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Individual Clinical Issues
Published in David M. Aronstein, Bruce J. Thompson, HIV and Social Work, 2014
One should consider whether this is an adjustment reaction to coping with a life-threatening illness, a major depression, or an organic mental disorder, known as AIDS dementia complex (ADC), which is also frequently referred to as HIV cognitive/motor complex, HIV encephalopathy, or AIDS dementia. The frequency of HIV dementia parallels the progression of systemic HIV disease. Such dementia affects less than 5 percent of patients with asymptotic HIV infection, but 15 to 66 percent of patients with AIDS-defining illnesses.
The Neuropsychiatric Aspects of HIV Infection and Patient Care
Published in Judith Landau-Stanton, Colleen D. Clements, Robert E. Cole, Ann Z. Griepp, Alexander F. Tartaglia, Jackie Nudd, Elisabet Espaillat-Piña, M. Duncan Stanton, AIDS, Health, and Mental Health, 1993
A. Griepp, J. Landau-Stanton, C.D. Clements
Their medical treatment was difficult, since Roberto periodically went out on drug sprees, which resulted in noncompliance with treatment and family chaos. Roberto began to show signs of cognitive impairment. He exhibited the classic signs of early HIV dementia, including confusion and cognitive slowing, balance problems and ataxic gait, forgetfulness and memory impairment, withdrawal and apathy, mood lability, difficulties in concentration, some dysarthric speech, and the inability to perform rapid alternating movements.17 Belinda took care of him as long as she could, until his behavioral change resulted in a violent episode in the home that made her feel frightened for her safety. At that point, she brought him to the emergency department where she insisted that he be admitted.
Terminal neurological disorders
Published in Ad (Sandy) Macleod, Ian Maddocks, The Psychiatry of Palliative Medicine, 2018
Ad (Sandy) Macleod, Ian Maddocks
Adjustment issues are liable to be influenced not only by the personal circumstances of the patient but also by the characteristics of the society they live in. Drug abuse, impoverished socioeconomic circumstances, lifestyle and social stigma may be relevant influences. Fatigue is an invariable complaint. Neuropathic pain may complicate in about 30–50%.22 Pain management in the drug-using HIV-positive patient is challenging (seeChapter 14). Major depressive disorder and the elevated risk of suicide deserve appropriate interventions. Suicide risk may be enhanced by impulsive behaviour and emotional lability, though most suicides occur early in the disease. Acute manic episodes may be indicative of early dementia, as mania is usually associated with cognitive impairments. The abrupt presentation of psychotic symptoms should be clinically considered to be an infective delirium until this has been excluded. Psychosis tends to herald dementia. Subtle personality and cognitive changes may occur early and potentially influence adjustment processes, decision-making and compliance with medications. Interruptions of medication compliance are liable not only to risk progression and complications, but subsequent re-introduction may prove ineffective. Cognitive impairment is present in 20–30% of those who are not on HAART therapy. The advent of HAART and longer survival are factors actually increasing the prevalence of cognitive impairment and AIDS dementia complex (ADC), but perhaps reducing its severity. The prevalence of HIV dementia is approximately 13%. The incidence of AIDS dementia has halved post-HAART from 7% per year to 3% per year, but the prevalence has doubled because of the increased survival.22,23 HAART provides only partial protection from the neurotoxicity of HIV. HAART is changing the typical neuropsychological features either directly or by delaying presentation to an older age group and thus adding other risk factors for dementia. ADC is not an inevitable consequence of HIV infection and nor is it always progressive.23 ADC is subcortical dementia with cognitive, motor and behavioural symptoms (seeTable 13.1). Insight can be preserved until late.23 Differentiation from depression can be difficult, and therapeutic trials of SSRIs and psychostimulants are not to be dismissed. ADC is a clinical diagnosis and many decline formal neuropsychological evaluation, for this merely highlights the deficits and provides no therapeutic advantage. Deficits able to be recognised by the self, such as memory impairment and psychomotor coordination, increase the desire for death, whereas executive dysfunction and abstract reasoning difficulties do not.24
Mental and cognitive healthcare training targeting primary healthcare workers providing HIV services in Africa: a scoping review
Published in AIDS Care, 2023
Adele Munsami, Anna J. Dreyer, Goodman Sibeko, Hetta Gouse, Sam Nightingale, John A. Joska
Eight interventions also included skills to deliver services to PWH as part of the training. The Kenyan study trained healthcare workers to use the International HIV Dementia Scale to identify HIV-associated dementia (Cettomai et al., 2011). Three studies focused on skills to screen for, diagnose and treat common mental illnesses. The first study conducted in South Africa, equipped healthcare workers with screening skills to identify common mental disorders, as well as basic counselling (Dos Santos & Wolvaardt, 2016). The second study focused on diagnosis and treatment of mental health problems in Ethiopia (Berheto et al., 2018). The study in Rwanda focused on the diagnosis and treatment of selected major mental disorders as well as communication skills (Smith et al., 2020). The Kenyan study conducted by Jenkins et al. (2013), trained healthcare workers to screen for mental health problems. However, these studies did not describe the diagnostic approach or screening tools that were used to identify common mental disorders (Berheto et al., 2018; Dos Santos & Wolvaardt, 2016; Jenkins et al., 2013; Smith et al., 2020). Data collection as well as referral and admission pathways for common mental illnesses were included in the training intervention in Zimbabwe (Duffy et al., 2017). Skills to provide support to patients and families were included in the South African study conducted by (Campbell & Baernholdt, 2016).
Neuropathogenesis of HIV and emerging therapeutic targets
Published in Expert Opinion on Therapeutic Targets, 2022
Alina Siddiqui, Celestine He, Gina Lee, Alex Figueroa, Alexander Slaughter, Jessica Robinson-Papp
More generally, CNS penetration effectiveness (CPE) scores have been used to rank the ability of individual antiretrovirals to penetrate the BBB. Although early studies found that lower CPE rank (i.e. less effective CNS penetration) correlated with higher HIV viral load in cerebrospinal fluid (CSF) [43], the clinical significance of this in terms of reducing the symptoms of HAND is unclear. Reasons for this uncertainty include challenges with study design, such as heterogeneity in study population demographics, cART treatment regimens, and comorbidities, as well as variations in neurocognitive assessments between different studies, making it difficult to isolate the impact of CPE on cognition. Therefore, while some studies have found improvement in cognition using treatment regimens with higher CPE, there is currently a paucity of large randomized clinical trials assessing this treatment strategy [44]. One large non-randomized observational study found that higher CPE was associated with an increased risk of HIV dementia [45]. Although causality could not be assessed given the study design, there is some evidence that highly CNS-penetrating cART can cause CNS dysregulation and inflammation on its own and that increasing its concentration may exacerbate these effects. Specifically, CNS-penetrating cART can cause resting astrocytes to activate into an A1 neurotoxic phenotype. Once activated, these cells secrete inflammatory cytokines that recruit the surrounding microglial cells as well as neurotoxic factors that impact surrounding neurons [46].
Neuro-Ophthalmic Manifestations of HIV Infection
Published in Ocular Immunology and Inflammation, 2020
Lynn K. Gordon, Helen Danesh-Meyer
Eye movement abnormalities are well recognized to occur with HIV.8,55,56 Abnormalities of saccades and smooth pursuits are the most common being reported to occur even in patients without other clinical manifestations of HIV infection.2 These abnormalities occur more frequently in HIV dementia and it has been suggested that it can suggest early manifestations of HIV dementia. Cranial nerve palsies have also been documented with HIV infection although the prevalence depends on the population characteristics.8 The most common palsies are the sixth and third cranial nerves. The underlying cause tends to be opportunistic infections with toxoplasmosis, cryptococcosis, and syphilis. In a series of 23 patients with involvement of the cavernous sinus, the third nerve and sixth nerve were involved in isolation or combination and the patients typically observed diplopia, blurred vision, and headache.16 A sixth nerve palsy may also occur with elevated intracranial pressure as a false localizing sign. The presence of cavernous sinus disease was worrisome for tuberculosis, neurosyphilis, high-grade B cell lymphoma, meningioma, or metastatic cancer, and therefore requires urgent neuroimaging and additional testing to try to define and treat the underlying etiology.