Managing Older PLWH

Physical function, frailty and geriatric syndromes have shown to better predict survival and quality of life among older people in the general population than co-morbidity alone. Managing older people with HIV has to move from the management of each condition separately to a multidimensional assessment focused on preserving physical function, aimed at promoting health aging and quality of life. This section will focus on important geriatric issues: polypharmacy, frailty and falls.

Polypharmacy

Polypharmacy is defined as the concurrent use of > 5 drugs, a cut-off that has been associated with an increased risk of adverse health outcomes. In HIV medicine, the term polypharmacy most often refers to non-HIV medications given in addition to ARVs.

The complexity of medication burden should be considered owing to its clinical consequences: the higher risk of drug-drug interactions and adverse events, the risk of non-adherence to HIV and non-HIV medications, and the risk of hospitalisation, falls, other geriatric syndromes and death. Polypharmacy is often unavoidable when treating a patient with multiple co-morbid conditions making the use of polypharmacy appropriate in this context whereas “unnecessary or inappropriate polypharmacy” is deleterious and should be avoided. Interventions to prevent unnecessary/inappropriate polypharmacy include medication reconciliation
and medication review. The concept of ‘deprescribing’ or the planned and supervised process of dose reduction or stopping of medication that may cause harm, or no longer provide benefit has gained increasing attention as a means to reduce unnecessary/inappropriate polypharmacy in older PLWH.
A freely-accessible resource to help deprescribe can be found at medstopper.com.

Prescribing in Older PLWH

i-iii The Beers and STOPP criteria are tools established by experts in geriatric pharmacotherapy to detect and reduce the burden of inappropriate prescribing in older persons (note: these tools were established for persons > 65 years old given that PK and PD effects may be more apparent after this age cut-off). Inappropriate medicines include, for instance, those which in older persons with certain diseases can lead to drug-disease interactions, are associated with a higher risk of adverse drug reactions in olderpersons, medicines that predictably increase the risk of falls in the older persons or those to be avoided in case of organ dysfunction. The START criteria consist of evidence-based indicators of potential prescribing omission in older persons
with specific medical conditions

Selected Top 10 Drug Classes To Avoid in Older PLWH

Drug class Problems / alternatives
First generation antihistamines
e.g., clemastine, diphenhydramine, doxylamine, hydroxyzine
Strong anticholinergic properties, risk of impaired cognition, delirium, falls, peripheral anticholinergic adverse reactions (dry mouth, constipation, blurred vision, urinary retention).
Alternatives: cetirizine, desloratadine, loratadine
Tricyclic antidepressants
e.g., amitryptiline, clomipramine, doxepin, imipramine, trimipramine
Strong anticholinergic properties, risk of impaired cognition, delirium, falls, peripheral
anticholinergic adverse reactions (dry mouth, constipation, blurred vision, urinary retention).
Alternatives: citalopram, escitalopram, mirtazapine, venlafaxine
Benzodiazepines
Long and short acting benzodiazepines
e.g., clonazepam, diazepam, midazolam
Non-benzodiazepines hypnotics e.g., zolpidem, zopiclone
Elderly are more sensitive to their effect, risk of falls, fractures, delirium, cognitive impairment, drug dependency. Use with caution, at the lowest dose and for a short duration.
Alternatives: non-pharmacological treatment of sleep disturbance/sleep hygiene.
Atypical antipsychotics
e.g., clozapine, olanzapine, quetiapine
Anticholinergic adverse reactions, increased risk of stroke and mortality (all antipsychotics).
Alternatives: aripiprazole, ziprasidone
Urological spasmolytic agents
e.g., oxybutynin, solifenacin, tolterodine
Strong anticholinergic properties, risk of impaired cognition, delirium, falls, peripheral
anticholinergic adverse reactions (dry mouth, constipation, blurred vision, urinary retention).
Alternatives: non-pharmacological treatment (pelvic floor exercises).
Stimulant laxatives
e.g., senna, bisacodyl
Long-term use may cause bowel dysfunction.
Alternatives: fibres, hydration, osmotic laxatives
NSAIDs
e.g., diclofenac, indomethacin, ketorolac, naproxen
Avoid regular, long-term use of NSAIDs due to risk of gastrointestinal bleeding, renal
failure, worsening of heart failure.
Alternatives: paracetamol, weak opioids
Digoxin
Dosage > 0.125 mg/day
Avoid doses higher than 0.125 mg/day due to risk of toxicity.
Alternatives for atrial fibrillation: beta-blockers
Long acting sulfonylureas
e.g., glyburide, chlorpropamide
Can cause severe prolonged hypoglycemia.
Alternatives: metformin or other antidiabetic classes
Cold medications
Most of these products contain antihistamines (e.g., diphenhydramine)
and decongestants (e.g., phenylephrine, pseudoephedrine)
First generation antihistamines can cause central and peripheral anticholinergic adverse
reactions as described above. Oral decongestants can increase blood pressure.

Legend
NSAID nonsteroidal anti-inflammatory drug