Delirium among people aging with and without HIV: Role of alcohol and Neurocognitively active medications

Abstract

Background People aging with and without HIV (PWH and PWoH) want to avoid neurocognitive dysfunction, especially delirium. Continued use of alcohol in conjunction with neurocognitively active medications (NCAMs) may be a largely underappreciated cause, especially for PWH who experience polypharmacy a decade earlier than PWoH. We compare absolute and relative risk of delirium among PWH and PWoH by age, level of alcohol use, and exposure to NCAMs. Methods Using the VACS cohort, we compare absolute and relative risk of inpatient delirium among PWH and PWoH by age, level of alcohol use, and exposure to NCAMs between 2007 and 2019. We matched each case based on age, race/ethnicity, sex, HIV, baseline year, and observation time with up to 5 controls. The case/control date was defined as date of admission for cases and the date corresponding to the same length of time on study for controls. Level of alcohol use was defined using Alcohol Use Disorder Identification Test–Consumption (AUDIT‐C). Medication exposure was measured from 45 to 3 days prior to index date; medications were classified as anticholinergic NCAM, non‐anticholinergic NCAM, or non NCAM and counts generated. We used logistic regression to determine odds ratios (ORs) for delirium associated with medication counts stratified by HIV status and adjusted for demographics, severity of illness, and related diagnoses. Results PWH experienced a higher incidence of delirium (5.6, [95% CI 5.3–5.9/1000 PY]) than PWoH (5.0, [95% CI 4.8–5.1/1000 PY]). In multivariable analysis, anticholinergic and non‐anticholinergic NCAM counts and level of alcohol use demonstrated strong independent dose–response associations with delirium. Conclusions Decreasing alcohol use and limiting the use of neurocognitively active medications may help decrease excess rates of delirium, especially among PWH.

Combining Charlson comorbidity and VACS indices improves prognostic accuracy for all-cause mortality for patients with and without HIV in the Veterans Health Administration

“…Conditions were considered present based on one or more inpatient or two or more outpatient codes. The ICD codes used to identify CCI comorbidities (Supplementary Table S2) were based on a careful examination of prior studies (24)(25)(26)(27). The codes identified in these three sources substantially overlapped.…”

Incidence and contributing factors of dementia among people living with HIV in British Columbia, Canada, from 2002 to 2016: a retrospective cohort study

“…The case definition used for episodes of delirium was previously validated using direct evaluation of postsurgical patients in an intensive care unit, which was reported to be sensitive to the use of alcohol and medications associated with delirium in PLWH. [31][32][33] Once identified, comorbidities were assumed to be irreversible and present until the end of follow-up. Other clinical covariates included viral load at index date (<200, ≥200 copies/mL), uncontrolled viremia (ie, ≥two consecutive viral loads>200 copies/mL; yes, no, not measured; assessed annually), 34 CD4 cell count (<50 cells/mm 3 , 50-199 cells/mm 3 , 200-349 cells/ mm 3 , ≥350 cells/mm 3 ; not measured; assessed annually), self-reported HIV acquisition risk category (PWID, gay, bisexual and other men who have sex with men (gbMSM), heterosexual/other, unknown) and ART initiation year (<2000, 2000-2004, 2005-2010 and >2010).…”

Contingency management with stepped care for unhealthy alcohol use among individuals with HIV: Protocol for a randomized controlled trial

“…Specifically, among PWH, consumption of alcohol exceeding an average of one drink per day is associated with a 30% increased risk of mortality with increasing risk observed with increasing levels of consumption (6). In addition, unhealthy alcohol use is associated with adverse effects on HIV-related outcomes and other medical conditions common among PWH (e.g., depression) and may interact with psychoactive medications frequently prescribed to PWH to cause harm (e.g., falls) (7,8). Thus, in some patients, there is rationale to intervene even on -(9)).Clinical guidelines recommend behavioral treatments (10) and, for those with AUD, medication too(11).…”