HAND diagnostic issues
Dr. Robbins of Columbia University shared his perspective on HIV associated neurocognitive disorder (HAND) diagnostic issues as a clinical psychologist and clinical neuropsychologist, and discussed research on HAND screening tools.
Typically, providers see patients with concerns about memory problems, slower thinking, or difficulty multi-tasking. In the current era these symptoms are often quite mild. However, they can still disrupt some activities of daily living (including medication use), and may present challenges to ongoing employment and quality of life. HAND may also lead to poor decision-making.
HAND screening tools
Ideally, a person with the symptoms above should undergo a full neurocognitive assessment. This can take hours of evaluation, including a lengthy history and extensive testing in several domains, including:
- verbal and visual learning and memory
- working memory/attention
- motor functioning
- speed of information processing
- executive functions (set-shifting, problem solving, abstract thinking)
- measures for psychological/emotional functioning.
A full neurocognitive assessment requires experts to score this extensive battery of tests and to interpret the results properly. It is intended to identify the cognitive effects of HIV and/or to identify effects that are better explained by other comorbidities. There are three potential HIV diagnoses:
- asymptomatic neurocognitive disorder – abnormalities in two or more cognitive abilities in 2 or more domains (> 1 standard deviation below norm) – no functional impairment
- mild neurocognitive impairment – abnormalities in two or move cognitive abilities in 2 or more domains (> 1 standard deviation below norm) – mild functional impairment
- HIV-associated dementia – marked cognitive impairment in 2 or more domains (> 2 standard deviations below norm) with marked functional impairment.
Screening tests for HAND have been developed, and many are now freely available on the internet or in the medical literature. Commonly used tests include the HIV Dementia Scale (HDS), the Montreal Cognitive Assessment (MoCA), and the Mini–Mental State Examination (MMSE). These tests might be used in a non-expert clinical setting in a routine, ongoing way to flag changes in cognitive ability or to identify people for follow-up, but they lack the sensitivity necessary to detect mild impairments. They also require some expertise to administer and assess.
Tablet-based screening tests
Tablet-based tests are being developed, often with lay counsellors, including:
- Brain Baseline
- NeuroScreen – specific to HIV
These tests are brief, and can be administered by people with a couple of hours of training. Computerized prompts help ensure that the tests are administered properly. They can potentially be connected to medical databases in order to generate provider alerts. These screening tests currently do not include measures of mental health or daily functioning, but they are a focus of research to provide resources for settings where expert testing is not available. It is an important to remember that these tablet-based measures are only preliminary assessments. They are not definitive and a positive result should trigger further expert follow-up whenever possible.
The forgetful patient: A practical approach to cognitive concerns in people living with HIV
Dr. Lesley Fellows, principal investigator of the Positive Brain Health Now study based at the Montreal Neurological Institute, presented a practical approach to diagnosing and treating a person with HIV who is reporting forgetfulness.
Listen to the person’s concerns
Neurologists are often sceptical about patient reports of forgetfulness because with more severe cognitive impairments, patients tend to deny symptoms and family typically report concerns. However, this does not appear true for mild cognitive impairments associated with HIV. In her experience, self-reports are more sensitive than available clinical measures. If people are worried about their memory it could indicate problems with memory or worry (anxiety) but both deserve attention. In the Positive Brain Health Now study, the researchers found that there was no direct link between depression and cognition, but anxiety about memory could indicate challenges with either memory or mood.
The Positive Brain Health Now study team has recently developed a questionnaire for assessing mild cognitive impairment associated with HIV. It focuses on attention, executive function, and memory, and will be available shortly.
Assess cognitive performance and look for patterns
Most of the typical bedside tests are not hard enough to detect HIV-associated mild cognitive impairment. Dr. Fellows’ clinic has begun thinking about measures of cognitive performance as quantifiable, like weight or blood pressure, so they can monitor change over time rather than focusing on HAND categorization.
There are three core questions:
- Is the cognitive problem typical (executive function, attention, memory) or is it atypical (language,visuospatial, praxis)? Does it involve other non-brain systems?
- Is it evolving over time?
- What is the cause? Is it HIV related? Is it related to a comorbidity? Is it coincidental? Is it normal aging?
A recent analysis of data from the Charter cohort study showed that most people with HIV-associated mild cognitive disorders are not declining (Yuan et al, 2016). Of those with undetectable viral loads only 12% declined over 3 years, and most on only one of 15 screening tests. If decline is happening, there may be other factors such as a cardiac comorbidity.
Conduct individualized investigations that focus on identifiable factors
- investigate personal and environmental factors, since these may point to underlying factors and can also help suggest changes to the patient’s life to keep them safe
- conduct focused bloodwork depending on the case (mostly looking for cardiac issues, etc.)
- undertake neuroimaging depending on the case (eg. signs of stroke)
- review medication
- think about sleep and mood.
In all investigations, Dr. Fellows recommended thinking about where we are likely able to make a change. There are many lifestyle and comorbid factors that are addressable through therapy and through practical measures around exercise and sleep. In follow-up, if you do see a marked decline, something else may be happening. (Alzheimer’s disease may get worse quickly, HIV memory loss typically does not.)
Healthcare practitioner perspectives: A psychosocial approach
Dr. Jose Muñoz-Moreno, of Spain’s Lluita contra la SIDA Foundation, focused on the psychosocial factors that may influence a diagnosis of HIV-associated neurocognitive disorder (HAND) and provided an overview of recent studies. He talked about how to integrate these factors into neurocognitive screening when establishing a diagnosis of HAND.
More than 10 years ago, a working group commissioned by the National Institute of Mental Health and the National Institute of Neurological Diseases and Stroke published a review of the factors to consider when diagnosing the neurologic manifestations of HIV-1 infection (Antinori et al, 2007). Comorbidities that influence a person’s emotional state, such as depression, were certainly included, but other factors that we now know are important were not.
Since that time, higher levels of perceived stress have been correlated with worse immunological (Remor et al, 2006) and inflammatory (Fumaz et al, 2012) outcomes and we now have data on the connections between perceived stress and cognitive outcomes (Rubin et al, 2015). More recent research has also shown changes in neuroimaging associated with past traumatic experiences in women with HIV (Spies et al, 2016). These are examples of factors not currently being considered in clinical practice.
We know that education is strongly related to cognitive performance, and that these factors often influence norms reported for different racial groups or people of lower socioeconomic status (Dotson et al, 2010; Jefferson et al, 2011). Such differences have clearly been reported with respect to testing for HIV associated neurocognitive impairment (Rohit et al, 2007) and need to be controlled for in the diagnostic process. Reading ability is a better predictor of impairment than years of education. Both education and reading ability are even more important in later‐life stages. Both education and socioeconomic factors should be considered in the evaluation of patients, and more research in this area is needed.
We now know that stigma and social isolation are significant variables in a HAND diagnosis and are generally associated with worse health-related outcomes in people living with HIV (Turan et al, 2016). Quick methods to assess mild cognitive impairments now often rely on self-reports of the impact on daily functioning (Brouillette et al, 2015), and we know that self-reports of such concerns are a meaningful (Obermeit et al, 2016) way to assess these disorders.