A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

A Guide to Primary Care of People with HIV/AIDS
Chapter 14: Mental Health Disorders
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ill, brain injured, or metabolically unstable patients.
The clinical presentation and the differential diagnosis
in HIV patients are the same as in HIV noninfected
individuals, with the additional possibility that delirium
is HIV-related. Presentation may vary in the presence
of psychomotor agitation or retardation. Emotional
changes are common and often unpredictable, and
hallucinations and delusions are frequently seen.
Electroencephalography may show diffuse slowing
of the background alpha rhythm, which resolves
as confusion clears. The syndrome has an acute or
sub-acute onset and remits fairly rapidly once the
underlying cause is treated.
How do you manage delirium in patients with
HIV infection?
Non-pharmacologic treatments include identification
and removal of the underlying cause, reorientation
of the patient (calendars, clocks, view of outside
world, and active engagement with staff members),
and pharmacologic management of behavior or
psychosis. Low doses of high-potency antipsychotic
agents such as haloperidol are often useful. Newer,
atypical antipsychotics are currently being used with
some success, but those with more anticholinergic
activity may worsen the condition. Benzodiazepines
should be used cautiously, as they may contribute to
delirium in some patients, except in cases of alcohol or
benzodiazepine withdrawal deliria. Physical restraint
should be used as little as possible as it often worsens
delirium.
How do you diagnose and treat
minor cognitive-motor disorder (MCMD)?
MCMD is a less severe neurocognitive disorder of earlier
HIV infection, and the symptoms are often overlooked
because they may be very subtle. Cognitive and motor
slowing are most prominent and are often discovered as
a result of a minor complaint, such as taking longer to
read a novel, dysfunction when performing fine motor
tasks, or an increased tendency to stumble. Diagnosis
is made by the finding of 2 or more of the following
symptoms for more than a month: impaired attention
and concentration, mental slowing, impaired memory,
slowed movements, lack of coordination, and changes
in personality (irritability or emotional lability). Some
patients continue to have minor problems, while others
progress to frank dementia. Antiretroviral therapy (ART)
may be of some benefit in slowing progression, but this
conclusion is confounded by a lack of understanding of
factors that lead some patients to progress while others
remain static.
How do you diagnose and treat HIV-associated
dementia?
HIV-associated dementia presents with the typical triad
of symptoms seen in other subcortical dementias—
memory and psychomotor speed impairments,
depressive symptoms, and movement disorders.
Initially, patients may notice slight problems with
reading, comprehension, memory, and mathematical
skills. Patients later develop global dementia, with
marked impairments in naming, language, and praxis.
Clouding of consciousness is absent, and there is no
evidence of another cause. Motor symptoms are often
subtle in early stages, including occasional stumbling
while walking or running, slowing of fine repetitive
movements, and slight tremor. There may be impaired
saccadic eye movements, dysdiadochokinesia, and
hyperreflexia. Apathy is also a common early symptom,
often causing noticeable withdrawal from social activity.
A frank depressive syndrome also commonly develops,
typically with irritable mood and anhedonia instead of
sadness and crying spells. Sleep disturbances are quite
common, as is weight loss. Psychosis may develop in a
significant number of patients and generally presents
with paranoid beliefs, although hallucinations may
exist. In 5%-8% of patients, a syndrome known as
AIDS mania develops in addition to the HIV-associated
dementia. In later stages, there may be frontal release
signs and rather severe motor symptoms, including
marked difficulty in smooth limb movements, especially
in the lower extremities.
HIV dementia is typically seen in late stages of illness,
usually in patients who have had a CD4 count nadir
of