A Practical Approach to HIV-Associated - PowerPoint Presentation

1. A Practical Approach to HIV-Associated Neurocognitive Disorders Drexel University College of MedicineDivision of Infectious Diseases and HIV MedicineGrand RoundsJanuary 16, 2015

2. Mary Ann Adler Cohen, MD, FACP, FAPM, DLFAPAClinical Professor of PsychiatryIcahn School of Medicine at Mount SinaiChair and Founder, Academy of Psychosomatic Medicine HIV/AIDS Psychiatry Special Interest GroupChair and Co-Founder of the World Psychiatric Association Section on HIV/AIDS PsychiatryFormer Director, AIDS Psychiatry, Mount Sinai Medical CenterFormer Director, Consultation-Liaison Psychiatry ServiceMetropolitan Hospital Center

3. Disclosure: Mary Ann Adler Cohen, MD With respect to the following presentation, there has been no relevant financial relationship between the party listed above (and/or spouse/partner) and any for-profit company in the past 24 months which could be considered a conflict of interest

4. IntroductionHIV/AIDS: severe, stigmatized, and complex multimorbid medical and psychiatric illnesses with a profound impact on patients, families, and caregiversHIV-Associated Neurocognitive Disorders (HANDs) magnify HIV-associated discrimination and stigmaUnderstanding HANDs can provide you with the tools to prevent and treat HIV-associated dementia

5. Outline of PresentationPrevalence of HAND and its Impact on Adherence to Risk Reduction, Medical Care, and ARTTreatment as prevention of HANDDefinition and Classification of Cognitive Disorders and HANDsControversial Aspects of HANDS: Diagnosis, Screening and Treatment of HANDClinical Pearls for Treatment of HAND

6. Prevalence of HAND The prevalence of HIV-associated dementia (HAD) decreased following the development of effective combination antiretroviral therapy (ART) in 1995In persons with access and adherence to ART, HAD prevalence is estimated to have decreased from 15% (MacArthur et al. 1993) to less than 5% (Heaton et al. 2010)However, there has been little change in the prevalence of asymptomatic neurocognitve impairment (ANI) and mild neurocognitive impairment (MCI) (Tozzi et al. 2007, Simioni et al. 2010)The prevalence of HAND in HIV is about 40 to 50%The work of Heaton, Letendre, Tozzi, Simioni, Cysique, Spudich, and others suggests that the CNS provides an independent reservoir for HIV

7. Treatment as Prevention: CNS as Independent Reservoir for HIV ReplicationStarting ARVs as soon as the diagnosis of HIV is made may prevent the development of an independent reservoir for HIV replication in the CNS and thus prevent future development of HAND and HADPre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) can prevent HIV transmission and also can prevent HANDTreatment as prevention of HIV, HAND, and HADHeaton RK, Franklin DR, Ellis RJ, McCutchen JA, Letendre SL et al. HIV-associatedneurocognitive disorders before and during the era of combination antiretroviraltherapy: differences in rates, nature, and predictors. J Neurovirol. 2011; 17:3–16Karim SSA et al. NEJM 2012;367:462Jay SJ and Gostin LE. JAMA 2012 ;308:867Marrazzo JM et al. JAMA 2014:312:390.

8. Prevalence of HAND in the ART EraCurrent Estimate is about 40% to 50%Cysique LA, Maruff P, Brew BJ. Prevalence and pattern of neuropsychological impairment in human immunodeficiency virus- infected/acquired immunodeficiency syndrome (HIV/AIDS) patients across pre- and post-highly active antiretroviral therapy eras: a combined study of two cohorts. J Neurovirol 2004; 10:350–357Cysique L, Murray JM, Dunbar M, Jeyakumar V, Brew BJ. A screening algorithm for HIV-associated neurocognitive disorders. HIV Medicine 2010;11:642-649.Heaton R, Franklin D, Clifford D et al. Persistence and progression of HIV-associated neurocognitive impairment (NCI) in the era of combination antiretroviral therapy (CART) and the role of comorbidities: the CHARTER study. 5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention. Cape Town, South Africa. July, 2009. (Abst)Heaton RK, Clifford D, Franklin DR, Woods SP et al. for the CHARTER Group. HIV-associated neurocognitive disorders persist in the era of potent antiretroviral therapy: CHARTER Study. Neurology 2010; 75:2087–2096Heaton RK, Franklin DR, Ellis RJ, McCutchen JA, Letendre SL et al. HIV-associated neurocognitive disorders before and during the era of combination antiretroviral therapy: differences in rates, nature, and predictors. J Neurovirol. 2011; 17:3–16Goodkin K, Cahn P, Concha M et al. Prevalence of HIV-1-associated Neurocognitive Disorders in Argentina. 5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention. Cape Town, South Africa. July, 2009. (Abst)Garvey L, Yerrakalva D, Winston A. High rates of asymptomatic neurocognitive impairment (aNCI) in HIV-1 infected subjects receiving stable combination anti-retroviral therapy (CART) with undetectable plasma HIV RNA. 5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention. Cape Town, South Africa. July, 2009. (Abst)Vassallo M, Harvey-Langton A, Malandain G et al. The Neuradapt Study: Clinical, Radiological and Immunovirologic Findings in Patients with HIV-associated Neurocognitive Disorders. 17th Conference on Retroviruses and Opportunistic Infections. San Francisco, United States of America. February, 2010. (Abst) Ciccarelli N, Fabbiani M, Di Giambenedetto S et al. Prevalence and Correlates of Minor Neurocognitive Disorders in Asymptomatic HIV-infected Outpatients. 17th Conference on Retroviruses and Opportunistic Infections. San Francisco, United States of America. February, 2010. (Abst)Robertson KR, Smurzynski M, Parsons TD, Wu K, Bosch RJ, Wu J,McArthur JC, Collier AC, Evans SR, Ellis RJ. The prevalence and incidence of neurocognitive impairment in the HAART era. AIDS 2007; 21:1915–1921Royal W, Akomolafe A, Habib A et al. Neurocognitive Impairment and HIV in Nigeria: Functional and Virologic Correlates. 17th Conference on Retroviruses and Opportunistic Infections. San Francisco, United States of America. February, 2010. (Abst)Simioni S, Cavassini M, Annoni JM, Rimbault Abraham A, Bourquin I, Schiffer V, Calmy A, Chave JP, Giacobini E, Hirschel B, Du Pasquier RA (2010) Cognitive dysfunction in HIV patients despite long-standing suppression of viremia. AIDS 24:1243– 1250 

9. Prevalence of Neurocognitive Impairment in Relation to ART Era

10. Definitions of Mild Cognitive Syndromes, Dementia, and DeliriumAsymptomatic neurocognitive impairment (ANI): Mild to moderate impairment in at least two cognitive domains but without obvious impairment in daily functioningMild cognitive impairment (MCI): Mild to moderate impairment in at least two cognitive domains that at least mildly interferes with daily activitiesDementia: A clinical syndrome not entirely due to delirium consisting of global cognitive decline with several areas being affected and significant impact on daily functioningDelirium: A clinical syndrome of global impairment of cognition especially orientation and attention, including abnormal sleep-wake cycle, thinking, perception, language and affect with acute onset and fluctuating course

11. Delirium – Terms UsedAcute brain failureAcute cerebral insufficiencyAcute confusional stateEncephalopathyIntensive Care Unit (ICU) PsychosisReversible toxic psychosis

12. Delirium SubtypesHyperactive DeliriumHypervigilance Restlessness Fast/loud speech Anger/irritability Combativeness 46% Impatience Uncooperative Laughing Swearing/singing 30% Euphoria Wandering Easy startle Distractibility Nightmares Persistent thoughts Misdiagnosed as psychosis, maniaMeagher, 1996Hypoactive DeliriumUnawareness Lethargy Decreased alertness Staring Sparse/slow speech Apathy Decreased motor activity Often misdiagnosed as depressionDelirium can beHyperactiveHypoactiveMixedSuperimposed on dementiaLiptzin and Levkoff. Br J Psych 1999

13. Delirium vs. DementiaDeliriumAcute or abrupt onsetFluctuation of symptom severity over 24-hour periodReversible when cause is treatedImpaired level of consciousnessImpaired attention, orientation, memory, executive functionsIllusions, hallucinations (visual)Delusions – poorly formed, fleeting and paranoidReversal of sleep-wake cycle, insomniaAffective labilityIrritabilityHypoactive – often misdiagnosed as depressionHyperactive – often misdiagnosed as psychosisDementiaInsidiousNon-fluctuatingProgressive, 85% not reversibleClear level of consciousness unless delirium is superimposed or the dementia is end-stage Impaired memoryCan have visual or auditory hallucinationsDelusions – paranoid and fixedApathyApraxiaAgnosiaAphasiaAmnesia

14. Signs and Symptoms of Normal Aging versus Dementia Normal Aging and CognitionNew onset beginning at age 50Lack of progressionSubjective memory complaintsAnnoying but not disablingFrequent problems with name retrievalMinor difficulties in recalling detailed eventsProblems related to overloaded neuronal systemsNot associated with any other signs or symptoms May be intermittentPrevalence is estimated at 18% Alzheimer’s DementiaInsidious onsetUnrelentingly progressive impairmentProminent memory impairmentLeading cause of dementia and functional disability in the elderly50 to 75% of all dementia is Alzheimer’sThe 4 As of Alzheimer’s Dementia: Amnesia, Aphasia, Apraxia, AgnosiaPrevalence is 6.5%

15. Neuropsychological Profile Normal Aging versus Dementia Normal Aging Loss of speed and efficiency of information processingImpaired fluid abilities – novel problem-solvingDeficiencies in memory retrievalModest declines in delayed free recallDecrements on executive tests of visuoperceptual, visuospatial, and constructional functionsAlzheimer’s DementiaImpaired memory consolidation with rapid forgettingDiminished executive skillsImpaired semantic fluency and namingImpaired visuospatial analysis and praxisRapid forgetting of new information after brief delays

16. Cortical versus SubcorticalDementia Cortical Dementia – 4 AsAmnesia - not helped by cuesAphasiaAgnosiaApraxia AlexiaAffective disorders – not frequentLoss of initiativePsychomotor retardationGait – normal until lateExtrapyramidal signs - latePathological reflexes – grasp, snout, suck, Babinski - lateSubcortical Dementia – 4 DsDysmnesia - helped by cuesDysexecutive – difficulty with planning and decision-makingDelay – slow thinking and movingDepletion – reduced complexity of thoughtAffective disorders – severeApathy and inertiaAbsence of the 4 AsSlow diminution of cognitive functionsPsychomotor retardationAbnormal gait Loss of initiative, vitality, physical energy and emotional driveExtrapyramidal signs

17. Neuropsychological Profile Normal Aging versus Dementia Normal Aging Loss of speed and efficiency of information processingImpaired fluid abilities – novel problem-solvingDeficiencies in memory retrievalModest declines in delayed free recallDecrements on executive tests of visuoperceptual, visuospatial, and constructional functionsAlzheimer’s DementiaImpaired memory consolidation with rapid forgettingDiminished executive skillsImpaired semantic fluency and namingImpaired visuospatial analysis and praxisRapid forgetting of new information after brief delays

18. Definition and Classification of HIV-Associated Neurocognitive Disorders (HANDs)Asymptomatic Neurocognitive Impairment – ANI – mild to moderate impairment in at least 2 domains without obvious impairment in daily functioningMild Neurocognitive Impairment – MCI – mild to moderate impairment in at least 2 domains with at least mild interference with daily functioningHIV-Associated Dementia – HAD – a subcortical and cortical dementia that is severe enough to cause functional impairment and is characterized by slowed information processing, deficits in attention and memory, and impairments in abstraction and fine motor skills

19. HIV-Associated Neurocognitive ProfileFronto-subcortical pattern in the following domains: Attention / Working Memory Executive Functioning Information Processing Speed Verbal Fluency Learning Motor Function Verbal Memory

20. Differentiating Delirium from HIV- Associated Dementia

21. Clinical Pearls for Differential Diagnosis of Psychiatric Symptoms in HIV and AIDSThere is a need for a comprehensive biopsychosocial approach to psychiatric symptom evaluation in persons with HIV/AIDSThis comprehensive approach to differential diagnosis includes exploring clues for infectious, neurologic, and psychiatric causes and requires complete medical, psychiatric, and psychosocial assessments as well as ancillary evaluationsDelirium is prevalent in inpatient medicine and may be superimposed on HIV-associated dementia Cohen, 1987, 1992; Cohen et al., 2010; Cohen and Alfonso, 2004; Cohen and Chao,2008; Cohen and Gorman, 2008; Cohen and Weisman, 1986, 1988; Peterson et al. J Am Geriatr Soc 2006; Pandharipande et al. IntensiveCare Med, 2007; Khurana et al Geriatr Gerontol Int, 2011

22. Clinical Pearls for Prevention and Recognition of HANDsEach person with HIV needs a complete cognitive assessment at baseline and on a semi-annual or at least annual basis and whenever there is evidence of a change in cognitive functionHIV-associated dementia can be prevented by early diagnosis of HIV infection and initiation of antiretroviral therapy immediately upon exposure to or diagnosis of HIV HAND can be prevented by pre-exposure (PrEP) prophylaxis and post-exposure prophylaxis (PEP)Cognitive impairment can contribute to nonadherence at any age or stage of HIV infection

23. Clinical Pearls for Prevention and Recognition of Cognitive DisordersAntiretroviral therapy may prevent HAND, prevent HAND progression, and, at times, reverse cognitive impairmentHAND is still prevalent and is the most common treatable cause of dementia in persons under 50 years of age (Ances and Ellis, 2007) Hypoactive delirium is prevalent in persons with HIV and AIDS, can masquerade as depression, can be superimposed on HIV-associated dementia, and is easily resolved if or when the underlying cause is identified and treated

24. Risk Factors for HADOlder ageHistory of CNS diseaseShorter duration of antiretroviral treatmentLow CD4 (current and nadir)Asymptomatic neurocognitive impairment (ANI)Mild neurocognitive impairment (MCI)Co-infection with hepatitis C (HCV)Insulin resistance, cardiovascular illnesses, metabolic syndromeSeroconversion disorderAnemiaVitamin deficiencies (B6, B12)High CSF viral loadDepressionAlcohol, amphetamines, cocaineValcour V, Sacktor N, Paul R et al. Insulin resistance is associated with cognition among HIV-1-infected patients: the Hawaii Aging with HIV cohort. J Acquir Immun Defic Syndr 2006;43:405-410.Cysique L, Murray JM, Dunbar M, Jeyakumar V, Brew BJ. A screening algorithm for HIV-associated neurocognitive disorders. HIV Medicine 2010;11:642-649.

25. Alzheimer’s Dementia (AD) versus HIV-Associated Dementia (HAD) – Note Overlap ADAge over 65 yearsInsidious onsetUnrelentingly progressive impairmentProminent memory impairmentAmnesiaAphasiaApraxiaAgnosiaImpaired semantic fluency and namingImpaired visuospatial analysis and praxisRapid forgetting of new information after brief delaysMay have incontinenceMay have cortical release signsHADCan occur at any age over 18 Can be preventedCan be reversed with antiretroviralsCognitive slowingPsychomotor slowingImpaired attention and concentrationImpaired impulse controlImpaired executive functionApathyRegressionPsychosisMood disordersDropping thingsImpaired balanceAtaxia, tremorIncontinence can occur late

26. What is Your Diagnosis of Mr. A’s Cognitive Impairment?Mr. A is a 64 year old with AIDS diagnosed in 1997 when he was found to have late-stage AIDS and a CD4 of 17 who self-referred in 2012 because of memory impairment, difficulty retaining new information, and multitaskingFluent in Greek, Russian, Italian, Portuguese, Spanish, French, and English, he resigned from his job at an international firm because he himself noticed that he was making mistakesHe mourns both the loss of his job and the loss of his excellent memory that was once a source of great pride

27. What is the Differential Diagnosis of Mr. A’s Memory Impairment?

28. What is the Differential Diagnosis of Mr. A’s Memory Impairment? DeliriumMood disorder with depressive featuresSubstance use disorderMr. A had no evidence of delirium, depression, or substance useMMSE is 30 and his clock and Bender drawings, formal tests of recall, registration, Mental Alternation Test (verbal Trailmaking), similarity testing, proverb interpretation, and serial 7s are all within normal limits

29. What is the Diagnosis of Mr. A’s Memory Impairment? His own complaints and validation by collateral informants suggest that his diagnosis is probably consistent with HIV-associated mild neurocognitive impairment (MCI) however, since he performed well on cognitive testing and did not have NP testing we cannot make this diagnosis. There is a need for a complete comprehensive cognitive assessment of persons with HIV/AIDS, better criteria for diagnosis of HAND, and at times for neuropsychological testing.

30. HIV/AIDS:A Paradigm for Comprehensive and Compassionate Care with a Biopsychosocial ApproachComplex and severe medical and psychiatric illnessPersons with HIV/AIDS are vulnerableMedicallyPsychiatricallySociallyCohen MA and Gorman JM. Comprehensive Textbook of AIDS Psychiatry. Oxford University Press, New York, 2008 Cohen MA, Goforth HW, Lux JZ, Batista SM, Khalife S, Cozza KL, and Soffer J. Handbook of AIDS Psychiatry. Oxford University Press, New York, 2010.

31. HIV/AIDSPsychiatryAdherence to Prevention and TreatmentVulnerable PopulationsWomenAfrican-AmericanLatino-AmericanMen who have sexwith menChildrenAddictedTabooTopicsPreventionBarrier contraceptionDrug treatmentSafe sexSterile worksTrauma preventionSexTraumaDrugsInfectionDeathLethality Stigmatized IllnessHepatitis C STDs TB PTSD Dementia DeliriumPsychosis Injecting Drug UseSevere MultisystemIllnessCardiacDermatologicalEndocrinologicalGIInfectiousNeurologicalOncologicalOphthalmologicPsychiatricPulmonaryRenal Elderly

32. Need for Recognition and Treatment of Psychiatric Disorders Vectors of HIV Barriers to adherence Psychiatric treatment:  transmission, morbidity, mortality, suffering  adherence

33. AdherenceNeed 95% adherence to ARVsNeed 100% adherence to safer sexNeed 100% adherence to use of sterile worksIn the USA, only 29% of persons with HIV and on ARVs have achieved viral suppressionOnly 69% are linked to care and 59% are retained in careThompson MA et al. Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an international association of physicians in AIDS care panel. Ann Intern Med 2012; 156:817-833

34. Adherence to Appointments and Mortality in Persons with HIVMugavero and colleagues found that adherence to HIV clinic appointments is an independent predictor of all-cause mortality in persons with HIV Mugavero MJ et al. Beyond Core Indicators of Retention in HIV Care: Missed Clinic Visits are Independently Associated with All‐cause Mortality. Clinical Infectious Diseases 2014; 59:1471-1479

35. Tragic Results of Psychiatric Barriers toAdherence Lack of access to careNonadherence to careStopping and starting ARVsEmergence of viral mutations and viral multidrug resistanceDevelopment of independent CNS reservoirsDying of AIDS and other causes of mortality in persons with HIV

36. Mr. B is a 37 year old disabled former investment banker with AIDS (CD4 112 and elevated viral load) who was admitted to a nursing home when he was no longer able to care for himself in the community or perform activities of daily living (ADLs) or instrumental ADLs (IADLs). He was referred for refusal to stay in the nursing home.Mr. B’s history revealed that he was no longer able to care for his partner or himself, wandered away from their apartment and got lost, and did not believe that he was ill or that he had AIDS.What Psychiatric Disorder is a Factor in Mr. B’s Refusal to Remain in a Nursing Home?

37. On initial psychiatric consultation Mr. B denied being ill or needing care. He wanted to return home to live with his partner. What is your diagnosis?Diagnosis and Treatment of Mr. B

38. On initial psychiatric consultation Mr. B denied being ill or needing care. He wanted to return home to live with his partner. He had impairment of memory, abstract thinking, planning, and executive function. Mr. B had anosognosia, constructional apraxia on clock and Bender drawings, psychomotor retardation, and profoundly diminished intellectual functioning relative to his educational (MBA) and occupational levels. He was incontinent of urine and feces. Diagnosis and Treatment of Mr. B

39. Mr. B met criteria for HIV-associated dementia (HAD). After two years of directly administered ART in the nursing home setting, evidence of HAD could not be detected on psychiatric examination. Mr. B was able to resume independent living and went from disabled young man in diapers to dapper investment banker. Dementia can occur at any age in persons with HIV infection. Early treatment with ART and early recognition of HAND can lead to decrease or resolution of cognitive impairment and restoration of function in some persons with HIV/AIDS.Diagnosis and Treatment of Mr. B

40. This vignette illustrates that although ART has had a major impact on both morbidity and mortality in persons with AIDS, HAND is still prevalent and is the most common treatable cause of dementia in persons under 50 (Ances and Ellis, 2007)It is important to diagnose HIV infection early and begin ART, since there is evidence that HIV has an affinity for neural tissue and can establish independent reservoirs in the brainEvery person with HIV infection needs a comprehensive evaluation for cognitive impairment at baseline and at least twice yearly to ensure early diagnosis and of HANDComprehensive psychiatric assessment for HAND and other psychiatric disorders in persons with HIV and AIDS is described in the Handbook of AIDS Psychiatry HAND is a prevalent diagnosis young persons as well as in elderly persons with HIV/AIDS Diagnosis and Treatment of HAND

41. HAND is found in 69% of virally suppressed persons with HIV (Simioni et al. 2010)Current estimates of HAND prevalence is 40% - 50% (CHARTER 2014)Neurocognitive disorders can resemble depression and are seldom diagnosedDiagnosis requires complete cognitive assessment but brief screening can help lead to diagnosisHAD leads to nonadherence with HIV careHAD may reverse with ARTOnce treated, adherence improves, preventing illness progressionHIV-Associcated Neurocognitive Disorder (HAND)

42. The “gold standard” is a full battery of neuropsychological testing administered by a neuropsychologistUnavailable in most clinical settingsOften available only as part of a research studyUnavailable in resource-limited settingsEfforts are made to develop reliable and valid screening tools but no screening tool has been identified thus farScreening for HIV-Associated Neurocognitive Disorders (HAND)

43. Do you experience frequent memory loss - do you forget the occurrence of special events even the more recent ones? Do you feel that you are slower when reasoning, planning activities, or solving problems? Do you find it more difficult to perform activities that used to be automatic for you (paying bills, writing checks, making plans) Do you have difficulties paying attention (to a conversation, a book, or a movie)? Do you have difficulty with complex learned tasks that were previously easy for you (playing the piano, speaking a second language, knitting a sweater)?Simioni et al, AIDS 2010 - adapted with additionsHIV-Associated Neurocognitive Disorders: Screening with Simioni Questions

44. The HIV Dementia Scale (HDS) was developed to screen for HADThe International HIV Dementia Scale (IHDS) was developed for global useThe Montreal Cognitive Assessment (MoCA) was developed to screen for HAND but reliability and validity are not adequatePower C, Selnes OA, Grim JA, McArthur JC. HIV Dementia Scale: a rapid screening test. J Acquir Immune Defic Syndr Hum Retrovirol 1995; 8:273–278 Sacktor NC, Wong M, Nakasujja N, Skolasky RL, Selnes OA, Musisi S, et al. The International HIV Dementia Scale: a new rapid screening test for HIV dementia. AIDS 2005; 19:1367–1374 Koski L, Brouillette MJ, Lalonde R, Hello B, Wong E, Tsuchida A, et al. Computerized testing augments pencil-and-paper tasks in measuring HIV-associated mild cognitive impairment. HIV Med 2011; 12:472–480   HIV-Associated Neurocognitive Disorders: The Use of Screening Tools is Controversial

45. Zipursky AR et al. Evaluation of brief screening tools for neurocognitive impairment in HIV/AIDS: a systematic review of the literature. AIDS 2013; 27:2385–2401.There is no adequate, reliable, valid screening tool for the diagnosis of HANDHIV-Associated Neurocognitive Disorders: The Use of Screening Tools is Controversial

46. Controversy in Diagnosis of HANDNo reliable and valid screening instrument has been developed as yet The best approach is neuropsychological testing – can be abbreviated and utilizedDo not use the Mini Mental State ExaminationCan use the Simioni questions and clock drawing for a baseline and semiannual assessment

47. Controversy in Treatment of HAND:How Important is CPE Rank?Initially thought to be important, the ability of ART to cross the blood brain barrier, or the CNS penetration effectiveness (CPE) rank is now in question Is lowering CNS viral load correlated with clinical improvement?Letendre S et al. Arch Neurol 2008;65:65Caniglia EC et al. Neurology 2014 Ellis RJ et al. CID 2014;58:1015.

48. Crisis Intervention Individual psychodynamic psychotherapy Supportive psychotherapy Cognitive behavioral therapy Group psychotherapy Couple therapy Family therapy Bereavement therapy Substance use treatment Palliative psychiatry Psychoeducational approaches to prevention PsychopharmacologyTreatment of Psychiatric Disorders in Persons with HAND

49. Provide a safe environment to discuss concerns about HIV, its stigma, and its treatmentsProvide support from both members and leadersConfidentialNon-judgmentalCompassionateCaring“All in the same boat”Acceptance and sense of family Treatment of Psychiatric Disorders in Persons with HAND: Support Groups

50.

51. Exercise emphasizing walking, balance, core strength Relaxation response Yoga, Qigong, Tai Chi Music therapy, dance therapy Reading, crossword and jigsaw puzzles, Ken Ken, movies Brain games including computer use Education and involvement of family in care Spiritual assessment and support Development of support networks if family or friends are unavailable Directly observed ART and other medications where indicatedIntegrative Treatments for Persons with HAND: Alleviation of Symptoms

52. High prevalence of multimorbid psychiatric disorders Increased risk of suicide Vulnerability to all side effects of medications Increased vulnerability to the psychiatric side effects of antiretroviral medications Increased vulnerability to anticholinergic side effects of medications (includes antihistamines, antispasmodics, most psychotropic medications, some ARVs, and warfarin) Special affinity of HIV to basal ganglia makes for high risk for extrapyramidal side effects especially psychotropic medications and antiemetics (except ondansetron) Psychopharmacologic Treatment of Psychiatric Disorders in Persons with HAND

53. START VERY LOW AND GO VERY SLOWThe maxim for geriatric psychiatry is even more significant for AIDS psychiatry because of the increased vulnerability of this populationIn the US, 26% of persons with HIV and AIDS are over 50 years oldAvoid use of psychotropic medications except where essential for safety or alleviation of distressAvoid combinations of psychotropic medications if possible to prevent multiplication of side effectsUse of Psychotropic Medicationsin Persons with HAND

54. HIV/AIDS Psychopharmacology:Effects on PatientsSlowing of MetabolismDrug-Drug InteractionsDrug–Illness Interactionsvulnerability to dysglycemiavulnerability to anticholinergic side effectsvulnerability to extrapyramidal side effectsvulnerability to fallsvulnerability to confusionvulnerability to lipodystrophy

55. The Role of Collaborative Care in the HIV PandemicPrevention Can promote adherence to: safe sexdrug treatmentharm reductionneedle exchangeTreatment Can improve adherence to:medical careantiretrovirals Can decrease:sufferingmorbiditymortality

56. Academy of Psychosomatic Medicine HIV/AIDS Psychiatry Special Interest Groupand World Psychiatric Association Section on HIV/AIDS PsychiatryFounded 2003, meets annually at the APMTo develop networksTo present work and share findingsTo develop consensus on treatmentTo develop collaborative researchTo educate other clinicians and traineesHas 337 mental health clinician membersWe welcome new membersPresentations at WPA meetings throughout the worldmacohen@nyc.rr.com to join – no dueswww.apm.org/sigs/oap