Responding to changes

Responding to Behavioral and Motor Changes

Behavioral changes that arise as HIV infection progresses may result from an underlying neurologic problem. It is important to recognize new or unusual behaviors, because often the person is in need of medical attention. For example, choking or spitting out food during meals can be the result of brain stem impairment. A change in motivation may indicate a serious mental health issue. In addition, side effects of medication, or drug or alcohol use can produce a variety of uncharacteristic behaviors. When an unusual new behavior is present in a person for whom you are caring, it is appropriate to consult the person's physician. Table 2 provides potential interventions to assist in adopting and executing health promoting patterns.

Table 2: Behavioral Changes

Symptom	Example	Interventions
Change in personality	Agitation/verbal outbursts. Outbursts of crying.	Avoid arguing with and aggressively confronting the person. Set guidelines for acceptable behaviors. Provide a supportive atmosphere for feelings of sadness to be shared.
Lack of motivation	Decreased desire to be involved in once pleasurable activities	Provide education by the person's peers. Pair people that have similar backgrounds and cultural belief systems. Ask them to share helpful techniques, talk about what works. Provide increased encouragement to engage in favorite pastimes. Help the person to schedule a time each week specifically for leisure activities.
Apathy	Feelings of indifference	Revive old hobbies or activities that s/he really enjoyed in the past. Find out what motivated the person in the past and learn about his/her belief system.
Social withdrawal	Isolation from others. Detachment from surroundings.	Encourage family/friends to visit on a one-to-one basis. Educate family/friends about dementia.
Loss of appetite	Avoids meals. May spit out food. Avoids social situations that are food related.	Provide favorite meals. Serve smaller portions throughout the day. Have "finger foods" and snack items handy. Consult a physician if problem persists.
Severe mood swings	Fear of dementia with first symptoms of forgetfulness. Suicidal thoughts	Seek medical advice/intervention from a certified mental health professional. Try to locate someone who specializes in HIV/AIDS care.

Mild to Moderate levels of HIV-related cognitive impairment are often associated with psychomotor slowing, a combination of slowness in movement and slowness in thought processes (Van Gorp, Dilley, & Buckingham, 1998). In addition, some HIV medication can cause muscle weakness and muscle atrophy. Neuropsychological tests administered by trained healthcare professionals can help detect the presence of HIV-Associated Dementia. Two diagnostic tests sensitive to psychomotor slowing are the Trail Making Test and Symbol Digit Modalities (Van Gorp, Dilley, & Buckingham, 1998).

Trail Making Test
Part A consists of encircled numbers from 1 to 25 randomly spread across a sheet of paper. The object of the test is for the subject to connect the numbers in order, beginning with 1 and ending with 25, in as little time as possible.
Part B is more complex than A. It requires the subject to connect numbers and letters in an alternating pattern (1-A-2-B-3-C,etc.) in as little time as possible.

Symbol Digit Modalities Test
Requires examinees to match numbers to a series of different symbols presented randomly on a single test page, using a key found at the top. There are 120 matches to be made in total. The subject has to make as many matches as possible in a 90 second period.

Motor changes can impact activities of daily living. Simple tasks such as eating, grooming, and getting dressed become more difficult for those in the later stages of AIDS. When motor symptoms are prominent or become markedly worse, a call to the primary care physician and/or a neurologist is in order. Table 3 outlines helpful interventions.

Table 3: Motor Changes

Symptom	Example	Interventions
Muscle weakness and muscle atrophy	Fatigues easily	Help the client conserve energy by sitting down for ADL tasks such as brushing teeth.
Slow, unsteady movements	Difficulty maintaining balance	Remove clutter from the environment. Keep furniture in same place. Remove throw rugs/adhere rugs to floor.
Gait disturbances	At increased risk for falls	An evaluation by physical therapist can lead to interventions such as issuing a cane/walker and exercise programs. Encourage sitting down for ADL tasks such as brushing teeth.
Poor coordination	Changes/variations in handwriting; Opens pill bottles and spills contents	Using built-up handles on writing instruments/ kitchen utensils improves grasp and control. Weighted utensils are helpful in reducing tremors. Repackage items and place in easy-to-open containers. An occupational therapist can recommend environmental modifications and adapted equipment.
Severe psychomotor slowing	Wheelchair bound, bedridden	Range of motion exercise can help maintain circulation and prevent muscle atrophy.
Incontinence	Inability to control bladder/bowel functioning.	Create a schedule - frequent "reminders to go."

Instant feedback

Some HIV treatment medications can cause muscle weakness and/or muscle atrophy.

Table 4: Sensory Changes

Symptom

Example

Interventions

Peripheral neuropathy Numbness in the hands and feet.

Tingling or burning sensation. Massage or warm foot baths.

Obtain a medical evaluation. Pain should be treated by removing the offending agent or by pain management interventions.

Instant feedback

The pain and discomfort of drug induced peripheral neuropathy represents nerve damage and is permanent.