Clinical Manual for Management of the HIV-Infected ... - myCME.com

Section 8—Neuropsychiatric Disorders | 8–17
HIV-Associated Dementia and Minor Cognitive Motor Disorder
Background
The HIV virus is neurotropic and directly invades brain
tissue shortly after infection. Accordingly, HIV may
cause cognitive difficulties, including HIV-associated
dementia (HAD), also called AIDS dementia complex
(ADC). In the United States in past years, HAD was
the most common neurologic complication of AIDS,
affecting 40-60% of all AIDS patients. In recent years,
the incidence of HAD has declined, probably because
of the use of potent combination antiretroviral therapy
(ART). Other HIV-related opportunistic infections of
the central nervous system (CNS) (eg, toxoplasmosis,
cytomegalovirus encephalitis) and malignancies (eg,
lymphoma) have declined in frequency even more
sharply than HAD. The fact that HAD has not declined
as much as other HIV-related CNS disease suggests that
the CNS may be an important reservoir for HIV and
that current antiretroviral medications do not protect the
CNS as well as they protect the rest of the body. The HIV
viral load in the CNS is correlated with cognitive decline;
however, it is not correlated with plasma viral load and
cannot be estimated from plasma viral load.
The American Psychiatric Association describes
dementia as “an organic mental disorder defined as
a loss of intellectual abilities of sufficient severity to
interfere with social or occupational functioning.” The
clinical presentation of dementia varies. Patients may
develop ambulation or gait problems, mania, panic,
psychosis, social isolation, or anxiety. Dementia is
progressive but with a variable course; some patients
have a rapid progression, whereas others have a slow
decline in function. Many patients with HIV-related
neurocognitive impairments are acutely aware of their
deterioration and may develop an adjustment disorder
characterized by profound fear, anxiety, or depression.
Some HIV-infected patients may develop a milder
form of cognitive disorder, called minor cognitive motor
disorder (MCMD), which is not necessarily an early
stage of dementia. The distinction between MCMD
and dementia is important and may have a major
psychological impact on the patient.
Manifestations of Dementia
Early manifestations of dementia may include the
following:
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Decreased attention or concentration
Reduced speed of information processing
Psychomotor slowing
Impaired executive functioning (eg, abstraction,
divided attention, shifting cognitive sets)
Late manifestations may include:
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Visuospatial difficulties
Language problems
Apraxias
S: Subjective
The patient complains of, or a care giver reports, the
following:
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Impairment in memory (short-term and long-term),
abstract thinking, judgment, and higher cortical
functioning
Personality changes that interfere with relationships
Inability to carry out normal social or occupational
functions
Some patients experience only minor forgetfulness
and diminished visual or motor skills
History
Take a thorough history, including the following:
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Medications
Approximate onset of symptoms
Drug and alcohol use
Symptoms of opportunistic infections
Pain
HIV history, including duration, opportunistic
illnesses, and CD4 levels
Common manifestations (see above)