eMedicine Specialties > Psychiatry > Psychosomatic

Dementia Due to HIV Disease: Treatment & Medication

Author: Soma Sahai-Srivastava, MD, Director of Neurology Ambulatory Care Services, LAC and USC Medical Center; Assistant Professor, Department of Neurology, University of Southern California
Coauthor(s): Arousiak Varpetian, MD, Assistant Professor of Clinical Neurology, Department of Neurology, University of Southern California Keck School of Medicine; Clinical Director, Rand Schrader Neurology Clinic (Los Angeles County-University of Southern California HIV Clinic)
Contributor Information and Disclosures

Updated: Jan 2, 2009

Treatment

Medical Care

The standard of care for a patient with AIDS is to use 3 or more antiretroviral agents. Triple therapy has been shown to improve neurologic outcome when compared with dual or single treatment regimens. The routine use of HAART has changed the epidemiology of HIV dementia in the Western hemisphere.28 HAART regimens can reverse some of the neurologic deficits of HIV-D, with patients showing improvements in motor and psychomotor speed. This improvement was independent of CNS penetration of specific antiretroviral drugs. Multiple studies have shown that patients on HAART show partial reversals of neuropsychological deficits and significant improvement, which is sustained, whereas patients not on HAART steadily decline.29

Several cohort studies have shown that treatment with multiple antiretroviral agents is superior to either no treatment or monotherapy in patients with AIDS dementia complex (ADC).30,12  This finding is based on clinical follow-up of patients with neuropsychological testing. ADC is clearly an indication for HAART, regardless of the combination of antiretroviral agents used. The Strategies for Management of Anti-Retroviral Therapy (SMART) study showed that it is better to follow HIV plasma viral load and consistently keep it suppressed than to adjust therapy based on peripheral CD4 counts.31,32

More than 20 antiretroviral medications are used to treat HIV. Most of them have poor CSF-to-plasma drug ratios, indicating poor CNS penetration. Exceptions include stavudine, abacavir, nevirapine, and zidovudine (ZDV). However, whether this translates into poor drug levels in CNS tissue, and whether drug penetrance is clinically important remains unclear. One study showed that patients treated with a HAART regimen containing multiple drugs with good CNS penetrance did not experience improved outcomes compared with patients treated with a HAART regimen composed of a single drug with good CNS penentrance.33  In the absence of more data, no general recommendation exists to change a patient’s therapy of HAART to higher penetrance based on their cognitive status.13  

ZDV is the most studied antiretroviral medication.34 Since its initial introduction in 1987, several studies have consistently shown that ZDV reduces the rate of HIV dementia from greater than 53% to 10%.35 It improves radiologic, neuropsychologic, and clinical findings in patients with ADC. However, adding ZDV, which is the drug with the best CSF penetrance, to an immunologically and virologically effective regimen does not improve the clinical efficacy of the HAART combinations.
 
Researchers are studying several experimental therapies (eg, memantine, nimodipine, delavirdine, peptide T, lexipafant). These therapies are either neuroprotective agents or they attempt to block the release of neurotoxic agents by macrophages or platelets. Several of these protocols are undergoing clinical trials.

Consultations

  • Specialist (infectious diseases or general practice physician) with expertise in HIV: An HIV treatment expert should treat all patients with ADC with a HAART regimen that is clinically, virologically, and immunologically effective.
  • Psychiatrist
    • Patients with ADC commonly exhibit agitation, anxiety, fatigue, depression, and other psychiatric manifestations. Mania and psychosis have been described as presenting symptoms or complications of ADC.
    • Consultation with a psychiatrist may be required to discuss appropriate use of antidepressants, antipsychotics, or stimulants.
    • Psychotherapy may be helpful for patients with mild-to-moderate dementia to help them understand, mourn, and adapt to this new impairment in functioning.
    • Neurologist with expertise in neurobehavior: As the population of patients with HIV ages, dementia is a risk because it occurs late in life. A neurologic workup by a neurologist specializing in neurobehavioral disorders may help to sort out the etiology of cognitive impairment. Older patient with HIV may develop Parkinson’s disease, frontotemporal dementia, Lewy body dementia, or Alzheimer’s disease unrelated to HIV.
  • Rehabilitation therapist
    • The care of patients with ADC is best accomplished with a team approach.
    • Both the physical and occupational therapist play a vital role in trying to maximize the functional capacity of the patient.

Diet

  • Nutritional therapies
    • Nutritional therapies may be considered as potential interventions in the follow-up care for patients with cognitive motor symptoms associated with HIV infection.
    • Oxidative free-radical scavengers, such as vitamin E, the experimental antioxidant OPC-4117, and the trace mineral and antioxidant selenium, may prove therapeutically useful.

Medication

HIV infection is significant in the pathogenesis of ADC. Initiate antiretroviral therapy for untreated patients, and optimize therapy for patients currently on antiretroviral therapy. For further information on antiretroviral therapy, see the eMedicine article HIV Infection, Antiretroviral Therapy.

More on Dementia Due to HIV Disease

Overview: Dementia Due to HIV Disease
Differential Diagnoses & Workup: Dementia Due to HIV Disease
Treatment & Medication: Dementia Due to HIV Disease
Follow-up: Dementia Due to HIV Disease
Multimedia: Dementia Due to HIV Disease
References
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Further Reading

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Keywords

AIDS dementia complex, ADC, subacute HIV encephalitis, AIDS-related dementia, HIV-related dementia, AIDS-induced dementia, HIV-induced dementia, viral dementia, virus-induced dementia, multinucleate giant cell encephalitis, HIV-1-associated cognitive/motor complex, AIDS encephalopathy, HIV dementia, HIV encephalopathy, dementia, mental illness, psychosis, subcortical dementia, depression

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Contributor Information and Disclosures

Author

Soma Sahai-Srivastava, MD, Director of Neurology Ambulatory Care Services, LAC and USC Medical Center; Assistant Professor, Department of Neurology, University of Southern California
Soma Sahai-Srivastava, MD is a member of the following medical societies: American Academy of Neurology, American Headache Society, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Arousiak Varpetian, MD, Assistant Professor of Clinical Neurology, Department of Neurology, University of Southern California Keck School of Medicine; Clinical Director, Rand Schrader Neurology Clinic (Los Angeles County-University of Southern California HIV Clinic)
Arousiak Varpetian, MD is a member of the following medical societies: American Academy of Neurology and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Ronald A Greenfield, MD, Professor, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine
Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist  Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eduardo Dunayevich, MD, Adjunct Assistant Professor, Department of Psychiatry, University of Cincinnati; Clinical Research Physician, Neuroscience, Lilly Research Laboratories
Eduardo Dunayevich, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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