HIV-Associated Neurocognitive Disorders (HAND)


HIV can mimic the effects of other neurocognitive disorders. An accurate diagnosis must differentiate from among a number of diseases that present similar symptoms. Some conditions that share symptoms include: depression, encephalitis, substance abuse, thyroid disorder, Alzheimer's, Parkinson's, Huntington's, pick's, Creutzfeldt-Jacob, cerebrovascular disease. Symptoms may include: delirium, memory impairment, apathy, social withdrawl, psychosis, seizures, behavioral changes, disinhibition, tremors, ataxia, repetitive movements, imbalance, hypertonia, visual impairment, etc.

The neurologic consequences of HIV were recognized early in the epidemic. AIDS dementia complex (ADC) was the term used to collectively describe the effects of HIV on the CNS. Today, the term ADC is a being displaced by standards that focus more on how HIV is currently affecting neurocognitive status and less on end stage disease.

Currently, highly active antiretroviral therapy (HAART) is still effectively suppressing the life threatening opportunisitic infections which are the hallmark of AIDS. HIV+ patients are living longer before their condition meets AIDS criteria. The incidence of the more severe form of neurocognitive disorder, HIV-associated dementia (HAD), has also decreased but improved testing and awareness has shown that HIV has a neurologic effect long before a diagnosis of AIDS. Regardless of HAART, the neurocogitive effects of HIV are still associated with the stage of HIV disease.

In 1991 the AIDS Task Force of the American Academy of Neurology published definitions to guide the diagnosis of HIV associated neurocognitive disorders (HAND). They defined two levels of HAND: HIV-associated dementia (HAD) and minor cognitive motor disorder (MCMD).

In 2007, the National Institute of Mental Health and the National Institute of Neurological Diseases and Stroke proposed an updated standard for diagnosing HAND. The new proposed criteria creates an additional category; HIV-associated asymptomatic neurocognitive impairment (ANI). It also modifies the name and criteria for what was called MCMD to mild cognitive disorder (MCD).

Recent proposed diagnostic standards for HAND (Simplified) :

HIV-associated asymptomatic neurocognitive impairment (ANI)
diagnostic criteria
(simplified)

Cognitive impairment must be attributable to HIV and no other etiology, i.e:
  • Dementia
  • Delirium
  • Depression
  • CNS neoplasm
  • CNS infection
  • Cerebrovascular disease
  • Substance abuse
  • etc.
Impairment involves at least two cognitive domains and result in neuropsychological testing performance at least 1 SD below the appropriate mean age/education norm.
  • Information processing speed
  • Sensory/motor skills
  • Short-term and long-term memory
  • Ability to learn new skills and solve problems
  • Attention, concentration, and distractibility
  • Logical and abstract reasoning functions
  • Ability to understand and express language
  • Visual-spatial organization Visual-motor coordination
  • Planning, synthesizing and organizing abilities
 
Mild Cognitive Disorder (MCD) diagnostic criteria (modified for elucidation)
Cognitive impairment must be attributable to HIV and no other etiology, i.e:
  • Dementia
  • Delirium
  • Depression
  • CNS neoplasm
  • CNS infection
  • Cerebrovascular disease
  • Substance abuse
  • etc.
Impairment involves at least two cognitive domains and result in neuropsychological testing performance at least 1 SD below the appropriate mean age/education norm.
  • Information processing speed
  • Sensory/motor skills
  • Short-term and long-term memory
  • Ability to learn new skills and solve problems
  • Attention, concentration, and distractibility
  • Logical and abstract reasoning functions
  • Ability to understand and express language
  • Visual-spatial organization Visual-motor coordination
  • Planning, synthesizing and organizing abilities
Patient or caregivers report that cognitive deficit interferes with:
  • Metal acuity, work efficiency, home making or social activity
 
HIV-associated dementia (HAD) diagnostic criteria (modified for elucidation)
Cognitive impairment must be attributable to HIV and no other etiology, i.e:
  • Delirium
  • Depression
  • CNS neoplasm
  • CNS infection
  • Cerebrovascular disease
  • Substance abuse
  • etc.
Impairment involves at least two cognitive domains and result in neuropsychological testing at least 2 SD below the appropriate mean age/education norm.
  • Information processing speed
  • Short-term and long-term memory
  • Ability to learn new skills and solve problems
  • Attention, concentration, and distractibility
  • Logical and abstract reasoning functions
  • Ability to understand and express language
  • Visual-spatial organization Visual-motor coordination
  • Planning, synthesizing and organizing abilities
Cognitive impairment significantly interferes with:
  • work
  • home life
  • social activities
  • ADL's
Cognitive impairment should be validated by neuropsychological testing, i.e.:
  • Mini-mental state examination (MMSE)
  • Memorial Sloan-Kettering (MSK) scale
  • HIV dementia Scale (HDS)

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