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HIV and Cognitive Impairment. For resource poor settings. Outline of the workshop. Garry Trotter- Causes Denise Cummins- S creening and S&S Group activity Azizul Haque- Resources Ken Murray- Annual monitoring Email address for results of group work. HIV and Cognitive Impairment.

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hiv and cognitive impairment

HIV and Cognitive Impairment

For resource poor settings

outline of the workshop
Outline of the workshop

Garry Trotter- Causes

Denise Cummins- Screening and S&S

Group activity

Azizul Haque- Resources

Ken Murray- Annual monitoring

  • Email address for results of group work
hiv and cognitive impairment1
HIV and Cognitive Impairment
  • Cognitive complaints are common in HIV
    • Acute delirium secondary to legion of metabolic and infectious complications
    • HIV-associated neurocognitive disorders - directly related to the presence of the virus in the CNS (HAND)
    • Other chronic cognitive impairments not directly related to HIV (alcohol and/or other drugs, Hep C, vascular)
    • Cognitive symptoms associated psychiatric illness
neuropsychological impairment in the era of haart 2007
Neuropsychological Impairment in the era of HAART (2007)

HIV Asymptomatic Neurocognitive Impairment

Mild Neurocognitive Disorder

HIV infection without cognitive impairment

HIV-associated Dementia

Consensus Working Group, Neurology 2007

hiv related risk factor for neurocognitive disorders
HIV related risk factor for Neurocognitive Disorders
  • BEFORE HAART
  • Cognitive impairment associated with HIV recognised from early in epidemic
    • Usually with advanced disease
    • Often a prelude to death
    • Both dementia and milder forms of cognitive impairment described
hiv related risk factor for neurocognitive disorders1
HIV related risk factor for Neurocognitive Disorders
  • AFTER HAART- people living longer
    • Cognitive symptoms were seen to persist but often milder
    • Length of HIV infection and lowest CD4 Count
    • The brain is a “sanctuary site”
    • Aging peoples with co-morbidities
other factors in cognitive impairment
Other factors in cognitive impairment
  • Smoking
  • Alcohol & drug use
  • Other viral infections which contribute to brain injury eg HCV
  • Other brain infections such as meningitis
  • Head injury
other factors in cognitive impairment1
Other factors in cognitive impairment
  • Diabetes
  • High Blood Pressure
  • Older age >45 years
  • Obstructive Sleep Apnoea
  • High cholesterol
hiv neurocognitive disorders
HIV Neurocognitive Disorders
  • Up to 60% of people with HIV will have a neuro-cognitive abnormality (asymptomatic or only mild impairment in the majority)
mild neurocognitive disorder mnd
Mild Neurocognitive Disorder(MND)
  • An acquired impairment of cognitive functioning that involves at least two ability domains ( memory, concentration, language, motor, social, executive function)
  • This impairment produces interference with daily functioning
other issues
Other issues
  • Vast majority have mild or no symptoms
  • People may not volunteer symptoms from lack of awareness or insight
  • Clinical Carers may not have relevant training for diagnosis and management of HAND
  • Clinical Carers may be focused on other issues in busy clinic settings
mnd may be missed
MND may be missed
  • Changes are slow and subtle
  • Symptoms may go unreported, as people and family attribute changes to:
      • Understandable stress responses to life events or to illness itself
      • Normal aging
      • Depression
depression in hiv
Depression in HIV
  • In HIV symptoms of depression overlap
    • with understandable unhappiness
    • with symptoms of cognitive impairment
    • with symptoms of physical illness eg fatigue
    • Diurnal variation of mood suggests depression

varidddddationof mood suggests depression

  • Cornerstone of depression is not sadness, but the symptoms of anhedonia
anhedonia
ANHEDONIA
  • Is the inability to experience pleasure from activities usually found enjoyable, e.g.
  • Hobbies
  • Music
  • Sexual activities
  • Social interactions
  • Exercise
impact of depression in hiv infection
Impact of depression in HIV infection

Depression in HIV people is under diagnosed

High prevalence

Depression in HIV is undertreated

Health costs

Poorer outcome of

HIV disease

Quality of life

mnd detection
MND - Detection
  • Clinical carers should be alert forevolvingcognitive impairment and screen for its presence even in people with undetectable viral load
  • Both people and their significant others should be questioned
if cognitive impairment is detected
If Cognitive Impairment is detected
  • Exclude depression
  • Exclude other potentially reversible causes of cognitive impairment
    • acute medical illness
    • alcohol and other recreational drug use, cerebro-vascular disease, neuroimaging for OIs
  • HAND is a diagnosis of exclusion
prognosis for mild neurocognitive disorder
Prognosis for Mild Neurocognitive Disorder
  • A significant proportion will get better with treatment
  • In a year, with treatment, 21% will improve from milder impairment to unimpaired
  • In the same time, without treatment, 23% will move from unimpaired to MND
  • Antiretroviral therapy that works betterin the brain leads to better outcomes
mild neurocognitive disorder summary
Mild Neurocognitive DisorderSummary
  • Cognitive impairment continues to be an

important problem for people living with HIV

  • Both dementia and MND should be screened for
  • They can be recognized clinically and confirmed

with neuropsychological testing

mild neurocognitive disorder summary1
Mild Neurocognitive DisorderSummary
  • Cognitive impairment in HIV can be managed
    • Antiretroviral therapy that better distributes into the CNS leads to better outcomes
    • Co-morbid risk factors can be minimised
    • Physical exercise and mental stimulation- Use it or lose it !
slide22
NEXT…
  • Signs and symptoms
  • Screening tools
  • Booklet
  • ADL tool
signs and symptoms
Signs and symptoms
  • Changes over time
  • May be new behaviour
  • May be subtle and missed or PLWH think it is something else
  • 4 domains are affected (memory, motor, concentration, social)
  • Changes in ability to organise
memory
Memory
  • Losing keys
  • Forgetting appointments
  • Lost in conversations
  • Going in to a room but cant remember why
  • Short term memory not as good
  • Misplace things
  • Trouble remembering names
  • Words on tip of tongue, word finding
motor skills
Motor Skills

The person may experience:

  • Tripping
  • Poorer keyboard skills
  • Driving skills worse
  • Difficulty doing up buttons
  • Using mobile
  • Signature and writing skills change
c oncentration
Concentration
  • Trouble following movie
  • Trouble reading
  • Gets distracted in conversations
  • Difficulty focusing
  • Can only do one thing at a time
  • Slower at doing usual things
  • Feel like in a fog?
changes in social behaviour 1
Changes in Social Behaviour (1)
  • Apathetic Picture
  • Do not go out as much
  • Not engaging with family or friends
  • Withdrawn even if they do go out
changes in social behaviour 2
Changes in Social Behaviour (2)
  • Disinhibited Picture
  • Increased irritability
  • Sexual disinhibition or risk taking
  • Increased risk taking generally
a lso
Also
  • Mental tasks take longer than in the past
  • More physically and mentally tired at the end of the day, as they have to concentrate harder than before to get the same things done
executive function
Executive function

Organisational ability has changed

  • e.g. ability to follow through or plan a task has deteriorated

Flexibility

  • e.g. need to do a task the same way

Problem solving

questions to ask people
Questions to ask people
  • Are you slower in your thinking than you used to be?
  • Are you more forgetful than you used to be?
  • Is it harder to organise things?
  • Are you able to find pleasure in the things you used to enjoy?
to ask their family friends
To ask their family/friends
  • Are they more forgetful?
  • Has their personality changed?
  • Are they finding it harder to organise their life?
screening tools
Screening tools
  • Mini Mental State Examination
  • International HIV Dementia Scale
  • MoCA
  • Neuropsychological Testing
  • MND – how to recognise S&S
  • Instrumental Activities of Daily Living Scale
activities of daily living scale
Activities of Daily Living Scale
  • Communication
  • Shopping
  • Food preparation
  • Housekeeping
  • Clothing and appearance
  • Medications
  • Medical issues
  • Money
  • Social interaction
  • ?Other
slide39

A projectofthe New MexicoAIDS EducationandTrainingCenter. PartiallyfundedbytheNationalLibrary ofMedicine FactSheetscanbedownloadedfrom the Internetathttp://www.aidsinfonet.org

list of resources
List of resources
  • http://www.mocatest.org/
  • http://www.aidsmap.com/HIV-mental-health-and-emotional-wellbeing/page/1321435/
  • http://www.aidsmap.com/Neurocognitive-impairment/page/1731943/
  • http://bestpractice.bmj.com/best-practice/monograph/900.html
  • http://www.hivguidelines.org/clinical-guidelines/hiv-and-mental-health/cognitive-disorders-and-hiv-aids/
  • http://www.hivguidelines.org/clinical-guidelines/hiv-and-mental-health/depression-and-mania-in-patients-with-hivaids/
  • http://www.nepjol.info/index.php/AJMS/article/view/8724
  • http://www.emedicinehealth.com/dementia_due_to_hiv_infection/article_em.htm
  • http://napwha.org.au/health-treatment/other-health-conditions/brain-health/why-treatment-good-your-brain
  • http://aidsinfonet.org/fact_sheets/view/558
  • http://cid.oxfordjournals.org/content/53/8/836.long
slide42

Annual Monitoring

Exclude or Treat

  • Age
  • T-cell (Current & nadir)
  • Meds ARVs
  • Smokers , diabetes and others
  • Depression

Alcohol and/or other drugs

Screening

After 3 months r/v and consider assessment for HIV related Cognitive Impairment

  • Follow the booklet or other tools
  • Changes

Depression

Intercurrent medical illness

Uncontrolled CVD risks (e.g. smoking)

questions
Questions

Don’t forget email address and we will send slides and information from today.

THANK YOU!