VIRULENCE

2017, VOL. 8, NO. 5, 577–585

https://doi.org/10.1080/21505594.2016.1219445

REVIEW

Geriatric syndromes: How to treat

Matteo Cesaria,b, Emanuele Marzettic, Marco Canevellid, and Giovanni Guaraldie
a
G
erontop^ole, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; bUniversit
e de Toulouse III Paul Sabatier, Toulouse, France;
c
Department of Geriatrics, Neurosciences and Orthopedics, Catholic University of the Sacred Heart, Rome, Italy; dMemory Clinic, Department of
Neurology and Psychiatry, Sapienza University, Rome, Italy; eDepartment of Medical and Surgical Sciences for Adults and Children, Clinic of
Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy

ABSTRACT ARTICLE HISTORY

The survival of HIV-infected persons has been increasing over the last years, thanks to the Received 25 March 2016
implementation of more effective pharmacological and non-pharmacological interventions. Revised 26 July 2016
Nevertheless, HIV-infected persons are often “biologically” older than their “chronological” age due Accepted 27 July 2016
to multiple clinical, social, and behavioral conditions of risk. The detection in this population of KEYWORDS
specific biological features and syndromic conditions typical of advanced age has made the HIV elderly; frailty; geriatrics; HIV;
infection an interesting research model of accelerated and accentuated aging. Given such integrated care; prevention
commonalities, it is possible that “biologically aged” HIV-positive persons might benefit from
models of adapted and integrated care developed over the years by geriatricians for the
management of their frail and complex patients.
In this article, possible strategies to face the increasingly prevalent geriatric syndromes in HIV-
infected persons are discussed. In particular, it is explained the importance of shifting from the
traditional disease-oriented approach into models of care facilitating a multidisciplinary
management of frailty.

Global aging and changing scenarios

if the obsolete chronological age criterion is used as
The demographic changes occurring worldwide are reference.
exposing the current models of healthcare to the risk of It is not far from reality saying that multiple disci-
collapsing.1 Patients that are today usually seen in clini- plines sharing this same problem are today looking with
cal services are indeed very different from those for increasing interest to the background and specificities of
whom the same services were designed decades ago. geriatric medicine. This is not surprising because the his-
Nowadays, the daily clinical routine is mostly absorbed torical background of geriatricians has always been cen-
by the assessment and treatment of patients character- tered on the management of frail and complex elders. In
ized by older age, more comorbidities and syndromes, this context, geriatric medicine has been contributing
and higher consumption of medications.2 over the years with the development of specific strategies
This transition is evident across most medical disci- and methodologies (although not always correctly inter-
plines, including infectious disease medicine (IDM). preted and applied).6
Indeed, with the widespread implementation of highly It is noteworthy that the nosographic entities at the
active antiretroviral therapy (HAART), the survival of basis of traditional medicine tend to lose their meaning
HIV-infected persons has been substantially extended, and relevance with advancing age. The simultaneous
approaching that of the general population in high- presence of multiple and interacting clinical and subclin-
income countries.3 At the same time, specific pathophys- ical conditions in the older individual leads to heteroge-
iological features brought about by HIV infection have neous phenotypic manifestations, which are often not
led to considering it a model of accelerated and accentu- attributable to any of the single conditions the person
ated aging,4 and a condition of possible use for develop- suffers from. In such a scenario, the concept of “stand-
ing strategies against age-related conditions.5 Indeed, alone” diseases (all individually targetable with specific
HIV-positive patients can often be considered “old and interventions) is therefore not applicable in contempo-
frail” under a biological viewpoint, although still “young” rary medicine. Indeed, by focusing the medical attention

CONTACT Matteo Cesari, MD, PhD macesari@gmail.com G
erontop^ole, Universit
e Toulouse III – Paul Sabatier, 37 All
ees Jules Guesde, 31000 Toulouse,
France.
© 2017 Taylor & Francis
578 M. CESARI ET AL.

on individual diagnoses and treating each of them exposing the individual to higher risk of negative out-
according to standard protocols and guidelines, the over- comes) is sometimes presented as a syndrome,9 some
all picture of the patient would be ineluctably lost, easily others as a state of health determined by the age-related
resulting in over-diagnosis and/or over-treatment. accumulation of deficits.10 Such ambiguity largely
A related problem is the lack of randomized con- depends on the operational definition adopted to frame
trolled trials recruiting participants with the characteris- it.11 In fact, frailty is frequently described as a syndrome
tics and complexities of the average patient attending because associated with the widely diffused model pro-
clinical services. This means doubting and arguing the posed by Fried and colleagues.12 The so-called frailty
appropriateness of standard protocols and decisional phenotype based on the assessment of 5 epidemiologi-
algorithms traditionally used in medicine.7 This issue cally-derived criteria (i.e., poor muscle strength, slow
may potentially drive toward the opposite condition of gait speed, exhaustion, sedentary behavior, and involun-
over-diagnosis and over-treatment, which is “ageism” tary weight loss) clearly describes frailty as a syndrome.
and preclusion from therapeutic options. However, the automatic translation of a condition with
In the present article, we discuss the possible treat- an instrument designed for measuring it should be cau-
ment strategies that can be adopted to face the increas- tious because highly arguable. In particular, by doing the
ingly prevalent geriatric syndromes in clinical settings. equivalence between frailty and frailty phenotype, several
In the first section, the need of reshaping the models of aspects are neglected:
care is linked to the geriatric condition of frailty. Frailty 1) Frailty existed and was treated in geriatric medicine
is often described as a syndrome and for this reason well before the development of the frailty pheno-
included in the present document. However, we believe type from the Cardiovascular Health Study
that frailty is something more than that and could repre- database;13
sent the umbrella under which conducting the clinical 2) The instrument was designed with the properties of
care of geriatric conditions and syndromes. In the second a screening tool;11 and as such it is unable to ade-
part of the article, we show how frequently major geriat- quately support the design of interventions against
ric syndromes occur in HIV-positive patients, and sug- the underlying causes of frailty;
gest possible ad hoc solutions developed by geriatricians 3) Many other instruments are available that similarly
over the years. identify older persons at increased risk of negative
health-related outcomes, sometimes even in an eas-
ier and more reproducible way;14,15
Frailty: A mere syndrome or a cornerstone
4) The detrimental consequences of frailty in the
condition for remodeling healthcare services?
older individual frequently find their causes in
A geriatric syndrome is a non-disease clinical condition domains beyond the physical dimension;16 and
of older persons characterized by multiple causes deter- 5) Adding the notion of frailty to a standard clinical
mining a unified manifestation. By definition, it encom- assessment has very modest relevance if the infor-
passes a group of signs and symptoms variably occurring mation is not translated into a specific counterac-
together and characterizing a particular abnormality. tion (obviously not doable on the basis of the result
This implies that geriatric syndromes present a multifac- of a screening test).17
torial and extremely heterogeneous background, ground- Differently, if frailty is more broadly considered a
ing its roots in clinical, psychological, social, and continuous parameter reflecting the “biological aging” of
environmental vulnerabilities.8 the individual, it might represent much more than a
As previously argued, in a world experiencing the mere condition to be screened. It may indeed assert to
consequences of global aging (even in low-income coun- the criterion for taking decisions of public health rele-
tries), the traditional concept of advanced age to define vance.16 In fact, if we disregard the concept of frailty as a
the “older” individual is no longer effective. The current syndrome and start looking at it as a point in the contin-
clinical reality calls for new paradigms that are able to uous process of aging, it will be possible to use it to
offer more accurate and personalized care. Such a transi- replace the obsolete criterion of chronological age in
tion may be accomplished through the quantification of clinical decisional algorithms. To put it differently,
the homeostatic reserves of the organism in order to instead of talking of older persons in terms of years of
obtain an estimate of its “biological age.” This is the life lived, we might focus the concept of aging on the
main reason why geriatric medicine started developing clinical and biological features determining the vulnera-
specific activities around the so-called “frailty” condition. bility of the older individual. This reasoning might
Frailty (defined as a condition of increased vulnerabil- directly affect the allocation of resources, which would
ity due to the reduction of homeostatic reserves, be used to cover different needs in a “biologically young”
 VIRULENCE 579

person of 80 y of age (suitable for traditional medical function, and increased risk of death, as well as for health
paradigms and protocols) versus a “biologically old” systems.
individual of 50 (as frequently occurring among HIV- Hip fracture is the most feared fall-related injury.
positive patients). Such eventuality is particularly nurtured by the age-
The incorporation of frailty assessment in clinical related reduction of bone mineral density. It is notewor-
practice might take advantage of the large and increasing thy that HIV infection and antiretroviral therapy have
diffusion of the frailty concept across medical specialties. both been associated with significant bone loss, resulting
Frailty is no longer an exclusivity of geriatricians and in osteopenia and osteoporosis.26
gerontologists. Having multiple disciplines familiar with In advanced age, falls have typically a multifactorial
the term may allow its use as common denominator/ etiology, including age-related comorbidities, postural
shared language for facilitating interdisciplinary cross- modifications, sensory impairment, musculoskeletal
talks and exchanges. This is really the direction to take to weakness, postural hypotension, medications, and envi-
effectively deal with frailty. ronmental hazards.27 The prevention of falls conse-
We believe that the only possibility, probably the only quently requires the multidimensional assessment of a
feasible at this time, to manage the growing number of number of heterogeneous risk factors. It is also impor-
frail individuals is to remodel healthcare services in order tant to establish if the patient has a history of falls,
to privilege and facilitate integrated and multidisciplin- because recurrent falls are a major cause of morbidity
ary models of care.18 The design of the interventions and mortality. Moreover, distinct interventions may be
around the patient’s needs and resources should thus be necessary for primary and secondary prevention. Indeed,
achieved on the basis of a coordinated and collegial dis- once an older person falls, a “post-fall syndrome” may
cussion of the case in which the different specialists par- develop.28 This condition is characterized by the patient’s
ticipate with their own expertise and background. fear of new events, leading the individual to unwittingly
Models of care based on a single-access point (e.g., case- modify his/her posture and movements. Such postural
manager19) and interdisciplinary exchanges formally modifications do nothing else that accentuating the risk
nested in clinical services (e.g., orthogeriatric units20) of new events through altering the mechanics of move-
have already shown their efficacy both for the patient (in ment. A vicious cycle may thus generate that accelerates
terms of improved quality of life, prevention of negative the disabling cascade.
health-related outcomes, and higher access to treat- Gait and balance evaluation through standardized
ments)21,22 and public health (in terms of reduction of tests is a crucial step in primary and secondary fall
healthcare expenditures).23 Moreover, preliminary prevention. Simply looking at how the patient walks
reports have started associating frailty to allocation of or sit down/stand-up from a chair may already pro-
healthcare resources,24 suggesting a higher profile for vide meaningful information about the risk profile.29
this concept in the near future. Each comorbidity reported by the patient or detected
during the clinical evaluation should be critically ana-
lyzed as a potential trigger of falls. Sensory deficits
Management of geriatric syndromes
should be corrected whenever possible. Special atten-
The concept of HIV infection as a model of pathological tion should be paid to specific medications (e.g., long
aging is reinforced by the fact that more than half of the half-life benzodiazepines, anticonvulsants, anti-hyper-
HIV-infected population presents 2 or more geriatric tensive drugs) potentially responsible for falls due to
syndromes.25 The following paragraphs are not intended their pharmacodynamics and/or schedule of adminis-
to be exhaustive. The aim is instead to show how fre- tration. Finally, a successful plan for reducing the risk
quent detrimental conditions affecting geriatric patients of falls cannot ignore the elimination of eventual
are found in HIV-positive persons. This population environmental hazards (both in the clinical facility
could therefore greatly benefit from the adapted and per- and at the home).
sonalized models of care envisioned for older patients.
Cognitive impairment and delirium
Falls
With the introduction of HAART, neurocognitive disor-
Falls (defined as an event which results in a person com- ders in HIV-positive patients have been substantially
ing to rest inadvertently on the ground or floor or other reduced although still present. Obviously, HIV-associ-
lower level) is a very common condition in older per- ated neurocognitive disorders present a pathophysiologi-
sons. Falls are particularly distressing for the individual, cal background completely different from those observed
due to the consequent higher morbidity, loss of physical in older age.30,31
580 M. CESARI ET AL.

The mechanisms leading to the HIV-associated neu- impairments, verification of patient’s hydration, critical
rocognitive disorders are not yet completely clear. Surely, review of drugs prescriptions, and promotion of physical
HIV plays a pivotal role in 1) permitting infected mono- activity are only few of the habits that every clinician
cytes to pass the blood-brain barrier, 2) turning them dealing with frail individuals should familiarize with.36
into perivascular macrophages with parallel microglia
activation, and 3) promoting the release of neurotoxic
Sleep disorders
molecules. The consequence of such events is neuron
demise via the direct actions of viral proteins, or indi- Sleep disorders are frequently listed among the tradi-
rectly via apoptosis triggered by the related inflammatory tional geriatric syndromes.37 They are also a common
response.30 complaint in HIV patients.38 Sleep disorders are a pow-
Alzheimer disease is traditionally believed to be the erful risk factor for physical and cognitive decline, and
most common cause of dementia at older age. However, able to enhancing the “pathological aging” of an individ-
the categorization of different forms of dementia is quite ual (independently of the HIV infection).
a complex (and probably meaningless) exercise in The evidence around the nature of sleep disorders in
advanced age. In fact, it cannot be ignored that 1) a clear HIV-positive patients is still limited, probably because
pathophysiological mechanism for many types of the problem is underestimated.39 Some reports suggest
dementia is not yet defined;32 2) the age-accumulation of that concurrent psychiatric conditions (e.g., depression)
subclinical and clinical deficits leads to a cloud of differ- may not completely explain sleep disorders in HIV
ent causes (frequently overlapping and all potentially patients, proposing that other factors (such as neuronal
valid);7 and 3) no specific treatment able to reverse the damage) may contribute to their pathogenesis.40
neurodegenerative process (whatever the etiology) is Again, in front of a geriatric syndrome (even when
available to date. translated in a different field and with potentially diverse
In the case of HIV, the direct link between the viral pathophysiological background), it is always important
infection and neurocognitive disorders lends support to proceeding with a first multidimensional evaluation
pharmacological interventions potentially acting at the aimed at determining the underlying cause(s). The detec-
very bases of the infectious disease. For example, tion of the problem might lead to specific diagnostic pro-
although evidence is still limited, antiretroviral drugs cedures (e.g., polysomnographic exam) to guide in the
characterized by higher central nervous system penetra- choice of optimal therapeutic strategies. If sometimes
tion seem to provide some additional benefits in this non-pharmacological interventions (e.g., weight loss,
context.33 At the same time, it should not be underesti- physical activity, sleep hygiene recommendations) might
mated the importance of multidomain interventions tar- be effective, some others special devices (e.g., oral appli-
geting exogenous risk factors. For example, interventions ances or positive airway pressure for sleep apneas),
aimed at assuring social support to the patient, promot- surgical interventions (e.g., nasal reconstruction, uvulo-
ing healthier lifestyles, and tackling clinical conditions pharynpalatoplasty) or medications may be needed. In
(e.g., sensory impairment, cardiovascular risk factors) this latter case, physicians should cautiously prescribe
potentially accentuating the cognitive decline and other the lowest effective dose, privilege molecules with shorter
commonly associated manifestations (e.g., behavioral half-life, and follow the patient over time. The risk of
and neuropsychiatric symptoms) might represent thera- polypharmacy and interactions among drugs is
peutic commonalities between HIV-associated neuro- extremely high in HIV-positive patients, who are chroni-
cognitive disorders and neurodegenerative disorders of cally exposed to multiple treatments as any frail and
advanced age.34 As previously argued, also in this case, complex older adult.41 A triage in the choice of interven-
the definition of an optimal plan of intervention, which tions is thus needed and should be based on functional
will have to necessarily be personalized according to the and pragmatic outcomes: quality of life and careful con-
patient’s characteristics, should imply a holistic approach sideration of the altered homeostatic reserves are key fac-
and integrated care. tors for improving prescriptions and strategies.
It is noteworthy that the cognitive impairment related
to HIV infection combined with polypharmacy and
Polypharmacy
reduced homeostatic reserves may expose the individual
to a high risk of delirium. Delirium is indeed a frequent The exposure to polypharmacy, generally defined as the
neurological complication of HIV infection, especially in daily use of 5 or more medications, is an extremely com-
critically ill patients.35 Noticeably, the prevention of mon and clinically relevant condition in older persons as
delirium passes through the (often non-pharmacologi- well as among HIV-positive patients. In a cornerstone
cal) management of risk factors. Amelioration of sensory study of geriatric literature, it was demonstrated that the
 VIRULENCE 581

risk of adverse drug reactions is not related to age per se, of medications and their daily schedule. In this context,
but rather to the number of administered medications.42 the use of combined drugs might be helpful, but only if
Surely, the aging process is associated with increasing allowing adequate calibration of the single molecules
“failure to thrive” of the homeostatic mechanisms, conse- according to the individual’s reserves. The general rule to
quently rendering the person more vulnerable to the follow in geriatric population and also applicable to frail
undesirable effects of drugs.43 With advancing age, the HIV-positive patients is “Start low, go slow.”47
metabolic capacities of kidneys and liver decline, expos-
ing the individual to the risk of drug intoxication. Such a
Mobility impairment and functional limitation
risk is also enhanced by the age-related changes in body
composition, characterized by the inversion of the lean Mobility is a basic function present in almost every living
mass-fat mass ratio (even in the presence of a stable being. The incapacity to move has been related to nega-
body mass). It is, for example, possible that a lipophilic tive health-related outcomes across species.48 It is note-
medication administered after standardization for body worthy that physical performance has repeatedly been
mass or weight might be overdosed because the metabol- considered as a marker of wellbeing. Its decline is closely
ically active tissues are reduced and the storage capacities related to the loss of the biological homeostasis of an
increased. These crucial aspects to consider when treat- organism as a whole. Thus, it is not surprising that indi-
ing an older person are equally important in HIV-posi- viduals experiencing an accelerated and/or accentuated
tive patients. They might be even more important given aging process are also characterized by impaired
the fact that this population is already (chronically) mobility.
exposed to HAART agents in addition to those used to Besides serving as an important marker to estimate
treat comorbidities. the biological age of a person, mobility impairment also
The best way for tackling polypharmacy is to reduce defines a major clinical outcome for older adults.49 In
inappropriate prescriptions. Specific guidelines and recom- fact, mobility disability is considered the first step of the
mendations for “de-prescribing” are available in literature.44 disabling cascade, a condition to be prevented before the
In general, clinicians should carefully evaluate the vicious circle of frailty-disability becomes more difficult
list of drugs taken daily by older persons and HIV- to be halted.
positive patients. During the evaluation process, it is The age-related impairment of the mechanisms
crucial that the physician is not driven at treating devoted to mobility is multi-causal. Although the quanti-
every single abnormality. Such an approach would tative and qualitative decline of skeletal muscle (often
easily conduct to overtreatment and risk of adverse referred to as “sarcopenia”) may represent the organ-
drug reactions. The choice of a treatment should be specific impairment responsible for the loss of mobility
judged on the basis of realistic and practical objec- with advancing age, it is indeed difficult to indicate one
tives, while maintaining a holistic vision of priori- single cause for the syndromic manifestation of mobility
ties.45 By doing so, it is important to keep in mind impairment. For example, sensory deficits as well as
that evidence for commonly used drugs is often environmental factors may easily explain the worsening
derived from trials conducted in different (healthier) of mobility.
populations.46 Moreover, in older persons and in A recent systematic review showed that mobility and
HIV-positive patients, it is also important to explore motor function disability is highly prevalent (about 25%)
social and economic issues potentially affecting the among people living with HIV in sub-Saharan Africa.50
patient’s adherence and compliance to the therapeutic HIV-positive patients receiving combination antiretrovi-
recommendations in order to reduce the risk of ral therapy frequently present specific body composition
adverse drug reactions. For this reason, it is always modifications (i.e., “lipodystrophy syndrome”), charac-
wise to check the medications really taken by the terized by adipose tissue redistribution. Interestingly,
patient at every clinical contact. Some evidence sup- central obesity has shown to be a strong predictor of
ports the benefits deriving from the adoption of com- frailty in community-dwelling older persons with HIV
puter-based prescribing systems.41 Indeed, software and to significantly impact physical performance meas-
applying specific algorithms for supporting the appro- ures.51 Moreover, lipodystrophy is often accompanied by
priateness of drugs prescription have shown to a reduction of bone quality,52 which can further contrib-
improve the healthcare provider’s behavior. Unfortu- ute to undermine the structure of the organism,53 leading
nately, evidence about the beneficial effect of these to a decline of function.
systems on the patient’s outcomes is still very limited. To date, the only intervention able to positively affect
The clinician should also try to simplify as much as mobility impairment is physical exercise. The Lifestyle
possible the drug prescriptions, both in terms of number Interventions and Independence for Elders (LIFE) trial
582 M. CESARI ET AL.

has recently showed that a long-term structured physical education curricula and often used for only justifying
activity is able to prevent mobility disability in older per- nosographic conditions.6,58
sons with physical function impairment.54 Similar results In the specific field of HIV, geriatric care might be
have been reported in preliminary studies recruiting promoted by facilitating interdisciplinary exchanges
HIV-positive patients.55 A physical activity program between geriatricians and infectious disease specialists.
should always be proposed in parallel with nutritional As mentioned above, the development of structured col-
counseling in order to meet the new (increased) energy laborations mirroring previous successful experiences
demands and provide adequate protein intake to pro- (e.g., orthogeriatric wards)59,60 might represent a first
mote muscle growth and strengthening. It is indeed promising (and not invasive) strategy. Surely, the special
important to stress how lifestyle modifications are crucial features of HIV-positive patients may require the design
and should be part of the HIV therapy. of ad hoc new tools for supporting the clinical assessment
Mobility impairment is usually considered to be the of this new frail population. In fact, the instruments used
first stage of the disabling process. After losing the capac- in geriatric medicine are based on scopes, criteria, and
ity to cover the necessary walking distance for maintain- cut-points which are likely not applicable (or relevant) to
ing independent life (traditionally estimated in 400 m HIV-positive patients. Nevertheless, geriatricians can
56,57
), the individual usually tends to develop additional provide the background and initial models for building
disabilities: first in the accomplishment of instrumental up specific tools aimed at capturing the clinical complex-
activities of daily living (IADL), then in the execution of ity and peculiarities of the frail HIV-positive patients.
basic activities of daily living (ADL). The gradual loss of For example, some studies conducted in HIV-positive
these capacities makes the clinical management increas- patients have started using the Frailty Index developed
ingly challenging because of 1) the instauration of a det- by Rockwood and Mitniski 61,62 with the aim of measur-
rimental vicious cycle, and 2) socio-economic barriers ing the individual’s “biological age” and predicting nega-
becoming more relevant and evident. For these reasons, tive outcomes.63 Being based on arithmetic and not
the care of individuals with functional limitations clinical assumptions, this instrument is more suitable
requires a multidisciplinary team working in a dedicated than others for an immediate translation of the frailty
network well nested in the territory. Actions aimed at concept from geriatrics to the IDM world given its quan-
treating disabilities and/or preventing further decline titative nature. Differently, other instruments structured
should foresee personnel dedicated to the identification around specific socio-demographic, biological, and clini-
of the underlying causes, the clinical management, and cal features may require adaptations before being imple-
the close follow-up of the patient. Such strategy has mented in the new setting, but may still provide ground
shown to be particularly effective in the geriatric popula- for thinking.64
tion when the members of the team (e.g., physician,
nurse, physical therapist, social worker, etc.) work syner-
Conclusions
gistically using shared information and closely monitor-
ing the patient’s clinical modifications.22 The growing prevalence and incidence of geriatric syn-
dromes across medical disciplines is a sign of the socio-
economic and cultural advances of our societies. At the
same time, global aging is substantially modifying the
How to incorporate geriatrics in the care of HIV
scenarios where clinical practice is conducted. Clinical
patients
decisions are indeed extremely complex in biologically
The increasing age of patients across multiple medical aged individuals and, as such, require multidisciplinary
disciplines (not only in care settings for HIV) is challeng- input. Healthcare systems are therefore called to aban-
ing the sustainability of traditional healthcare systems. don traditional paradigms in favor of new models of care
The old-fashioned models of care based on single dis- in order to accommodate novel needs and demands.
eases are no longer functional. In order to tackle the spe- Such an endeavor may take advantage of the wealth of
cial needs brought by the “gray tsunami,” it is important experience accrued by geriatricians over the last
to shift toward different paradigms based on syndromes, decades.6
chronic conditions, multimorbid individuals, and per- The birth of clinical services convening healthcare
son-tailored interventions.16 Such mind setting is crucial professionals from multiple disciplines might be a prom-
for geriatric care and should be better nested in the train- ising venture to pursue, following the successful experi-
ing of healthcare professionals. In our “gray societies,” it ence of other “mixed” clinical units. If medical specialties
is not anymore acceptable that the study of aging (and of will continue to work in parallel without combining their
its consequences) is only marginally included in the expertise for the care of multimorbid and frail elders,
 VIRULENCE 583

current healthcare systems will simply collapse. Such a [10] Rockwood K, Mitnitski A. How might deficit accumula-
revision is particularly urgent in those disciplines, like tion give rise to frailty? J Frailty Aging 2012; 1:8-12;
IDM, which increasingly face the management of geriat- PMID:27092931
[11] Cesari M, Gambassi G, Abellan van Kan G, Vellas B.
ric syndromes in biologically aged individuals. The frailty phenotype and the frailty index: different
On the other hand, the transposition of the geriatric instruments for different purposes. Age Ageing 2014;
background to other disciplines is a difficult task to 43:10-12; PMID:24132852; https://doi.org/10.1093/
accomplish, especially because geriatric medicine does ageing/aft160
not typically operate under definitive rules. Older [12] Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C,
Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, et al.
patients represent an extremely heterogeneous popula-
Frailty in older adults: evidence for a phenotype. J Geron-
tion, in which medical complexity is not determined by tol A Biol Sci Med Sci 2001; 56:M146-56;
chronological age. The implementation of geriatric care PMID:11253156; https://doi.org/10.1093/gerona/56.3.
in HIV clinics therefore requires the acceptance of new M146
paradigms in the personalization of pharmacological and [13] Old and frail. Br Med J 1968; 1:723-4; PMID:5641431;
non-pharmacological interventions. https://doi.org/10.1136/bmj.1.5594.723
[14] Hoogendijk EO, van der Horst HE, Deeg DJ, Frijters DH,
Prins BA, Jansen AP, Nijpels G, van Hout HP. The iden-
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Disclosure of potential conflicts of interest the accuracy of five simple instruments. Age Ageing
2013; 42:262-5; PMID:23108163; https://doi.org/10.1093/
No potential conflicts of interest were disclosed. ageing/afs163
[15] Theou O, Cann L, Blodgett J, Wallace LM, Brothers TD,
Rockwood K. Modifications to the frailty phenotype cri-
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