dementia

1. Edson Mutandwa
MBBS IV

2. Presentation outline
 Introduction
 Epidemiology
 Pathophysiology
 Risk factors
 Clinical features
 Diagnostic criteria
 Differential diagnosis
 Work-up
 prognosis
 management

3. Introduction
 HIV associated dementia is one of the HIV-associated
neurocognitive disorders
 The term AIDS dementia complex was introduced by
Navia and colleagues in 1986 to describe a unique
constellation of neurobehavioral finding.

4. Epidemiology
 The risk of severe neurocognitive disorders in patients
with HIV is 1 in 1000
 The annual incidence of HIV dementia in the Western
world prior to HAART was 7%, with a cumulative risk of
5-20%.With HAART, the incidence of HIV dementia
started declining, but it has begun to increase again

5. Pathophysiology
 The mechanism by which HIV infection of the CNS leads
to neurocognitive disorders is likely multifactorial and is
the subject of intense research
 It has been proposed that HIV enters the CNS via infected
monocytes that traverse the blood-brain barrier to
replenish perivascular macrophages (Trojan horse
mechanism)

6. Pathophysiology
 Cellular proteins-secretion of chemokines,
proinflammatory cytokines, nitrous oxide, and other
neurotoxic factor
 HIV proteins (virotoxins)-Damage to neurons may occur
through the actions of specific HIV proteins, including
gp120, gp41, Tat, Nef, Vpr, and Rev
 Autoimmune disease-CNS damage may occur by
humoral immune mechanisms, as evidenced by the
presence of anti-CNS antibodies in AIDS patients with
dementia but not in those without dementia

7. Risk factors
 low weight
 Anemia
 constitutional symptoms
 low CD4+ count
 high plasma HIV-RNA load
 Female gender
 Old age (>50)

8. Clinical features
 substantial memory deficits
 negative personality
 mood changes
 impaired executive functioning
 poor attention and concentration
 mental slowing
 apathy

9. Diagnostic criteria
No other etiology of dementia and must not have the
confounding effect of substance use or psychiatric illness.
Criteria for the diagnosis of HAD included cognitive
deficits in 2 or more cognitive domains that cause
impairment in activities of daily living (ADL) and an
abnormality in either motor or neurobehavioral function

10. Diagnostic criteria
The domains included
Cognition
Language
Attention
executive function
Memory
speed of information processing
perceptual and motor skills

11. Differential diagnosis
 Alzheimer Disease
 Frontal and Temporal Lobe Dementia
 HIV-1 Associated Opportunistic Infections:
Cytomegalovirus Encephalitis
 Multiple Sclerosis
 Multiple System Atrophy
 Neurosyphilis
 Parkinson Disease
 Parkinson-Plus Syndromes
 Pick Disease

12. Prognosis
 AIDS dementia complex (ADC) has a variable
progression.
 Without treatment, the disease typically has a rapid
progression over a few months, with a mean survival rate
of 3-6 months for patients with AIDS who have untreated
ADC.
 As a result of HAART, however, the survival rate
increased from 5 months in 1993-94 to 38.5 months in the
1996-2000 period. Cognitive improvement is observed in
patients with ADC after the initiation of HAART

13. Prognosis
Poorer prognosis has been associated with the following:
 Lower educational levels
 Older age
 Lower CD4+ counts and higher HIV RNA levels
 Decreased hemoglobin level
 Reduced platelet count
 Thrush
 Low body mass index
 More constitutional symptoms
 Hepatitis C virus co-infection

14. Work-up
 Lumber puncture with CSF analysis
 neuroimaging studies (MRI)
 Electroencephalography (EEG)
 syphilis serology testing
 thyroid studies
 electrolyte levels
 drug screen
 Vitamin B-12 and folic acid levels

15. management
 highly active antiretroviral therapy (HAART) is the
cornerstone of treatment for HIV-related cognitive
disorders (aggressive therapy)
 Family counselling- psychosocial and emotional burden
on family
 Family education- patient have problems with compliance
and adherence to their medication regimen are likely to be
less inhibited . (indulge in unprotected sex)

16. Management
 caution is required when patients with ADC are treated
with psychoactive drugs because of enhanced
susceptibility to sedative properties and possible
paradoxical reactions
 These drugs can up regulate the metabolism of HAART
drugs, thus reducing its bioavailability.
 Efavirenz should be avoided in psychiatric patients
because of CNS toxicity and sucidality

17. References
 Up-to date (www.uptodate.com)
 Medscape