HIV-Associated Dementia and Minor Cognitive Motor Disorder

ART may be helpful in treating MCMD and HAD and should be recommended for all patients, unless there are contraindications. The ability of particular antiretroviral drugs to penetrate the blood-brain barrier may be less important to treatment success than the overall potency of the regimen and the ability of the patient to adhere to it.

Studies from the 1980s showed that zidovudine monotherapy was beneficial in patients with HAD, so some clinicians include it in the ART regimen for anyone with neurocognitive impairment. Others suggest using at least 2 drugs that cross the blood-brain barrier (eg, zidovudine, stavudine, abacavir, lamivudine, and nevirapine). Efavirenz, didanosine, and lamivudine cross to a lesser degree. As a class, protease inhibitors (PIs) have poor blood-brain barrier penetration. Nevertheless, patients have shown neurocognitive improvement while taking PI-containing regimens, perhaps because of indirect effects on HIV activity in the CNS.

Treat depressive symptoms with low dosages of selective serotonin reuptake inhibitors (SSRIs) (see chapter Depression for details).

Antipsychotic medications may be useful in treating agitation and hallucinations, but patients with these conditions are often extremely sensitive to anticholinergic adverse effects and extrapyramidal symptoms. Newer neuroleptic or antipsychotic agents, such as olanzapine and risperidone, have lower rates of significant side effects compared with older drugs. The starting dosage of olanzapine is 2.5 mg orally at bedtime; that for risperidone is 0.5-1 mg orally at bedtime. Note that these drugs may interact with antiretroviral medications, especially ritonavir, and can cause weight gain and other metabolic adverse effects. Avoid benzodiazepines, which tend to increase confusion and decrease concentration. Consult with a knowledgeable psychiatrist or pharmacist.

Psychostimulants such as methylphenidate (Ritalin) and dextroamphetamine (Dexedrine) have been used to improve attention, concentration, and psychomotor function. Dosages of methylphenidate start at 5 mg for a test dose, then 2.5-5.0 mg twice daily, increasing by doses of 5 mg every other day until the desired effect is achieved. Usual dosages are in the range of 20-30 mg per day. Monitor blood pressure, heart rate, and symptoms of restlessness, agitation, nausea, and psychosis. No data are available regarding the use of atomoxetine (Strattera) to improve attention and concentration in patients with HAD.

For a patient who is knowledgeable about HIV, a dementia workup or diagnosis often precipitates a crisis, with an increased risk of suicide. Carefully screen for depression and suicidality, and treat these if they develop.

Behavioral management strategies may assist the patient with early manifestations of dementia to continue living with some degree of independence and safety in the home. Memory aids such as posted notes, calendars, alarmed pill-boxes, and other environmental cues may help.

It is critical to enlist the support of family members and significant others at an early stage of the illness. Because the disease is frightening and may be progressive, the patient and members of the support system need assistance in anticipating and planning for the future. Plans for assisted living or other in-home custodial care should be made early. Severe or late dementia causes fear, misunderstanding, and frustration for both the patient and care givers. All involved will require help from visiting nurses, social workers, hospice workers, and physicians. Recommend the preparation of an advance directive for the patient with early manifestations of dementia.