A Structured Telephone Interview for collecting Geriatric health domains in Older People with HIV during COVID era

doi:10.21203/rs.3.rs-2742687/v1

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A Structured Telephone Interview for collecting Geriatric health domains in Older People with HIV during COVID era

https://doi.org/10.21203/rs.3.rs-2742687/v1

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Background

Elderly people living with HIV show a significant prevalence of multimorbidity, polypharmacy and frailty that increase the risk of disability. Telehealth has been suggested as a new tool to monitor people living with HIV in the COVID era, but its effectiveness in elderly is unknown. The aim of this study was two-fold: to explore feasibility of a telephone interview and its capability to collect relevant geriatric outcomes.

Methods

Assessed health domains included comorbidities, falls, urinary incontinence, antiretroviral drugs exposure and comedications (polypharmacy), and the following patient reported outcomes: quality of life, intrinsic capacity, and resilience.

Results

214 (70.6%) answered and completed the interview. During confinement period, 57 (26.7%) of people switched antiretroviral therapy : 119 (55.4%) to dual therapy regimens and 95 (44.6%) to triple regimens. Prevalence of geriatric syndromes were falls in 31 cases (14.7%), urinary incontinence in 48 cases (22.7%) and polypharmacy 122 cases (57.2%). Mean Health-related Quality of Life score was mildly impaired (0,88%) with good concordance of Helath-related Quality of Life self-perception in a visual analogue scale (8/10) (r=+0.348; p <0.01). Intrinsic capacity depicted impaired functional ability in multiple domains (0.737 ) and Resilience (CD-RISC) was suboptimal (0.6).

Conclusions

A structured telephone call was feasible in elderly people living with HIV and allowed to collect clinically meaningful geriatric health domains when face-to-face visits are not needed or discouraged.

Interview as topic

HIV

Geriatric assessment

COVID-19 pandemic

Quality of life

Resilience

Frailty .

In the last decade several HIV clinics have been launched to address unmet clinical needs of Older People Living with HIV (OPLWH) aspiring to the geriatric person-centered model defined as comprehensive geriatric assessment [1]. In this context the COVID pandemic has been calling for a change in geriatric HIV care models being OPLWH the most at risk when reaching hospital-based clinics.

As such, new care models have been considered, including reduced F2F visits [2] and telehealth (ranging from teleconsulting to advanced telemedicine diagnostic and treatment tools) [3]. In consideration of the well described digital divide affecting the elderly, telephone calls have been considered the most suitable telehealth approach for this special population.

The objective of the study was to assess the feasibility of a structured telephone-based interview (STBI) to evaluate geriatric health domains in OPLWH .

Assessed health domains included comorbidities, falls, urinary incontinence, antiretroviral therapy (ART) exposure and comedications (polypharmacy), and the following patient reported outcomes: quality of life, intrinsic capacity, and resilience.

This was a cross-sectional multicentric study including patients from GEPPO cohort (Geriatric Patient living with HIV: a Prospective multidimensional assessment of an aging cohort & community) [4] from three Italian hospital centers: Turin, Modena and Brescia.

Telephone interviews were performed in Italian language by health care professionals, in particular research nurses and Infectious Diseases (ID) residents. The length of interview varied from 20 to 50 minutes depending mainly on difficulties in understanding questions (telephone line connection, hearing problems, etc.). Telephone interviews were conducted during COVID confinement measures, between November 2020 and April 2021. Inclusion criteria were HIV infection, age > 65 years, being previously included in the GEPPO cohort at the Outpatient Clinics of Turin, Brescia and Modena.

The structured interview included 63 questions exploring demographic, lifestyle and anthropometric data, as well as comorbidities diagnosed since the last visit.

Geriatric syndromes included falls and urinary incontinence by simple questions and polypharmacy assessing current ART and comorbidity medication. Polypharmacy was defined as the use of > 5 drugs other than ART.

Patient reported outcomes (PROs) included:

Health related Quality of life (HRQoL). This is a multi-dimensional construct which includes domains related to physical, mental, emotional, and social functioning. It was assessed using EQ-5D-5L exploring 5 domains: movement capacity, personal care, habitual activities (leisure, work, study), pain/discomfort and anxiety/depression. The EuroQoL Visual Analogue Scale (EQ-VAS) recorded the respondent’s self-rated health from 0 to 100 on a 20 cm visual analogue scale with endpoints labelled ‘the best health you can imagine’ and ‘the worst health you can imagine’.
Resilience. It represents the capacity to recover after exposure fully or partially to stressor, such as COVID. Resilience was assessed by mean of CD-RISC© (Connor Davidson Resilience Scale) score was used to assess resilience and we selected 5 questions out of the 25 from the original form. The final score and general population cut-off reported in previous study [5] were readapted respectively from the original 100 points to 20 points for the one used in our study and from 75.7 / 100 to 15.14 /20.
Intrinsic Capacity (IC). This is both a multidisciplinary and a multidimensional process, designed to evaluate the individual’s five functional domains: locomotion, cognition, psychology, vitality, and sensory [6]. It was evaluated with 19-item questionnaire, based on Integrated Care for Older People (i-COPE) guideline [7] higher score was related to higher intrinsic capacity.

Collected data were merged and analyzed using standard statistical methods through SPSS software (version 27.0, IBM).

Descriptive epidemiological analysis

303 subjects were eligible for telephone call interview: 214 (70.6%) answered and completed the interview (i), 42 (13.9%) did not reply (ii), 38 (12.5%) did not complete the call or refused to proceed with the interview (iii) and 9 (3%) were dead at the time of interview (iV). Among responders, 9 (4%) resulted to have had SARS-CoV-2 infection without need of hospitalization at time of the interview. Age was the he only difference among these 4 groups: respectively 72.7 (± 5.4), 73 (± 5.5), 75.2(± 6.0), 75.6 (± 4.5) years (p = 0.014)

Out of the 214 participants who answered the call and completed the questionnaire, 79% were male with a median age of 72.7 (± 5.4). Table 1 summarizes demographic, anthropometric, HIV, geriatric, and PROS data of the study population.

Table 1

Demographic, anthropometric, HIV, geriatric, and person-reported outcomes (PROS) data of the study population
VARIABLE	Number
Demographics, anthropometrics and lifestyles
Gender (M); n (%)	169 (79)
Age (years); mean (± SD)	72.7 (± 5.4)
Waist circumference (cm); mean (± SD)	98.6 (± 12.5)
BMI (Kg/m²); mean (± SD)	26.3 (± 4.3)
Live alone; n (%)	105 (49.5)
Active smoker: n (%)	33 (15.3)
Alcohol use: n (%)	114 (53.5)
Children: n (%)	116 (54.4)
Education (yrs); mean (± SD)	9.92 (± 4.36)
Physical activity: n (%)	132 (61.5)
Working status: Still working; n (%) Retired; n (%) Retired occasionally working; n (%) Receives disability pension; n (%)	6 (2.7) 167 (78) 28 (13.3) 13 (6.2)
Retirement (years since); mean (± SD)	13.2 (± 7.60)
HIV variables and COVID-19 data
HIV-RNA < 20 cp/mL: n (%)	224 (95.5)
CD4 + T lymphocytes (n/mm³): mean (± SD)	634.4 (± 275.7)
SARS-CoV-2 coinfection: n (%)	9 (4.1)
Geriatric syndromes
Falls (last 6 months): n (%)	31 (14.7)
Urinary incontinence: n (%)	48 (22.7)
Polypharmacy, n (%)	113 (52.7%)
Person-reported outcomes
QoL (EQ-5D-5L), median (Q1,Q3)	0.887 (0.932 − 0.781)
QoL today, median (Q1,Q3)	8 (8 − 6)
QoH today, median (Q1,Q3)	7 (8 − 6)
IC %, median (Q1,Q3)	0.737 (0.790 − 0.632)
Resilience %, median (Q1,Q3)	0.600 (0.750 − 0.450)
QoL, quality of life; QoH, quality of health; IC, intrinsic capacity.

Regarding occupational status, 167 (78%) were retired, 13 (6.2%) received a disability pension, 28 (13.3%) were retired and occasionally working and 6 (2.7%) were still working.

Participants had a median HIV duration of 19.1 years (± 7.9).

The vast majority (204, 95.5%) had undetectable HIV viremia (< 20 copies/ml), with a median lymphocytes T CD4 + cells count of 634.4 (± 275.7) cells/mm3.

Prescribed antiretroviral regimen was 3 drugs regimen (3DR) in 102 (54.8%) of pts, 2 drugs regimen (2DR) in 91(41.4%) and monotherapy in 3 (1.4%) and 18 (8.4%) using more than 3 ART drugs. Integrase Inhibitors (INSTIs) were the mostly prescribed class 149 (69.5%), followed by Non-Nucleoside Trascriptase Inhibitors (NNRTIs) 73 (34.3%) and Protease Inhibitors (PIs) 44 (20.5%).

In the previous year, i.e. during confinement period, 57 (26.7%) of people switched ART: 119 (55.4%) to dual therapy regimens and 95 (44.6%) to triple regimens. In this setting, INSTI were prescribed in 191 (89.3%) and PIs in 15 (7.1%).

Figure 1 shows prevalence of 2-drug regimen (2DR) vs 3-drug regimen (3DR) ART regimens in participants who switched or not switched ART during the study period.

Prevalence of geriatric syndromes were falls in 31 cases (14.7%), urinary incontinence in 48 cases (22.7%) and polypharmacy 122 cases (57.2%). Table 1 also depicts collected PROS.

Mean HRQoL score was mildly impaired (0,88%) with good concordance of HRQoL self-perception in a visual analogue scale (8/10) (r = + 0.348; p < 0.01). Intrinsic capacity depicted impaired functional ability in multiple domains (0.737 ) and CD-Risc was suboptimal (0.6).

Correlations among these 3 PRO measures were explored after correction for multiple covariates In detail:

In linear regression, HRQoL inversely correlated with with age (r=-0.242; p < 0.01), and years spent after retirement (r=-0.235; p = 0.01).

The correlation between HRQoL and resilience (r = + 0.204; p < 0.01), HRQoL with IC (r = + 0.389; p < 0.01) and resilience with IC (+ 0.366; p < 0.01) were significant but weak.

This study demonstrated that a structured telephone-based interview was feasible in evaluating geriatric health domains in OPLWH .

Older age was the main obstacle to the success of this specific telehealth tool which may not be appropriate in “older old” and patients with hearing loss and cognitive impairment

Despite the relative long duration of the telephone call, most OPLWH were able to complete the interview (84.9%). Telephone call is not time sparing and may be considered complementary rather than alternative to traditional vis a vis encounter [8].

Data were collected between November 2020 and April 2021 at the very beginning of mass SARS-CoV-2 vaccination campaign during the II and III COVID waive. In this scenario 4,1% only of our population reported an infection with SARS-Cov-2 probably reflecting a higher awareness on preventive strategies of OPLWH due to the perception of a potential higher risk of severe disease and mortality [9–10]. Contrary to recommendation of various HIV scientific societies not to change ARV regimens during COVID crisis, a significant number of OPLWH switched to 2DR, presumably to the increased confidence of ID prescribers in safety, effectiveness, and low burden of drug-drug interactions (DDIs) of dolutegravir based regimens in particular. Interesting this approach goes in the direction of a deprescribing strategy in OPLWH with polypharmacy, representing 57.2% of enrolled patients [11]. Deprescribing is a personalized intervention aimed to remove unnecessary drugs seeking for HRQoL amelioration.

In our population, QoL was found to be 85% (± 0.143), lower than the cut-off reported in literature of 89.7% from a general Spanish population [12] but close to other reported cut-off of 84.8 (+/- 13.8)% from a multicenter cohort of general Italian population [13] representing all ages in a pre-pandemic period.

We may argue that the COVID crisis did not significantly impact HRQoL or rather that EQ5D5L tool is not sufficiently sensitive to capture changes in long term well-being. This is the reason why resilience was contemporary addressed depicting a different vulnerability status related to the capacity to restore health homeostasis to the level before COVID crisis.

The considered stress condition was the lockdown associated with COVID-19 crisis and not COVID-19 disease itself potentially more related to mental rather physical health status. Therefore, a non-validated 5 items CD-RISC questionnaire explored psychological rather than physical resilience. We may argue that the combination of QoL and resilience should be used contemporary to describe health related well-being in the context of COVID-19 crisis.

We were obviously unable to objectively assess frailty phenotype with telephone e call, we therefore describe IC, that is a measure of functional reserve. So far, few studies have used IC as a health domain and validated cut-off are still not present in literature, we therefore used valued above or below the mean to classify high or low IC.

Most PROs had significant inter-relation, but most of the time the strength of correlation was weak. This is the case between HRQoL and age, which mean that in older age also optimal QoL should be perused. The weak correlation among HRQoL, resilience and IC underlines that these multidimensional constructs although overlapping, still depicts different angles of long-term well-being and should be used as complementary tools.

Our study has limits derived from the potential bias of the interviewers’ skills in posing questions during the telephone call and the long duration of the interview. Different level of trust between the interviewer and the OPLWH may also influence accuracy of the answers.

In conclusion, a structured telephone call was feasible in OPLW and allowed to collect clinically meaningful geriatric health domains when face-to-face visits are not needed or discouraged.

This study paves the way to a person-centered geriatric HIV medicine that can be conducted in hybrid form through vis a vis encounter and telehealth.

OPLWH

Older People Living with HIV

STBI

Structured telephone-based interview

ART

Antiretroviral therapy

GEPPO cohort

Geriatric Patient living with HIV:a Prospective multidimensional assessment of an aging cohort & community

Infectious Diseases

PROs

Patient reported outcomes

HRQoL

Health related Quality of life

EQ-VAS

EuroQoL Visual Analogue Scale

CD-RISC

Connor Davidson Resilience Scale

Intrinsic Capacity

iCOPE

Integrated Care for Older People guideline

INSTIs

Integrase Inhibitors

NNRTIs

Non-Nucleoside Trascriptase Inhibitors

PIs

Protease Inhibitors

2DR

2-drug regimen

3DR

3-drug regimen

DDIs

Drug-drug interactions

Ethics approval and consent to participate: This study was conducted in accordance with the Declaration of Helsinki. It was conducted after receiving approval from The Protocol was approved by all participating centers' Ethics Committees (Brescia's EC as coordinating center in 2016) as well as following protocol amendments. The patients’ informed consent to participate in this study was obtained via consent forms.

Consent for publication: not applicable

Availability of data and materials: The data that supports the results of this study will be provided by the corresponding authors upon receipt of reasonable requests.

Competing interests: The authors declare that they have no competing interests

Funding: Not applicable

Authors' contributions: MF collected data and wrote the manuscript; LM collected data; GG and AC conceived and designed analysis and involved in manuscript review with revisions for important intellectual content; JM involved in manuscript review with revisions for important intellectual content; All authors provided critical feedback and helped shape the research, analysis and manuscript.

Acknowledgements: None

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No competing interests reported.

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A Structured Telephone Interview for collecting Geriatric health domains in Older People with HIV during COVID era

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Descriptive epidemiological analysis

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