1. www.aids2014.org HIV and Cognitive Impairment For resource poor settings

2. www.aids2014.org Outline of the workshop Garry Trotter- Causes Denise Cummins- Screening and S&S Group activity Azizul Haque- Resources Ken Murray- Annual monitoring Email address for results of group work

3. www.aids2014.org Cognitive complaints are common in HIV –Acute delirium secondary to legion of metabolic and infectious complications –HIV-associated neurocognitive disorders - directly related to the presence of the virus in the CNS (HAND) –Other chronic cognitive impairments not directly related to HIV (alcohol and/or other drugs, Hep C, vascular) –Cognitive symptoms associated psychiatric illness HIV and Cognitive Impairment

4. HIV infection without cognitive impairment HIV Asymptomatic Neurocognitive Impairment Mild Neurocognitive Disorder HIV- associated Dementia Neuropsychological Impairment in the era of HAART (2007) Consensus Working Group, Neurology 2007

5. www.aids2014.org BEFORE HAART Cognitive impairment associated with HIV recognised from early in epidemic –Usually with advanced disease –Often a prelude to death –Both dementia and milder forms of cognitive impairment described HIV related risk factor for Neurocognitive Disorders

6. www.aids2014.org AFTER HAART - people living longer –Cognitive symptoms were seen to persist but often milder –Length of HIV infection and lowest CD4 Count –The brain is a “sanctuary site” –Aging peoples with co-morbidities HIV related risk factor for Neurocognitive Disorders

7. www.aids2014.org Other factors in cognitive impairment Smoking Alcohol & drug use Other viral infections which contribute to brain injury eg HCV Other brain infections such as meningitis Head injury

8. www.aids2014.org Other factors in cognitive impairment Diabetes High Blood Pressure Older age >45 years Obstructive Sleep Apnoea High cholesterol

9. www.aids2014.org Up to 60% of people with HIV will have a neuro-cognitive abnormality (asymptomatic or only mild impairment in the majority) HIV Neurocognitive Disorders

10. www.aids2014.org An acquired impairment of cognitive functioning that involves at least two ability domains ( memory, concentration, language, motor, social, executive function) This impairment produces interference with daily functioning Mild Neurocognitive Disorder (MND)

11. www.aids2014.org Other issues Vast majority have mild or no symptoms People may not volunteer symptoms from lack of awareness or insight Clinical Carers may not have relevant training for diagnosis and management of HAND Clinical Carers may be focused on other issues in busy clinic settings

12. www.aids2014.org Changes are slow and subtle Symptoms may go unreported, as people and family attribute changes to: Understandable stress responses to life events or to illness itself Normal aging Depression MND may be missed

13. www.aids2014.org In HIV symptoms of depression overlap –with understandable unhappiness –with symptoms of cognitive impairment –with symptoms of physical illness eg fatigue –Diurnal variation of mood suggests depression varidddddation of mood suggests depression Cornerstone of depression is not sadness, but the symptoms of anhedonia Depression in HIV

14. www.aids2014.org Is the inability to experience pleasure from activities usually found enjoyable, e.g. Hobbies Music Sexual activities Social interactions Exercise ANHEDONIA

15. www.aids2014.org Impact of depression in HIV infection High prevalence Depression in HIV people is under diagnosed Depression in HIV is undertreated Poorer outcome of HIV disease Quality of lifeHealth costs

16. www.aids2014.org Clinical carers should be alert for evolving cognitive impairment and screen for its presence even in people with undetectable viral load Both people and their significant others should be questioned MND - Detection

17. www.aids2014.org Exclude depression Exclude other potentially reversible causes of cognitive impairment –acute medical illness – alcohol and other recreational drug use, cerebro-vascular disease, neuroimaging for OIs HAND is a diagnosis of exclusion If Cognitive Impairment is detected

18. www.aids2014.org A significant proportion will get better with treatment In a year, with treatment, 21% will improve from milder impairment to unimpaired In the same time, without treatment, 23% will move from unimpaired to MND Antiretroviral therapy that works better in the brain leads to better outcomes Prognosis for Mild Neurocognitive Disorder

19. www.aids2014.org CNS PE Score

20. www.aids2014.org Cognitive impairment continues to be an important problem for people living with HIV Both dementia and MND should be screened for They can be recognized clinically and confirmed with neuropsychological testing Mild Neurocognitive Disorder Summary

21. www.aids2014.org  Cognitive impairment in HIV can be managed Antiretroviral therapy that better distributes into the CNS leads to better outcomes Co-morbid risk factors can be minimised Physical exercise and mental stimulation- Use it or lose it ! Mild Neurocognitive Disorder Summary

22. www.aids2014.org NEXT… Signs and symptoms Screening tools Booklet ADL tool

23. www.aids2014.org Signs and symptoms Changes over time May be new behaviour May be subtle and missed or PLWH think it is something else 4 domains are affected (memory, motor, concentration, social) Changes in ability to organise

24. www.aids2014.org Memory Losing keys Forgetting appointments Lost in conversations Going in to a room but cant remember why Short term memory not as good Misplace things Trouble remembering names Words on tip of tongue, word finding

25. www.aids2014.org Motor Skills The person may experience: Tripping Poorer keyboard skills Driving skills worse Difficulty doing up buttons Using mobile Signature and writing skills change

26. www.aids2014.org Concentration Trouble following movie Trouble reading Gets distracted in conversations Difficulty focusing Can only do one thing at a time Slower at doing usual things Feel like in a fog?

27. www.aids2014.org Changes in Social Behaviour (1) Apathetic Picture Do not go out as much Not engaging with family or friends Withdrawn even if they do go out

28. www.aids2014.org Changes in Social Behaviour (2) Disinhibited Picture Increased irritability Sexual disinhibition or risk taking Increased risk taking generally

29. www.aids2014.org Also Mental tasks take longer than in the past More physically and mentally tired at the end of the day, as they have to concentrate harder than before to get the same things done

30. www.aids2014.org Executive function Organisational ability has changed –e.g. ability to follow through or plan a task has deteriorated Flexibility –e.g. need to do a task the same way Problem solving

31. www.aids2014.org Questions to ask people Are you slower in your thinking than you used to be? Are you more forgetful than you used to be? Is it harder to organise things? Are you able to find pleasure in the things you used to enjoy?

32. www.aids2014.org To ask their family/friends Are they more forgetful? Has their personality changed? Are they finding it harder to organise their life?

33. www.aids2014.org Mini Mental State Examination International HIV Dementia Scale MoCA Neuropsychological Testing MND – how to recognise S&S Instrumental Activities of Daily Living Scale Screening tools

35. www.aids2014.org Activities of Daily Living Scale Communication Shopping Food preparation Housekeeping Clothing and appearance Medications Medical issues Money Social interaction ?Other

36. www.aids2014.org RESOURCES....Azizul

39. A project of the New Mexico AIDS Education and Training Center. Partially funded by the National Library of Medicine Fact Sheets can be downloaded from the Internet at http://www.aidsinfonet.org AIDS InfoNetwww.aidsinfonet.orgFact Sheet Number 558 DEPRESSION AND HIV WHAT IS DEPRESSION? Depression is a mood disorder. It is more than sadness or grief. Depression is sadness or grief that is more intense and lasts longer than it should. It has various causes: events in your daily life chemical changes in the brain a side effect of medications several physical disorders About 5% to 10% of the general population gets depressed. However, rates of depression in people with HIV are as high as 60%. Women with HIV are twice as likely as men to be depressed. Being depressed is not a sign of weakness. It doesn’t mean you’re going crazy. You cannot “just get over it.” Don’t expect to be depressed because you are dealing with HIV. And don’t think that you have to be depressed because you have HIV. IS DEPRESSION IMPORTANT? Depression can lead people to miss doses of their medication. It can increase high-risk behaviors that transmit HIV infection to others. Depression might cause some latent viral infections to become active. Overall, depression can make HIV disease progress faster. It also interferes with your ability to enjoy life. A study in 2012 showed that patients with depression, especially women, were more likely to stop receiving care and to not achieve undetectable viral load. Depression often gets overlooked. Also, many HIV specialists have not been trained to recognize depression. Depression can also be mistaken for signs of advancing HIV. WHAT ARE THE SIGNS OF DEPRESSION? Symptoms of depression vary from person to person. Most health care providers suspect depression if patients report feeling blue or having very little interest in daily activities. If these feelings go on for two weeks or longer, and the patient also has some of the following symptoms, they are probably depressed: Fatigue or feeling slow and sluggish Problems concentrating Low sex drive Problems sleeping: waking very early, or excessive sleeping Feeling guilty, worthless, or hopeless Decreased appetite or weight loss Overeating WHAT CAUSES DEPRESSION? Some medications used to treat HIV can cause or worsen depression, especially efavirenz (Sustiva). Diseases such as anemia or diabetes can cause symptoms that look like depression. So can drug use, or low levels of testosterone, vitamin B6, or vitamin B12. People who are infected with both HIV and hepatitis (see fact sheet 506) are more likely to be depressed, especially if they are being treated with interferon. Other risk factors include: Being female Having a personal or family history of mental illness, alcohol and substance abuse Not having enough social support Not telling others you are HIV-positive Treatment failure (HIV or other) TREATMENT FOR DEPRESSION Depression can be treated with lifestyle changes, alternative therapies, and/or with medications. Many medications and therapies for depression can interfere with your HIV treatment. Your health care provider can help you select the therapy or combination of therapies most appropriate for you. Do not try to self-medicate with alcohol or recreational drugs, as these can increase depression and create additional problems. Lifestyle changes can improve depression for some people. These include: Regular exercise Increased exposure to sunlight Stress management Counseling Improved sleep habits Alternative therapies Some people get good results from massage, acupuncture, or exercise. St. John’s Wort is widely used to treat depression. However, it interferes with some HIV medications. Fact Sheet 729 has more about St. John’s Wort. Be sure to tell your health care provider if you are taking St. John’s Wort. Valerian or Melatonin may help improve your sleep. Supplements of vitamins B6 or B12 can help if you have low levels of these vitamins. Antidepressants Some people with depression respond best to medication. Antidepressants can interact with ARVs. They must be used under the supervision of a health care provider who is familiar with your HIV treatment. Protease inhibitors have many interactions with antidepressants. The most common antidepressants used are Selective Serotonin Reuptake Inhibitors, called SSRIs. They can cause loss of sexual desire and function, lack of appetite, headache, insomnia, fatigue, upset stomach, diarrhea, and restlessness or anxiety. The tricyclics have more side effects than the SSRIs. They can also cause sedation, constipation, and erratic heart beat. Some health care providers also use psychostimulants, the drugs used to treat attention deficit disorder. A recent study showed that treatment with dehydroepiandrosterone (DHEA) can reduce depression in some HIV patients. THE BOTTOM LINE Depression is a very common condition for people with HIV. Untreated depression can cause you to miss medication doses and lower your quality of life. Depression is a “whole body” issue that can interfere with your physical health, thinking, feeling, and behavior. The earlier you contact your health care provider, the sooner you can both plan an appropriate strategy for dealing with this very real health issue. Revised July 17, 2013

41. List of resources http://www.mocatest.org/ http://www.aidsmap.com/HIV-mental-health-and-emotional-wellbeing/page/1321435/ http://www.aidsmap.com/Neurocognitive-impairment/page/1731943/ http://bestpractice.bmj.com/best-practice/monograph/900.html http://www.hivguidelines.org/clinical-guidelines/hiv-and-mental-health/cognitive-disorders- and-hiv-aids/ http://www.hivguidelines.org/clinical-guidelines/hiv-and-mental-health/depression-and- mania-in-patients-with-hivaids/ http://www.nepjol.info/index.php/AJMS/article/view/8724 http://www.emedicinehealth.com/dementia_due_to_hiv_infection/article_em.htm http://napwha.org.au/health-treatment/other-health-conditions/brain-health/why- treatment-good-your-brain http://aidsinfonet.org/fact_sheets/view/558 http://cid.oxfordjournals.org/content/53/8/836.long

42. Age T-cell (Current & nadir) Meds ARVs Smokers, diabetes and others Depression Annual Monitoring Screening Follow the booklet or other tools Changes Alcohol and/or other drugs Depression Intercurrent medical illness Uncontrolled CVD risks (e.g. smoking) After 3 months r/v and consider assessment for HIV related Cognitive Impairment Exclude or Treat

43. www.aids2014.org Questions Don’t forget email address and we will send slides and information from today. THANK YOU!