Right. Hello, my name is Carol Preston. I'm a nurse and the executive director of Welcome to this activity entitled HIV co occurring conditions and comorbidities in this learning activity. You'll hear from dr Jeff Kwong, an adult gerontology, primary care nurse practitioner and HIV specialist. He will delve into the intersections of HIV and renal and liver disease, cancer and diabetes. He is joined by Bridget Picou, a licensed vocational nurse with a large HIV practice in Palm Springs that includes many who are living in aging with HIV. She brings the perspective of day to day management and helping our patients with the challenges they and their providers face as they navigate the management of these common get serious conditions. Along with managing HIV, you will also hear from dr laura a breeze easy, a physical therapist about the mobility and frailty challenges and solutions experienced by people living and aging with HIV, including the impact of peripheral neuropathy, a co occurring condition experienced by many older adults living with HIV as a result of earlier HIV medications. Finally, the last module with the focus on care coordination will describe the many roles of nurses in managing and coordinating the complex and multidisciplinary care of people living and aging with HIV. From the unique nursing perspective of seeing and treating the whole patient. We, as nurses have an important role in supporting people living and aging with HIV as they and their caregivers navigate the complex environment of multiple health conditions, either in patient and supportive or skilled care settings or at home environment. Thank you for taking the time to view this learning activity for additional information and resources. Please refer to the links provided on the main web page of this learning activity. Hello and welcome to this module. An overview of renal disease and liver disease in persons aging with HIV. This episode is part of an ax HIV and aging learning series. My name is Jeffrey Kwong. I'm an adult gerontology nurse practitioner and HIV clinician. And these are the learning objectives for this module. By the end of this module, you'll be able to describe the impact of renal disease and liver disease in persons aging with HIV discuss the clinical considerations for persons aging with HIV who have renal and or liver disease and identify considerations for cure coordination in persons with HIV who have chronic liver or renal disease. So let's start by talking a little bit about renal and kidney disease. So we know that the overall prevalence of kidney disease in persons with HIV is much higher compared to those without HIV. In fact, the risk of developing kidney disease is elevated and it's been estimated to be about 2 to 20% higher in persons with HIV compared to those without. And why is that? Well, we know that the development of kidney disease is really multifactorial. There conditions such as other chronic diseases like diabetes or hypertension which may play a role, other medications which can contribute to the development of renal impairment or renal disease as well as genetic or non modifiable risk factors. However, we also know that persons with HIV um in fact are more predisposed due to HIV itself and there are interactions with HIV and the renal system that can occur that can lead to chronic green alert kid agencies and of course there are also the effects of antiretrovirals and we'll talk a little bit more specifically about those medications in just a moment. But when we think about renal disease, it's really large umbrella term. There are actually several different forms of kidney disease that we can see in persons with HIV and those include things such as HIV associated naturopath, e also known as Hy van. And this is a condition that is seen less today in the current era of antiretroviral therapy. But we saw this a lot earlier in the very early stages of HIV epidemic. We know that this condition is typically manifested by the presence of protein area and the rapid decline into end stage renal disease. Other forms of kidney disease that we see in HIV include acute kidney injury or chronic kidney disease. These are very similar to what people without HIV might experience as well as immune complex kidney disease. These are conditions in which immune cell components depositing the kidney system and cause renal complications such as I. G a naturopath e or other similar conditions. Also, there are the effects of other chronic co infections such as hepatitis C. So individuals with hepatitis C and HIV may be predisposed to conditions such as HCV associated memory, learn nephritis and I talked a little bit about the impact of antiretroviral therapy on kidney disease. And so I'm going to explore a little bit or talk a little bit about specifically which medications are associated with some real impairment. So we know one of the foundational drugs, the N. R. T. I. S. Or the nucleoside reverse transcriptase inhibitors, specifically Tenofovir, and there are two forms of Tenofovir. Tenofovir disa proximal humerus, also known as T. D. F. And turn off of your elephant of mine, also known as Taff. These medications have been known to affect the renal system. Taf affects the renal system a little bit less than TDF and it's something to be considered when providing medications or doing those adjustments on individuals who are on antiretroviral therapy. Other classes of drugs in the HIV treatment arena that can be associated with renal impairment include the produce inhibitors and there's been some documentation that medications such as amazon a beer or and interfere have and can lead to kidney complications. Now, many individuals are no longer on amazon or indinavir. These are sort of earlier generation protease inhibitors. However, there are some individuals because of tolerance because of drug resistance history may not be able to take some of the newer ones and may still be on medications such as amazon a beer. So you may still see that in your clinical practice today. However, there are other medications that can alter renal function or at least the values that we that we see in terms of kidney kidney numbers. So drugs such as Kobe system or W tag Revere, which is an integrase inhibitor and Kobe system is a pharmacologic booster used with producing computer therapy can actually alter the excretion of creating. Now this means that the creatine levels can rise, but it doesn't necessarily mean that the kidney function itself is altered. So you may need to look at those medications when looking and reviewing lab reports for people who may have indications of altered glam annular function. Um just to make sure that they may not have any artificially elevated creatinine due to some of these medications. And again, these medications alter creatine excretion. They don't necessarily indicate um poor or declining renal function. But nonetheless, this is something to consider when managing these patients. Other drugs that we use in HIV treatment but that are not specifically HIV related include things like Acyclovir foss carnet, Try method from cell phone boxes, all and contaminating these medications used to treat other co occurring infections or opportunistic infections may also be really excreted or affect the renal system. So these are things to be considered or to monitor as well. Yeah. Now let's talk a little bit about diagnosis and clinical assessment. So, of course one of the obvious things to do with individuals with renal diseases to monitor renal function And there are several ways that we can do that. We can do that by measuring serum creatine levels and calculating angular filtration rate. R. G. F. R. These are things that are typically monitored on a regular basis. Other things that can be monitored include your analysis for evidences for evidence of protein urea patients may be symptomatic and this is something that is important to convey that. Many patients similar to say hypertension which is known as silent type of condition, may not have any symptoms until they have more advanced disease. So when we're thinking about early detection and early recognition of renal disease, it's important to monitor things such as creating and renal function on a regular basis. Um The guidelines recommend that renal function be measured at least twice yearly in most individuals. However if somebody presents with conditions or symptoms such as itching, nausea, xia or fatigue renal disease is something to think about in terms of differential diagnoses. And these are also things to monitor patients who may have known renal disease or complications. Let's talk a little bit about C. K. D. Or chronic kidney disease. This is something that is seen in many individuals as they age and the way that we classify CKD is in different stages. So the staging goes from one through five and it's based really on classification of the molecular filtration rate or the estimated G. F. R. And you can see here that the category categories are for stage one, anybody with a creatinine clearance, that's nine year greater. Uh Is somebody who would fall into that category. What we see a lot of in most individuals who are um aging with HIV typically fall into the stage two and three levels. So these are people with mild to minimal renal impairment where the G. F. R falls between anywhere from 30 to 90. And um for people who are in the stage two level of disease, we typically um watch and monitor these individuals. People who have more advanced disease, Stages three four or five typically do need some sort of intervention for people with Stage three disease. We typically might add things such as ace inhibitors or are inhibitors to help minimize the long term impact of CPD progression. And of course individuals who have more advanced disease such as stage four or stage five may need other more complex interventions such as renal replacement therapy, which includes things such as dialysis. What about patient management and education? So here is a great opportunity for clinicians. Frontline workers, nurses um to really talk about and help patients thrive in preventing and minimizing the complications of renal disease. So things that can be done include checking and monitoring renal function regularly, adjusting medication dosing if needed. We know that many medications are really excreted and so taking that into consideration and making some juice adjustments may be appropriate as an individual's renal function starts to decline or change, counseling, counseling patients on limiting or avoiding other medications that make cause toxicity to the kidneys, including things such as non steroidal anti inflammatories. Um is a big educational piece for these individuals in terms of lifestyle modification. Talking about diet and nutrition is also key and important. We wanted uh counsel patients to monitor their sodium and protein intakes for patients with more advanced kidney disease and also talk about the importance of physical activity and weight management. These are very important aspects of Promoting health and preventing long term complications that we see in patients with renal disease. And of course, in individuals who experience a more significant decline in the renal function or may have excessive amounts of protein greater than 300 mg of protein excreted in their urine. Uh, you would refer them to nephrology for ongoing co management or other assessment as well. In terms of prevention. Things that can help minimize or reduce the impact of long term kidney disease include controlling blood pressure, counseling patients on the importance of tobacco cessation. Um we talked about maintaining a healthy weight in activity, but also screening and preventing other complications such as diabetes and hepatitis C. Are also very important and then making sure that patients receive all appropriate vaccines and immunizations, including things such as the flu vaccine or other conditions that may be vaccine preventable are also important to make sure that our patients are able to stay healthy. Now, patients who have more advanced disease often require the use of other services and resources. And this is where nurses and other care coordinators can play a key role in terms of managing patients. So one of the key roles of care coordination in patients with CKD is helping to um prevent or slow kidney progression and promoting physical and psychosocial well being monitoring disease and treatment complications. Um there is some data that shows that more than two thirds of individuals with CKD will be hospitalized within two years or have been hospitalized within the preceding two years. What about patients with more advanced disease who require interventions such as renal replacement therapy. So these include things like hemodialysis, peritoneal dialysis or kidney transplant. Um in these situations, definitely working with specialist is key. But the role of the care coordinator in this situation is critical to help coordinate things such as transportation, needs supplies and making sure that people are able to maintain, be maintained in care and follow up with all the specialists that are required to provide care for persons with chronic kidney disease. Let's switch gears here and talk a little bit about chronic liver disease. Now, patients with chronic liver disease, this again is sort of a large umbrella term and can include things such as viral hepatitis cirrhosis, nonalcoholic fatty liver disease or even conditions such as hip pato, cellular carcinoma. And we know that the rates of liver disease are much higher in persons with HIV compared to those without. Um some of the considerations in terms of clinical management, especially with with with the antiretroviral therapies that we use. We know that medications processed by the liver such as a ton of beer and Kobe system that are important to monitor and make adjustments in patients who have more advanced liver disease. If there are any of these medications that contained katana beer co basis yet, because those medications impact or can impede hip hip attic metabolism of other drugs. So really sort of being cautious about these medications and persons with no liver disease is critical. What about patients with chronic hepatitis B? So um it's estimated that anywhere from 15 to 20% of persons with HIV also have chronic hepatitis B. Now, the good thing about some of the foundational HIV drugs such as Tenofovir, decided bean and lamiVUDine is that these medications not only treat HIV, they also treat and manage Hepatitis B. So, in patients with chronic hepatitis B and HIV, it's important that they have and include medications such as Tenofovir emphasize being and or lamiVUDine as options in their baseline antiretroviral regimen. However, what is important to note that if for some reason patients are on these medications. Um and they have chronic hepatitis B and they have to stop or somebody needs to change their medications that these patients be watched very closely for rises or a flare up of their Hepatitis B. And in those situations, it's important that if you need to discontinue or stop patients who have chronic Hepatitis B and HIV and you need to stop either to enough of your decided being or FTC or three TC that you replace that with a Hepatitis B specific medication. And this is something that can be discussed with and managed with the Hepatology ist as well. Now I talk a lot about drug drug interactions and it's very hard and very challenging for even HIV experts to remember all of the different drug drug interactions. So there is a great website and this is just one of the resources that is available to people. This is a website that's right out of the University of Liverpool and it is a drug interaction checker and you can put in HIV antiretrovirals as well as other medications and it will describe or indicate if there are any medications that need to be used cautiously or avoided because of potential drug drug interactions. Let's talk a little bit about clinical assessment and monitoring and the role of nurse and nurse clinicians in this. So one of the great things that we do as nurses is making sure that patients are taking all of the right medications and so I can't stress the importance of medication reconciliation as a key component of providing nursing care here. So going through a patient's medication list and this includes taking a assessment of both prescribed and over the counter nonprescription medications that somebody might be taking is critical. Also counseling about alcohol or substance use, making sure that patients get and have their liver functions monitored on a regular basis of course checking and assessing for hepatitis A. B and C. Is an important part of care If patients are not immune for hepatitis A and B. And they're eligible for vaccines, it's important that they be vaccinated for those two vaccine, preventable illnesses. Hepatitis C is important to continue to monitor on an ongoing basis for individuals who may be at risk because we know that patients can't acquire hepatitis C through other forms, including sexual and drug use methods. So making sure that if individuals report those types of risk or behaviors that they be monitored on a regular basis for hepatitis C. Even for patients who may have previously received treatment for hepatitis C in the past. Other things that can be done include managing or looking at coagulation studies for patients who may have more advanced cirrhosis. Um In terms of physical exam, you want to make sure that you monitor patients wait if you and see if they have any evidence of jaundice by looking for scleral actress, looking at their skin for any signs of a kIM Asus or um looking at their abdomen for the presence of besides um adama and also checking and monitoring cognition. We know that some patients with acute hepatic encephalopathy can present with cognitive changes that may be due in fact to liver disease or more advanced liver presentations in terms of preventive health and patient education here. As I mentioned earlier vaccinations and making sure that patients receive vaccination and protection against hepatitis A and B. Is critical for patients who have um cirrhosis or more advanced liver disease. Screening for SARS viruses is important if patients have a sophos virus is making sure that they're an appropriate preventive medications to help control or reduce the risk of very seal rupture is important for patients who may have a history of hepatitis C and cirrhosis, or who have other risk factors for hepatitis cellular carcinoma. It's important that they receive ongoing surveillance, monitoring counseling patients about the importance of healthy weight and nutrition. Also very critical here and avoiding anything that might further impede their liver function, including avoiding other hip to toxic, including avoiding other HEPA toxic medications, alcohol and of course smoking cessation is also critical here. Let's talk a little bit about care coordination for patients with more advanced liver disease such as cirrhosis. We know that there are high rates of rehospitalization and patients with end stage liver disease. It's been estimated that about 25% of patients with end stage liver disease are re admitted to the hospital within 30 days of discharge. Oftentimes patients with more advanced disease may experience mental health conditions such as depression by feeling very overwhelmed with their disease or by dealing with many specialists and re hospitalizations and changes in their function. So, as part of care coordination. One of the things that we can do or that nurses can do is to make sure that we assess these areas and make sure that patients are cured for both physically socially and psychologically. In terms of other types of care coordination required for people with more NCH that were disease roles that are important to address include things such as mental health, palliative care and even transplant care. So, um many individuals might need the resources of these other specialties or these other services. And so care coordinators should be able to make those appropriate referrals as needed. One patients have more advanced disease. So to summarize kidney and liver disease are growing concerns for persons aging with HIV medication, reconciliation and monitoring of liver and renal function can prevent unintended adverse events, physical activity, nutrition, tobacco cessation, avoiding limiting substance use and controlling other chronic conditions such as diabetes. High blood pressure are critical aspects of care and clinicians should ensure that patients complete appropriate screenings and preventive vaccines as needed. Thank you for viewing this learning module on renal and liver disease. For additional information, we have provided some additional resources for you on the website. We encourage you to view our other learning modules in our series and working together, we can help improve the lives of persons aging with HIV here are some additional resources and here is a knowledge check question which of the following places. Persons living with HIV at risk for kidney disease, genetic predisposition. HIV antiretroviral therapy, tobacco use both B and C or E. All of the above the answer is E. All of the above kidney disease. In persons with HIV is multifactorial and can be due to genetic predisposition. HIV antiretroviral therapy, tobacco use and other chronic conditions. Welcome to this module on care considerations for persons with HIV and cancer. This episode is part of an ax HIV and aging learning series. My name is Jeffrey Kwong and I'm an adult gerontology nurse practitioner and HIV clinician. And these are the learning objectives for today. By the completion of this activity, you'll be able to describe the impact of cancer in older persons with HIV discuss the clinical considerations for older persons with HIV and cancer and articulate the role of care, coordination and older persons with HIV and cancer. When we think about cancer and HIV, we know that there has been a significant decline in what is termed HIV associated cancers, especially now in the current era of antiretroviral therapy. However, what we're seeing is an increase in non AIDS defining cancers in persons with HIV compared to those without. And I'm going to talk a little bit about what those two distinctions are, but we know that overall persons with HIV actually have a poor prognosis in terms of overall cancer mortality compared to those without HIV. Now, I alluded to both HIV and non HIV defining cancers. And so what are those distinctions? HIV or AIDS defining cancers are those cancers that we typically associate with more advanced HIV infection and those include things such as Kaposi's sarcoma, non hodgkin's lymphoma, primary cns lymphoma and invasive cervical cancer. Non AIDS defining cancers, what we're seeing an increase or rise of include those cancers such as anal cancer associated with human papilloma virus or HPV infection, lung cancer, breast cancer, colon, prostate liver cancer and other cancers. You see listed here. What are the risk factors and how does HIV play a role in terms of cancer and the development of other oncological conditions? Well, we know that HIV infection in and of itself can cause an alteration in the cellular processes which in turn lead to or make an individual more likely to develop certain types of cancers. There's also the impact of immune suppression and chronic inflammation that plays a role. Other factors such as co infection with other viruses or other organisms that are associated with cancer such as infection with human herpes virus eight, which is associated with Kaposi's sarcoma, Hepatitis B and hepatitis C, which we can see in conditions such as Hepatitis cellular carcinoma and I mentioned earlier human papilloma virus or HPV, which is associated with anal cancer cervical cancer and certain head and neck cancers as well. Other risk factors that we see in persons with HIV include some of these other social determinants um such as tobacco use. We know that rates of tobacco use are actually much higher, estimated to be about 2-3 times higher in persons with HIV compared to those without. And so we know that tobacco use in and of itself as a risk factor for cancers. And so the fact that there's an overall greater prevalence of tobacco use is potentially one of the reasons why we see an over abundance of certain types of cancers in persons with HIV as well. What about treatment considerations in persons with HIV who may be diagnosed with cancer. So one of the big issues that we're always concerned about is drug drug interactions. And we know that certain chemotherapeutic agents interact with certain antiretrovirals in these situations. It's important to consult with pharmacologist or and HIV experts to talk about the potential role of drug drug interactions and potentially the need to alter therapy. Um Other things that are considered important when managing or treating patients with HIV and cancer include other symptoms that people experience such as fatigue, weight loss, nausea and vomiting. Um these types of symptoms um can occur in the setting of HIV in and of itself. So individuals may already be experiencing these types of conditions and then to have cancer and chemotherapy. Side effects on top of that can make things much more challenging or difficult for individuals who are diagnosed with cancer. Other things that are important to consider include p management medication, adherence. We know that with certain chemotherapeutic agents that require oral therapy. This may also impact HIV adherence therapy and so talking and assessing these uh issues are important with patients assessing mental health. We know that the occurrence or presence of depression or anxiety may be exacerbated in these situations and of course um managing and looking for secondary infections is also an important consideration in persons with HIV and cancer. One of the important characteristics or principles of geriatric medicine is really identifying what are the patient's goals of care and what matters most to individuals. And this is a time to really think about when you're looking at a treatment options or treatment opportunities. Um Prognosis of someone's cancer diagnosis to really assess what are the patient's goals of care um if they're interested um and receiving palliative care is part of their treatment Management protocol is important and in certain situations if appropriate. Having discussions and open honest discussions about hospice care is also important and we know that by providing hospice care earlier individuals actually have better outcomes and may benefit more when hospices brought in earlier. What about clinical assessment? So, um in terms of physical exam and clinical assessment, it's important to assess the patient's pain level. Looking at their vital signs, especially weight, we know that patients may be more susceptible to weight loss. And so, assessing for their weight on a regular basis when they come to clinic or when you see them in the hospital or even in the home setting is important. So seeing if they have any constitutional symptoms such as fever, night sweats, Linfen, empathy, assessing the respiratory function, mobility and overall physical function is also important to assess. We know that as people become more frail, that their mobility and function can decline and making sure that they're able to do things such as their A DLS is important to make sure that they're able to care for themselves and if not to provide those needed assistance is also a great way to intervene to help patients improve their quality of life, assessing their skin nutrition. And again, as I mentioned earlier, mood and sleep are also key components of physical and clinical exam assessments. Now, what about screening and prevention? So there are many different screening modalities and ways to identify cancer. Some of them are appropriate for some individuals based on their risk factors and some are recommended for everybody. So we'll sort of go through some of these prevention and screening options here. So, um, for individuals who are smokers or former smokers and may be at risk for lung cancer screening for the presence of lung cancer with low dose cT is recommended intervention for individuals with or without HIV. And so making sure that our patients receive appropriate screening is a key an integral part for patients who report a history of smoking or maybe current smokers as well for individuals who have a history of chronic hepatitis B or hepatitis C. Or some evidence of cirrhosis screening for the presence of a patio cellular carcinoma with either C. T. M. R. I. Or um ultrasound are also options to consider. Then there are other age related screenings for everybody, including things such as colonoscopy. Uh this is something that many individuals tend to overlook and you know that although colonoscopy is listed here on the slide that there are other forms of colon cancer screening that are viable options, although the frequency of screening is different and they may require more frequent screening for less invasive types of colon cancer screening. Other types of screening are listed here, including mammograms, prostate cervical and anal pap smears as well. However, in terms of prevention, some other things that we can do include talking about and counseling our patients on the importance of tobacco cessation, Making sure that patients get the appropriate vaccines for preventable conditions such as hepatitis B, um HPV vaccination typically approved up to age 45 so for older adults would be considered an off label use. But nonetheless, if you're counseling individuals who may still be eligible for the vaccine based on their age for younger adults, making sure that they get the vaccines in order to prevent long term complications as the age is important as well. And then, of course, other things to do in terms of preventive cancer screening include things such as skin checks to just make sure that people do not have any evidence of um basal cell or squamous cell or melanoma. Any sort other types of patient education that are important to incorporate into care include talking about and educating individuals on the adherence of both antiretroviral therapy and if they're taking any sort of chemotherapeutic agents on the importance of adhering to that therapy as well. Um Talking about and educating about the importance of pain management and making sure patients pain level is adequately addressed. Talking about diet and nutrition and counseling on the importance of monitoring one's weight during therapy. We talked about smoking cessation um and a couple of other things fall under this umbrella as well in terms of patient education and that includes for patients who successfully complete therapy for cancer is survivorship plans of care and we'll talk a little bit about survivorship in just a second. But in terms of some of the complexities of providing cancer care, we know that navigation and care coordination here is an integral part of providing inter professional oncology care. So there have been lots of work done in terms of the role of oncology nurse navigators and the oncology nursing society has provide or developed a list of competencies specifically for oncology Nurse navigators and they are listed here. Um So nurse navigators should be able to be able to provide coordinated care, assist with overcoming health system barriers, providing education, facilitating shared decision making and promoting advanced care planning is important and also supporting palliative care and mental health support as well. One of the effects of cancer and cancer treatment can be alterations or changes in physical function. And so there is a whole field on cancer rehabilitation and this is something that maybe HIV specialists may not be fully aware of. But in terms of cancer rehab there are a whole cadre of professionals that help individuals stay as active and functional as possible and they helped lessen the side effects and symptoms that somebody might experience due to certain conditions or certain treatment side effects. And these professionals include physical therapists, occupational therapist, lymphedema, specialist speech therapist, vocational therapist, recreational therapist and nutritionist. Let's talk a little bit about survivorship. We know that today with effective chemotherapy that many individuals are able to survive cancer. Um there have been estimates that about 16.9 million individuals have survived cancer in the US and about 67% of today's cancer survivors were diagnosed five or more years ago. And this is really sort of a paradigm shift from probably what many individuals think of when they think about cancer. And um and prognosis. But now with individuals surviving cancer due to effective therapy and treatment um we need to learn how to care for these individuals. So people have developed survivorship programs or survivorship clinics to help really manage the long term complications or effects that might be seen in these individuals. Um and we think about survivorship really in three phases. So there's a cute survivorship sort of immediately following the diagnosis and the treatment extended survivorship might be from the end of treatment through the first few months, um post completion of chemotherapy or other treatment for cancer. And then there's permanent survivorship. So these are people who have been diagnosed many years ago, who may still need ongoing surveillance and monitoring. And there are special programs offered through different oncology centers that really help monitor patient's conditions to make sure that there is no recurrence of cancer or other complications that may be associated with treatment in the long term. What are some other aspects of care coordination. When we think about cancer patients living with cancer diagnosis for patients who have more advanced disease or terminal disease. Hospice is something to be considered in a role that many individuals are probably familiar with, but just in terms of the types of professionals and the types of coordination that might be needed in terms of coordinating with hospice, we know that within the hospice environment there typically are physicians and nurses and social workers and pharmacists and so being able to, as a care coordinator, talk and communicate with these individuals is important, but there's also other people that play a role in this hospice team and those include nutritionist and again, oT or Pt chaplain or spiritual adviser, hospice aides, volunteers and bereavement counselors and so making sure as a coordinator of care if that is your role to really um integrate and include these individuals as part of the care plan are also important to consider so to summarize rates of non AIDS defining cancers are on the rise, screening and early detection can improve outcomes and care, Coronation can improve outcomes for persons with HIV and cancer. So thank you for viewing this learning module on HIV and cancer. For additional information, we've provided some resources for you on the web page. We encourage you to view our other learning modules as part of our series. Working together, we can help improve the lives of persons aging with HIV. Here are some additional resources and to ask your knowledge, here's a quick question for you which of the following cancers is seen in disproportionately higher numbers in persons with HIV compared to those without HIV, a leukemia, B anal cancer C pancreatic cancer. D esophageal cancer. The answer is b anal cancer rates of non AIDS defining cancers is increasing in persons with HIV HPV associated anal cancer is seen at disproportionately higher rates in persons with HIV nearly 2 to 3 times higher compared to those without HIV. Hello and welcome to this module on addressing issues of function and mobility. This episode is part of an ax HIV and aging learning series. My name is Jeffrey Kwong, I'm an adult gerontology nurse practitioner and HIV clinician and joining me today is my colleague, laurel Daniels Abruzzi, Hello and I'm a physical therapist and an associate professor in the physical therapy program at Columbia University. In terms of our learning objectives on completion of this activity, participants will be able to describe the risk factors that may impact mobility and function in aging. Persons with HIV discussed clinical considerations for people with HIV with mobility issues and identify strategies to help individuals maintain function as they age. So when we think about mobility and function, we're really talking about issues of quality of life because when we think about mobility and function, mobility is such an integral part of being able to do things such as activities of daily living. And we know that individuals as the age may be more likely to experience conditions such as frailty or alterations in their ability to um move or walk or ambulance. And we also know that individuals with HIV are more risk for certain conditions that may impact things such as mobility and function, including alterations in bone mineral density? We know that certain antiretroviral therapy can be associated or has been associated with things such as decreased bone mineral density. And so what are some of those implications as that can occur as a result of some of these changes or risk factors? Well, we know that individuals who may be more prone to conditions such as osteopenia or osteoporosis are at increased risk for fractures, um and falls, in fact, it's been estimated that Fall rates in persons with HIV about 25% higher than in persons without HIV laura. Would you like to talk a little bit more about some other risk factors for falls? Certainly there are several factors that put people with HIV at an increased risk for falling. Some of the medications being taken, antidepressants, opiates, Sedatives all can increase fall risk. Some of the risk factors that overlap with frailty, like shrinking and exhaustion can increase a person's risk for falls And then difficulty with specific tasks. Um like the specific task of standing in a tandem as pictured here, um if someone can't hold that position for at least three seconds, there at an increased risk for falls by 13.5. So um aging alone comes with an increased risk for falls. But we have these additional risks that put people with HIV at a higher risk for falling. So we need to be screening for falls and one of these risk factors also can be a change in the sensation that helps one understand where their position is in in space and a peripheral neuropathy can impact one's balance and one's risk for falls. Peripheral neuropathy is one of the most prevalent neurological problems in people with HIV. The prevalence is between nine and 63% of all people with HIV And then the prevalence is over 68% in people on antiretroviral therapies. Some of the symptoms that one might experience with a peripheral neuropathy include pain and tingling, a burning sensation or aching numbness, chronic pain and most importantly the impact on function, difficulty with balance and difficulty with walking. So early diagnosis of a peripheral neuropathy can really help health care workers start interventions to prevent the progression of impairment the onset of disability and decrease in the quality of life that might be associated with the peripheral neuropathy. In individuals with HIV. Um one particular type of neuropathy that is common is a distal symmetrical sensory pollen neuropathy, D. S. P. N. Um This occurs because of damage to the nerves and the hands or feet. So you end up with a stocking, glove distribution. Um It's the most common neurological problem in HIV disease and symptoms range from numbness to excruciating pain, Jeff. Can you talk a little bit about some other types of peripheral neuropathy that individuals with HIV might experience? Yeah, certainly especially in persons who are older and living with HIV, they may have been exposed to some of the earlier generation antiretroviral therapies such as what we call the D. Drugs. So those were things like did adenosine D. 40 or D. D. So these are medications we don't usually use in current day into retroviral therapy, but individuals who maybe have diagnosed in their In the 90s or in the late 80s who are now aging into older adulthood may experience a type of neuropathy, and this is often referred to as antiretroviral toxic neuropathy. So the this is very similar to somebody with distal sensory peripheral neuropathy. Um and um individuals who experience this type of neuropathy usually will have onset of symptoms fairly quickly after starting therapy. Um and we typically diagnose and manage it pretty much the same way. So, when we think about management of peripheral neuropathy, Really, the key thing is to correct and treat reversible factors. So um we know other causes of neuropathy can include things such as diabetes. Um people who have um extensive history of alcohol use or abuse may experience neuropathy as well, and vitamin B-12 issues. So making sure that those issues are corrected is important in terms of overall symptom management. Now we know that once people experience some nerve damage, that it's hard to actually cure per se. But in terms of managing symptoms for people who have chronic or ongoing symptoms, we can use interventions such as anticonvulsants like Gaba Penton is one common medication. Other classes of drugs like tricyclic antidepressants are used. You can use anti inflammatories or even topical agents. Some individuals may have such severe symptoms that they required the use of chronic opioid therapy. There are other options that are being used today as well, including things such as cannabis. There's some evidence about al Philippe poet acid as well as non traditional methods such as acupuncture laurel, are there other methods or other treatments that are available as well? Well, certainly um being a physical therapist, we're gonna concentrate more on non pharmacological approaches to managing the pain. And certainly the pain associated with peripheral neuropathy and the impact on function is is significant and can be complicated to manage. Um sandoval at all in 2010 showed that individuals with HIV and peripheral neuropathy that wore night splints on their feet for three weeks could significantly reduce their pain and improve their sleep since reduced sensation can contribute to fall risk. So even you know past drugs like the d drugs that still put you at risk if you have a peripheral neuropathy you want to be paying attention to anything else that can be managed to reduce fall risk. So um being attending to the environment um maybe um reducing current medications or making sure that those are evaluated um balance training, home safety and an exercise program and exercise really is where most of the attention is in terms of ways to improve mobility and manage that peripheral neuropathy. So a physiotherapist led exercise program was shown to reduce those peripheral neuropathy symptoms and severity and that included Aerobic exercise. Um some stretching and isometric um work. Um and it was a sustained program for over 12 weeks. So the recommendation is that all individuals with peripheral neuropathy be engaged in physiotherapy, supervised exercise as part of the management. So we're gonna shift gears a little bit and talk about another concept when we think about mobility and function and that is the concept of frailty. So I think many individuals probably have a concept of what frailty is. And in fact in the literature there are many different models or many different definitions of frailty or how to identify or classify frailty. One of the most common types or common classifications is the freed frailty phenotype And this is really characterized by several different uh symptoms or presentation. So this can include things such as shrinking. So unintentional weight loss of more than £10 or decrease of 5% of body weight in the last year is one particular factor exhaustion, feeling that the people are not able to just get going 3-4 times a week is kind of potentially a signal or sign that somebody might be experiencing this phenomenon. Other factors include things such as low activity weaknesses measured by hand grip strength is another way to measure frailty as part of the freed frailty phenotype and also slow gait speed. So these are the components that sort of make up the freed frailty phenotype, but there are also other forms that have been used to help diagnose somebody who's frail and we know that actually frail to your pre frailty is fairly common in persons with HIV. There was actually a study out of UCSF that showed that more than half of their patients who were 50 years or older had some form or some indication of pre frailty. And when we look at frailty overall in persons with HIV, we know that there are several risk factors associated with that, including not only um advanced age and HIV infection, but also some other factors as well, such as smoking and chronic hepatitis c infection as well as things such as depression play a role in terms of frailty risk factors. If you look at this slide that's presented here, you can see on the right hand side of the graph, the differences of the occurrence of frailty and persons with HIV compared to those without. And you can see on the bottom part of the graph, those are the different factors that are part of or constitute the freed frailty phenotype. And then on the left hand side of the screen in the purple and green image, you can see here the prevalence of both frailty and pre frailty as I alluded to earlier, where there is a greater prevalence or risk for pre frailty identified in persons with HIV compared to those without laurel. Do you want to talk a little bit about kind of the impact of frailty on falls? Yes, I mean it's not only that there's an increased prevalence of frailty and individuals with HIV but the relationship between frailty and falls, that makes it something significant to be mindful of. Uh in this figure here. Uh we see on the far left, those who would be non frail. So they have zero of fried's characteristics of frailty in the middle pre frail, which means they have maybe one or two criteria that would suggest that they are on the path towards frailty. And then on the right we have individuals that would be considered frail because they have three or more of Fried's criteria. And for those who are non frail on the far left, um 470 report no falls, 52 report a single fall and only 13 report recurrent falls. Whereas on the far right as you move into that frail classification, The risk for recurrent falls increases. Um and there are fewer people without falls. So for those classified as frail, only 30 report no falls seven with single falls and 22 with recurrent falls. So identifying frailty can help us also identify those that are at increased risk for falls and recurrent falls. And some of the characteristics of frailty are modifiable. So there are things we can do to reduce that risk. Um I think now you wanted to um share a little bit more about the prevalence of fracture risk as well as something else to be concerned about. Right Jeff correct. Um So, you know, we think about falls and frailty but really, you know, what are some of the ramifications of falls and one of the big things that we worry about our fractures because we know that um as older adults experience fractures, there's greater risk for um overall mortality associated with this. So we know that persons with HIV have a greater risk for fractures compared to those without HIV. This was actually a study that was done out of boston and the Partners Healthcare System where they looked at individuals 32 79 divided by gender. Both men and women living with HIV and those without. And you can see in the dark orange bars or dark orange line, I should say That the fracture prevalence was higher across all age groups, but more notable in older adults, 60 and over in both genders. Persons living with HIV much greater fracture prevalence and again, this can be multifactorial in nature and actually laurel. You want to tell us a little bit about some of the fracture risk in persons with? Yes, well, because people with HIV have an increased bone resort option and increased risk of osteoporosis and fractures. The current guidelines recommend that we use the frack sites as a prediction tool to to identify someone's risk of actually sustaining a fracture given other risk factors that are present. So, if someone with HIV is over age 40, um it's recommended to have a bone mineral density test as well as use the fax to predict fracture. Other risk factors for bone loss include things such as HIV antiretroviral therapy. We know that certain medications such as um Tenofovir has been associated with changes or alterations in bone density but there are other causes as well. So some of these are modifiable and some of them are non modifiable. But things such as smoking, things such as physical and activity are all modifiable risk factors that I think clinicians nurses, physical therapist, nutritionist, everybody can talk about an educator, patients on helping minimize or reduce the impact of bone loss by addressing some of these modifiable risk factors. There are other conditions such as low vitamin D. Hypogonadism, low testosterone or menopause, which can also affect someone's risk or alter their risk for bone mineral density loss as well. So how can we reduce from um prevent these complications from occurring? Well, one way is to um you know supplement individuals who may have vitamin D. Deficiency making sure that people are getting adequate calcium bisphosphonates therapy is one other option that is commonly used for people with either osteopenia or osteoporosis. And I cannot stress the importance and laura will be talking a little bit about this as well in terms of exercise and resistance training, Tenofovir, as I mentioned earlier, one of the medications associated with some bone mineral density changes. However, it's important to know that in terms of the data there's actually no evidence that switching antiretroviral therapy will reduce fracture risk um in those with already established osteoporosis but if you can try to um minimize or avoid Tenofovir in certain situations. Uh somebody that maybe um not fully diagnosed with osteoporosis but may be at risk with some mild osteopenia. That's something definitely to consider. Do you want to talk a little bit about screening? Sure. So we've we've summarized a number of mobility related health issues and individuals with HIV including peripheral neuropathy, frailty, osteoporosis and fracture risk, all of these impact functional mobility. So when we're thinking about the clinical management of individuals with HIV that are have these increased risks, we want to make sure that screening as a part of our practice. So we want to be sure to screen for falls and use fall risk screening tools. A great resource for the entire clinical team. Um is the steady site on the CDC website which identifies um some functional measures as well as questionnaires that can be used to identify fall risks. Um The Fedex of scan um can help understand bone mineral density and then the fracture risk assessment. The fractures can be found online. We can use any number of frailty screens. One that we introduced today was the freed criteria for frailty which can identify pre frail and frail with those associations for um mobility, impairment and and falls. The brief peripheral neuropathy screen is the is the tool that's been used most frequently in the research with uh persons with HIV and peripheral neuropathy to see the impact of interventions and then just because all of these risk factors are interrelated. We also want to make sure we're doing general screens as we would with most older adult patients, a home safety evaluation, a DLS activities of daily living and instrumental activities of daily living and to better understand the impact on function. Other things that individuals can do in terms of clinical assessment include things such as monitoring vital sides, checking for blood pressure if somebody is Ortho static and has Ortho static hypertension, that's a potential fall risk. So that's something to monitor um checking for other neurologic changes. Vision changes, even just checking for gross vision or vision discrimination is important. Some individuals may not be able to see depth, their their depth perception may be altered. Again, putting them at risk for falls assessing gait and balance is laurel had alluded to discussing elimination. We know that many individuals sometimes fall on their way to get to the bathroom in the middle of the night and trip and fall at home. And so that's something of individuals are having issues with that to assess their ways to intervene, To minimize those types of risks and also any alteration. An assessment of mood and cognition is an important component of overall care and assessment, especially for older adults. When we think specifically for persons with HIV would and fall risk and frailty assessments, we want to make sure that we assess appropriately for pain and if they're using any sort of pain medication. We always think about drug drug interactions as an important aspect of managing patients and making sure that they're safe. We know that certain medications can also predispose people to dizziness or falls as well. So again, checking for drug drug interactions or other conditions that may put them at risk for falls or fractures is important. And other things of course, if somebody does have pre frailty or maybe have suffered a fall to engage with other rehabilitation services such as physical therapy or oT as appropriate. And what are some other options in terms of treatment? The one intervention that is a common and one of the most effective interventions for all of the problems we've discussed today is exercise. So the recommendation is to have progressive resistive exercise as part of regular regular program at least three times a week if there's been a functional loss or an incident, Um there might be a six week intervention. Uh but then this really should be incorporated into lifestyle and then a combination of both aerobic and resistive practices. I want to reiterate that this is something that should be part of someone's lifestyle. But there may be individuals that need physical therapy or physical therapy led interventions, particularly if they've been identified as being at a high risk for falls or having some sort of mobility deficit, some decline in their functional mobility, Having someone who can really tailor and individualize the intervention can be helpful to someone with greater needs um, strengthening exercises will improve strength. Um but it's one of the most effective exercises for frailty for fall risk for improving functional mobility. It's an intervention for peripheral neuropathy as we've mentioned in this slide here, highlighting moderate or high intensity exercise in older adults living with HIV. This highlights all of the different benefits that um moderate and high intensity exercise can have. So in addition to those strength, outcomes like grip strength or a bench press or leg press lat, pull down, there are cardiovascular benefits with a vo two max and then there are functional tasks that improve the ability to walk faster, the ability to get out of a chair um more efficiently and faster and the ability to go up and down stairs faster. So research has shown that um there are numerous benefits of of exercise um and that can't be understated. Other components of patient education is uh in addition to what we have mentioned in terms of exercise include um counseling and educating patients about the importance of walking devices and how to use them properly for people who need them. And also encouraging patients who are prescribed them to use them uh as appropriate. Because we know that many people sometimes don't always do that. So making sure that they're using their walking devices and the importance of that checking about home safety, making sure that rugs, anything on the floor maybe loose to keep hallways and other areas of the home free of clutter is also a very important part of fall risk education and um in terms of using assistive devices. As I mentioned, making sure that those are used appropriately to summarize mobility and function are critical aspects of quality of life screening for and preventing falls and frailty can reduce morbidity and mortality. Multiple factors affect bone health and fracture risk and persons aging with HIV and exercise is safe and beneficial for improving the health. Medically stable adults, aging with HIV. These are some resources to assess your knowledge. We have a quick quiz for you. Risk factors for recurrent falls and persons with HIV include a being physically active. Be peripheral neuropathy. See use of protease inhibitors or d being obese or overweight. The correct answer is peripheral neuropathy. There are multiple risk factors for falls, including use of medications like sedative opiates and antidepressants as well as chronic conditions such as poor for neuropathy which may impact a person's mobility and sense of balance. Hello and welcome to this module on care, coordination for persons with HIV with diabetes and other metabolic conditions. This episode is part of an ax HIV and aging learning series. My name is Jeffrey Kwong and I'm an adult gerontology, nurse practitioner and HIV clinician joining me today is my colleague Brigitte Picchu from the will project. Hi Bridget Hi Jeff, nice to see you. So my name is Bridget kiku. I'm an L. V. N. Working primarily in Palm springs California. But again, I do some work with the World Project, which is focused on HIV and women. So our learning objectives are as follows. On completion of this activity, participants will be able to describe the impact and clinical considerations of metabolic conditions and persons living with HIV identify strategies to help persons living with HIV prevent complications associated with metabolic conditions and identify considerations for care, coordination in persons living with HIV who have diabetes. When we think about diabetes and metabolic conditions. When we think specifically a persons living with HIV, we know that many individuals with HIV s age are more likely to develop um metabolic conditions such as diabetes. In fact, The prevalence has been about 10-15% of older adults with HIV will be diagnosed with diabetes at some point. In terms of other metabolic conditions, specifically in terms of metabolic syndrome. And just as a reminder metabolic syndrome is a cluster of conditions that increases one's risk for heart disease, stroke and diabetes. And these are characterized by hypertension, high blood sugar, Excess abdominal animosity or excess body fat around the waist and abnormal cholesterol levels. All of these factors are known as metabolic syndrome and in fact in persons with HIV, the prevalence of metabolic syndrome has been estimated to almost 48% of individuals in some studies tell me a little bit or tell us a little bit Brigid about lipo dystrophy and lipo atrophy. Another type of metabolic condition. Absolutely. So um lipo dystrophy and lipo atrophy were associated more with the early generation of art medications. A lot of the long term survivors are very familiar with it. Um we're talking about things like loss of limb fat, there is an increase in the abdominal capacity and visceral fat. So that's gonna be the vet versus the set, the the subcutaneous fat and then there is cervical dorsal fat accumulation that's going to be around the neck and what patients referred to commonly as the the buffalo hump. Um and then both men and women can find that they have some breast enlargement and then there is the loss of facial fat. And so all of these things can lead to a sense of self stigma as well as external stigma. Um even for patients who are newly diagnosed, there is some fear about these types of lipo atrophy and lipo dystrophy conditions, even though it is associated with earlier medications, any one of these conditions or several of these conditions can occur in any patient at any given time. So Jeff, what about the risk factors for diabetes and metabolic conditions? Sure. So when we think about risk factors specifically for diabetes or some of these other metabolic conditions in the setting or context of HIV we know that it's really multifactorial. So there are things such as HIV infection in and of itself can cause different types of immune um this regulation or changes in the immune system which may make individuals more prone to inflammation or chronic inflammation, which can predispose individuals to alterations in metabolic function. A certain antiretroviral therapy has been associated with increases in cholesterol um and other body changes is Bridget alluded to earlier. There's some information that some of the newer classes of medications may be associated with weight gain, which again is something that is modifiable or can be managed but nonetheless is a potential risk factor for some metabolic complications. Other HIV specific risk factors include lower CD four accounts. So, individuals who may have untreated HIV or who may be diagnosed later um are more susceptible to some metabolic complications if they have a low cD four count or low cd for later. Um of course then there are the non modifiable risk factors such as age genetics that play a role in terms of metabolic disorders or conditions. What about some of the complications that we can see? So we talk about diabetes in and of itself as a complication of some metabolic issues. But we when we think about some of the sort of broader context of complications, we know that diabetes can result in both microvascular changes as well as macro vascular changes. And so what does that mean specifically, we know that people with diabetes are more at risk for things such as diabetic retinopathy or naturopath. E so um, iron kidney issues, we know that um macro vascular changes can be seen, which predispose individuals to things such as atherosclerotic heart disease or coronary artery disease. And of course there are changes in the nervous system. And if you refer back to the mobility and function module you'll learn more about peripheral neuropathy as well as the management of that condition. But that is one of the consequences of diabetes as well. What about management and assessment of individuals? How do we do that on a clinical basis? So there are some basic things such as monitoring someone's weight um checking for their laboratory values. Specifically things such as a fasting glucose is important hemoglobin. A one C. Although used for monitoring persons with diabetes. Sometimes people use it also for screening for diabetes. But what we do know is that the hemoglobin a one C actually can underestimate glucose and persons with HIV. So um the understanding of why this occurs is that they think potentially that there is some low grade Hamal icis that occurs that makes the A one C underestimate the true level of glucose in someone's system. So individuals without HIV You can use the a one c. of 6.5% as a diagnostic criteria for diabetes. However, in someone with HIV, if someone has a slightly lower value such as 6.46.3 you may want to think that that number could actually be underestimating the true value. And in fact it could be higher. So the guidelines typically recommend a fasting glucose level as a slightly better indicator. Of course. There are other things that can be used, including monitoring lipid function, hepatic function and thyroid function um Bridget any other things that are important to consider in terms of clinical assessment. Um So we also want to consider patient's vital signs there. Bp There. Wait. Um how well their oxygen is? Profusion? Um That's particularly important in our older patients. Um We want to check their vision. We need to be checking cardiopulmonary function. We want to look at doing neurological exams and these patients, we want to monitor and keep an eye on what their pain is. Um Then there's also mood and cognition which is really important. And that's one of the things that we want to kind of visually take a look at when patients come and see us because they may not always tell us what's going on with them. But sometimes if we do that visual head to toe examination we can see what's going on with them. Um and then also their function. How are they walking? Um Are they able to put two and two together? Are they following the conversations? Um All of those things are important uh in our assessment of how these patients are actually doing. So let's talk a little bit about treatment of diabetes and metabolic conditions and persons with HIV we know that as mentioned in several of our other chronic disease modules here the significance of drug drug interactions and this also holds true in the setting of diabetes management. We know that some of the medications we use for um diabetes such as Metformin can interact with some of the medications we use, such as W photography or Big Tech Revere. There are some dosing issues that should be monitored or taken note of. In terms of co administration of Metformin with those types of integrase inhibitors. We also know that statin therapy, particularly things such as atorvastatin, Simvastatin, atorvastatin and pravastatin are safe to use. But the other types of statins can interact, especially if people are taking produce inhibitors. We know that there is a drug drug interaction there, but just to make sure that if somebody is on a statin that they're on one of the preferred statins is an important consideration or role that nurses can do in terms of reviewing medications and looking forward drug drug interactions in terms of treatment of other metabolic complications or side effects. Bridget talked a little bit about lipo dystrophy and lipo atrophy. So, in terms of addressing the fat accumulation that some people might experience, there are some interventions, um nothing's perfect here. There's been some uh use of growth hormone to potentially address some of that visceral capacity that people can develop our experience from some of the earlier generation and to Richard virals um surgery has been done to help physically remove some of the accumulation or some individuals have gone through breast reduction surgery for people where there are some complications or quality of life issues associated with that. Other things in terms of lipo atrophy where there's a loss of facial fat. There are things such as spatial fillers that can be used. And of course in terms of treatment when we think about things like complications from diabetes, there's also considerations for treatment of things like peripheral neuropathy. And again, please refer to our module and mobility and function where we talk a lot more about perform their apathy treatment and management. Richard, do you want to talk a little bit about prevention and patient education? Sure. Prevention and and patient education are probably one of the most important things that we can do for our patients. Um So we get tired of saying it, they get tired of hearing it but it's so very very important that we continue to try to educate them on diet and exercise and the importance of diet and exercise. It's easier to get ahead of it than try to catch up and lose the weight. And so that's one of the things that we should be stressing to our patients? Um We want to make sure that we're screening for complications of disease. So particularly with metabolic diseases. Are they examining their feet? Um Do they know what's going on in case they have um some peripheral neuropathy going on. Do they know how to manage that? Are they taking proper care of their feet? Um There is tobacco sensation, which is huge. We always want our patients to quit smoking. It's the healthiest thing that you can do for your heart. And um like I said, they never want to hear it, but we have to keep saying that smoking cessation is paramount. We want to monitor patients blood sugar um teach patients how to use their glucose monitors, make sure that they're aware of how that works and that they're doing it um according to their disease process enough times a day to really get a handle on what their sugar levels are. Um And then we want to monitor their ability to adhere to and administer their medication and that's something that we want to be checking periodically and assessing patients ability periodically. Um I know that sometimes older patients from experience like to kind of play with their their diabetes medication so they can have a little extra ice cream or a little extra suites and so we need to be sure that we're assessing that and making sure that that's not something that they're doing and that they understand the risks involved in that. And then do they still know how to administer their medication? Um You know, one of the things that happens is sometimes formularies change and they make it a different type of pin or their pen injector. They may not be covered for anymore and they need to use actual needles. So do they know how to use the equipment too? Give themselves their medication and then along with that um for care, coordination for benefits um in diabetes. So one of the good things is that a lot of the insurances now are offering specialty clinics and medication management for patients. So we should be referring patients to those whenever possible. Um We know that when they are paying attention to their their diabetes numbers and paying attention to their diet and exercise. We see improved glycemic control. We have improved patient, we have increased patient follow up which is also very very important. There is greater patient satisfaction. When patients start to lose weight they start to feel better about themselves, they start to want to take better care of themselves. There is reduced risk of diabetes complications. You know there's they're less likely to get those wounds that don't heal um or less likely to feel sick and um have low energy when they are controlling their glycemic index. Um It definitely definitely increases patient quality of life and we can't stress that to patients enough that they will feel and see an improvement in their quality of life. Um It reduces hospitalizations which is great for the patients and grateful organizations because that reduces costs. Um And so all of those things together should be discussed with patients fairly regularly so that they understand the importance of them. Um And so when we talk about diabetes care, coordination. Um And this is part of the whole continuum of taking care of our patients and keeping them keeping them in care and keeping them linked to care. So we want to also be discussing nutrition with our patients. Do we need to refer them to a nutritionist so that they know what they're eating and how they're eating it? Um Mental health counseling, this is very very important. Especially now in the times that we're living in with covid being an overlay to everything, mental health is important. Are they aware of where they can go? Do they need referrals? Do they need information on what type of services are available? Um And then we have here again um their pharmacists, their physical therapists and their occupational therapists. Are they keeping those appointments? Do they feel comfortable following those directions? Do they have questions on what's coming out of those appointments? Are they actually seeing improvement from using those services? So all of these units and all of these different people and all of these different professionals need to work together to again treat the whole patient right? Because that's the model that we want to try to follow is treating the whole patient. So and then also we have specialists which again is that whole patient thing? There's their cardiologist there ophthalmologists, podiatry and then we have their nephrologist and their neurologists if they need that. So our patients keeping these appointments, are we referring them when it's necessary. Do they need to sometimes make insurance changes so that they have the ability to go to and keep these appointments. So these are all things that we need to consider um as part of the whole patient model for diabetes care coordination. So Jeff, what are our key points for this? Thank you so much Bridget. So to summarize diabetes and other metabolic conditions can occur frequently in older persons with HIV. It's important to reduce or minimize contributing factors and the importance of physical activity, nutrition, tobacco cessation, avoiding or limiting substance use, controlling other chronic conditions such as diabetes and high blood pressure. All critical aspects of care for our patients. Clinicians should also ensure that patients complete appropriate screenings and preventive vaccines as needed. Thank you so much for viewing this learning module on diabetes and metabolic conditions. For additional information. We've provided some resources for you. We encourage you to view the other learning modules in our series. Working together, we can help improve the lives of persons aging with HIV. Here are some additional resources. So let's go ahead and do a quick knowledge check. Um Which of the following statements is true with regard to diabetes management and persons living with HIV. A Hemoglobin. A one C may underestimate glucose and persons living with HIV Be hemoglobin. A one C may overestimate glucose and persons living with HIV. See use of insulin is contraindicated in Persons living with HIV or D insulin needs are higher and persons living with HIV if you selected hemoglobin a one C may underestimate glucose and persons living with HIV you are correct. And the rationale for that is that hemoglobin a one C may underestimate glucose. One Persons living with HIV clinicians should consider use of fasting plasma glucose and clinical correlation to identify persons with diabetes and or to monitor glucose. Thank you for joining us. Hello and welcome to this module on care, coordination and chronic disease management. For persons with HIV this episode is part of an ax HIV and aging learning series. My name is Jeffrey Kwong. I'm an adult gerontology nurse practitioner and HIV clinician joining me today is my colleague Bridget Picchu from the Well Project. Hi Bridget. Hi Jeff, nice to see you. So my name is Bridget Picchu. I'm an L. V N. Working primarily in Palm springs, California. But again, I do some work with the Well project which is focused on HIV and women on completion of this activity. Participants will be able to describe the principles of care coordination and persons aging with HIV discuss the role of nurses and other professionals in health care coordination, describe ways in which care coordination can improve health outcomes for persons aging with HIV and chronic disease. When we think about care, coordination. Uh this really is a broad term that has many multiple definitions and I think the term care coordination has been referred to in some instances as case management, Perhaps care management, integrated care co ordinated care or even patient navigation. But when it comes down to it, what we're really talking about is really the principle that's been defined by the Agency for Healthcare Research and Quality as the deliberate organization of patient care activities between two or more participants involved in a patient's care to facilitate the appropriate delivery of health care services and central to this is that the patient is also part of this relationship and this dynamic. And when we think about why this is important, um we know that as individuals age the prevalence of other chronic conditions such as diabetes, high blood pressure, Cancer, other conditions that are part of this learning series that we've talked about um increase. In fact there's data that shows that nearly 70% of Medicare recipients have two or more chronic conditions as they age through the aging continuum. And what does that mean? Well, we know that with more and more chronic conditions, people are more likely to use increased health services. There's been data that there's an associated increase in costs with healthcare utilization and this requires the need and the highlights the role of care clinician as an integral part of controlling and managing some of these issues that arise Bridget. Do you want to talk about your coronation specifically for persons with HIV? So one of the things that we know is that when we are cognizant and aware of following the care coordination model, that it improves very logic suppression rates in patients? There's an increase in life expectancy and a reduction in cost. So that works for both the patient and organizations. And then it's also the best value for people with moderate severity of medical and psychosocial needs. So what makes up kind of those psychosocial needs? So it's a little different for persons living with HIV because they face things like stigma and transphobia, homophobia. Maybe they're incarcerated, There's immigration issues sometimes. Also some substance abuse may be involved and then ages them. And so all of those things together mean that we need to approach patients living with HIV from a trauma informed kind of lens in order to take the best care of them. So, um there's some basic principles involved in trauma informed care. So there's six here in no particular order and then they will also put some links in for additional information. But what trauma informed care looks like is safety. There is trustworthiness and transparency, your support, collaboration and mutuality patients feel empowered to use their voice and make choices and then there are cultural, historical and gender issues. So all of these need to be addressed in order for patients to feel safe and like they're getting the best possible care. So how do we know if we're following the care coordination model successfully. So there are some certain elements and tools that we can look at that can kind of judge our successes. So do patients feel as though they have easy access to a range of services and providers. So their specialty care, there is good communication and effective care plan transitions when we send them to these providers, do they have the records that they need? Do the patients know why they're going to see these specialists? There's a focus on total health care needs for the whole patient. So it's important to look at patients particularly with trauma informed care from a whole patient perspective and then there is clear and simple information that patients can easily understand. So are we using medical jargon or are we talking to them in terms they can understand, you know, Bridget talked a lot about the words of trauma informed care. I'm going to talk a little bit now about different care coordination models I alluded to earlier about different terms that we use for care coordination, but if we think about it just sort of in terms of different models or different venues or environments that care coordination can occur in there are basically three broad types of care coordination models that have been described include things such as primary care coordination more in the ambulatory setting. Um There's acute care coordination within a hospital setting even within um specialist and integrating services in the anger within the hospital is an important role that there are dynamic individuals who are able to navigate those complexities for patients. There's also post acute or long term care according. So this is coordination that involves transition from you care to long term care, but also for individuals who may be living in long term care, residing in residential facilities and care for outside specialists if they need to um go outside of the residential facility for, say specialty um nephrology care, hepatology care, being able to coordinate all of those um is an important role, and nurses and other professionals do a fantastic job at doing this and this is a very critical piece of the care continuum. Now I mentioned nurses as care coordinators but in fact in different institutions, depending on how the care coordinator is used, there are different skill sets and different professionals that can fall into this role. So those include individuals such as social workers, physiotherapist, even occupational therapist can play a role as a care coordinator and in some organizations or in some settings, people may be pure navigators or patient navigators who may not necessarily have a professional license or professional disciplines such as nursing or social work, but are truly hired and trained as navigators who can um who know benefit systems, who know how to engage in routine people in care and also are very integral and important part of the health care team. What is the evidence that supports care coordination. Well, the literature shows nurse led care coordination models can lead to improved access, appropriate treatment can help reduce healthcare costs and expenditures, importantly, it can improve clinical outcomes and quality of care for individuals, improves communication for staff between care transitions and helps reduce unplanned readmissions, which we know is a very important part of CMS. The Center for Medicare Services in terms of their value based healthcare planning, we know that hospital readmissions is a quality indicator. And care coordinators can help improve outcomes specifically along uh those quality metrics. What about roles for care coordinators in terms of others in an individual's life? So not only does care coordinator help with patient issues, but it also they can also help with family and caregiver concerns. So, an important role of a care coordinator, working with a client or an individual is to also assess and see what type of needs are required of the family or the other caregivers? Caregivers do they need things such as respite care? Um that can do they need other support services in the home that can help make caring for an individual who may be more frail or homebound. Much more manageable for those individuals. Care coordination can also help again for this continuity of care concept, providing education and support management for uh caregivers and family members. Also integral and also helping them help patients understand the importance of adherence to medication or other treatment plans is also a part of their role. One of the other things that we talk about a lot in HIV care is the importance of retention and care and we talk about it, you know, in sort of the ambulatory care practices as a concept, but really when we think about the whole continuum of care, even for people who may be in long term care facilities or in other uh types of facilities, really kind of keeping them engaged in care and retained in cure is so important to ensuring that people are able to maintain their viral loads and to keep them as healthy and provide as quality, as much quality of life as possible throughout the aging continuum, of course, in certain situations where an individual may also be facing end of life issues or concerns, a care coordinator can help bring those issues to the forefront and help ensure again that there is good continuity and continuation of services in end of life care or end of life planning. Do you wanna talk a little bit about thinking services? So, when we're talking about linking services, it's part of, again, like Jeff said this care continuum that we want to provide to patients because as we know, the care continuum doesn't just end with diagnosis and getting them prescribed medications. So, um one of the important things with linking services would be making sure that they know about their community resources, should they need housing or financial assistance or food. Um sometimes patients will need or have a desire to get involved into groups so that they can, you know, talk about their experience and share their experience with other persons living with HIV as well. Um there is there specialist care. So again, like Jeff was talking about the referrals to go see those specialists when they have these chronic issues that come up as we age and we want to make sure that they know where they're going. Do they have transportation to get to those specialist appointments? So that's a concern. We also want to make sure that we're providing and facilitating patient family and provider meetings. Sometimes as patients age they start to have cognition issues or memory issues. And so we want to make sure that the families when applicable are aware of what's going on so that they can be a part of the patient's care um and make sure that they're keeping appointments and getting to see us. So and then the other thing that we want to make sure of is that we are facilitating care transitions. So again that ties back into their specialist care. Do patients know why they're going to see the specialist? Do they have the records that they need to see this specialist? Do they know to communicate back with us what the specialist has told them and do they know to communicate to the specialist information that we need them to know about their care and about why they're being sent there. So linkage to care is really important because it's again that whole person model that we need to take a look at and not just the individuals medication and viral load needs. So just kind of to summarize today are key points would be care coordination is effective in improving quality safety and health outcomes for older persons with chronic conditions, incorporating the principles of trauma informed care is integral to care delivery and team coordination and knowledge of resources are critical to our success. Um So we want to thank you for joining us on this learning module on care coordination and the older adult living with HIV for additional information. We will provide some links that you can go and see. Um And we encourage you to view the other learning modules here in our series here are the links to the resources that you can click on in order to be able to find out some additional information. And then let's just do a quick knowledge check. So care coordination for persons living with HIV is associated with which of the following? A improve urologic suppression, be decreased health care costs. See, increased life expectancy. D and the only or E all of the above, if you answered e all of the above that is correct. The rationale for our knowledge check is that care coordination plays a critical role in the delivery of comprehensive care to persons living with HIV effective care coordination has been associated with improved neurologic suppression, decreased health care costs and increased life expectancy for persons living with HIV, we thank you for joining us today.
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