• New York State Department of Health. Cognitive disorders and HIV/AIDS: HIV-associated dementia and delirium. New York (NY): New York State Department of Health; 2007 Sep. 12 p. [6 references]

This is the current release of the guideline.

This guideline updates a previous version: New York State Department of Health. Cognitive disorders and HIV/AIDS: HIV-associated dementia and delirium. New York (NY): New York State Department of Health; 2005 Oct. 7 p.

• Human immunodeficiency virus (HIV) infection
• Cognitive disorders in HIV patients:
  • HIV-associated dementia (HAD)
  • Delirium associated with HIV

Diagnosis
Evaluation
Management
Treatment

Allergy and Immunology
Family Practice
Infectious Diseases
Internal Medicine
Neurology
Psychiatry

Advanced Practice Nurses
Health Care Providers
Physician Assistants
Physicians
Public Health Departments

To provide guidelines for diagnosis and treatment of cognitive disorders in human immunodeficiency virus (HIV)-infected patients in primary care settings

Human immunodeficiency virus (HIV)-infected persons

Diagnosis/Evaluation

1. Use of brief, standardized rating scale
2. Exclusion of other treatable, reversible causes of change in mental status
3. Complete evaluation including neuroimaging studies (computed tomography [CT], magnetic resonance imaging [MRI]) and lumbar puncture

Treatment/Management of HIV-associated Dementia (HAD)

1. Referral for psychiatric consultation, as appropriate
2. Antiretroviral drugs
3. Pharmacologic treatment of symptoms (psychotropic medications)
4. Non-pharmacologic treatment including
   • Family support, nursing case management, nursing home care services
   • Discussing advance directives and documenting the content of these discussions in the medical record

Treatment/Management of HIV-associated Delirium

1. Immediate referral of patients with signs and symptoms of delirium to the hospital
2. Correcting the underlying conditions that have led to delirium (low doses of antipsychotics with or without lorazepam)
3. Consultation with a psychiatrist

• Morbidity and mortality
• Cognitive status

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Not stated

Not stated

Expert Consensus (Committee)

Not applicable

Review

Not stated

Expert Consensus

AIDS Institute clinical guidelines are developed by distinguished committees of clinicians and others with extensive experience providing care to people with HIV infection. Committees* meet regularly to assess current recommendations and to write and update guidelines in accordance with newly emerging clinical and research developments.

The Committees* rely on evidence to the extent possible in formulating recommendations. When data from randomized clinical trials are not available, Committees rely on developing guidelines based on consensus, balancing the use of new information with sound clinical judgment that results in recommendations that are in the best interest of patients.

*Current committees include:

• Medical Care Criteria Committee
• Committee for the Care of Children and Adolescents with HIV Infection
• Dental Standards of Care Committee
• Mental Health Committee
• Women's Health Committee
• Substance Use Committee
• Physician's Prevention Advisory Committee
• Pharmacy Committee

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review

All guidelines developed by the Committee are externally peer reviewed by at least two experts in that particular area of patient care, which ensures depth and quality of the guidelines.

General Recommendation

Key Point:

Early stages of dementia and delirium are often subtle, difficult to recognize, and may resemble primary psychiatric disorders.

Human Immunodeficiency Virus (HIV)-Associated Dementia

Presentation

Diagnosis

Clinicians should exclude other treatable, reversible causes of change in mental status before a diagnosis of HIV-associated dementia (HAD) can be made (see Table 2 in the original guideline).

Clinicians should conduct neuroimaging studies and a lumbar puncture as part of a complete evaluation for HAD.

Key Point:

HAD may be incorrectly diagnosed as Alzheimer's disease. Early HAD differs from Alzheimer's disease in that it is more likely to present with behavioral changes, progresses more rapidly, may be associated with abnormal cerebrospinal fluid (CSF) findings, and is rarely associated with aphasia.

Management of Patients with HAD

Referral

Clinicians should refer patients with HAD who present with accompanying depression, mania, psychosis, behavioral disturbance, or substance use for psychiatric consultation to assist in psychopharmacologic treatment and management.

Clinicians should refer patients who require treatment with multiple psychotropic medications and/or are using illicit substances for psychiatric consultation because of the risk of drug-drug interactions and toxicity.

Treatment

Antiretroviral Drugs

Clinicians should assess the efficacy of the highly active antiretroviral therapy (HAART) regimen when patients receiving HAART present with symptoms of HAD.

Clinicians should initiate HAART when patients not receiving HAART present with symptoms of HAD.

Non-Pharmacologic Management

Clinicians should involve members of the patient's primary support system, such as family or friends, in both medication management and attending appointments and should educate them about HAD and its course.

Clinicians should assess patients' ability to function independently at home and arrange for assistance in the form of family support, nursing case management, and nursing home care services when indicated. Clinicians should refer patients who are unable to be safely cared for at home for placement in a skilled nursing facility.

Clinicians should discuss advance directives such as a living will, healthcare proxy, or durable power of attorney early in the course of illness, while patients have the capacity to make decisions about their treatment. Clinicians should clearly document the content of these discussions in the medical record and include copies of advance directives as part of the medical record.

Clinicians should consult with a psychiatrist if questions exist about a patient's mental capacity to make decisions about his or her treatment.

Refer to the original guideline document for a full discussion of the non-pharmacologic management of patients with HIV-associated dementia.

Delirium Associated with HIV

Clinicians should immediately refer patients who present with signs and symptoms of delirium to the hospital.

Presentation and Diagnosis

Clinicians should assess for delirium when there is a sudden change in a patient's cognitive functioning, consciousness, or behavior.

* Delusions are usually paranoid but more disorganized than those seen in psychoses.

Management of Patients with Delirium

Treatment should be aimed at correcting the underlying conditions that have led to delirium. Refer to the original guideline document for a discussion.

Key Point:

HIV-infected patients may be more sensitive to the side effects of psychotropic medications. Older patients and those with more advanced disease are at highest risk for side effects.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

• The prompt diagnosis and treatment of cognitive impairment/dementia and delirium may significantly decrease morbidity and mortality.
• There have been marked improvements in the cognitive status of some people with HIV-associated dementia associated with the initiation of highly active antiretroviral therapy (HAART).

• HIV-infected patients are more likely than the non-infected population to develop extrapyramidal side effects with antipsychotic agents and hepatotoxicity with drugs that are metabolized primarily by the liver.
• Refer to Appendix XII, Table XII-1 (see the "Availability of Companion Documents" field) for information on drug-drug interactions between HIV-related medication and psychotropic medication.

Refer to Appendix XII, Table XII-1 (see the "Availability of Companion Documents" field) for lists of psychotropic medications contraindicated in patients on specific antiretroviral drugs.

The AIDS Institute's Office of the Medical Director directly oversees the development, publication, dissemination and implementation of clinical practice guidelines, in collaboration with The Johns Hopkins University, Division of Infectious Diseases. These guidelines address the medical management of adults, adolescents and children with HIV infection; primary and secondary prevention in medical settings; and include informational brochures for care providers and the public.

Guidelines Dissemination

Guidelines are disseminated to clinicians, support service providers and consumers through mass mailings and numerous AIDS Institute-sponsored educational programs. Distribution methods include the HIV Clinical Resource website, the Clinical Education Initiative, the AIDS Educational Training Centers (AETC) and the HIV/AIDS Materials Initiative. Printed copies of clinical guidelines are available for order from the New York State Department of Health (NYSDOH) Distribution Center for providers who lack internet access.

Guidelines Implementation

The HIV Clinical Guidelines Program works with other programs in the AIDS Institute to promote adoption of guidelines. Clinicians, for example, are targeted through the Clinical Education Initiative (CEI) and the AETC. The CEI provides tailored educational programming on site for health care providers on important topics in HIV care, including those addressed by the HIV Clinical Guidelines Program. The AETC provides conferences, grand rounds and other programs that cover topics contained in AIDS Institute guidelines.

Support service providers are targeted through the HIV Education and Training initiative which provides training on important HIV topics to non-physician health and human services providers. Education is carried out across the State as well as through video conferencing and audio conferencing.

The HIV Clinical Guidelines Program also works in a coordinated manner with the HIV Quality of Care Program to promote implementation of HIV guidelines in New York State. By developing quality indicators based on the guidelines, the AIDS Institute has created a mechanism for measurement of performance that allows providers and consumers to know to what extent specific guidelines have been implemented.

Finally, best practices booklets are developed through the HIV Clinical Guidelines Program. These contain practical solutions to common problems related to access, delivery or coordination of care, in an effort to ensure that HIV guidelines are implemented and that patients receive the highest level of HIV care possible.

End of Life Care
Getting Better
Living with Illness

Effectiveness
Patient-centeredness

• New York State Department of Health. Cognitive disorders and HIV/AIDS: HIV-associated dementia and delirium. New York (NY): New York State Department of Health; 2007 Sep. 12 p. [6 references]

Not applicable: The guideline was not adapted from another source.

2001 Mar (revised 2007 Sep)

New York State Department of Health - State/Local Government Agency [U.S.]

New York State Department of Health

Mental Health Committee

Chair: Milton L Wainberg, MD, New York State Psychiatric Institute, New York, New York

Members: Bruce D Agins, MD, MPH, New York State Department of Health AIDS Institute, New York, New York; Kalyana Battu, MD, Albany Medical Center, Albany, New York; Barbara A Conanan, RN, MS, Saint Vincent's Manhattan Department of Community Medicine, New York, New York; Joseph Z Lux, MD, Bellevue Hospital, New York, New York; Peter Meacher, MD, AAHIVS, FAAFP, South Bronx Health Center for Children and Families, Bronx, New York; Yiu Kee Warren Ng, MD, New York Presbyterian Hospital, Columbia University Medical Center, New York, New York; Bella M Schanzer, MD, MPH, Columbia University Medical Center, New York, New York

Liaisons: Francine Cournos, MD, Liaison to the New York/New Jersey AIDS Education and Training Center, Columbia University, New York State Psychiatric Institute, New York, New York; James J Satriano, PhD, Liaison to the New York State Office of Mental Health, Columbia University College of Physicians and Surgeons, New York, New York

AIDS Institute Staff Liaison: L Jeannine Bookhardt-Murray, MD, Harlem United Community AIDS Center, New York, New York

AIDS Institute Representative: Heather A Duell, LMSW, New York State Department of Health AIDS Institute, Bureau of Community and Support Services, Albany, New York

Not stated

This is the current release of the guideline.

This guideline updates a previous version: New York State Department of Health. Cognitive disorders and HIV/AIDS: HIV-associated dementia and delirium. New York (NY): New York State Department of Health; 2005 Oct. 7 p.

None available

This NGC summary was completed by ECRI on May 4, 2005. It was updated by ECRI on October 19, 2005 and on June 6, 2008. This summary was updated by ECRI Institute on July 25, 2008, following the U.S. Food and Drug Administration advisory on Antipsychotics.