AIDS-Related Dementia: Diagnosis, Assessment and Management

Abstract

  AIDS-related dementia occurs in the advanced stages of the HIV virus. When the virus attacks there is a worsening of both motor skills and mental declining. It also attacks the nervous system and can cause brain damage. HIV has been directly linked to neurocognitive disorders. Some of these disorders include memory loss, short attention span, confusion, slowed learning, weakness, depression, irritability, and poor balance and coordination. In this paper, we will discuss the different assessment techniques and methods needed to treat individuals who have early AIDS-related dementia. We will investigate the mental status and cognitive functioning using tests such as The Test of Memory Malingering (TOMM),Trails A & B, Digit-Symbol Test, the WAIS-IV and Wide Range Achievement Test (WRAT), Rivermead Behavioral Memory Test for dementia due to HIV Disease and the Minnesota Multiphasic Personality Inventory (MMPI) test. The level and stage of AIDS/Dementia will be discussed while recognizing the cognitive deficits the intellectual has been experiencing.Assessment deficits will also be observed.The diagnosis, assessment, and management of early AIDS-related dementia are critical in achieving a successful and/or manageable outcome.

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Dan is a 40-year-old man who has been incarcerated for over five years now. When he arrived at the prison, it was documented that he had received some sporicidal treatment in regard to his HIV-AIDS infection that he has had for several years now. Both the guards and inmates have recently noticed that Dan has been uncommunicative, lethargic, and has stopped going out to the exercise yard. After looking at his medical records, it’s apparent that his speech has become sparse and slowed. Dan also has little to no desire for any physical activities. Dan has been on a medication regime for his HIV-AIDS infection, but his health seems to be declining. Dan expresses that he is struggling to concentrate and he’s having problems with his memory and with his learning. When consulting with the prison infirmary physician, he states that he believes that the HIV-AIDS disease process has made its way into Dan’s cerebral spinal fluid and brain, thus, producing early AIDS-related dementia. Dan’s mental status and cognitive functioning will be assessed to determine whether or not he will remain in general custody of the prison, or if he will be transferred to a psychiatric hospital for the criminally insane for a higher level of observation and care. Dementia can evolve directly from the HIV virus/infection to the brain and rapid deterioration of cerebral functioning will occur (Lezak, Howieson, Bigler & Tranel, 2012). Subtle symptoms of AIDS-related dementia start to appear. These symptoms include the same ones that Dan has been complaining about. These include memory problems, mental sluggishness, lack of concentration, and cognitive and motor impairments.

When an individual has HIV, in its advanced stages the virus will attack the nervous system and then cause damage to the brain and then cause HIV-associated neurocognitive disorders otherwise known as HIV-associated neurocognitive disorders (HAND). There are three classes of HAND and looking at Dan’s health history and current mental and cognitive status, we are led to believe that he has the third class of HAND- HIV-associated dementia. This stage really limits someone’s ability to lead a somewhat normal life. When someone has the HIV virus, it makes its way to the brain early in the disease process. It is one reason why people get dementia. HIV encephalopathy is an infection that spreads to the brain due to the HIV virus, thus, causing dementia. If the infection spreads or becomes greater, then the dementia symptoms become worse. Dementia is seen as a serious consequence of an HIV infection. Some symptoms of HIV-associated dementia include a loss of memory, a reduction in the ability to think clearly, difficulty speaking and/or speaking accurately, a loss of motor skills and reduced coordination, and a lack of interest in activities. These are a lot of the symptoms that we clearly see Dan displaying. It’s critical to know that the symptoms of HIV-associated dementia can resemble other medical problems and an individual may not at first, be properly diagnosed. An examination, assessment, and evaluation are crucial in determining both the extent and presence of dementia. HIV treatments have become so advanced that individuals are living longer which makes the risk of cognitive decline, greater (Kimani, 2018). HIV infected individuals are at a higher risk of developing neurocognitive deficits and/or impairments. HIV- associated dementia can be diagnosed through a mental status test, neuropsychological testing, magnetic resonance imaging (MRI), computed tomography scan (CAT Scan), blood tests, and through a spinal fluid test. In the later stages of AIDS-related dementia, cerebral atrophy (a loss of neurons and the connections between them) will appear on an MRI scan.

When looking at the DSM-5 criteria in regard to Dan’s case, dementia due to the HIV virus can occur at any age and those with HIV are more likely to develop dementia. Genetic and environmental influences can contribute to dementia. Genetic factors and disease-causing genes can be hereditary and caused by dominant-acting disease gene mutations (a mutant MCP-1 allele). The MCP-1 genotype was also associated with an accelerated disease progression which increases the risk of HIV-associated dementia (HAD). The MCP-1 allele linked to increased monocyte infiltration of tissues and MCP-1 levels, thus, serving as a genetic determinant of the outcome of other disease states. Environmental influences such as poor air quality, exposure to high levels of air pollution, can wreak havoc on the brain and cognition and can lead to brain abnormalities such as dementia.

Biological, social and psychological factors all play a part in the cause of depression with HIV patients. Depression in HIV patients could be the result of neurotrophic effects of the HIV virus on the central nervous system (Judd, Komiti, Chua, Mijch, Hoy, Grech & Williams, 2005). The Minnesota Multiphasic Personality Inventory test (MMPI) is used to asses an individual who show signs of mental health issues. Depression has been linked to those who have HIV which is a mental health issue very common in HIV patients.

The Test of Memory Malingering (TOMM) is a test is a 50-item recognition test and is seen as a great test to administer to an individual when discriminating between both true memory-impaired patients and malingerers. It is a visual recognition test and this test was found to be sensitive to malingering (fabrication of symptoms) but insensitive to an extensive variety of neurological impairments (dementia). This is why the TOMM test was found to be very reliable. This test can determine if Dan’s memory impairments are true or if he’s fabricating to get out of doing his daily tasks.

The WAIS-IV Battery test is also a great test to administer when assessing levels of cognitive functioning and cognitive abilities to see how the brain is functioning after a brain injury (i.e., AIDS virus). This test uses 10 core subtests in order to determine Dan’s full-scale intelligence quotient (FSIQ). Verbal comprehension, perceptual reasoning, working memory, and processing speed will be tested. Numerous scales are used to assess different types of intellectual functioning. The test will allow professionals to exam the relationship between both memory and intellectual functioning.

The Trails A & B, Digit-Symbol Test

Wide Range Achievement Test (WRAT), 

The Minnesota Multiphasic Personality Inventory (MMPI) test

Rivermead Behavioral Memory Test for dementia due to HIV Disease is a test that will determine cognitive deficits, such as impairment in an individual’s memory function (Wester, van Herten, Egger & Kessels, 2013). This test is a valid test battery when determining memory deficits that affect memory every day. This test consist of 11 different subtests that assess memory difficulties and it is highly sensitive. It predicts everyday memory problems with those who have changes within the brain due to injury or illness and it can monitor these changes over time.

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Some recommendations for accommodations or rehabilitation for Dan would start with implementing an antiretroviral therapy in order to maintain a suppressed viral load in the blood. Although there is no cure for HIV, different medications are available to control the virus. One of the most effective treatments for HIV-associated dementia is ART. Antiretroviral Therapy has been known to reduce the amount of HIV within the individual’s blood along with the surrounding fluid in the spinal cord and the brain. There is much different ART approved drugs to help day to day living. It is important that Dan continues his medications while continuing to engage in self-care so that he can prevent any further complications. Aggressive treatment for symptoms can lead to positive benefits while helping Dan to live a more controlled and comfortable life. Lifestyle changes and coping strategies can be put into place so that Dan can better manage his daily life. Ethically, a multidisciplinary approach involving HIV/dementia physicians, psychologists, nurse specialists, psychiatrists and neurologists is critical when working with HIV patients and ensuring the best possible outcome (Barber, Bradshaw, Hughes, Leonidou, Margetts, Ratcliffe & Catalan, 2014).

CONCLUSION

Living with AIDS-associated dementia is anything but easy and can take a toll on the individual and families but finding the right medication regime along with daily physical exercise will help the patient in living a more balanced and comfortable life. Keeping your immune system as healthy as possible will aid in a possible decrease in symptoms and complications. There are numerous tests available for managing both symptoms and treatments when looking for an effective, manageable outcome. If HIV is left untreated it will attack the immune system, thus, leading to life-threating infections and even possibly cancer.

References

• Barber, T. J., Bradshaw, D., Hughes, D., Leonidou, L., Margetts, A., Ratcliffe, D., … Catalan, J. (2014). Screening for HIV-related neurocognitive impairment in clinical practice: challenges and opportunities. AIDS Care, 26(2), 160–168. https://doi.org/10.1080/09540121.2013.819401
• Judd, F., Komiti, A., Chua, P., Mijch, A., Hoy, J., Grech, P., … Williams, B. (2005). Nature of depression in patients with HIV/AIDS. The Australian And New Zealand Journal of Psychiatry, 39(9), 826–832.
• Kimani, R. W. (2018). Assessment and diagnosis of HIV-associated dementia. The Journal for Nurse Practitioners, 14(3), 190-195. doi: http://dx.doi.org.libauth.purdueglobal.edu/10.1016/j.nurpra.2017.12.031
• Lezak, M., Howieson, D., Bigler, E. & Tranel, D. (2012). Neuropsychological Assessment. (5th ed.). Oxford, NY: Oxford University Press.
• Wester, A. J., van Herten, J. C., Egger, J. I., & Kessels, R. P. (2013). Applicability of the Rivermead Behavioral Memory Test – Third Edition (RBMT-3) in Korsakoff’s syndrome and chronic alcoholics. Neuropsychiatric disease and treatment, 9, 875–881. doi:10.2147/NDT.S44973