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 ProblemsTable 10-5: Clinical Signs and Symptoms of HIV-Associated Dementia (continued)Behavioral • Psychomotor retardation26 picas(e.g. slowed speech or response time)• Personality changesLATE:• Hallucinations• DelusionsAffective • Apathy, loss of interest in friends and others• Irritability• ManiaNeuropsychiatric Disorders in AdultsAdults typically present with complaints of difficulty with short term memory, difficulty payingattention and finding words, and feeling slowed down in thought process. Since memorydifficulty is a common symptom, other psychiatric disorders and prior brain trauma must beruled out. (See Table 10-6).XTable 10-6: Differential Diagnosis of Early HIV Dementia in Adults• Anxiety• Depression• Medication side effects• Metabolic encephalopathy• Drug-drug interactions (especially with protease inhibitors)• Alcohol and other recreational drugsHIV-infected patients may have mild neuropsychological impairment that does not meet criteriafor any specific disorder. It is important to recognize that this may be the initial stage of developingdisease and should be followed closely. In doing so, clinicians must consider other conditionssuch as head trauma, epilepsy, learning disorders, aging, low intellectual ability, and alcohol orsubstance use. Deficits due to HIV would be evident as decline from previous function prior toHIV infection, thus requiring monitoring of impairment over time. Cognitive deficits due to otherconditions would not necessarily be expected to progress if the underlying condition was stableor in remission, whereas impairment due to HIV would be expected to progress over time.DementiaWhile prior estimates of dementia had been reported at 20% to 25% of individuals with AIDS, 15 itis now thought that the cumulative prevalence of dementia has been reduced to 7% to 10%, as aresult of multidrug antiretrovitral therapy. 3 This figure may rise as drug resistance increasesand adherence falls over time. This may be due to the relatively poor penetration of antiretroviralsinto the CNS, leading to incomplete viral suppression, resistance and reseeding of the peripheralblood with drug resistant strains of virus. The blood brain barrier (BBB) thus creates asanctuary for HIV in the CNS, making it impossible to achieve complete viral suppression.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 213