and NCI may share similar pathologic mechanisms," the researchers suggest, "interventions targeted at reducing and reversing frailty may have greater impact on these adverse outcomes than NCI-specific interventions."
1. Erlandson K, Abdo M, Robertson K, et al. Frailty has a stronger association than neurocognitive impairment with poor outcomes. Conference on Retroviruses and Opportunistic Infections (CROI), February 13-16, 2017, Seattle. Abstract 665. http://www.croiconference.org/sites/default/files/posters-2017/665_Erlandson.pdf
Frailty has a Stronger Association than Neurocognitive Impairment with Poor Outcomes
Kristine M. Erlandson1, Mona Abdo2, Kevin Robertson3, Susan L. Koletar4, Robert Kalayjian5, Babafemi Taiwo6, Frank J Palella Jr6, Katherine Tassiopoulos2 1 University of Colorado, Aurora, CO, USA; 2 Harvard T.H. Chan School of Public Health, Boston, MA, USA; , 3 University of North Carolina, Chapel Hill, NC; 4Ohio