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Understanding and Evaluating the Neuropsychological Functioning of HIV-infected Persons
 

Understanding and Evaluating the Neuropsychological Functioning of HIV-infected Persons

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David Moore, PhD, of UC San Diego HIV Neurobehavioral Research Program, presents "Understanding and Evaluating the Neuropsychological Functioning of HIV-infected Persons"

David Moore, PhD, of UC San Diego HIV Neurobehavioral Research Program, presents "Understanding and Evaluating the Neuropsychological Functioning of HIV-infected Persons"

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    Understanding and Evaluating the Neuropsychological Functioning of HIV-infected Persons Understanding and Evaluating the Neuropsychological Functioning of HIV-infected Persons Presentation Transcript

    • AIDS CLINICAL ROUNDS The UC San Diego AntiViral Research Center sponsors weekly presentations by infectious disease clinicians, physicians and researchers. The goal of these presentations is to provide the most current research, clinical practices and trends in HIV, HBV, HCV, TB and other infectious diseases of global significance. The slides from the AIDS Clinical Rounds presentation that you are about to view are intended for the educational purposes of our audience. They may not be used for other purposes without the presenter’s express permission.
    • Neuropsychology of HIV for Non-Neuropsychologists David J. Moore, Ph.D. Associate Professor, Department of Psychiatry University of California, San Diego HIV Neurobehavioral Research Program djmoore@ucsd.edu HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • This training is sponsored in part by the American Psychological Association’s HIV Office for Psychology Education (HOPE) Program funded by the Center for Mental Health Services (CMHS) of the Substance Abuse and Mental Health Services Administration (SAMHSA) under contract number HHSS280200900004C. Views expressed do not necessarily reflect the official policies of the Department of Health and Human Services. HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Brief Outline  HIV-Associated Neurocognitive Disorders (HAND)  HIV Disease Indicators  Impact of Comorbidities  Daily Functioning  Emerging Treatments for Neurocognitive Complications  Summary & Recommendations HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Meet Joe  43 y.o., African American male, one yr of college education, man who has sex with men, HIV+  Dr. Smith is treating Joe with Cognitive Behavioral Therapy (CBT) for depression  Progress in therapy has been slow  Dr. Smith, having heard that some HIV+ may have neurocognitive difficulties, wonders if this is impacting their progress  She’s observed: 1) slow processing of instructions, 2) difficulty learning new strategies, and 3) ineffective problem solving HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • HIV NEUROBEHAVIORAL DISTURBANCES NEUROCOGNITIVE (NC) Primary EMOTIONAL & OTHER BEHAVIORAL New Onset Asymptomatic NC Impairment Mild Neurocognitive Disorder HIV-associated Dementia Secondary Infection Neoplasia Cerebrovascular Nutritional Treatment Related Depression Anxiety Adjustment Disorders HIV Mania HIV Psychosis Recurrent/Comorbid Mood Disorders Substance Use Disorders Other Mental Disorders HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • HIV Associated Neurocognitive Disorders (HAND) Criteria ASYMPTOMATIC NEUROCOGNITIVE IMPAIRMENT MILD NEUROCOGNITIVE DISORDER (ANI) (MND) HIVASSOCIATED DEMENTIA (HAD) NEUROCOGNITIVE IMPAIRMENT > Mild > Mild > Moderate FUNCTIONAL IMPAIRMENT None > Mild > Moderate • Impairment must be attributed to HIV, at least in part • Neurocognitive impairment required in 2 domains to receive overall impairment Antinori, et al., Neurology 2007, 69 (18):1789-99 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • COMORBID CONDITIONS  MINIMAL: may have minor effects on NP test results, but unlikely to cause even mild global impairment, e.g., hypertension  MODERATE: likely to have at least mild effects on NP results but unlikely to cause clinically significant global NP impairment by itself, e.g., current Hepatitis C infection (HCV)  SEVERE: likely to have major effects on NP test results, with significant neurocognitive impairment and functional disability, or NP results invalid due to poor effort, e.g., mental retardation, severe TBI HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO HAND Diagnosis Possible Precludes HAND Diagnosis
    • Despite ART Benefits on Morbidity and Mortality HAND remains prevalent 50% 46% Pre-CART Percent Impaired 43% p=.03 40% 36% 29% 30% 20% CART 19% 16% 10% 0% N=179 N=94 HIV- N=516 N=336 Non-AIDS N=162 N=507 AIDS Heaton et al, Journal of Neurovirology, 2011 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Neurocognitive Impairment (NCI) by Domain in HIV+ from Pre-ART and Post-ART Eras Pre-CART 70% Post-CART * Percent Impaired 60% ** 50% 40% ** *** *** 30% 20% 10% 0% Verbal * p<.05; ** p<.01; ***p<.001 SIP Learn Recall Attn/WM Exec Motor Heaton et al, Journal of Neurovirology, 2011 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • How Do HIV Disease Factors Impact HAND? HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Higher nadir CD4  Lower Risk of Impairment Ellis et al., AIDS, 2011 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • CHARTER: Neurocognitive Impairment Related to HIV Disease Factors only in Minimal Comorbidity Group NC Impaired n = 339 NC Normal n = 504 % AIDS * 64.6% 57.1% % Nadir (lowest ever) CD4 < 200 * 59.6% 50.6% * P < 0.05 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Joe’s HIV Disease Characteristics       Current CD4: 420 cells/µL Nadir CD4: 174 cells/µL Plasma Viral Load: Undetectable Duration of HIV infection: 10 years ART on/off: On Meets Criteria for AIDS HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Risk and Protective Factors for Joe’s Neurocognitive (NC) Functioning HIV Disease Factors Con: AIDS, Nadir CD4 <200, Chronic HIV Pro: On ART, VL Undetectable Joe’s NC Fxn HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • How Do Comorbidities Influence HAND? HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • % Impairment is Related to Disease Factors only with Minimal Comorbidity (Pts on ART) Severe 1.0 Probability of Impairment Moderate 0.8 N+/VL+ N-/VL+ N=27 N=62 Minimal N-/VLN+/VLN=65 N=14 0.6 N-/VLN-/VL+N+/VL- N=98 N+/VL+ N=129 N=36 N=60 0.4 0.2 0.0 N-/VL+ N=210N+/VL- N-/VLN=68 N=111 N+/VL+ N=111 N+: Nadir CD4 ≥ 200 N-: Nadir CD4 < 200 VL+: Undet Plasma VL VL-: Det Plasma VL Heaton et al., Neurology, 2010 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • % GLOBAL NP Impairment Rates of NP Impairment by Number of Risk Factors HIV, HCV, Meth n=8 0 n=186 n=99 n=35 Cherner et al., Neurology, 2005 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Incident Depression Does Not  NCI in HIV BDI Total Score 18 16 1 Incident Depression Global Deficit Score 20 No Incident Depression 14 12 10 8 6 4 2 0.9 0.8 Incident Depression No Incident Depression 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 0 Baseline Follow-up Baseline Follow-up Cysique et al., JINS, 2007 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Joe’s Comorbidities  Substance Use Diagnoses: » » » » Lifetime Hx. of Methamphetamine dependence Lifetime Hx. of Cannabis abuse No current substance use disorder Last used Methamphetamine 8 years ago  Mood Disorders: » Lifetime Major Depressive Disorder (MDD) » Current MDD » Beck Depression Inventory–II Total = 19  Medical Comorbidities » Hypertension » Remote mild Traumatic Brain Injury (mTBI) HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Risk and Protective Factors for Joe’s Neurocognitive (NC) Functioning Comorbidities Con: LT Hx. Meth Dep, Past mTBI Pro: No current Sub Use dep; no HCV HIV Disease Factors Con: AIDS, Nadir CD4 <200, Chronic HIV Pro: On ART, VL Undetectable Joe’s NC Fxn HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Does Joe Have Neurocognitive Complaints? HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Joe’s Neurocognitive Complaints  Dr. Smith asks him about his cognitive abilities  Joe has some recent cognitive complaints that are a change from his normal functioning: » » » » Loses track of time Forgets to do things he’s agreed to do Has some difficulty coming up with correct words Difficulty planning and organizing activities HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Risk and Protective Factors for Joe’s Neurocognitive (NC) Functioning Comorbidities Con: LT Hx. Meth Dep, Past mTBI Pro: No current Sub Use dep; no HCV HIV Disease Factors Con: AIDS, Nadir CD4 <200, Chronic HIV Pro: On ART, VL Undetectable Joe’s NC Fxn Cognitive Complaints Con: Loses track of time, forgetting some things, problems planning Pro: Only four complaints where many more possible HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • How is Joe Performing Neurocognitively? HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Example Neuropsychological (NP) Test Battery  Verbal Fluency  Executive Functioning » Animals » Letter » WCST-64 PR » Trail Making Test B  Attn/Working Memory » PASAT-50 » Letter-Number Sequencing  Processing Speed » WAIS-III Digit Symbol » WAIS-III Symbol Search » Trail Making Test A = 15 individual NP measures  Learning » Verbal (HVLT-R) Total » Visual (BVMT-R) Total  Recall » Verbal (HVLT-R) Recall » Visual (BVMT-R) Recall  Motor » Grooved Pegboard DH » Grooved Pegboard NDH HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Joe’s Objective Neurocognitive Performance  Impaired: » Learning » Executive Functioning  Within Normal Limits: » » » » » Verbal functioning Speed of Information Processing Recall Motor Attention/Working Memory  His global neuropsychological performance is mildly impaired (impairment ≥ 2 Domains) HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Risk and Protective Factors for Joe’s Neurocognitive (NC) Functioning Comorbidities Con: LT Hx. Meth Dep, Past mTBI Pro: No current Sub Use dep; no HCV HIV Disease Factors Con: AIDS, Nadir CD4 <200, Chronic HIV Pro: On ART, VL Undetectable Joe’s Mild NCI Cognitive Complaints Con: Loses track of time, forgetting some things, problems planning Pro: Only four complaints where many more possible HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Do Joe’s Neurocognitive Impairments Impact His Daily Functioning? HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Comorbidity Group Comparisons for Daily Functioning Minimal Moderate Severe 843 (54%) 473 (31%) 239 (15%) % Impaired 41% 59% 84% Min<Mod<Sev % Employed 33.0% 19.7% 13.0% Min>Mod,Sev Cognitive Symptoms 4.9 (6.3) 7.4 (8.0) 9.3 (9.0) Min<Mod<Sev IADL Declines 1.3 (1.8) 1.9 (2.1) 2.1 (2.3) Min<Mod, Sev  Unemployment, increased cognitive symptoms, and increased Instrumental Activities of Daily Living (IADL) Declines significantly correlated with worse levels of neurocognitive impairment (p <0.01) Heaton et al., Neurology, 2010 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Methamphetamine Increases Risk of Unemployment in HIV * p < .01 90 80 % Unemployed 70 60 50 40 30 20 10 0 HIV-/MA- HIV-/MA+ HIV+/MA- n=217 n=237 N=155 HIV+/MA+ n=189 Blackstone et al., JAM, 2013 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Agreement between self report (SR) and performance based (PB) functional measures 80% 70% Agreement rate (%) 60% 50% 40% 30% 20% 10% 0% Agree: No Functional Impairment (n=156) Agree: Functional Impairment (n=20) Disagree: Impaired by Self-report Only (n=37) Disagree: Impaired by Performance-based Only (n=20) Blackstone, et al., JINS, 2012, 18: 79-88 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • How is Joe doing in everyday life?  Joe is unemployed  Previously worked as a manager of an apartment complex but stopped about 6 years ago  He has some declines from his baseline (pre-HIV) with managing his medications and finances HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Risk and Protective Factors for Joe’s Neurocognitive (NC) Functioning Comorbidities Con: LT Hx. Meth Dep, Past mTBI Pro: No current Sub Use dep; no HCV HIV Disease Factors Con: AIDS, Nadir CD4 <200, Chronic HIV Pro: On ART, VL Undetectable Joe’s Mild NCI Cognitive Complaints Con: Loses track of time, forgetting some things, problems planning Pro: Only four complaints where many more possible Daily Functioning Con: Unemployed, Med and Financial mgmt problems Pro: Still maintains social relationships HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • What’s Joe’s HAND Diagnosis  NP: Definite mild impairment  Daily functioning: » Unemployed » Declines from baseline with managing medications and finances » Some cognitive complaints (although have to be careful of these in context of depression)  Diagnosis is: » Mild Neurocognitive Disorder (MND) HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Risk and Protective Factors for Joe’s Neurocognitive (NC) Functioning Comorbidities Con: LT Hx. Meth Dep, Past mTBI Pro: No current Sub Use dep; no HCV HIV Disease Factors Con: AIDS, Nadir CD4 <200, Chronic HIV Pro: On ART, VL Undetectable Joe’s Mild NCI Cognitive Complaints Con: Loses track of time, forgetting some things, problems planning Pro: Only four complaints where many more possible Daily Functioning Con: Unemployed, Med and Financial mgmt problems Pro: Still maintains social relationships HAND Dx. MND HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • How Might You Screen for NP Impairment If Joe Was In Your Office? HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Classification Accuracy of the HIV Dementia Scale (HDS) 100% 92% 90% 80% 69% 70% 57% 60% Sensitivity 50% Specificity 40% 30% 27% 20% 10% 0% Raw cutpoint (≤ 10) *Overall Accuracy: Raw = 57% Norms = 63% Norms CHARTER study, N = 1580 Sakamoto et al., JAIDS, 2013 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Brief Screening Predicts Larger NP Battery Minutes • • • • Action Fluency Stroop Color PASAT HVLT-R Learning • Trail Making Test A • PASAT • Grooved Pegs Nondominant Sensitivity Specificity 18 86.5 (71.1–95.0 87.1 (80.8–91.7) 9 76.3 (60.0–88.2) 80.1 (73.5–85.9)  Less intensive NP assessment can provide a screen  Requires some expertise; when in doubt refer Moore et al., PLoS ONE, 2012 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Can We Improve Joe’s HAND? HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Neurocognitive Rehabilitation of Real-World Problems in HIV: A Call To Action  HAND persists despite effective ART » Non-ARV pharmacological approaches have not held up in trials  Few studies to date examined NC Rehab in HIV » Large literature in other conditions Slide Courtesy of S.P. Woods HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Neurocognitive Rehabilitation of HAND: Memory  Neurocognitive remediation rooted in models of changing specific neuropsychological deficits  Interventions often NC domain specific  Few studies using these NC rehabilitation techniques in HIV but growing interest/demand Weber et al., 2012 Slide Courtesy of S.P. Woods HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Executive Functioning Training Executive Dysfunction (planning, monitoring, setshifting) Compensatory Strategy Application (e.g., alarm) Antiretroviral Antiretroviral NonAdherence adherence Impaired Metacognition Metacognitive deficits  Poorer rehabilitation outcomes and motivation and poorer vocational attainment Blackstone Dissertation HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Computerized Speed of Processing Training  All participants HIV+ 1000  Intervention group 900 significantly increased 800 their speed of 700 processing compared 600 to control (p <.05) 500  Also improved their performance on a 400 timed IADL measure 300  Self-reported that 200 “games” improved their 100 mental functioning 0 Control Δ = 115.21 ms Intervention Δ = 212.41 ms Intervention Control Pre Training Post Training Vance et al., J Assoc Nurses AIDS Care, 2013 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Directly Target Daily Functioning HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Mean Dose Delay (min) Time from Target Dose by Group Antiretroviral N=25 N=25 Psychotropic N=25 N=25 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • % with Neurocognitive Impairment Exercise and NP Functioning in HIV 35 30.95 30 25 20 15 15.66 10 5 0 Exercisers n=83 Non-Exercisers n=252 Dufour et al., JNV, 2013 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Text Messaging for Physical Activity Neurobiological Mechanisms Outcome Measures Inflammation Physical Activity Neurocognition Cerebral blood flow Everyday function Neurogenesis Quality of life Metabolic function HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Joe Makes a Nice Story… but what about others? HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • John             58 y.o., Caucasian male, one yr of college education, man who has sex with men, HIV+ Current CD4: 790 cells/µL Nadir CD4: 256 cells/µL Plasma VL: Undetectable ART on/off: On Substance Use Diagnoses: Lifetime Hx. Meth dependence, No Current Substance Use Dx. Mood Disorders: Lifetime Hx. MDD Medical Comorbidity: HCV+ Global Neurocognitive Impairment Classification: Within normal limits Neurocognitive Impaired Domains: 0 Daily Functioning and Cognitive Complaints: 0 HAND Dx: None HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Gabe             29 y.o., Hispanic male, college graduate, man who has sex with men, HIV+ Current CD4: 360 cells/µL Nadir CD4: 354 cells/µL Plasma VL: Detectable ART on/off: On Substance Use Diagnoses: Lifetime Hx. Alcohol Abuse Mood Disorders: None Medical Comorbidity: None Global Neurocognitive Impairment Classification: Mild-to-Moderate Impairment Impaired Neurocognitive Domains: Learning, Executive Function, Attention/Working Memory Daily Functioning and Cognitive Complaints: None HAND Dx: ANI HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Actions to Take with HIV+ Clients with Possible NCI  Determine severity of disease » In cases without comorbidities nadir CD4, off ART, detectable VL, AIDS related to increased NCI  Ask about changes in: » Cognitive Functioning » Daily Functioning » Recognize that cognitive complaints may be elevated in persons with MDD  Identify comorbidities  If trained, screen for HAND, if not make referral for screening HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Take Away Message  Despite improved HIV survival, neurocognitive complications persist and can impact everyday functioning  Comorbidities can complicate and worsen neurocognitive problems in HIV, but HIV-related neurocognitive problems exist even in those without comorbidities  Need to find effective treatments for HAND HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Acknowledgments  SAMHSA  Funding Support » » » » NIMH NIDA California HIV/AIDS Research Program Henry M. Jackson Foundation  HNRP Co-Investigators/Collaborators » » » » » » » » » » J. Hampton Atkinson, M.D. Mariana Cherner, Ph.D.* Ronald J. Ellis, M.D. Igor Grant, M.D. Robert K. Heaton, Ph.D. Scott Letendre, M.D. Thomas Marcotte, Ph.D. Erin Morgan, Ph.D. Maiko Sakamoto, Ph.D. Steven P. Woods, Psy.D.  Trainees » » » » » Kaitlin Blackstone, M.S. Catherine Dufour Pariya Fazeli, Ph.D. Maria Marquine, Ph.D. Jessica Montoya  Staff » » » » Candy Carson Matthew Dawson Ben Gouaux Alexandra Rooney  Contact Information » David J. Moore, Ph.D. » djmoore@ucsd.edu » 619-543-5093 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Your feedback is important to us. Please visit http://survey.abtassociates.com/s/APANeuropsych/ to provide an evaluation of this training. HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Neuropsychology of HIV for Non-Neuropsychologists David J. Moore, Ph.D. Associate Professor, Department of Psychiatry University of California, San Diego HIV Neurobehavioral Research Program djmoore@ucsd.edu HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Age: 56 Education: 7 Sex: Male Ethnicity: Native American Current CD4: 433 Nadir CD4: 184 Plasma VL: Undetectable ART on/off: On Substance Use Diagnoses: Lifetime Alcohol Dependence, Cannabis Dependence, Inhalant Dependence  Mood Disorders: Major Depressive Disorder, Panic Disorder with Agoraphobia, Generalized Anxiety Disorder  Global Impairment Classification: Mild-toModerate Impairment (6)  Impaired Domains: Learning, Working Memory  IADL Complaints: 2  HAND Dx: ANI HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO Chris         
    • Raul                Age: 34 Education: 15 Sex: Male Ethnicity: Hispanic Current CD4: 294 Nadir CD4: 255 Plasma VL: 0 ART on/off: On Substance Use Diagnoses: None Mood Disorders: None Global Impairment Classification: Definite Mild Impairment (5) Impaired Domains: Learning, Memory, Executive Function IADL Complaints: 0 PAOFI Complaints: 0 HAND Dx. ANI HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • David J. Moore et al. (P21) • Does individualized Texting for Adherence Building (iTAB) improve med adherence and dose timing for HIV-infected persons with bipolar disorder? Mean % MEMS Adherence Improve Overall Adherence? Maybe Mean Dose Delay (min.) Improve Dose Timing? YES! * CTRL (n = 25) iTAB (n = 25) * p < 0.05 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • Comorbidity Group Comparisons Minimal 473 (31%) 239 (15%) 41% Depression (BDI) Severe 843 (54%) % Impaired Moderate 59% 84% Min<Mod<Sev 12.3 (10.0) 15.7 (11.1) 16.5 (11.9) Min<Mod, Sev Heaton et al., 2010 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • METH Abuse and HIV Combine to Increase Neurocognitive Impairment Percent Neurocognitively Impaired 80 70 60 50 40 30 20 10 0 HIV- HIV+ Non-Meth Abusing Group HIV- HIV+ Meth Abusing Group Rippeth et al., J Int Neuropsychol, Soc, 2004,10(1): 1-14 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • FUNCTIONAL IMPAIRMENT CRITERIA (NEED 2) 1. IADL dependence, after person became HIV+, attributed to cognitive (not physical) impairment, 2. Unable to work, or significantly reduced work efficiency, attributed to HIV related cognitive changes, 3. Complaints of increased cognitive difficulties in everyday life (cannot use this if person has clinically significant depression), 4. Impaired performance on objective everyday functioning tasks: standardized work samples or medication management (available only for CHARTER longitudinal cohort). HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • HIV+ with Bipolar Disorder More NP Impaired HIV+/BD+ HIV+/BD- 1.00 0.90 NP Deficit Scores 0.80 0.70 0.60 0.50 Impairment 0.40 0.30 0.20 0.10 0.00 Speed of Info. Processing Learning** Recall** Executive functions* Verbal Fluency Attn/Working Memory Motor Global Deficit Score** *p<0.05; **p<0.01 Moore et al., in prep HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
    • General Association of NC Impairment with Everyday Functioning in CHARTER p-value Unemployment .005 IADL Dependence .0002 Cognitive Complaints <.0001 HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO