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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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• 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

HIV and Cognitive Impairment

HIV infection without cognitive

impairment

HIV Asymptomatic Neurocognitive

Impairment

Mild Neurocognitive

Disorder

HIV-associated Dementia

Neuropsychological Impairment in the era of HAART (2007)

Consensus Working Group, Neurology 2007

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• 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 Disorders

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• 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

HIV related risk factor for Neurocognitive Disorders

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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

• Diabetes• High Blood Pressure • Older age >45 years• Obstructive Sleep Apnoea• High cholesterol

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

HIV Neurocognitive Disorders

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• 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

Mild Neurocognitive Disorder(MND)

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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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• 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

MND may be missed

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• 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

varidddddation of mood suggests depression• Cornerstone of depression is not sadness,

but the symptoms of anhedonia

Depression in HIV

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• Is the inability to experience pleasure from activities usually found enjoyable, e.g.

• Hobbies• Music• Sexual activities• Social interactions• Exercise

ANHEDONIA

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Impact of depression in HIV infection

High prevalence

Depression in HIV people is under diagnosed

Depression in HIV is undertreated

Poorer outcome ofHIV disease

Quality of lifeHealth costs

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• 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

MND - Detection

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• 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

If Cognitive Impairment is detected

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• 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

Prognosis for Mild Neurocognitive Disorder

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CNS PE Score

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•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 DisorderSummary

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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 !

Mild Neurocognitive DisorderSummary

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NEXT…

• 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

• 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

• 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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• Mini Mental State Examination• International HIV Dementia Scale• MoCA• Neuropsychological Testing

• MND – how to recognise S&S• Instrumental Activities of Daily Living Scale

Screening tools

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Activities of Daily Living Scale

• Communication• Shopping• Food preparation• Housekeeping• Clothing and appearance• Medications• Medical issues• Money• Social interaction• ?Other

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RESOURCES....Azizul

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

AIDS InfoNet www.aidsinfonet.org Fact Sheet Number 558

DEPRESSION AND HIVWHAT IS DEPRESSION?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:• events in your daily life• chemical changes in the brain• a side effect of medications• several physical disorders

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.

IS DEPRESSION IMPORTANT?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.

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 ARE THE SIGNS OF DEPRESSION?Symptoms of depression vary from person to person. Most health

care providers

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:

• Fatigue or feeling slow and sluggish• Problems concentrating• Low sex drive

• Problems sleeping: waking very early, or excessive sleeping

• Feeling guilty, worthless, or hopeless• Decreased appetite or weight loss• Overeating

WHAT CAUSES DEPRESSION?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.

Other risk factors include:• Being female

• Having a personal or family history of mental illness, alcohol and

substance abuse

• Not having enough social support• Not telling others you are HIV-positive• Treatment failure (HIV or other)

TREATMENT FOR DEPRESSIONDepression 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.

Lifestyle changes can improve depression for some people. These include:

• Regular exercise• Increased exposure to sunlight• Stress management• Counseling• Improved sleep habits

Alternative therapiesSome people get good results from massage, acupuncture, or exercise. St. John’s Wort is widely used to treat depression. However, it interferes with some

HIV medications. Fact Sheet 729 has more about St. John’s Wort. Be sure to tell your health care provider if you are taking St. John’s Wort.

Valerian or Melatonin may help improve your sleep. Supplements of vitamins B6 or B12 can help if you have low levels of these vitamins.

AntidepressantsSome 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.

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.

The tricyclics have more side effects than the SSRIs. They can also cause sedation, constipation, and erratic heart beat.

Some health care providers also use psychostimulants, the drugs used to treat attention deficit disorder.

A recent study showed that treatment with dehydroepiandrosterone

(DHEA) can reduce depression in some HIV patients.

THE BOTTOM LINEDepression is a very common condition for people with HIV. Untreated

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

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

• Age• T-cell (Current &

nadir) • Meds ARVs• Smokers ,

diabetes and others

• Depression

Annual Monitoring

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

Exclude or Treat

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Questions

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

THANK YOU!