Hardiness, cognitive function, psychosocial support: overlooked factors in slowing HIV-related aging?
Article Type: Report
Subject: Aging (Health aspects)
Aging (Research)
Cognition disorders (Risk factors)
Cognition disorders (Research)
HIV infection (Complications and side effects)
HIV infection (Research)
Author: Mascolini, Mark
Pub Date: 03/22/2010
Publication: Name: Research Initiative/Treatment Action! Publisher: The Center for AIDS: Hope & Remembrance Project Audience: General; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 The Center for AIDS: Hope & Remembrance Project ISSN: 1520-8745
Issue: Date: Spring, 2010 Source Volume: 15 Source Issue: 1
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 228993672

Understanding hardiness, aging, and HIV

Mascolini: Please explain the concept of hardiness and describe how it may affect aging and longevity in people with HIV.

Vance: When we talk about hardiness, we're referring to one's commitment to life, one's sense of control, and the ability to see obstacles as a challenge instead of as obstacles. (1) Hardiness means looking at what you can do instead of what you can't do. It relates to aging because hardiness entails both the cognitive and the emotional sides of looking at life in a positive way, despite how we're feeling and the knowledge that life may not be the way we want it to be.

Aging can exacerbate HIV-related problems, and HIV can exacerbate aging issues. Many changes and challenges can tax one's coping resources or compromise one's ability to age successfully with HIV infection. An HIV-infected person may become more discouraged and more likely to engage in behaviors that do not promote successful aging. If someone is not feeling well and doesn't have a sense of hardiness, they may resort to negative adaptations, such as substance use, not get ting out of bed, not taking their medications, not exercising, not taking care of themselves, not socializing, and so forth. We want to promote hardiness as much as possible, so people keep living their lives the best they can, and keep reaching for goals, because it's important to get out of bed and do something with your life.

Aging with HIV is fraught with all sorts of problems, not just medical problems, but also psychosocial problems. When some people are diagnosed with HIV, they feel like they're damaged goods. Because we live in a youth-oriented culture, aging people also feel damaged. So HIV-infected aging people have a double whammy: You're older and you have HIV.

If you haven't been working, you may compare yourself with contemporaries who are going on with their lives and looking to retirement some time in the near future. But someone older with HIV may not have a complete work history because of their illness and so cannot realistically plan for a quality retirement. So an older person with HIV may have a more difficult time adjusting to the developmental social aspects of where they think they should be in their lives. Social isolation is another important issue for aging people, and especially those with HIV. Shippy and Karpiak found that many older adults with HIV report not having their emotional needs met, and many of them report not being in a committed relationship. (2) We know from the literature that being in a committed, intimate relationship buffers you from a whole host of problems.

Can hardiness be measured and learned?

Mascolini: How objectively can hardiness be measured?

Vance: There are instruments that measure hardiness, such as the Proactive Coping Inventory. (3,4) But these instruments don't have a cutoff score; they don't say "you're hardy and you're not." It's a continuum.

To judge hardiness, I listen to attributions people make. That's where the Proactive Coping Inventory comes in handy because such attributions are imbedded in the scale. (3) One attribution people might make is, "I can manage most things, given enough time." Or they might say something like, "I always try to find a way to work around obstacles; nothing really stops me." Those are positive affirmations--what we call hardiness. We want to hear people say those things because these are people who are going to be taking their medication, they're going to be exercising, they're going to be looking for ways of investing in their life.

Other people may make negative attributions, such as this one from the Proactive Coping Inventory: "I often see myself failing, so I don't get nay hopes up too high." If you believe that, you're not going to try any more. You'll think, "Why bother? I'm older, I have HIV, I probably have some other comorbidity. I'm going to just be." It doesn't have to be that way.

But there isn't an objective measure that will tell you who's hardy and who's not. I think the important thing when clinicians are working with patients--whether it be nurse practitioners, nurses, social workers, physicians, or clergy--is to pay attention to the little statements people make. These statements are also clues to depression, and we know that depressed people have a harder time coping with HIV infection and aging. A lot of studies suggest that people who are more depressed don't adhere to their medications as well and generally don't take as good care of themselves. That could lead into a downward spiral of suicidal ideation and all those stress hormones that are not friends of the immune system. Some research shows that people who score high on hardiness actually have better immune systems. (5)

Mascolini: Is hardiness something that health workers can help people attain or strive for?

Vance: I would like to think so. I haven't done any pilot work on this yet, but I want to. In the literature some people say hardiness is a trait and it can't be changed. I don't believe that. Even in terms of my own life, I see that on some days I feel like I can take on the world, and at other points I feel that everything's against me and I don't know how I can take one more thing.

These reactions are both emotional and cognitive, and I think they can be changed (Figure). I have proposed a cognitive-behavioral approach to hardiness that relies on an individualized hardiness training program. (6) You could also call it an individualized depression program or an individualized resilience training program. The nomenclature doesn't really matter; whatever you call it, the point is to focus on what you can do and not on what you can't do.


As an example, I wrote one such program for myself. The goal is to become more hardy in my daily affairs, and there are specific steps to accomplish this goal. Those steps might include: Every day I'll get out of bed and take at least 5 minutes to visualize what being hardy means to me: never giving up; taking care of myself physically, emotionally, socially, and spiritually; not focusing on things I can't change, but focusing on what I can; and reminding myself that the wise never wish to be younger, just wiser.

I also have some mantras to repeat because, when you're feeling down, it's important to put positive thoughts back in your head. Here are some of my favorites: perseverance is the ornament of the strong; falling down is fine, staying down is not; even the strong get tired, but that does not mean they're not strong; and (my personal favorite) I am not my circumstances.

A third thing I do is actively seek out positive energy, which means listening to upbeat music, listening to comedians and laughing, and watching movies and TV shows that emphasize hardiness and can-do attitudes. One of my personal favorites is "Star Trek" because they just never give up. An individualized hardiness program for me would include watching "Star Trek" as part of my routine. Another favorite is the movie "Secondhand Lions," which includes the line, "Die with your boots on." In other words, just keep trying till you can't. There's a movie called "Flawless" in which a drag queen says, "Can't lives on won't street." It's not that you can't do it; it's that you won't do it.

There are other steps in the individualized program that I developed, including visualizing, aspects of spirituality, prayer, doing good deeds, and so forth. It's basically a way of investing in your own life. It's not rocket science. But when people are down and discouraged, they need to hear about how to focus on the good stuff in their life while minimizing the bad stuff.

Recognizing psychosocial factors that affect aging

Mascolini: In an overview of aging with HIV, you mention several factors that can negatively affect successful aging, such as social isolation, HIV-related stigma, and suicidal ideation. (7) What should HIV physicians do to recognize and address psychosocial issues like these?

Vance: I think many physicians are fully aware of these issues. But they may not always remember that older adults with HIV are more vulnerable to these problems of social isolation. Karpiak's study found that 71% of their HIV population 50 and over were living alone. (2) The doctor may say, "I need you to take your pills at this time of day and to monitor this and monitor that." If you have a partner, they're going to help you take your pills on time and monitor yourself.

Physicians may sometimes forget that they're barking a lot of orders at patients but the patients may be absorbing only a little bit of this. For most patients it would help if physicians wrote down this kind of medical advice and also inquired about a partner and whether that partner can help remind them about things they should be doing to care for themselves. When a patient lives alone, the physician can ask how they are you going to remember these things. Some people with HIV also have memory problems, and those problems may grow worse with age.

If the doctor only tells patients what to do, it can go in one ear and out the other, especially if they get bad news. The patient may focus only on the bad and might not necessarily focus on how to deal with it, especially if they're already depressed or discouraged.

Mascolini: You've written about the synergistic effect of aging and HIV on cognitive impairment. (8) How can health workers prevent or delay cognitive impairment in aging people with HIV?

Vance: It's the same as in people without HIV. We can start with stressing a healthy lifestyle, and that includes sleep hygiene because sleep is important for cognitive functioning. We know that our sleep patterns become degraded with aging. We also know that depression interferes with sleep, whether that depression is due to social isolation or being diagnosed with HIV or the comorbidities common with HIV.

We also want to focus on emotional stabilization by reducing depression and anxiety. And we should emphasize good nutrition, physical activity, and social stimulation. Many studies at our center have focused on these issues in HIV-negative older adults, and I'm trying to turn that focus on older adults with HIV.

At our center we also do cognitive remediation training, which involves a computerized program that helps older adults improve their "useful field of view" so they can take in more visual information at a moment's glance. That's especially useful for older drivers. We know this training works in older adults without HIV. A pilot study of cognitive remediation training in older people with HIV is already showing that it improves their useful field of view as well. I don't know what mechanisms cause some of these declines in HIV, but this intervention is working. I'm hoping to use these pilot data to obtain funding for a long-term study in people with HIV.

We do know that cognitive simulation--whether it's being socially engaged or having intellectual pursuits or using a computerized cognitive training program--all are probably effective.

Sharpening the focus on psychosociologic issues

Mascolini: Are HIV clinicians giving neuropsychological issues in aging patients the attention they deserve?

Vance: I don't think so. Not yet. Of course physicians take steps to address very marked changes, but they may overlook more subtle changes or minor cognitive complaints because of the limited amount of time physicians have to spend with patients. At our center we've been discussing how to integrate a sharper focus on neuropsychological issues into our own database.

Before HAART we saw a lot of concern about these problems because HIV-related dementia was much more common. But as the incidence of dementia decreased with HAART, more attention turned to other HIV-aging-related issues, such as heart disease, liver disease, and kidney disease.

I don't think we're focusing enough on the neurological aspect. But because more of our HIV patients are 50 and over, that focus will have to increase in the next 5 to 10 years in order for us to provide more holistic care.

Mascolini: What are the biggest research priorities on questions of psychosocial factors, aging, and HIV?

Vance: One of the main priorities is diminishing cognitive ability and how that impacts everyday functioning, whether that means driving, the ability to do your job, medication adherence, or other aspects of daily living.

There are also many psychosocial aspects that need more research, such as fatigue. Are older people with HIV tired because they're older or because of their HIV? It's probably both. If you don't feel well, if you don't have a lot of energy, you're not going to be as socially engaged as you normally would be. A lot of that's related to medication toxicity and interactions between HIV medications and medications for age-related comorbidities. Many HIV medications were tested in younger adults and they haven't been tested well in older adults living with the disease. We're just putting the pieces together right now and extrapolating based on the HIV literature and the aging literature and trying to figure out how all these drugs interact.

An interview with David E. Vance, PhD, MGS

Associate Professor

University of Alabama at Birmingham

Edward R. Roybal Center for Translational Research in Aging and Mobility

Birmingham, Alabama


(1.) Vance DE, Struzick TC, Masten J. Hardiness, successful aging, and HIV: implications for social work. J Gerontol Soc Work. 2008;51:260-283.

(2.) Shippy RA, Karpiak SE. The aging HIV/AIDS population: fragile social networks. Aging Merit Health. 2005; 9:246-254.

(3.) Greenglass E, Schwarzer R, Taubert S. The Proactive Coping Inventory (PCI): a multidimensional research instrument. 1999. http://userpage.fu-berlin.de/~health/greenpci.htm.

(4.) Frequently asked questions regarding the Proactive Coping Inventory (PCI). http://userpage.fu-berlin.de/health/pci_faq.pdf.

(5.) Dolbier CL, Cocke RR, Leiferman JA, et al. Differences in functional immune responses of high vs. low hardy healthy individuals. J Behav Med. 2001;24:219-229.

(6.) Vance DE, Burrage J Jr, Couch A, Raper J. Promoting successful aging with HIV through hardiness: implications for nursing practice and research. J Gerontol Nuts. 2008;34:22-29.

(7.) Vance DE, Childs G, Moneyham L, McKie-Bell R Successful aging with HIV: a brief overview for nursing. J Gerontol Nurs. 2009;35:19-25.

(8.) Vance DE, Struzick TC. Addressing risk factors of cognitive impairment in adults aging with HIV: a social work model. J Gerontol Soc Work. 2007;49:51-77.
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