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This article is a pre-published chapter from the upcoming 2021 Fundamentals of HIV Medicine textbook. We anticipate the entire publication will be available for purchase in Spring of 2021. Please check the Academy’s website at www.aahivm.org for updates!
Comprehensive Geriatric Assessment (CGA)
CGA is defined as a multidisciplinary diagnostic and treatment process that evaluates medical, psychosocial, and functional deficits in order to develop a coordinated intervention/plan to maximize overall health with aging (Stuck, 1993). CGA is based on the idea that a systematic evaluation of an older person may lead to early detection of geriatric problems, help prevent complications and aid the formation of comprehensive treatment plans (Bellera, 2012).
There is no peer-reviewed literature to demonstrate the efficacy of CGA in older PWH, although due to increased risks of geriatric syndromes in older PWH, many studies advocate for CGA in this population. In HIV-negative patients, CGA in the home may improve functional status, prevent institutionalization, and reduce mortality (Huss, 2012). CGA in the hospital, especially in dedicated Acute Care for the Elderly (ACE) units, may improve survival (Ellis, 2017). Although CGA as part of inpatient geriatric consultation (except for specific conditions such as hip fracture) have shown little benefit (Stuck, 1993; Ellis, 2017). CGA in the outpatient settings has not been found to consistently show benefits (Stuck, 1993), possibly due to variability in adherence to recommendations in CGA. Studies have shown that more complex CGA programs that address adherence or target patients at higher risk of admission may improve outcomes including physical functioning, social functioning, pain, mental/physical/emotional health and overall well-being (Reuben, 1999).
Performing CGA in PWH
How CGA is conducted will depend on resources including time and available team members. Consider avoiding assessing all domains of CGA in a single visit – this could be overwhelming and tiring for an elderly patient and their family members. It may make sense to prioritize domains that are most likely to be abnormal or most urgent (likely to cause complications or catastrophic outcomes), which depends on the patient profile. Once the most urgent domains have been managed, patients can be brought back to complete the remaining non-urgent domains at subsequent visits. Various team members may be delegated certain domains of the CGA based on their expertise or availability. For example, it may make sense for a pharmacist to assess patients for polypharmacy instead of a physician.
There is no consensus on selection criteria for patients who may benefit from CGA However, prior programs have used criteria such as age, medical comorbidities/complexity, specific geriatric syndromes such as falls/dementia, previous or predicted high utilization rates, or at times of transition, such as from hospital to home, or from home to nursing homes.
There is no consensus on what domains should be included in CGA and what tools are appropriate for each domain. However, most programs include some or all of the following domains. Except when noted, corresponding interventions are described in more details in the European AIDS Clinical Society guideline, accessible through website or mobile app at https://www.eacsociety.org/guidelines/eacs-guidelines/eacs-guidelines.html (EACS, 2020).
1. Functional status
Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) have been utilized in PWH, are simple to perform and can readily identify essential deficits that may guide interventions. To assess function, providers may ask about ADL/IADL and determine who does them (patient or others). ADLs consist of tasks such as bathing, dressing, grooming, toileting, transferring, and eating. IADLs consist of cooking, shopping, managing medications, using the phone, doing housework, doing laundry, driving or using public transportation, and managing finances (Katz, 1963).
For subjective measures, PWH may be asked if they had a fall in the past 12 months, defined as unexpectedly dropping to the floor or ground from a standing, walking or bending position (Erlandson, 2012; Ruiz,2013; Erlandson, 2016). This can be used as a screening question, and if positive, objective tools can be subsequently used for more detailed assessment. For objective measures, providers may use the Timed Get-Up-and-Go (TUG) test (Podsiadlo, 1991), in which the patient is timed while he/she rises from a chair, walks 3 meters, turns, walks back, and sits down again. The TUG has been used in prior HIV studies (Grinspoon, 1996; Grinspoon, 1998) and explores multiple components of mobility, including gait speed, balance, and proximal muscle strength. The TUG has also been shown to correlate with functional capacity and more formal tests on balance and gait speed (Podsiadlo, 1991). Although various cutoffs have been used in prior studies, the CDC recommends that an older adult who takes ³12 seconds to complete TUG should be considered at risk of falling (CDC, 2017).
There is no consensus on the best tools to assess for frailty in older PWH (Conroy, 2009; Brothers, 2019). The Fried frailty phenotype (Fried, 2001) is commonly used in HIV research and has been operationalized for clinical practice in one study (Rockwood, 2007) to consist of five components (no items=robust, 1-2=pre-frail, 3-5=frail):
The VACS index is another frailty tool specifically validated in PWH, with more details described elsewhere. An online calculator is accessible at: https://vacs-apps2.med.yale.edu/calculator. Prior HIV studies have also used the frailty index (Jacqueline, 2020). Because the frailty index follows the cumulative deficit approach and assesses for at least 30 and up to 75 health variables (Searle, 2008), this may prove cumbersome in clinical practice.
4. Cognition/safety concerns
Age is a risk factor for cognitive impairment associated with HIV as well as other causes (Chan, 2014). It should be noted that many studies of cognitive impairment screening in PWH focus on the entity of HIV-associated neurocognitive disorder (HAND), although in clinical practice, providers would likely need to screen for cognitive impairment from all causes as older PWH are not immune from Alzheimer’s or vascular dementia. Providers may consider using the Montreal Cognitive Assessment (MoCA), since it has been studied extensively in PWH (Rosca, 2019; Sangarlangkarn, 2019) and is commonly used to screen for other causes of cognitive impairment. The HIV Dementia Scale (Power, 1995) and the International HIV Dementia Scale (Sacktor, 2005) were developed to screen for HAND, but their effectiveness in screening for other causes of dementia is unclear and are less sensitive for milder forms of HAND. Even though the Mini-Mental Status Exam (MMSE) is regularly used in HIV-negative individuals, it does not assess for executive function, which may be impaired in HAND (Valcour, 2011). Neuropsychological testing may be inaccessible, time-consuming and without evidence-based superiority compared to in-office testing in its ability to improve patient-centered outcomes such as improved function or cognition.
Depression and posttraumatic stress disorder (PTSD) are common in older PWH, (Gallagher, 2008). Screening for depression and assessment of its severity are important, since depression affects quality of life and medical compliance. Multiple tools have been used in PWH to screen for depression, including the Patient Health Questionnaire (PHQ-2) with subsequent diagnostic PHQ-9 (EACS, 2020; Chibanda 2016), the Beck Depression Inventory II (BDI-II) (Rodkjaer, 2016), or the Center for Epidemiological Studies (CES-D) (Mueses-Marin, 2019). Although as many as 14 tools have been used to screen for PTSD in PWH (Gallagher, 2008), the posttraumatic stress disorder checklist (PCL-5) was validated for use in HIV primary care (Verhey, 2018). Because the understanding and perception of depression or other mental illnesses can be affected by culture, it is important to use tools that have been validated locally if available (Sangarlangkarn, 2019).
Older PWH face a unique challenge of managing the burden of HIV disease in the context of chronic multidrug antiretroviral therapy, increased risk of polypharmacy due to multimorbidity, decreasing end organ function, and physiologic pharmacodynamic changes resulting in a narrower therapeutic index for many drug therapies. HIV providers need to be aware of polypharmacy in older PWH and take steps to optimize medication safety and effective medication use.
The term “polypharmacy” has been variably defined in the literature, usually meaning that a patient medication profile has reached a threshold number of medications (often 5 or more) with the degree of polypharmacy correlated to a larger number of absolute medications, though it has also been associated with duration of time on multiple medications, and characterized as to whether or not multiple medications were appropriate for a given condition (appropriate vs inappropriate polypharmacy) (Masnoon, 2017). The nature of chronic combined antiretroviral therapy for PWH in an aging population already at risk of higher medication burden predisposes for potential drug therapy issues (drug interaction, additive adverse effects/toxicities, pharmacodynamic sensitivity, pill burden, medication errors, etc.). Consequently, it has been shown that the burden of polypharmacy is greater in older PWH than older patients in the general population (5Kong, 2019) and also greater than in younger PWH (Marzolini, 2011; Holtzman, 2013).
Other domains addressed elsewhere:
Aroonsiri Sangarlangkarn MD MPH
Assistant Professor of Medicine
Section of Geriatrics, Division of General Internal Medicine
Temple University Hospital