which tools, which patients and when...
TRANSCRIPT
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Developing Skills on Neuropsychological Screening in Clinical Practice:
Which Tools, Which Patients and When Monitoring
3rd Symposium on Psychiatry and HIV
- - -
Barcelona, May 7th 2010
3rd Symposium on Psychiatry and HIV
- - -
Barcelona, May 7th 2010
Jose A. MuÄoz-Moreno- - -
Lluita contra la SIDA FoundationGermans Trias i Pujol University Hospital
- - -Barcelona, Catalonia, Spain
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Which Tools?
Which Patients?
When Monitoring?
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Which Tools?
Which Patients?
When Monitoring?
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Neuropsychological Testing
PROS:
- Strongly recommended- Large experience in clinical neuropsychology- Experience in HIV infection- Different areas potentially assessed- Variable tools
CONS:
- Availability / feasibility- Duration of evaluations
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Neuropsychological Testing
PROS:
- Strongly recommended- Large experience in clinical neuropsychology- Experience in HIV infection- Different areas potentially assessed- Variable tools
CONS:
- Availability / feasibility- Duration of evaluations
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Recommendations
National Institute of Mental Health, 1990
American Tasks Force, 1991
UNAIDS, 1997
Antinori, 2007
Significant number of reviews and studies recommending
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Neuropsychological Testing
PROS:
- Strongly recommended- Large experience in clinical neuropsychology- Experience in HIV infection- Different areas potentially assessed- Variable tools
CONS:
- Availability / feasibility- Duration of evaluations
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Clinical Neuropsychology
In multiple diseases regardless of HIV infection!
Pattern of neurocognitive alteration in...:
Multiple SclerosisSchizophrenia
AgingAlzheimer's DiseaseParkinson's Disease
ETC.
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Neuropsychological Testing
PROS:
- Strongly recommended- Large experience in clinical neuropsychology- Experience in HIV infection- Different areas potentially assessed- Variable tools
CONS:
- Availability / feasibility- Duration of evaluations
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HIV Infection
PubMed:
Early publications: 1985-1987 (Grant et al, 1987)
"Evidence for early central nervous system involvement in theacquired immunodeficiency syndrome (AIDS) and other humanimmunodeficiency virus (HIV) infections. Studies withneuropsychologic testing and magnetic resonance imaging".
Currently: Neurocognitive + HIV: 357 studies / 75 reviewsNeuropsychological + HIV: 1014 studies / 129
reviewsCognitive + HIV: 1934 studies / 357 reviews
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Neuropsychological Testing
PROS:
- Strongly recommended- Large experience in clinical neuropsychology- Experience in HIV infection- Different areas potentially assessed- Variable tools
CONS:
- Availability / feasibility- Duration of evaluations
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HIV-associated Neurocognitive Profile
- Fronto-subcortical pattern, with altered areas well defined:
Attention / Working Memory Executive FunctioningInformation Processing Speed Verbal FluencyLearning Motor FunctionVerbal Memory
- Maybe currently is this changing??
Cortical hypothesis:Brew, 2004Valcour, 2006
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Neuropsychological Testing
PROS:
- Strongly recommended- Large experience in clinical neuropsychology- Experience in HIV infection- Different areas potentially assessed- Variable tools
CONS:
- Availability / feasibility- Duration of evaluations
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Neuropsychological Testing
PROS:
- Strongly recommended- Large experience in clinical neuropsychology- Experience in HIV infection- Different areas potentially assessed- Variable tools
CONS:
- Availability / feasibility- Duration of evaluations
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Availability and Feasibility
MAIN LIMITATIONS:
- Need of a trained neuropsychologist
- Expertise and skills are relevant aspects in the application
- Multiple and variable instructions / correction processes
- Manipulative tools
- Duration of assessments (next section)
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Neuropsychological Testing
PROS:
- Strongly recommended- Large experience in clinical neuropsychology- Experience in HIV infection- Different areas potentially assessed- Variable tools
CONS:
- Availability / feasibility- Duration of evaluations
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Multiple Tools
NIMH, 1990: 2 recommendations
Extended: 7-9 hours of durationBrief: 1-2 hours of duration
Nowadays...
Extended: 2-3 hours of duration Relevant need of screening tools!
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What Do We Know About Screening Tools?
1) HIV Dementia Scale (HDS)
2) HNRC (Carey, 2004): 2 combinations of Cognitive Measures
3) Brief Z Scores: NPZ4, NPZ9, NPZ16, ...
4) Computerized Time Reaction Tests
5) CogState (Cysique, 2006)
6) Algorithm (Cysique, 2010)
7) NEU (MuÄoz-Moreno, 2010): Brief Instrument in Development
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HIV Dementia Scale
1) HIV Dementia Scale (HDS):
- Brief (10-15 minutes)- Easy instructions (5 items)- Well validated (USA and Uganda)
But...
- Specific for dementia- Sensitivity with clinical manifestations
JAIDS, 2003: Clifford A. Smith, Wilfred G. van Gorp, Elizabeth R.Ryan, Stephen J. Ferrando, Judith Rabkin
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HNRC (Carey, 2004)
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Reduced Z Scores
3) Used in different AIDS Clinical Trial Group (ACTG) studies -NPZ4:
- Brief (20-25 minutes)- Standardized- Used in longitudinal studies
But...
- Assessing 3 areas- Learning / training effect??
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Computerized Tools
4) Computerized vs Traditional Batteries:
They do not measure exactly the same Both are adequate for neurocognitive testing Traditional batteries continue as appropiate
GonzÄlez et al, JINS, 2003
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CogState
5) CogState (Cysique, 2006):
- Computerized- Assessing 3 areas
- 10-15 minutes
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New Screening Algorithm (Cysique, 2010)
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Brief Quantitative Instrument in Development
7) NEU Instrument (MuÄoz-Moreno, et al):
- Brief (25-30 minutes)- Assessing 7 areas
- Not only a screening tool: quantitative outcomes(adapted to HAND diagnosis)
- Printable- Easy instructions and correction
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Other Tools?
Neurophysiology and neuroimaging:
1) Research setting: economical cost, variable feasibility inclinical practice, ...
2) Lower number of published studies, although increasing!
3) Expectation in future, because of probable advances...
However, relevant to exclude other causes: for differential diagnosis
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PRACTICE PART:
Neurocognitive Testing
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- Assessment of the 7 recommended areas
- Evaluation and control of demographic, clinical and emotionalvariables
- Exclusion of other conditions not associated with NCI currentlyor in past (possible confounds to HIV-associated neurocognitivedisorders)
CNS-related pathologyDrug usePsychiatric conditions...
- To follow the diagnosis classification proposed by:
Antinori et al, 2007 in Neurology
Requirements for Comprehensive NC Testing
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Neuropsychological Tests
- TMT-A: Trail Making Test - Part A
- GPT: Grooved Pegboard Test
- CVLT-II: California Verbal Learning Test - II
- TMT-B: Trail Making Test - Part B
- WCST: Wisconsin Card Sorting Test
- Stroop's Test
INFORMATION PROCESSING SPEED:
MOTOR FUNCTION:
VERBAL MEMORY:
LEARNING:
EXECUTIVE FUNCTIONS:
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Trail Making Test - Part A (TMT-A)
Reitan, 1974
Information Processing Speed
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Matthews, 1964
Motor Function
Grooved Pegboard Test
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Delis, 2000
Verbal Memory and Learning
California Verbal Learning Test - II
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Trail Making Test - Part B (TMT-B)
Reitan, 1974
Executive Functioning
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Kongs, 1993
Executive Functioning
Wisconsin Card Sorting Test (WCST)
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Stroop's Test
Golden, 1978
Executive Functioning
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Neurology, 2007:
Table 1. Criteria for clinical diagnosis of central nervous systemdisorders in HIV-infected adults and adolescents
Table 2. HAND Criteria
Table 3. Examples of Tests
Table 4. Guidelines for classifying confounds to HIV-associatedneurocognitive disorders
Confounding Factors
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"Evidence of another etiology, including active CNS opportunisticinfection or malignancy, psychiatric disorders (e.g., depressivedisorder), active alcohol or substance use, or acute or chronicsubstance withdrawal, must be sought from history, physical andpsychiatric examination, and appropriate laboratory andradiologic investigation (e.g., lumbar puncture, neuroimaging). Ifanother potential etiology (e.g., major depression) is present, it isnot the cause of the above cognitive, motor, or behavioralsymptoms and signs."
Mainly:
- Drug abuse- CNS opportunistic infections
- Psychatric or emotional disorders
Confounding Factors
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- Hospital Anxiety and Depression Scale (HADS):
Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale.Acta Psychiatr Scand 1983; 67: 361-370.
- Beck Depression Inventory (BDI):
Beck AT, Rush AJ, Shaw BF, and Emery G: Cognitive Therapy ofDepression. Guilford Press, New York, 1979.
- State-Trait Anxiety Inventory (STAI):
Spielberger CD, Gorsuch RL, and Lushene RE: Manual for theState-Trait Anxiety Inventory. Consulting Psychologists Press, PaloAlto, CA, 1970.
Depression and Anxiety Symptoms
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Hospital Anxiety and Depression Scale (HADS)
Golden, 1978
Depression Symptoms
- 14 items- 2 scales
- 1 total scale
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Beck Depression Inventory (BDI)
Golden, 1978
Depression Symptoms
- 21 items- 1 scale
- 2 sub-scales
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State-Trait Anxiety Inventory (STAI)
Golden, 1978
Anxiety Symptoms
- 20 items
- 1 scale
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Which Patients?
When Monitoring?
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Characteristics of Patients: Which Predictors?
According to biomarkers?
According to clinical factors?
According to demographic variables?
According to emotional variables?
According to subjective complaints?
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Characteristics of Patients: Which Predictors?
According to biomarkers?
According to clinical factors?
According to demographic variables?
According to emotional variables?
According to subjective complaints?
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Biomarkers
Dr. Letendre and Dr. Antinori
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Characteristics of Patients: Which Predictors?
According to biomarkers?
According to clinical factors?
According to demographic variables?
According to emotional variables?
According to subjective complaints?
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Clinical Factors
High number of clinical factors are associated
Some of most representative:
AIDS CD4 Nadir
Time with HIV Interruptions of ART Coinfection with HCV
Virological Failure (in Plasma) CSF Viral Load *
*: Considering availability of lumbar puncture in clinical practice!
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New Potential Risk Factors
Tozzi et al, Journal of Neurovirology, 2005
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Nadir CD4 Cell Count
MuÄoz-Moreno, et al, 2008 Ellis, CROI, 2010
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And Interruptions of ART?
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Characteristics of Patients: Which Predictors?
According to biomarkers?
According to clinical factors?
According to demographic variables?
According to emotional variables?
According to subjective complaints?
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Demographic Factors
Well identified:
Age
Alcohol and Drug Use
Education
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Characteristics of Patients: Which Predictors?
According to biomarkers?
According to clinical factors?
According to demographic variables?
According to emotional variables?
According to subjective complaints?
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Both Depression and Anxiety symptoms related to self-reported NC complaints
Neurocognitive impairment and depression differentindependent mechanisms
Wide evidence about the need of including both constructs inassessments!
Emotional Status
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Characteristics of Patients: Which Predictors?
According to biomarkers?
According to clinical factors?
According to demographic variables?
According to emotional variables?
According to subjective complaints?
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Self-reported NC Complaints
MuÄoz-Moreno et al, INS, Helsinki, 2009
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3 patients' patterns according to presence or not of NC complaints:
1) NC Complaint + Neurocognitive Impairment
2) NC Complaint + No Neurocognitive Impairment
3) No NC Complaint + Neurocognitive Impairment!!
Self-reported Complaints
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Self-reported NC Complaints
Unpublished Data
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3 strategies:
1) To assess different scales of complaints:
PAOFI QuestionnaireAn adapted NC Complaints Questionnaire
2) To assess daily functioning:
IADLs Questionnaire
Self-reported Complaints
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Which Patients?
When Monitoring?
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Algorithm Proposed - Cysique
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Similar Findings
MuÄoz-Moreno et al, CROI, 2010
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Algorithm Proposed - Cysique
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Algorithm Proposed
2 prior aspects...
- Applicable regardless of ART status: both in ART-naÅve or experienced patients
- Based only on assessment and monitoring, not interventions (!)
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Training in Neuropsychological Skills