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A model of cognitive decline and suicidal ideation in adults aging with HIV.


The number of older adults with HIV continues to grow primarily because of the effectiveness of highly active antiretroviral therapy. Despite this welcomed benefit from pharmaceutical advances, aging with this disease presents an entirely new set of problems. The combination of aging and HIV can create a variety of stressors that may weaken one's resolve and further debilitate already compromised cognitive systems, which may increase rates of depression, suicidal ideation, and suicide. Studies indicate that older adults with HIV experience higher levels of depression and suicidal ideation than other older adults do or than younger adults with HIV do. Cognitive declines associated with both HIV and aging may provide insight into this phenomenon. A model of cognitive decline and suicidal ideation in adults aging with HIV is provided. Implications for nursing practice and research are discussed.


In countries that have access to highly active antiretroviral therapy, people are aging with HIV if they have access to treatment, are adherent to the medication regimen, tolerate the medication, and have a nonresistant strain of the virus (Cellerai, Little, & Loes, 2008; Perez & Moore, 2003). On the basis of the 2005 data, the Centers for Disease Control and Prevention (2008) reported that the number of older people living with HIV (PLWH) is increasing. In the United States, PLWH 50 years old and older constitute 15% of all new diagnoses of HIV/AIDS, 24% of all PLWH, 29% of all persons living with AIDS diagnoses, and 35% of all AIDS-related deaths. It is projected that, with the unprecedented growth in the aging population in general, coupled with later-life infections, the number of older PLWH will continue to climb (Vance & Robinson, 2004). After years of poor prognosis, aging with this disease is welcome; however, the combination of aging and HIV poses a new set of challenges for patients, families, nurses, and allied health professionals.

Many PLWH experience a variety of negative emotions such as guilt, prejudice, anxiety, and depression (Prachakul, Grant, & Keltner, 2007; Vance, 2006). Paired with the difficulties associated with age-related changes and losses, the challenges of aging with HIV may exacerbate existing stressors and severely compromise one's resources for coping (Vance, Moneyham, Fordham, & Struzick, 2008). Specifically, such challenges may overwhelm one's coping abilities, making one vulnerable to depression, suicidal ideation, and suicide. This assertion was derived from the HIV and gerontological literatures, which clearly demonstrate that depression, suicidal ideation, and suicide are higher in older individuals and in PLWH than those in the general population. Thus, older PLWH may be especially vulnerable to the challenges, or stressors, of aging with this disease.

Because risks for depression and suicidal ideation are evident in both older adults and adults with HIV, an important question is whether older PLWH may be particularly vulnerable. Researchers are only now beginning to address this question. In examining a group of older and younger adults with and without HIV, Vance (2006) found depressive symptoms were significantly related to being older and HIV-positive and to reporting higher levels of perceived HIV-related stigma and loneliness. Kalichman, Heckman, Kochman, Sikkema, and Bergholte (2000) found that in a sample of 113 older PLWH, 27% reported having had suicidal ideation within the past week, a rate much higher than the 19% reported among PLWH by Carrico et al. (2007).

Vance et al. (2008) provided the first model of suicidal ideation in older PLWH by proposing that stressors associated with both aging and HIV may contribute collectively to exacerbate one's predisposition to depression, suicidal ideation, and suicide. Specifically, such stressors include ageism, HIV-related stigma, declines in social support, loneliness, financial distress, and mitochondrial-related fatigue. Collectively, these factors may interact synergistically to overwhelm coping resources. Cognitive ability, one of the internal resources that may help with coping with such age- and HIV-related stressors, may be particularly compromised by the combination of aging with HIV.

Of the three primary components required for successful aging that were proposed by Rowe and Kahn (1997), cognitive ability may be the cornerstone. Cognitive ability allows one to solve problems, make plans, develop ways to cope with unique and challenging situations, and actively engage in life. HIV and aging each independently exerts negative influences on cognitive ability, and there is evidence suggesting that their combination results in even greater vulnerability to declines in cognitive resources (Hinkin, Castellon, Atkinson, & Goodkin, 2001). In fact, cognitive declines themselves have been shown to be associated with suicidal ideation in some clinical populations such as those with epilepsy (Kalinin, 2007) or early-stage Alzheimer's disease (Lim, Rubin, Coats, & Morris, 2005). Likewise, evidence suggests that cognitive ability may be just as relevant in mitigating depression and suicidal ideation in adults aging with HIV.

This report underscores the potential neurological and cognitive mechanisms that are associated with HIV and aging and can contribute to depression and suicidal ideation. Specifically, the report focuses primarily on the mechanisms that contribute to a negative perceptual set that is characterized by negative appraisals of one's life situations and of one's ability to cope with life's challenges and by negative repetitive thoughts (e.g., ruminative thinking), all of which can lead to depression and suicidal ideation. This focus is described within the context of declining cognitive resources that occur in response to HIV and aging. Furthermore, the relationship between such cognitive declines and negative thinking is examined in lieu of other influences that exacerbate decline in cognitive resources, such as substance use, posttraumatic stress disorder (PTSD), declining health, and mitochondrial-related fatigue. From this review, a visual representation of these relationships is modeled for didactic purposes (see Figure 1). This model provides nurse clinicians and researchers an evidence-based model in which to examine and conceptualize this phenomenon and intervene.

Neurological and Cognitive Mechanisms

The effects of aging and HIV can weaken cognitive resources and therefore result in neurological impairment and cognitive decline, especially in older PLWH (Vance, 2007; Vance & Burrage, 2006). Two cognitive resources that have been shown to be especially affected by HIV and aging are initiation/perseveration and executive functioning.

Initiation and perseveration are two interrelated cognitive abilities. Initiation, an important cognitive ability, refers to the process of instigating a new thought or behavior. This cognitive ability to switch and initiate a new thought or behavior is an important skill especially when an old thought or behavior is no longer effective or useful. Conversely, the cognitive ability of perseveration refers to persistently and repetitively thinking or acting in a manner that does not deviate. In other words, perseveration means thinking about the same subject over and over. The neural mechanisms largely responsible for these cognitive abilities are two subcortical structures--the basal ganglia and the substantia nigra (Lezak, 1995). These subcortical structures are necessary in regulating mood. In addition, both have been shown to be compromised in aging and HIV (Vance, 2004).

With age, damage to the basal ganglia and substantia nigra is gradual. Thus, as an individual ages with HIV, these subcortical structures may be more severely compromised, and poorer regulation of mood and more perseveration may result. Such perseveration, especially on a stressor or a negative thought or feeling, may make it more difficult to think about other subjects, and someone experiencing this problem may ruminate. Once they engage in such negative ruminative thoughts and sustain damage to these subcortical structures, older PLWH may find it more difficult to initiate an alternative thought that may be more positive. In fact, it has been found that having a ruminative personality was significantly related to suicidal ideation (Fairweather, Anstey, Rodgers, Jorm, & Christensen, 2007).


Executive functioning is a cognitive ability that allows one to examine problems, develop solutions, judge alternatives, and make decisions. The frontal and prefrontal lobes of the brain are responsible for this cognitive ability. Gradual declines in these structures are observed in normal aging; however, in HIV, declines in dendritic complexity and synaptic density in these structures have been observed. As a result, individuals aging with HIV are more likely to experience declines in executive functioning (Vance, 2004). Such declines mean that, although many older PLWH cope with stressors, they may be less able to formulate strategies for confronting and adapting to stressors, particularly when the stressors are novel. Thus, without being able to develop a working plan to cope, individuals aging with HIV may perceive such stressors as being especially challenging.

Declines in initiation and executive functioning, when combined with perseveration and ruminative thinking, may further compromise one's cognitive functioning and coping responses. As a result, the individual may become overwhelmed by even the simplest demands and challenges and thus begins a pattern of depression and suicidal ideation. Furthermore, negative states such as loneliness, depression, and anxiety, which are common in HIV and aging, have been shown to further compromise cognitive abilities (Bassuk, Berkman, & Wypij, 1998; Vance, Woodley, & Burrage, 2007) and to deplete vital cognitive resources needed to cope with stressors. In turn, this process creates a downward spiral that further predisposes one to more depressive symptoms and suicidal ideation. This downward spiral further exacerbates cognitive declines; thus, a continuing downward cycle is evidenced (see Figure 1).

Exacerbating Influences

The neurological and cognitive insults that can predispose an individual to depression and suicidal ideation can be exacerbated by a host of influences. Although by no means an exhaustive list, substance use, PTSD, declining health, mitochondrial-related fatigue, and sleep deficits may be included among such influences. All of these influences are common in HIV; however, their interaction may exacerbate the influence of other stressors and may advance ruminative thinking in this clinical population.

Substance use and its accompanying lifestyle can be stressors unto themselves by producing anxiety, which reduces the cognitive resources needed to adjust to stressors associated with aging with HIV. For example, Brady (2006) posited that chronic alcohol abuse impairs neurological and cognitive functioning and adds stressful adverse events that precipitate suicidal behavior. Alcohol is classified as a depressant; therefore, chronic abusers feel tired and fatigued and are more susceptible to suicidal ideation (Julien, 1998; Kolodziej & Weiss, 2000). Furthermore, the chronic use of marijuana has been found to be predictive of suicidal ideation in a heterogeneous sample of 2,909 PLWH (Carrico et al., 2007). Thus, in older PLWH who already may be experiencing declines in cognitive ability and other mental health problems, substance use may further contribute to the loss of cognitive ability as a resource and therefore may place them at greater risk for depression and suicidal ideation.

For some PLWH, PTSD may have contributed to their diagnosis because of a chaotic lifestyle stemming from substance abuse, sexual or domestic violence, or other life-threatening events. For others, a diagnosis of HIV alone may be a highly stressful, life-threatening event, which for some may overwhelm existing coping mechanisms. Specifically, PTSD can compromise cognitive resources even further in older PLWH and exacerbate ruminative thinking, depression, and suicidal ideation. In fact, cognitive abilities are known to be impeded in the presence of intense emotional reactions (Hartlage, Alloy, Vazquez, & Dykman, 1993). When someone with PTSD is confronted and overwhelmed by age and HIV stressors, flashbacks of the life-threatening event can occur that further deplete cognitive resources needed to cope with such stressors.

As with many stressors, declining health can contribute to this model of depression and suicidal ideation in two ways. First, the stress of declining health and medical complications can lead to feelings of helplessness, loss of control, and pain and can further contribute to depression and suicidal ideation (Fishbain, Cutler, Rosomoff, & Rosomoff, 1997). For example, Kalichman, Difonzo, Austin, Luke, and Rompa (2002) found in a sample of older PLWH that those who reported suicidal ideation were also more likely to report medical side effects and to have a high or detectable viral load and low CD4+ lymphocyte counts. Furthermore, aging with HIV predisposes one to frailty, chronic pain, and pulmonary disease, all of which are associated with suicidal ideation (Heisel & Flett, 2006; Ratcliffe, Enns, Belik, & Sateen, 2008; Vance & Robinson, 2004).

Second, declining health itself may undermine the physiological foundation upon which such cognitive resources depend. As is also the case with many opportunistic infections associated with HIV and age-related conditions, high cholesterol levels and heart disease (Hann & Wallace, 2004), hypertension (Artero et al., 2004), reduced lung function (Richards, Strachan, Hardy, Kuh, & Wadsworth, 2005), and diabetes (Trento et al., 2004) have been shown to compromise cognitive resources. Some HIV-related medications facilitate conditions such as insulin resistance, dyslipidemia, and hypertension (Heath et al., 2001), which can further diminish the cognitive resources needed for coping with age- and HIV-related stressors.

Mitochondria-related fatigue is more common in aging and HIV and thus can also contribute to depressive symptoms and suicidal ideation. Mitochondria are organelles responsible for metabolism and energy production in all cells. The Mitochondrial Theory of Aging (Ozawa, 1998) posits that mitochondria DNA (mtDNA) replicates itself less efficiently with age; with each replication, the organelles generate less energy. Ultimately, less energy is available to the cells, and the cells are less able to function within their physiological system; the result, in poorer functioning overall for the body, is often observed as poor physical reserve or as greater fatigue (Brierley, Johnson, James, & Tumbull, 1996). Fatigue in PLWH is often related to depression (Ferrando et al., 1998), although the direction of this relationship is not clear. However, such declines in energy production translate into less energy for the brain in general and into declines in cognitive ability. In fact, this decline in energy may be exacerbated for older PLWH. Furthermore, studies show that HIV medications such as nucleoside reverse transcriptase inhibitors may decrease mtDNA. Such a decrease results in there being available fewer of the mtDNA mitochondrial enzymes needed to produce energy (Medina, Tsai, Hsiung, & Cheng, 1994). Thus, older PLWH may experience more rapid aging, as well as increased mitochondrial-related fatigue; in addition, fatigue, depression, and suicidal ideation are further exacerbated with the use of HIV medications (O'Mahony, Myint, Steinbusch, & Leonard, 2005).

Related to fatigue and declining health are sleep disorders, which can be triggered or exacerbated by age- and HIV-related stressors. In a sample of PLWH, those who reported more insomnia were found by Vance and Burrage (2005) to perform worse on a cognitive measure of psychomotor ability and to indicate more symptoms of depression. Rubinstein and Selwyn (1998) also reported that PLWH were more likely to experience declines in cognitive performance if they also had a sleep disturbance such as insomnia. In fact, reports of insomnia are common in individuals with HIV, and insomnia is a commonly reported side effect of some of the medications used to treat HIV (Reid & Dwyer, 2005). When age and HIV are combined, sleep disorders may be exacerbated (Vance & Burrage, 2006) and further contribute to cognitive declines, depression, and suicidal ideation.

Cognitive Model of Suicidal Ideation of Aging With HIV

The cognitive model of suicidal ideation in older PLWH is shaped as a downward spiral that represents the interconnected process of stressors contributing to the depletion of cognitive resources needed to cope with aging with this disease (see Figure 1). The model begins with the stressors of aging with HIV that were originally presented by Vance, Struzick, and Masten (in press) and included ageism, HIV stigma, changes in appearance, declines in social support, loneliness, financial distress, declining health, and mitochondrial-related fatigue. All of these stressors eventually can lead to depression, suicidal ideation, and suicide; however, cognitive resources mediate the relationship among these stressors. Although all stressors can impact the efficacy of cognitive resources, substance use, PTSD, declining health, mitochondrial-related fatigue, and sleep hygiene are particularly salient in depleting cognitive resources; these stressors are indicated with an asterisk in the model. The double-headed arrows in the model represent the dynamic interactions between age- and HIV-related stressors, cognitive resources, depression, suicidal ideation, and suicide. The double-headed arrow between age- and HIV-related stressors and cognitive resources highlights the interplay in which stressors and the negative emotions produced by them can reduce cognitive resources and interfere with cognitive efficiency; likewise, cognitive resources can be used to reduce the negative impact of such stressors unless overwhelmed. The double-headed arrow between cognitive resources and depression shows that, as cognitive resources are overwhelmed, this stressor results in ruminative thinking that underlies depression; in turn, depression and other negative mood states can further compromise cognitive ability and reduce cognitive resources. The double-headed arrow between depression and suicidal ideation indicates that depression can lead to suicidal ideation; however, experiencing suicidal ideation is a noxious event that can also perpetuate depression. In other words, contemplating suicide represents a painful and disturbing stimulus that can serve to maintain or exacerbate depression. Last, the double-headed arrow between suicidal ideation and suicide indicates that the potential of completing suicide increases with the frequency of suicide attempts, which may strengthen suicidal ideation.

This model, which illustrates a downward spiral that begins with age- and HIV-related stressors and culminates in suicidal ideation and possibly in suicide, also provides insight into points for intervention. First, the model shows factors that contribute to depression and suicidal ideation in this population. Although the list of factors is by no means exhaustive, it provides clinicians and researchers a starting point on which to flame their efforts. Second, on the basis of the literature, the model provides a cognitive explanation as to why depression and suicidal ideation may be more prevalent in this growing population. Addressing cognitive problems may alleviate some of the symptoms of depression. Likewise, modification of factors that deplete cognitive resources obviously leads to actions that restore such resources so that the individual can respond and cope more effectively with such stressors. Third, the model also highlights the importance of preventing such cognitive resources from being taxed and overwhelmed. Once cognitive resources are compromised by the emotional and physiological influences, breaking free of this downward spiral becomes difficult. Last, research has demonstrated that interventions that foster the development of cognitive coping skills can help with stress management in people with HIV. Lutgendorf et al. (1998) demonstrated that cognitive coping in gay men with HIV improves with 10 sessions of cognitive behavioral-stress management group interventions. Specifically, Lutgendorf et al. found that emotional distress was reduced as cognitive coping increased; this finding also suggests that cognitive coping decreases as emotional distress increases. Thus, the entangled interaction between stress and cognitive resources cannot be overstated.

Implications for Nursing Practice and Research

Because depression and cognitive decline are often associated with or considered expected outcomes for both aging and living with HIV, nurses might deem such conditions as being within normal limits for older patients and for adults with HIV. However, nurses who provide care to adults with HIV can consider this model when assessing their patients, especially as these patients age. The impact of the additive effects of the interactive components is apparent in the spiral toward depression and suicide. Any one of the components, such as poor sleep hygiene, PTSD, or a decline in cognitive ability, is reason enough for nursing assessment and for the implementation of interventions to resolve such conditions. Because of the additive effects of stressors and demands on coping resources, multiple intervention strategies may be needed. The holistic nature of nursing care supports the model as a guide to the assessment of patients with HIV, especially as they age, with the objective of disrupting or slowing their journey down the spiral. Furthermore, nurses are in frequent contact with patients and can explore ways in which to strengthen cognitive functioning and thus interrupt the patients' downward spiral. Nurses also intervene regularly with patients experiencing the common problems of aging and living with HIV and can explore the interactive effect of the components; thus, improving knowledge for future assessment can be improved.

Nursing researchers can use the model in identifying and testing interventions designed to assist PLWH as they age. Again, because nursing deals with patients' behavioral responses to life stressors, nursing research can incorporate findings from other behavioral disciplines into the identification of supportive interventions. In cognitive psychology, for example, cognitive remediation therapy is used with older adults to improve cognitive functioning (Vance et al., 2006). Such an approach may be beneficial to nursing interventions aimed at improving cognitive resources needed to deal with the stressors of aging with HIV (Vance & Burrage, 2006). In social work, Vance et al. (in press) suggested that a cognitive behavioral approach that incorporates various strategies may improve a person's resolve in the face of adversity. Such hardiness training suggests that resilience may grow as one learns new strategies for coping, such as the cognitive and behavioral tools that are needed to stop ruminative thinking, to build positive thoughts and behaviors, and to become hardier and less susceptible to depression and suicidal ideation. With these approaches, nurses are in a key position to establish the evidence needed to make interventions common practice. Also, because allied disciplines can contribute to the care of patients aging with HIV, the need for appropriate referrals cannot be emphasized enough.


As more people age with HIV, there is increasing concern that many will face great difficulty with depression and suicidal ideation. Neurological and cognitive changes that accompany aging and HIV may act synergistically to place many of these individuals at risk. Problems with executive functioning and initiation and perseveration may prevent some individuals from developing strategies for coping with the stressors associated with aging with this disease and keep many from breaking free of ruminative thinking. Substance use, PTSD, declining health, and mitochondria-related fatigue may further compromise the neurological integrity of older PLWH and exacerbate decline already associated with aging with this disease; as a result, this emerging clinical population may be placed at increased risk. However, many behavioral strategies are available that can be applied to helping older adults with HIV maintain cognitive viability (Vance & Burrage, 2006) and become psychologically hardy (Vance et al., in press). Nonetheless, many of these techniques need to be tailored for use with aging PLWH and tested for their efficacy with this population. As the number of older PLWH continues to grow, research is needed to develop and test interventions that are predictably effective in promoting positive outcomes for this population.


Artero, S., Tiemeier, H., Prins, N. D., Sabatier, R., Breteler, M. M., & Ritchie, K. (2004). Neuroanatomical localisation and clinical correlates of white matter lesions in the elderly. Journal of Neurology, Neurosurgery, and Psychiatry, 75, 1304-1308.

Bassuk, S. S., Berkman, E. F., & Wypij, D. (1998). Depressive symptomatology and incident cognitive decline in an elderly community sample. Archives of General Psychiatry, 55, 1073-1081.

Brady, J. (2006). The association between alcohol misuse and suicidal behaviour. Alcohol and Alcoholism, 41(5), 473-478.

Brierley, E. J., Johnson, M. A., James, O. F., & Tumbull, D. M. (1996). Effects of physical activity and age on mitochondrial function. Quarterly Journal of Medicine, 89(4), 251258.

Carrico, A. W., Johnson, M. O., Morin, S. F., Remien, R. H., Charlebois, E. D., Steward, W. T., et al. (2007). Correlates of suicidal ideation among HIV-positive persons. AIDS, 21, 1199-1203.

Cellerai, C., Little, S. J., & Loes, S. K. (2008). Treatment of acute HIV-I infection: Are we getting there? Current Opinion in HIV and AIDS, 3(1), 6274.

Centers for Disease Control and Prevention. (2008). HIV/AIDS among persons aged 50 and older: CDC HIV/AIDS facts. Washington, DC: U.S. Department of Health and Human Services.

Fairweather, A. K., Anstey, K. J., Rodgers, B., Jorm, A. F., & Christensen, H. (2007). Age and gender differences among Australian suicide ideators: Prevalence and correlates. Journal of Nervous and Mental Disorders, 195(2), 1301-1336.

Ferrando, S., Evans, S., Goggin, K., Sewell, M., Fishman, B., & Rabkin, J. (1998). Fatigue in HIV illness: Relationship to depression, physical limitations, and disability. Psychosomatic Medicine, 60, 759-764.

Fishbain, D. A., Cutler, R., Rosomoff, H. L., & Rosomoff, R. S. (1997). Chronic pain-associated depression: Antecedent or consequence of chronic pain? A review. Clinical Journal of Pain, 13(2), 116 137.

Hann, M. N., & Wallace, R. (2004). Can dementia be prevented? Brain aging in a population-based context. Annual Review of Public Health, 25, 1-24.

Hartlage, S., Alloy, L., Vazquez, C., & Dykman, B. (1993). Automatic and effortful processing in depression. Psychological Bulletin, 113(2), 247 278.

Heath, K. V., Hogg, R. S., Chan, K. J., Harris, M., Montessori, V., O'Shaughnessy, M. V., et al. (2001). Lipodystrophy-associated morphological, cholesterol and triglyceride abnormalities in a population-based HIV/AIDS treatment database. AIDS, 15, 231-239.

Heisel, M. J., & Flett, G. L. (2006). The development and initial validation of the Geriatric Suicide Ideation Scale. American Journal of Geriatric Psychiatry, 14(9), 742-751.

Hinkin, C. H., Castellon, S. A., Atkinson, J. H., & Goodkin, K. (2001). Neuropsychiatric aspects of HIV infection among older adults. Journal of Clinical Epidemiology, 54(Suppl.), 44-52.

Julien, R. M. (1998). A primer of drug action. New York: Freeman.

Kalichman, S. C., Difonzo, K., Austin, J., Luke, W., & Rompa, D. (2002). Prospective study of emotional reactions to changes in HIV viral load. AIDS Patient Care and STDs, 16, 113-120.

Kalichman, S. C., Heckman, T., Kochman, A., Sikkema, K., & Bergholte, J. (2000). Depression and thoughts of suicide among middle-aged and older persons living with HIV=AIDS. Psychiatric Services, 51, 903-907.

Kalinin, V. V. (2007). Suicidality and antiepileptic drugs: Is there a link? Drug Safety, 30(2), 123 142.

Kolodziej, M. E., & Weiss, R. D. (2000). Comorbid alcohol dependence and depression. Current Opinion in Psychiatry, 13(1), 87-89.

Lezak, M. D. (1995). Neuropsychological assessment (3rd ed.). New York: Oxford University Press.

Lim, W. S., Rubin, E., Coats, M., & Morris, J. (2005). Early-stage Alzheimer disease represents increased suicidal risk in relation to later stages. Alzheimer Disease and Associated Disorders, 19(4), 214-219.

Lutgendorf, S. K., Antoni, M. H., Ironson, G., Starr, K., Costello, N., Zuckerman, M., et al. (1998). Changes in cognitive coping skills and social support during cognitive behavioral stress management intervention and distress outcomes in symptomatic human immunodeficiency virus (HIV)-seropositive gay men. Psychosomatic Medicine, 60(2), 204-214.

Medina, D. J., Tsai, C. H., Hsiung, G. D., & Cheng, Y. C. (1994). Comparison of mitochondrial morphology, mitochondrial DNA content, and cell viability in cultured cells treated with three anti-human immunodeficiency virus dideoxynucleosides. Antimicrobial Agents and Chemotherapy, 38, 1824-1828.

O'Mahony, S. M., Myint, A. M., Steinbusch, H., & Leonard, B. E. (2005). Efavirenz induces depressive-like behaviour, increased stress response and changes in the immune response in rats. Neuroimmunomodulation, 12(5), 293-298.

Ozawa, T. (1998). Mitochondrial DNA mutations and age. Annals of the New York Academy of Sciences, 854, 128-154.

Perez, J. L., & Moore, R. D. (2003). Greater effect of highly active antiretroviral therapy on survival in people aged [greater than or equal to] 50 years compared with younger people in an urban observational cohort. Clinical Infectious Diseases, 36, 212-218.

Prachakul, W., Grant, J. S., & Keltner, N. L. (2007). Relationships among functional social support, HIV-related stigma, social problem solving, and depressive symptoms in people living with HIV: A pilot study. Journal of the Association of Nurses in AIDS Care, 18(6), 67-76.

Ratcliffe, G. E., Enns, M. W., Belik, S. L., & Sareen, J. (2008). Chronic pain conditions and suicidal ideation and suicide attempts: An epidemiologic perspective. Clinical Journal of Pain, 24(3), 204-210.

Reid, S., & Dwyer, J. (2005). Insomnia in HIV infection: A systematic review of prevalence, correlates, and management. Psychosomatic Medicine, 67, 260-269.

Richards, M., Strachan, D., Hardy, R., Kuh, D., & Wadsworth, M. (2005). Lung function and cognitive ability in a longitudinal birth cohort study. Psychosomatic Medicine, 67, 602-608.

Rowe, J. W., & Kahn, R. L. (1997). Successful aging. Gerontologist, 37, 433-440.

Rubinstein, M. L., & Selwyn, P. A. (1998). High prevalence of insomnia in an outpatient population with HIV infection. Journal of Acquired Immune Deficiency Syndrome, 19(3), 260-265.

Trento, M., Passera, P., Borgo, E., Tomalino, M., Bajardi, M., Cavallo, F., et al. (2004). A 5-year randomized controlled study of learning, problem solving ability, and quality of life modifications in people with type 2 diabetes managed by group care. Diabetes Care, 27, 670-675.

Vance, D. E. (2004). Cortical and subcortical dynamics of aging with HIV infection. Perceptual and Motor Skills, 98, 647-655.

Vance, D. E. (2006). Self-rated emotional health in adults with and without HIV. Psychological Reports, 98, 106-108.

Vance, D. E. (2007, November). Neurocognitive impairment and everyday functioning in older HIV patients'. Invited speaker to the Gerontological Society of America Conference, San Francisco, CA.

Vance, D. E., & Burrage, J. Jr. (2005). Sleep disturbances and psychomotor decline in HIV. Perceptual and Motor Skills, 100, 1004-1010.

Vance, D. E., & Burrage, J. Jr. (2006). Promoting successful cognitive aging in adults with HIV: Strategies for intervention. Journal of Housing for the Elderly, 32(11), 34-41.

Vance, D., Dawson, J., Wadley, V., Edwards, J., Roenker, D., Rizzo, M., et al. (2006). The Accelerate Study: The longitudinal effect of speed of processing training on cognitive performance of older adults. Rehabilitation Psychology, 52(1), 89-96.

Vance, D. E., Moneyham, L., Fordham, P., & Struzick, T. C. (2008). A model of suicidal ideation in adults aging with HIV. Journal of the Association of Nursing in AIDS Care, 19(5), 375-384.

Vance, D. E., & Robinson, F. R (2004). Reconciling successful aging with HIV: A biopsychosocial overview. Journal of HIV/AIDS and Social Services, 3(1), 59-78.

Vance, D. E., Struzick, T. C., & Masten, J. (in press). Hardiness, successful aging, and HIV: Implications for social work. Journal of Gerontological Social Work.

Vance, D., Woodely, R., & Burrage, J. Jr. (2007). Predictors of cognitive ability in adults with HIV: A pilot study. Clinical Gerontologist, 30(3), 83-101.

Questions or comments about this article may be directed to David E. Vance, PhD MGS, at He is an assistant professor at the School of Nursing, University of Alabama at Birmingham, Birmingham, AL.

Jill A. Ross, RN PhD MLS, is an assistant professor at the School of Nursing, University of Alabama at Birmingham, Birmingham, AL.

Linda Moneyham, DNS RN FAAN, is a professor and Rachel Z. Booth Endowed chair at the University of Alabama at Birmingham, Birmingham, AL.

Kenneth F. Farr, MS CNS-BC, is an instructor and clinical nurse specialist at the Adult and Geriatric Psychiatric/Mental Health Nursing, School of Nursing, University of Alabama at Birmingham, Birmingham, AL.

Pam Fordham, PhD RN, is an assistant professor and chair of the Family/Child Health and Caregiving Department, and project director of the Palliative Care NP Program at the School of Nursing, University of Alabama at Birmingham, Birmingham, AL.
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Author:Vance, David E.; Ross, Jill A.; Moneyham, Linda; Farr, Kenneth F.; Fordham, Pam
Publication:Journal of Neuroscience Nursing
Article Type:Clinical report
Geographic Code:1USA
Date:Jun 1, 2010
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