The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

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A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 10: Psychiatric ProblemsINITIAL ASSESSMENT■ Changes in mental status are always to be considered abnormal, not simply an understandableproblem26 picasassociated with having HIV, and should be considered a medical emergency. Theinitial assessment should begin by ruling out and treating any acute process (see Table 10-2).Some questions that may be useful to the clinician in the differential diagnosis are listed inTable 10-3.Table 10-2: Causes of Change in Central Nervous System (CNS) FunctionType of ManifestationConditionAcute HIV-1 infection • Viral meningitis• Ascending polyneuropathy• EncephalitisChronic HIV-1 infection • Subclinical cognitive-motor impairment• Minor cognitive motor disorder• HIV-1 associated dementia (HAD)OPPORTUNISTIC INFECTIONSViral • Herpes simplex encephalitis• Cytomegalovirus encephalitis• Progressive multifocal leukoencephalopathyFungal • Cryptococcal meningitisProtozoal • Toxoplasma cerebritisOther • Mycobacterium tuberculosis meningitis• NeurosyphilisNeoplastic disease • Primary CNS lymphoma• Metastatic disease• Kaposi’s sarcomaSystemic/metabolic disorders • Pneumonia ➝ hypoxia• Anemia ➝ hypoxia, depression, lethargy• Addison’s disease• Thyroid disease• HypogonadismTOXIC DISORDERSPrescribed • Antiretrovirals• Antimicrobials• Antineoplastic agents• Psychiatric agents• Anabolic steroidsNon-prescribed • Substances of abuse• Withdrawal states• Herbal remedies208U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau
A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 10: Psychiatric ProblemsTable 10-3: Assessing Changes in Mental Status• Is the change acute? or chronic? What is the time frame for the change?• 26 Does picas the problem appear to be in thinking, attention, mood or behavior?• What specific changes in function, or symptoms, are reported by patient orothers that might give a clue to the particular problem?• Are presenting symptoms accompanied by fever? pain? other signs ofautonomic dysfunction?• Are there any focal neurological signs or symptoms?• Have any new medications been started recently, including antivirals,psychiatric medications?• Is there evidence of substance use by a complete toxic screen or other reportrather than the patient’s own report?• Are there pre-existing psychiatric symptoms?Since a patient may be unable to give a complete or accurate history, family and friends must beasked about any unusual behavior or sudden changes in the person’s mental state. Any changein the patient’s typical behavior or engagement must be evaluated urgently. Irritable and anxiouspatients often come to attention because they are obviously disturbed. Attention must alsobe paid, however, to the withdrawn and quiet patient.Changes in personality, level of activity or interest in others may signal an acute CNS disturbance.Some changes are the direct effect of brain dysfunction, while others may be due to theacute psychological distress of a systemic problem. For example, the acute onset of pain in thefeet due to neuropathy might affect cognition and behavior because of an acute anxiety or panicthat the person is dying. On the other hand, the presence of transverse myelitis is often associatedwith HIV-related cognitive impairment.The first step is to make an accurate diagnosis of one or more disorders that might account for theclinical presentation. The most common psychiatric diagnoses are depression, adjustment disorders,anxiety disorders, and the neuropsychiatric disorders resulting from HIV in the central nervoussystem. Table 10-4 presents a format to use to conduct a complete mental status exam.XTable 10-4: The Mental Status Exam in Primary PracticeElements of theComplete PsychiatricHistoryHistory of psychiatric disorders in patient and familyNumber of psychiatric hospitalizationsHistory of outpatient mental health treatmentHistory of psychotropic medications used by patient or familymembers (note those deemed effective)History of suicidal ideation or violence in patient or familyHistory of education and performance in schoolHistory of occupational functioning; current statusFamily/other supportLegal historyRisk behavior historyU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 209
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DedicationA Clinical Guide to Suppo
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Lynn A Jansen, RN, PhDAssistant Res
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TABLE OF CONTENTSPart IChapter 1Cha
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IChapter 1.26 picasHIV and Palliati
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IA Clinical Guide to Supportive and
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A Clinical Guide to Supportive and
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IIIChapter 3.Assessment of Physical
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Chapter 6.26 picasPulmonary Symptom
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Chapter 14.26 picasCulture and Care
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Chapter 15.26 picasSpecial Populati
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Chapter 17.26 picasEthical IssuesLy
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Chapter 18.26 picasLegal and Financ
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Chapter 19.Palliative 26 picas Care
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Chapter 25.26 picas Prevention of S
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Chapter 26.26 picasResourcesMagda B
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DRUGS AND THERAPIES INDEXNOTES: Ent
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