BY HEBA ESSAWY

NEUROPSYCHIATRY AND BEHAVIORAL ASPECT

OF HIV SPECTRUM DISEASE

PATHOGENESIS

• Human immunodeficiency virus (HIV) is a blood-borne, sexually transmissible virus

• The virus is typically transmitted via - Sexual intercourse. - Shared intravenous drug. - Mother-to-child transmission (MTCT): *during the birth process or *during breastfeeding.

PATHOGENESIS

• Two distinct species of HIV HIV-1 and HIV-2 • HIV-1 originated and transfers from

chimpanzees in central Africa.• HIV-2 is closely related to viruses that infect

sooty mangabeys in western Africa.• Genetically, HIV-1 and HIV-2 are superficially

similar, but each contains unique genes and its own replication .

TYPES OF CNS COMPLICATIONS

• - By HIV infection either direct or indirect •HIV-1–associated cognitive/motor complex or AIDS dementia complex (ADC) •Vacuolar myelopathy •Certain peripheral neuropathies• By infectious, autoimmune, or neoplastic secondary

to immunodeficiency include the following:•CNS lymphoma•Kaposi sarcoma•Fungal infections •Tuberculous meningitis•Toxoplasmosis•Cytomegalovirus (CMV) encephalitis

CNS COMPLICATIONS IN HIV

• Neurologic complications occur in more than 40% of patients with HIV infection.

• They are the presenting feature of AIDS in 10-20% of cases.

HIV ENCEPHALOPATHY AND AIDS DEMENTIA COMPLEX

• HIV encephalopathy • AIDS dementia complex. • HIV-associated progressive encephalopathy (HPE)

is a syndrome complex with cognitive, motor, and behavioral features seen in children.

SPECTRUM OF PSYCHIATRIC DISORDERS IN AIDS

• Psychologically determined reaction to diagnosis and illness

• Neuropsychiatric complications• Neuropathological findings

PSYCHOLOGICAL REACTION

• psychosocial stress associated with socially stigmatising terminal illness

• Frequent infections . • Loss to health• Loss of financial security.• Independence .

PSYCHOLOGICAL REACTION

• In Seropositive : -Adjustment disorder in 22% of cases - High lifetime rates of mood disorders in group of 207 individuals who has positive HIV testing was 16%. - Suicide may be a possible complication

NEUROPSYCHIATRIC COMPLICATIONS

• complication is directly related to the viral infection rather than the immune-deficiency states induced by the virus, the major complications may be classified as follows:

• a) Cognitive impairment• b) AIDS dementia /HIV encephalopathy• c) Delirium• d) Affective disorder• e) Anxiety state• f) Psychosis• g) Substance use disorder• h) Pain syndrome

COGNITIVE IMPAIRMENT

• Subtle neuropsychological deficits: - Loss of cognitive flexibility. - Difficulty in problem solving. - Mental slowness - Difficulty in concentration. - Delayed recall.

HIV ENCEPHALOPATHY

• Encephalopathy Occur as a part of the acute HIV syndrome during seroconversion.

• HIV-associated progressive encephalopathy (HPE) is a syndrome complex with cognitive, motor, and behavioral features seen in children.

AIDS DEMENTIA

• The prevalence of AIDS-related dementia, and the AIDS-dementia complex (ADC) varies between 8 and 16% in cases .

• ADC is characterized by cognitive, motor, and behavioral features in advanced cases .

• Highly active antiretroviral therapy (HAART,) minor cognitive motor disorder (MCMD), is common than ADC.

EARLY SYMPTOMS OF ADC

• Difficulty in performing complex tasks at work and at home.

• Appearance of primitive frontal lobe reflexes as snout and glabellar reflex .

AIDS DEMENTIA COMPLEX

• ADC encompasses Cognitive deficits. Behavioral changes. Motor involvement.• Affected persons may manifest deficits in each of

the 3 aspects at varying severity.

AIDS DEMENTIA COMPLEX

• Apathy,• Social withdrawal, • Impaired concentration,• Mental and motor slowing.• Motor weakness and clumsiness• Problems with complex sequential mental

activities.

STAGES OF ADC• Stage 1• In stage 1 (mild), the patient is able to perform all but the

more demanding aspects of work but has unequivocal evidence of functional, intellectual, or motor impairment. Signs or symptoms may include diminished performance on neuropsychological testing. Patient can walk without assistance.

• Stage 2• In stage 2 (moderate), the patient is able to perform basic

activities of self-care but cannot work or maintain the more demanding aspects of daily life. The patient is ambulatory but may require a single prop.

STAGES OF ADC

• Stage 3• In stage 3 (severe), the patient has major intellectual

incapacity (cannot follow news or personal events, cannot sustain complex conversation, shows considerable slowing of all outputs). Motor disability , walking is usually slowed and accompanied by clumsiness of arms.

• Stage 4• In stage 4 (end stage), the patient is in a nearly

vegetative state. Intellectual and social comprehension. Mute , paraparetic or paraplegic, with urinary and fecal incontinence.

DELIRIUM

• Delirium is a consequence of - Severe medical illnesses . - Treatment course - With acute, profound cognitive impairment. Behavioural manifestations: Agitation, psychosis . Aggressive behaviour . Mutism Marked withdrawal.

AFFECTIVE DISORDER

• Grief, as they adjust to living with a terminal illness.

• Dysphoric affect is expected part of this grieving process .

• Organic mood disorder may exist either as a feature of or independent of ADC

• did not respond to conventional antidepressant therapy, but remitted coincidentally with treatment with zidovudine (AZT),

ANXIETY STATE

• Anxiety disorder is common in groups at high risk for HIV infection irrespective of HIV status.

• Individuals with pre-existing disorder may be at increased risk for exacerbation of symptoms.

PSYCHOTIC REACTION

• Is a symptom of delirium ,

• from any CNS opportunistic infected CNS, • result of medication used in the treatment.

- Paranoid delusions, - Auditory hallucination. - Manic symptoms - Catatonia .

PAIN SYNDROME

• Polyneuropathy is distal and symmetrical -Occur at all stages of HIV - Occur during serious illness as herpes zoster and advance malignancies. • Characterised by :

-painful, burning dysesthesias.

NEUROPSYCHOLOGICAL TESTING

• Domains of cognition: Language. Attention. Executive function, memory, Speed of information processing, Perceptual and Motor skills.

MODIFIED HIV DEMENTIA SCALE

• The scale consists of subsets for memory (eg, recall, registration),

• psychomotor speed, • constructional ability,• concentration.• A total of 12 points can be earned,• and a score lower than 6 points is considered

abnormal. • Takes 10 minutes to administer

ANTIRETROVIRAL AND OTHER THERAPIES

• highly active antiretroviral therapy (HAART) is the treatment for HIV-related cognitive disorders.

• Aggressive early treatment of patients with HIV disease with antiviral medications and early suppression of viral replication prevents most of the devastating consequences of HIV dementia.

• Several studies have shown that early and aggressive treatment of HIV infection decreases the rate of dementia from greater than 50% to 10%.

• Multiple studies have shown that patients on HAART show partial reversals of neuropsychological deficits and significant improvement, which is sustained, whereas patients not on HAART steadily decline.

• Thank you

RATIONALE

• HAND 2011• Still frequent• Often not diagnosed• Increased risk of death (poster TUPE 204)• Reduced adherence • Poor QoL

CLINICAL METHODS

• Demographics• Medical assessments• Neurological assessments • Standard brain MRI• Routine laboratory, CD4, plasma HIV RNA• Neuropsychological (NP) assessment on 5

domains• Exclusion of confounding conditions

NP BATTERY AND DOMAINS• Concentration and Speed of Mental Processing

– Trail Making A– WAIS-R Digit Span (forward)– WAIS-R Digit Span (backward)

• Concentration and Speed of Mental Processing• Trail Making A• WAIS-R Digit Span (forward)• WAIS-R Digit Span (backward) • Digit Symbol• Stroop Word and Colour• Corsi Cube Test

• Mental Flexibility• Trail Making B• Stroop Colour-Word • Controlled Oral Word– Digit Symbol– Stroop Word and Colour– Corsi Cube Test

• Mental Flexibility– Trail Making B– Stroop Colour-Word – Controlled Oral Word

• Memory– Rey Auditory Verbal Learning (immediate)– Rey Auditory Verbal Learning (immediate)– Rey Complex Figure (after 45’)

• Fine Motor Functioning– Lafayette Grooved Pegboard (dominant hand)– Lafayette Grooved Pegboard (non dominant hand)

• Visuospatial and Constructional Abilities– Rey Complex Figure (copy)