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HIV and Cognitive Impairment
For resource poor settings
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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
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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
www.aids2014.org
Neuropsychological Impairment in
the era of HAART (2007)
HIVassociated
Dementia
Mild
Neurocognitive
Disorder
HIV
Asymptomatic
Neurocognitive
Impairment
HIV infection
without cognitive
impairment
Consensus Working Group, Neurology 2007
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
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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
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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
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Other factors in cognitive
impairment
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Diabetes
High Blood Pressure
Older age >45 years
Obstructive Sleep Apnoea
High cholesterol
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HIV Neurocognitive Disorders
• Up to 60% of people with HIV will have a
neuro-cognitive abnormality
(asymptomatic or only mild impairment in
the majority)
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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
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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
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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
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Depression in HIV
• In HIV symptoms of depression overlap
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with understandable unhappiness
with symptoms of cognitive impairment
with symptoms of physical illness eg fatigue
Diurnal variation of mood suggests depression
varidddddation of mood suggests depression
• Cornerstone of depression is not sadness,
but the symptoms of anhedonia
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ANHEDONIA
• Is the inability to experience pleasure from
activities usually found enjoyable, e.g.
• Hobbies
• Music
• Sexual activities
• Social interactions
• Exercise
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Impact of depression in HIV
infection
Depression in HIV people is under diagnosed
High prevalence
Depression in HIV is undertreated
Health costs
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Poorer outcome of
HIV disease
Quality of life
MND - Detection
• Clinical carers should be alert for evolving
cognitive impairment and screen for its
presence even in people with undetectable
viral load
• Both people and their significant others
should be questioned
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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
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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 better in the
brain leads to better outcomes
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CNS PE Score
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Mild Neurocognitive Disorder
Summary
•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
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Mild Neurocognitive Disorder
Summary
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 !
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NEXT…
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Signs and symptoms
Screening tools
Booklet
ADL tool
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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
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Memory
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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
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Motor Skills
The person may experience:
• Tripping
• Poorer keyboard skills
• Driving skills worse
• Difficulty doing up buttons
• Using mobile
• Signature and writing skills change
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Concentration
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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?
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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
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Changes in Social Behaviour (2)
• Disinhibited Picture
• Increased irritability
• Sexual disinhibition or risk taking
• Increased risk taking generally
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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
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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
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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?
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To ask their family/friends
• Are they more forgetful?
• Has their personality changed?
• Are they finding it harder to organise their
life?
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Screening tools
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Mini Mental State Examination
International HIV Dementia Scale
MoCA
Neuropsychological Testing
• MND – how to recognise S&S
• Instrumental Activities of Daily Living Scale
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Activities of Daily Living Scale
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Communication
Shopping
Food preparation
Housekeeping
Clothing and appearance
Medications
Medical issues
Money
Social interaction
?Other
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RESOURCES....Azizul
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AIDS InfoNet
www.aidsinfonet.org
Fact Sheet Number 558
DEPRESSION AND HIV
HIV medications. Fact Sheet 729 has more about St. John’s W ort. Be sure
to tell your health care provider if you are taking St. John’s Wort.
WHAT IS DEPRESSION?
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Problems sleeping: waking very early, or excessive sleeping
Depression is a mood disorder. It is more than sadness or grief.
Depression is sadness or grief that is more intense and lasts longer than
it should. It has various causes:
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events in your daily life
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chemical changes in the brain
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a side effect of medications
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several physical disorders
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Feeling guilty, worthless, or hopeless
Decreased appetite or weight loss
Overeating
Valerian or Melatonin may help improve your sleep. Supplements of
vitamins B6 or B12 can help if you have low levels of these vitamins.
WHAT CAUSES DEPRESSION?
Antidepressants
Some people with depression respond best to medication. Antidepressants
can interact with ARVs. They must be used under the supervision of a
health care provider who is familiar with your HIV treatment. Protease
inhibitors have many interactions with antidepressants.
About 5% to 10% of the general population gets
depressed.
However,
rates
of depression in people with HIV are as high as 60%. Women
with HIV are twice as likely as men to be depressed.
Being depressed is not a sign of weakness. It doesn’t mean you’re going
crazy. You cannot “just get over it.” Don’t expect to be depressed because
you are dealing with HIV. And don’t think that you have to be depressed
because you have HIV.
Some medications used to treat HIV can cause or worsen depression,
especially efavirenz (Sustiva). Diseases such as anemia or diabetes
can cause symptoms that look like depression. So can drug use, or low
levels of testosterone, vitamin B6, or vitamin B12.
People who are infected with both HIV and hepatitis (see fact sheet 506)
are more likely to be depressed, especially if they are being treated with
interferon.
The tricyclics have more side effects than the SSRIs. They can also cause
sedation, constipation, and erratic heart beat.
Other risk factors include:
•
Being female
Some health care providers also
used to treat attention deficit disorder.
IS DEPRESSION IMPORTANT?
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Depression can lead people to miss doses of their medication. It can
increase high-risk behaviors that transmit HIV infection to others.
Depression might cause some latent viral infections to become active.
Overall, depression can make HIV disease progress faster. It also interferes
with your ability to enjoy life. A study in 2012 showed that patients with
depression, especially women, were more likely to stop receiving care and
to not achieve undetectable viral load.
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substance abuse
A
Not having enough social support
Not telling others you are HIV-positive
Treatment failure (HIV or other)
(DHEA)
THE
SIGNS
Symptoms of depression vary from person to person. Most health care
providers
Lifestyle changes can improve depression for some people. These include:
suspect depression if patients report feeling blue
or
having
very
little
interest in daily activities. If these feelings go on for two weeks or
longer, and the patient also has
some of the following symptoms, they are probably depressed:
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Fatigue or feeling slow and sluggish
Problems concentrating
Low sex drive
study
showed
that
treatment
with dehydroepiandrosterone
can reduce depression in some HIV patients.
Depression is a very common condition for people with HIV. Untreated
Depression can be treated with lifestyle changes, alternative therapies,
and/or with medications.
Many
medications
and therapies for
depression can interfere with your HIV treatment. Your health care
provider can help you select the therapy or combination of therapies most
appropriate for you. Do not try to self-medicate with alcohol or
recreational drugs, as these can increase
depression and create
additional problems.
OF DEPRESSION?
recent
THE BOTTOM LINE
TREATMENT FOR DEPRESSION
ARE
use psychostimulants, the drugs
Having a personal or family history of mental illness, alcohol and
Depression often gets overlooked. Also, many HIV specialists have not
been trained to recognize depression. Depression can also be mistaken
for signs of advancing HIV.
WHAT
The most common antidepressants used are
Selective
Serotonin
Reuptake Inhibitors, called SSRIs. They can cause loss of sexual desire
and function, lack of appetite, headache, insomnia, fatigue, upset stomach,
diarrhea, and restlessness or anxiety.
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Regular exercise
Increased exposure to sunlight
Stress management
Counseling
Improved sleep habits
depression can cause you to miss medication doses and lower your quality
of life.
Depression is a “whole body” issue that can interfere with your physical
health, thinking, feeling, and behavior.
The earlier you contact your health care provider, the sooner you can
both plan an appropriate strategy for dealing with this very real health
issue.
Revised July 17, 2013
Alternative therapies
Some people get good results from massage,
exercise. St. John’s
W ort
is
widely
used
to
However, it interferes with some
acupuncture, or
treat depression.
A project of the New Mexico AIDS Education and Training Center. Partially funded by the National Library of Medicine Fact Sheets can be downloaded from the
Internet at http://www.aidsinfonet.org
List of resources
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http://www.mocatest.org/
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http://www.aidsmap.com/HIV-mental-health-and-emotional-wellbeing/page/1321435/
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http://www.aidsmap.com/Neurocognitive-impairment/page/1731943/
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http://bestpractice.bmj.com/best-practice/monograph/900.html
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http://www.hivguidelines.org/clinical-guidelines/hiv-and-mental-health/cognitive-disorders-
and-hiv-aids/
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http://www.hivguidelines.org/clinical-guidelines/hiv-and-mental-health/depression-andmania-in-patients-with-hivaids/
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http://www.nepjol.info/index.php/AJMS/article/view/8724
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http://www.emedicinehealth.com/dementia_due_to_hiv_infection/article_em.htm
• http://napwha.org.au/health-treatment/other-health-conditions/brain-health/whytreatment-good-your-brain
• http://aidsinfonet.org/fact_sheets/view/558
• http://cid.oxfordjournals.org/content/53/8/836.long
Annual Monitoring
• Age
• T-cell (Current &
nadir)
• Meds ARVs
• Smokers ,
diabetes and
others
• Depression
Exclude or Treat
Screening
• Follow the
booklet or
other tools
• Changes
Alcohol and/or other
drugs
Depression
Intercurrent medical
illness
Uncontrolled CVD risks
(e.g. smoking)
After 3 months
r/v and
consider
assessment for
HIV related
Cognitive
Impairment
Questions
Don’t forget email address and we will send
slides and information from today.
THANK YOU!
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