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

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 10: Psychiatric ProblemsChildren and adults manifest the impact of CNS HIV infection somewhat differently. In adultsthe impact is on the developed brain and peripheral nervous system, with deterioration evidentas the loss of neurological integrity or mental capacity. In children and adolescents HIV canprevent26thepicasnormal growth and development of neural pathways, achievement of developmentalmilestones, or integration of cognitive, motor and affective components of the self at age-appropriatestages. For adults the impact is a loss of function whereas in children it is the failure tothrive or achieve some function altogether.HIV DementiaThere is now evidence that the presence and severity of HIV dementia correlates with thelevels of HIV production in the CNS, as well as with macrophage activation. 5,6 HIV vRNA in theperipheral blood may not reflect the level of brain vRNA nor the degree of neurological dysfunction.7-13HIV dementia is classified as a subcortical dementia and manifests as one or more of a clinicaltriad of progressive cognitive decline, motor dysfunction, and behavioral abnormalities. 14 Earlysymptoms include slowed information processing, cognitive and psychomotor slowing, and problemswith verbal memory and new learning. Later on, evidence of difficulty with executive functioningappears, along with visual and spatial difficulties, and apraxias, and in the end stagesmay look similar to the global cortical dementias. (See Table 10-5.)Table 10-5: Clinical Signs and Symptoms of HIV-Associated DementiaType of Impairment ManifestationsCognitive • Impaired concentration and attention• Impaired verbal memory (e.g. word finding)• Mental slowing• Difficulty with calculations/abstractions• Impairment of visuospatial memory• Lack of visuomotor coordination(e.g. eye movement abnormalities)• Difficulty with complex task sequencingLATE:• Global cognitive impairment• MutismMotor • Unsteady gait or ataxia• Loss of balance• Slowed fine motor speed (noticeable morein non-dominant hand)• Tremors• Change in handwriting• Hyperactive DTRs• WeaknessLATE:• Seizures• Decorticate posturing• Myoclonus• Spastic weakness• Frontal release signs212U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau