Alcohol, HIV, AIDS and Older Adults
At age 75, Ben is what is generously called a "heavy drinker". He lives in a SRO (single room occupancy -in other words marginal one-room housing in the downtown core). He worked all of his life, and has two solid pensions (over $2200 a month) one from the armed forces, and another from the major brewery.
I met first Ben, he was coming off a bender. As we sat drinking coffee, he was surprisingly candid about what had happened over the previous days. One of his pension cheques came in, so he went to the bar to "have a few" and to "see the ladies". Now he has next to nothing in his wallet. He says "It is ok, there'll be another cheque along in ten days."
Ben regularly experiences a problem. He often has "friends" that show up to drink with him when the cheque comes in, and on occasion he has sexual relations with one of the women in exchange for sharing his good supply or he has sex with a prostitute. Ben's lady friends are heavy drinkers, and they've dabbled in quite a variety of drugs over the years. I asked him about if he takes precautions, and he just looked at me quizzically.
From Ben's descriptions of his life, his risk of developing HIV/AIDS are significant, but he is completely oblivious to that possibility. It may be that the length of time he has been drinking and the quantity he drinks significantly affect his overall judgment and his risk taking.
Here's what some of the current research tells us about older adults and HIV/AIDS (from Ageline):
1. It happens, and a lot more frequently than we might think.
Although the perception exists that older adults are not at great risk for HIV, data from the National AIDS Behavior Study indicates that 10 percent of persons over age 50 have, at minimum, one risk factor for infection. (Zellentz & Epstein, 1998)
At the same time, approximately 10 percent of AIDS cases are among people older than age 50. Many health care providers lack an awareness of the risk of HIV/AIDS in the older population (Wooten, 1999, Rickard, 1995). Part of this relates to the fact that many health care providers tend to think of older adults as non-sexual individuals. (Mueller, 1997)
2. A good portion of the HIV among older adults occurs through sexual contact.
In a recent study, 38 percent of the infected older adults acquired HIV/AIDS through sexual contact, 16 percent were infected through intravenous drug use, and only 9 percent from infusions.
3. Older adults often do not view themselves as at risk.
One risk factor for older adults is that they often do not view themselves as being at risk for HIV/AIDS. Therefore they may not take precautions, such as using condoms or practicing "safe sex". (Szirony, 1999, Mueller, 1997))
In addition, they are particularly vulnerable to the social stigma of the disease, because of the prevailing cultural image that they are not sexually active (Mueller, 1997) or their sexuality is expressed passively (Rickard, 1995).
4. The other risk factors are varied.
Other risk factors are homosexual or bisexual behavior, heterosexual contact, intravenous drug use, and age-related decline in immune function. (Szirony, 1999)
HIV/AIDS disproportionately affects older minority persons in comparison to older whites. Minority groups face both higher incidence rates of HIV/AIDS and higher mortality rates (Brown & Sankar, 1998)
5. So, don't necessarily assume it involves heterosexual contact.
A 1992 Australian study on active homosexual men found that 10% were aged 50 and over. They were likely to live alone (52.7 percent), and to be or have been married (62.9 percent). Older men are less likely than younger men to have disclosed their sexual orientation. Older men reported having had as many male and female sexual partners in the past 6 months as did younger men. (Van-de-Ven-Paul, Rodden, et al, 1997)
6. Misdiagnosis is common.
There are many issues confounding timely diagnosis and treatment for older adults. Initial complaints of an undiagnosed older adult can vary from nonspecific constitutional symptoms to those resembling an AIDS-defining disease. (Zellentz & Epstein, 1998)
Many older people with HIV/AIDS are misdiagnosed with other ailments. One study found that dementia was the only sign of HIV infection in 25 percent of patients investigated. (Whipple & Scura)
Both normal age-related changes in the immune function and poor nutrition may confound the differential diagnosis or contribute to disease progress. (Zellentz & Epstein, 1998)
Major manifestations of HIV/AIDS in older adults include pneumonia, herpes zoster, tuberculosis, cytomegalovirus, oral thrush, and HIV dementia, (Wooten, 1999)
Opportunistic infections associated with AIDS often are misdiagnosed as other chronic conditions that commonly affect older adults. (Szirony, 1999)
7. As a result, the HIV/ AIDS is often discovered much later than in younger adults.
The process of differential diagnosis should include a history to uncover risk factors. (Whipple & Scura)
8. At present, the overall situation can be more difficult for older adults
Older persons living with HIV/AIDS had greater physical limitations, were less likely to disclose their HIV status, and reported more comorbidities such as diabetes or hypertension (Nokes, Holzemer et al, 2000)
The disease develops and progresses differently in older adults compared to younger adults. Being older affects how long they survive. Survival is affected by differences in their social and economic characteristics, medical comorbidity, psychiatric comorbidity, and their access to medical care. (Crystal & Sambamoorthi, 1998) Older adults are also affected by receiving inappropriate treatment.
Even if the diagnosis is made early, drug therapies create their own difficulties, such as interactions with one of the many other prescribed medications an older person may be taking.
Also, older adults in general have a higher risk of developing side effects and less ability to tolerate those side effects from drug therapies (Wooten, 1999, Szirony, 1999)
9. The diagnosis can be devastating for the older adult.
HIV/AIDS can have a profound psychosocial effect on older adults. Responses include initial shock and denial, depression, suicide (Cellucci & Cellucci, 1998). They face stigmatization, Many older adults with HIV/AIDS tend to experience extreme social isolation (Rickard, 1995)
10. It can have a deep impact on family too.
In many cases, the older adult's disclosure of having HIV involves admissions that are deeply traumatic to the family (Whipple & Scura, 1996), particularly where the person is disclosing not only the disease, but also disclosing his sexual orientation to family.
11. The prognosis is worse for older adults.
In 1983-1984, median survival for older and younger people was 153 versus 274 days, respectively. By 1991-1992, median survival had improved for both groups: 396 and 731 days, respectively. (Justice & Weissman, 1998) However, the relative and absolute gap in survival grew.
As age increases, the incidence of mortality does as well; 37 percent of individuals aged 80 and older have been reported to die within a month of diagnosis. (Zellentz & Epstein, 1998)
A substantially larger proportion of older adults died within 90 days of diagnosis, plus older people are failing to benefit from new effective therapies as much as their younger counterparts. (Justice & Weissman, 1998)
12. Older people can look at the disease somewhat differently than younger adults.
Age or maturity influences older adults' emotional reactions to the HIV/AIDS, their experiences living with the disease, and their coping capacities.
On the positive side, some older adults will express that they do not feel as cheated by the illness (as a younger person might). When talking about perceived advantages of dealing with it at their age, some stress with age comes wisdom; with age comes greater respect for health and life; with age comes patience, contentment, and moderation. Some express that older people are less psychologically threatened by disability and fatigue; and older people can focus more on their own needs.
They also see the downsides. These are that older people' bodies are more worn down and less resilient; older people are more socially isolated; older people get less sympathy and are judged more harshly; doctors set higher goals when treating younger patients; and older people are too compliant and conservative. (Seigel, Raevis, 1998)
Brown, D.R & Sankar, A. (Nov. 1998).HIV/AIDS and aging minority populations. Research on Aging. Vol. 20 (No. 6): p. 865-884.
Cellucci, L.W. & Cellucci, T. (1998). HIV disease and the elderly: coming of age in the era of AIDS. In Redburn. D.E. & McNamara, R. P. (eds) Social gerontology. Auburn House, Westport, CT, p. 93-113.
Mueller, M. R (Nov, 1997). Social barriers to recognizing HIV/AIDS in older adults . Journal of Gerontological Nursing. Vol. 23 (No. 11): p. 17-21 (5p.).
Nokes, K.M., Holzemer, W. L. et al (May, 2000) Health-related quality of life in persons younger and older than 50 who are living with HIV/AIDS. Research on Aging. Vol. 22 (No. 3): p. 290-310
Rickard, W. (Sept. 1995). HIV/AIDS and older people. Generations Review.Vol. 5 (No. 3): p. 2-6.
Siegel, K., Raveis, V., & Karus, D. ( Nov. 1998) Perceived advantages and disadvantages of age among older HIV-infected adults. Research on Aging. Vol. 20 (No. 6): p. 686-711.
Szirony, T. A. (Oct. 1999). Infection with HIV in the elderly population. Journal of Gerontological Nursing. Oct 1999; Vol. 25 (No. 10): p. 25-31.
Van-de-Ven, P., Rodden, P., Crawford, J. et al. (1997). Comparative demographic and sexual profile of older homosexually active men. Journal of Sex Research. Vol. 34 (No. 4): p. 349-360
Whipple, B. & Scura, K. W. (Feb 1996). Overlooked epidemic: HIV in older adults. American Journal of Nursing. Vol. 96 (No. 2): p. 23-29
Wooten, B. K. (Sep-Oct 1999) HIV and AIDS in older adults. Geriatric Nursing.Vol. 20 (No. 5): p. 268-272.
Zelenetz, P. D. & Epstein, M.E. (1998) HIV in the elderl. AIDS-Patient Care and STDs.Vol. 12 (No. 4): p. 255-262
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