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HIV and Cognitive Impairment

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

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  1. HIV and Cognitive Impairment For resource poor settings

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. Other factors in cognitive impairment • Diabetes • High Blood Pressure • Older age >45 years • Obstructive Sleep Apnoea • High cholesterol

  9. HIV Neurocognitive Disorders • Up to 60% of people with HIV will have a neuro-cognitive abnormality (asymptomatic or only mild impairment in the majority)

  10. 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

  11. 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

  12. 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

  13. 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

  14. ANHEDONIA • Is the inability to experience pleasure from activities usually found enjoyable, e.g. • Hobbies • Music • Sexual activities • Social interactions • Exercise

  15. 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

  16. 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

  17. 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

  18. 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

  19. CNS PE Score

  20. 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

  21. 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 !

  22. NEXT… • Signs and symptoms • Screening tools • Booklet • ADL tool

  23. 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

  24. 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

  25. Motor Skills The person may experience: • Tripping • Poorer keyboard skills • Driving skills worse • Difficulty doing up buttons • Using mobile • Signature and writing skills change

  26. 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?

  27. 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

  28. Changes in Social Behaviour (2) • Disinhibited Picture • Increased irritability • Sexual disinhibition or risk taking • Increased risk taking generally

  29. 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

  30. 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

  31. 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?

  32. To ask their family/friends • Are they more forgetful? • Has their personality changed? • Are they finding it harder to organise their life?

  33. 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

  34. Activities of Daily Living Scale • Communication • Shopping • Food preparation • Housekeeping • Clothing and appearance • Medications • Medical issues • Money • Social interaction • ?Other

  35. RESOURCES....Azizul

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

  37. 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

  38. 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)

  39. Questions Don’t forget email address and we will send slides and information from today. THANK YOU!

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