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
Clinical Manifestations of HIV-Associated Dementia |
Type of Impairment |
Manifestations |
Affective |
- Apathy (depression-like features)
- Irritability
- Mania, new-onset psychosis
|
Behavioral |
- Psychomotor retardation (e.g., slowed speech or response time)
- Personality changes
- Social withdrawal
|
Cognitive |
- Lack of visuospatial memory (e.g., misplacing things)
- Lack of visuomotor coordination
- Difficulty with complex sequencing (e.g., difficulty in performing previously learned complex tasks)
- Impaired concentration and attention
- Impaired verbal memory (e.g., word-finding ability)
- Mental slowing
|
Motor |
- Unsteady gait, loss of balance
- Leg weakness
- Dropping things
- Tremors, poor handwriting
- Decline in fine motor skills
|
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.
Clinical Manifestations of Delirium in HIV-Infected Patients |
Impairment of memory, orientation, prefrontal "executive" functions
- Difficulty with abstraction
- Difficulty with sequential thinking
- Impaired temporal memory
- Impaired judgment
|
Disturbances in thought and language
|
Disturbances in perception
- Hallucinations (primarily visual)
- Illusions (misinterpretation of visual cues, e.g., mistaking shadows for people)
|
Disturbances in psychomotor function
- Hypoactive
- Hyperactive
- Mixed hypo- and hyperactive
|
Disturbances in sleep-wake cycle
- Daytime lethargy
- Nighttime agitation
|
Delusions* |
Affective lability |
Neurologic abnormalities
- Tremors
- Ataxia
- Myoclonus
- Cranial nerve palsies
- Asterixis
- Cerebellar signs
- Nystagmus
|
* 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.