El reto de envejecer con el VIH Vivir más y mejor - Eugenia Negredo Fundació de la Lluita contra la Sida - XIX Congreso ...
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El reto de envejecer con el VIH
Vivir más y mejor
Eugenia Negredo
Fundació de la Lluita contra la Sida
Hospital Germans Trias i Pujol
Spain
Abril 2019Antecedentes y situación actual
Definition of Aging 1. Increase in the percentage of elderly people in a population group. 2. Biological process that involves a structural and functional changes that appear over time and are not the result of disease or accidents. Aging is a gradual process of degradation of the human organism.
Definition of Aging 1. Increase in the percentage of elderly people in a population group. 2. Biological process that involves a structural and functional changes that appear over time and are not the result of disease or accidents. Aging is a gradual process of degradation of the human organism.
“Elderly people” in the world
Envejecimiento
6Envejecimiento
• Progresivo envejecimiento del individuo:
– esperanza de vida al nacer:
-hombres 75,2 a. (40 años en 1900)
-mujeres 82,4 a (42 años en 1900)
• Progresivo envejecimiento de la población:
-13.5 % de individuos mayores de 65 a. (5.000.000)
-Un millón, mayores de 80 a.
-Año 2010: >65a 6.200.000; >80a 1.6 millones.
-Aumento progresivo del envejecimiento relativo
7Envejecimiento
• 3/5 partes de la población anciana son mujeres.
65 - 69 años: 86 hombres/ 100 mujeres
>90 años: 38 hombres / 100 mujeres
• Mayor mortalidad masculina:
1.-sobremortalidad profesional,
2.-hábitos no saludables (alcohol, tabaco)
3.-costumbres sociales (diferencia de años al casarse)
8Envejecimiento
Hombres:
- casados
- viven en el hogar.
Mujeres:
- viudas.
- soledad frecuente.
A partir de los 75 a. 1 viudo por cada 4 viudas.Definition of Aging 1. Increase in the percentage of elderly people in a population group. 2. Biological process that involves a structural and functional changes that appear over time and are not the result of disease or accidents. Aging is a gradual process of degradation of the human organism.
Envejecimiento
• Se inicia el proceso a partir del momento de máxima vitalidad
(30 años)
• La probabilidad de muerte:
• x2 cada 8 años.
11Envejecimiento
Factores que influyen en el envejecimiento
• HERENCIA:
– Condicionante fundamental
• La longevidad se hereda en el 90%
• SEXO: en la mayoria de los animales, mayor longevidad de la
hembra
• FACTORES EXTERNOS:
• Dieta
• Ejercicio físico
12Edad
• Cronológica: directamente relacionada con la fecha de
nacimiento.
• Biológica: Relacionada con el grado de envejecimiento del
individuo.
– Se relaciona con: acontecimientos sociales, factores externos
(condiciones de vida, pérdida sentimental...)
13Mechanisms of aging
Infecciones
crónicas
Radiaciones
Quimioterapia
Fármacos
Tóxicos….Mechanisms of aging
Infecciones
crónicas
Radiaciones
Quimioterapia
Fármacos
Tóxicos….Cellular Senescence or apoptosis Infecciones crónicas Radiaciones Quimioterapia Fármacos Tóxicos ….
Mechanisms of aging
Mechanisms of aging
Infecciones
crónicas
Radiaciones
Quimioterapia
Fármacos
Tóxicos….
-Disminución en el número de células
-Disminución capacidades físicas y fisiológicasInflammation
Inflammaging The aging immune system is characterized by a low level chronic systemic inflammatory state, termed “InflammAging”. This inflammatory phenotype is marked by elevated circulating levels of markers of: - Inflammation (e.g., C-reactive protein (CRP) - Pro-inflammatory cytokines (interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α)) It is associated with increased morbidity and mortality in older adults -Franceschi C, et al. Inflamm-aging. An evolutionary perspective on immunosenescence. Ann N YAcad Sci. 2000;908:244–54. -De Martinis Met al. Inflammation markers predicting frailty and mortality in the elderly. Exp Mol Pathol. 2006;80(3):219– 27. -Roubenoff R, et al. Cytokines, insulin-like growth factor 1, sarcopenia, and mortality in very old community-dwelling men and women: the Framingham Heart Study. Am J Med. 2003;115(6):429–35.
Inflammation and HIV
Markers of inflammation may persist at elevated levels despite ART
40,000 N=115 HIV-infected patients
N=30 HIV-uninfected matched controls
Plasma concentration of hsCRP (ng/mL)
35,000 *
30,000
25,000
20,000 **
15,000
10,000
5,000
0
HIV uninfected HIV infected, HIV infected, HIV infected,
untreated 3 months of 12 months of
ART ART
* PInflammation and HIV
Inflammation and HIV
Deeks et al.
Annual Review
of Medicine 2011.Inflammation: Consequences
Aging and HIV
ART
HIV - INFLAMMATION AGING- INFLAMAGING
•Heart disease •Heart disease
•Kidney disease •Kidney disease
•Liver disease •Liver disease
•Osteoporosis •Osteoporosis
•Cancer •Cancer
•Cognitive declines •Cognitive declines
Adapted from Vance DE. Am J Nurs 2010Nuevos retos
Aging
• We all get old, but not everybody in the same way ...
Deshung Wang Tommy Lee Jones
81 years 71 yearsEnvejecimiento Más allá de las comorbilidades…
Over50 cohort
This is a cross-sectional cohort study designed to compare two cohorts:
HIV-infected HIV-uninfected
• Over60 Cohort is an ongoing
• HIV-uninfected subjects, matched by
prospective cohort that includes all
age and gender, are being included
those HIV-infected people attended in
from a center of Primary care with a
our Unit, aged 60 years old or older,
ratio 2 to 1 (2 cases, 1 control)
who accept to participate.Over50 cohort A comprehensive multidisciplinar geriatric assessment including the following variables:
Epidemiological data, cardiovascular risk factors of HIV-infected patients and controls
and HIV-related data
HIV-infected patients Controls P value
(n=104) (n=49)
Epidemiological data
Age, years1 70 (6) 72 (6) 0.146
Gender (male) (%) 80 78 0.749
Qualified profession (%) 72 69 0.755
MSM (%)
46 0 0.000
Cardiovascular risk factors
Never smokers (%) 49 61 0.181
Alcohol intake [>3 units/day 0 2 0.288
(%)]
Recreational drugs (%) 10 0 0.031
Sedentary (%) 40 13 0.001
Alteration of lipids (%) 60 25 0.000
HIV-related data
Time since HIV diagnosis 19 (8) - -
(years)
Patients receiving 100 - -
antiretroviral therapy (%)
Adherence to antiretrovirals > 97 - -
95% (%)
Nadir CD4 Tcell count, 176 (144) - -
cell/mm3
Nadir CD4 Tcell count 62 - -Comorbidities of HIV-infected patients and controls.
Geriatric syndromes of HIV-infected patients and controls.
Differences between HIV-infected patients and controls stratified by age (2a) and stratified by time of exposure to HIV in the infected group (2b)
Most relevant differences of characteristics between HIV infected patients
and controls according to the smoking habit
The same analyzes were performed stratifying subjects according to
the smoking habit, to exclude tobacco as a cardiovascular risk factor.
- Among those who never smoked, significant differences were
found between HIV subjects and controls with respect to the
percentage of:
- 3 or more than 3 comorbidities (58% vs 32% P=0.028);
- lipids alteration (62% vs 25% P=0.002);
- a trend in the cognitive complaint (24% vs 6% P=0.074).Social and psychological parameters
HIV-infected
Controls
patients P values
(n=49)
(n=104)
Social environment
Poor or very poor quality of life (%) 16 15 0.934
Unsatisfactory social environment (%) 19 18 0.927
Altered Barber test 13 14 0.880
[elderly at risk (%)]
Married, separated or widowed (%) 73 98 0.000
Live alone (%) 39 14 0.002
Psychological and cognitive alterations
Cognitive complaints % 26 13 0.092
(P5 (%)1 44 27 0.046Accelerated and accentuated aging?
Accentuated Accelerated
Pathai S et al. J Gerontol A Biol Sci Med Sci 2014Strategies to minimaze aging
Comorbidities
Polypharmacy
Geriatric Functional
syndroms
Mental Social
PsychologicalIdentificar a los pacientes
frágiles
Incremento de Tratar
actividades sociales enfermedades
Revisar polifarmacia
Evitar potencial
Nutrición adecuada interacciones
Aporte Vit D y calcio
Intervención
Ejercicio físico
multidisciplinar Tratamiento
(2 días/semana) depresión
Corrección déficits
Control de factores RCV
sensoriales (visión y
Corrección hábitos tóxicos
audición) Estimulación cognitiva (alcoholismo, tabaquismo)
(razonamiento y
entrenar memoria)Medical visit
General and specific (at least twice per
year)
Special approaches
(annually)
Interventions/Recommendations
recommendations for
older HIV-infected Medical history:
Medical problems,
Age-appropriate Treat comorbidities if
necessary. Distinguish a
assessment of
subjects hospitalizations,
allergies, adverse
comorbidities (e.g.,
cancer, CVD,
normal age-related
physiological deterioration
events, toxic habits, bone,...) (28,33,34) from a disease.
sexual habits
Check drug-drug
interactions
Centralized Evaluation of
medication history: geriatric syndromes
Prescription Stop unnecessary drugs
medications, over- (STOP/START criteria)
the-counter and Check vaccines and
STIs (62,63)
alternative remedies
Physical function / Choose the most appropriate
Frailty antiretroviral regimen
Physical
measurements according to the patient's
examination:
(e.g., gait speed on conditions (77,78)
Vital signs,
measurement of a quarter mile
waist circumference walk, time to rise
from a chair, or grip Counseling on diet and
strength) (45,55) physical activity
Routine blood/urine
test, including viral Intervention for sensory and
load and CD4/CD8 T Neuropsycological
and psychological physical problems
cells
evaluation (e.g.,
depressive
symptoms, QoL, Cognitive remediation if
neuropsychological neurocognitive impairment
test) (37) (37)
Evaluation of social Psychologist/psyquiatry if
problems
Aging in HIV-infected subjects: A review and a new view psychological problems (e.g.,
anxiety, depression)
E Negredo, D Back, JR Blanco, J Blanco, K Erlandson, M Garolera,
G Guaraldi, P Mallon, J Moltó, JA Serra, B Clotet.
Social workers if social
Biomed Res Int. 2017. problemsModifiable Risk Factors 30 minuts of exercise 3 times / week
New treatment targets
Micronutrientes
Existen varios micronutrientes que tienen un efecto beneficioso sobre los
telómeros y la telomerasa, sugiriendo así su potencial antienvejecimiento.New treatment targets
Cellular SenescenceNew treatment targets
Cellular Senescence
Navitoclax
M. SerranoNew treatment targets
Telomere length
TA-65 is a dietary supplement
based on an improved
formulation of a small molecule
telomerase activator that was
discovered in a systematic
screening of natural product
extracts from traditional Chinese
medicines.New treatment targets
SurgeryComing in May www.clinicalcasesD
2019… DIs.com
Web page on clinical cases on drug interactions between antiretroviral drugs
and other drugs (including OTC, recreational drugs and/or complementary
treatments).
The page can be used for:
- Reporting new clinical cases on drug combinations.
- Searching for information on specific combinations.
- Share information on real-life experiences about drug
combinations that may be used in the clinic.
An editorial board will assure good quality of the reports.
Case reports will be open-access to be consulted by other users.Muchas gracias
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