HIV-Associated Dementia: Symptoms, Stages, and Treatment

HIV infection and AIDS are still today a global pandemic. Despite the fact that more and more prevention policies are established and that the existing pharmacotherapy today allows there to be ceased to be a death sentence in a few years to be a chronic disease in a large number of cases, the truth is that it continues being a problem of the first order in a large part of the globe that requires a much greater investigation in order to try to find a cure.

Even though most people know what HIV and AIDS are (even though they are often identified even though they are not exactly the same) and their effects at the level of weakening of the immune system, less well known is the fact that in some cases it can cause, in advanced phases, a type of dementia. This is HIV-associated dementia., which we are going to talk about throughout this article.

• Related article: "Types of dementias: the 8 forms of loss of cognition"

HIV and AIDS: Basic definition

Before discussing what HIV-associated dementia is, it is necessary to briefly review what are HIV and AIDS (as well as mentioning that they are not synonymous and that HIV does not necessarily imply the appearance of AIDS).

The acronym HIV refers to the Human Immunodeficiency Virus, a retrovirus whose action affects and attacks the human immune system, especially affecting T lymphocytes. CD4+ (causing, among other things, the cells of the intestinal mucosa that generate them to deteriorate and disappear) and causing a progressive deterioration of said system as the virus spreads. multiply.

AIDS would refer to Acquired Immunodeficiency Syndrome, in which the immune system is so damaged that it is no longer able to respond to infections and pathogens efficiently. It is an advanced stage of the HIV infection, but that nevertheless may not appear. And it is that HIV infection may not progress to this point.

The appearance of neurological symptoms throughout HIV infection or during AIDS is not unknown, and some nervous alteration may occur (with symptoms that can range from hypotonia, loss of sensitivity, paresthesias, physical retardation, behavioral changes or mental retardation, among others) at different points of the system at any time during the infection.

In some cases Cognitive impairment may occur as a result of HIV infection or derived from opportunistic infections. The presence of cognitive deterioration is generally more characteristic of advanced phases, generally already during AIDS. It is possible that a minor cognitive impairment appears without serious complications, but a much more important complication can also occur: HIV-associated dementia.

HIV-associated dementia: basic characteristics and symptoms

HIV-associated dementia, or dementia-AIDS complex, is understood to be a neurological disorder characterized by progressive neurodegeneration that causes the progressive loss of faculties and capacities, both cognitive and motor, derived from the affectation produced by the infection of the HIV. The involvement of the immune system and the action of the virus end up damaging the nervous system, especially affecting areas such as the basal ganglia and the frontal lobe.

The mechanism by which they do so is not fully known, although it is hypothesized about the release of neurotoxins and cytokines by infected lymphocytes, especially in the cerebrospinal fluid, which in turn would cause an excessive increase in the release of glutamate that would generate excitotoxicity, damaging neurons. The involvement of the dopaminergic system is also suspected given that the most damaged areas initially correspond to pathways linked to this neurotransmitter and the symptoms are similar to other dementias in which there are alterations in this.

We are facing a dementia with an insidious onset but rapid evolution in which abilities are gradually lost as a result of neurological involvement, with a profile that debuts in a frontosubcortical manner (that is, the alteration would start in the internal parts of the brain located in the front, and not in the Cortex). We would be talking about a primary type of dementia, characterized by the presence of cognitive deterioration, behavioral changes and motor dysfunctions. The type of symptomatology is similar to the dementia that can appear with Parkinson's or Huntington's Korea.

It usually starts with a loss of the ability to coordinate different tasks, as well as mental retardation or bradypsychia (which is one of the most characteristics), despite the fact that at first the reasoning capacity remains preserved and planning. As the disease progresses, memory and concentration problems appear, as well as deficits. visuospatial and visuoconstructive, depressive-like symptoms such as apathy and slowing down engine. Reading and problem solving are also affected.

In addition to this, it is common for apathy and loss of spontaneity, delusions and hallucinations (especially in the final stages), as well as confusion and disorientation, language disturbances, and progressive isolation. Autobiographical memory may be altered, but it is not an essential criterion. In verbal memory they tend to be affected at the level of evocation, in addition to also appearing alterations regarding procedural memory (how to do things, such as walking or going by bike).

And not only affectation occurs at the level of cognitive functions, but also alterations usually appear Neurological disorders such as hyperreflexia, muscular hypertension, tremors and ataxias, seizures and incontinence. Eye movement disorder may appear.

Another point that should be especially emphasized is that the appearance of this type of dementia usually implies the existence of AIDS, being typical of the final phases of this syndrome. Unfortunately, the evolution of this disorder is surprisingly fast: the subject loses abilities at great speed until his death, which usually occurs about six months after the onset of symptoms if he does not undergo any treatment.

Finally, it is worth mentioning that children can also develop this dementia, with developmental delays and microcephaly appearing in addition to the above symptoms.

Stages of HIV-associated dementia

HIV-associated dementia usually has a rapid development and evolution over time. However, it is possible to distinguish between different phases or stages of evolution of this type of dementia.

stadium 0

Stage 0 is defined as the moment in time when the person infected with HIV He still does not present any type of neurodegenerative symptoms. The subject would maintain his cognitive and motor abilities, being able to perform daily activities normally.

stadium 0.5

This is the point at which some anomalies start to appear. Alterations may be detected in some activity of daily living, or appear some type of symptom such as a slight slowdown even if there are no difficulties on a day-to-day basis.

stage 1

At this stage, alterations in the patient's abilities begin to manifest. Activities of daily living and neurological examinations reflect mild involvement. The subject is able to face most activities except those that involve a greater demand. He does not need help to get around, although signs of cognitive and motor impairment appear.

stage 2

At this stage the dementia is in a moderate phase. Although he can perform basic activities, loses the ability to work and begins to need external help to move. Clear alterations are observed at the neurological level.

stage 3

severe dementia. The subject is no longer able to understand complex situations and conversations, and/or requires help to get around at all times. Slowdown is common.

stage 4

The final and most serious stage, the person only maintains the most basic capacities, not being possible to carry out any type of neuropsychological evaluation. Paraplegia and incontinence appear, as well as mutism. It is practically in a vegetable state, until death.

Treatment of this rare dementia

The treatment of this type of dementia requires a rapid response in the form of treatment, since the symptoms evolve and progress rapidly. As with other dementias, there is no curative treatment, but it is possible to prolong functionality and improve the patient's quality of life. Treating this dementia is complex. First of all, it must be taken into account that dementia is caused by the effects of the human immunodeficiency virus on the brain, making it imperative to reduce and inhibit the viral load in the cerebrospinal fluid to the greatest extent possible.

Pharmacology

Although there is no specific pharmacological treatment for this type of dementia, it is necessary to take into account that the Regular treatment with antiretrovirals will continue to be necessary, although it will not be enough to stop the evolution of the disease. dementia. It is recommended to use those that can best penetrate the blood brain barrier. Various antiretrovirals (at least two or three) are used in combination, this treatment being known as retroviral combination therapy or Targa.

One of the most widely used drugs and with the greatest evidence in reducing the incidence of this dementia is zidovudine, usually in combination with other antiretrovirals (between two, three or more). Also azidothymidine, which seems to improve neuropsychological performance and serve as a prophylactic against the onset of this dementia (which has decreased over time).

The use of neuroprotectors such as calcium channel blockers, glutamate NMDA receptor antagonists and inhibitors of free radical production of oxygen. Selegiline, an irreversible MAOI, has been seen to be useful in this sense, as well as nimodipine. In addition, the use of psychostimulants, anxiolytics, antipsychotics and other drugs with the purpose of reducing hallucinatory, anxious, depressive, manic or other disorders that may emerge.

Other aspects to work on and take into account

Beyond medical and pharmacological treatment, it is very useful for the patient to be in a protected environment that provides support, as well as the presence of aids that facilitate her orientation and stability. Following a routine greatly facilitates the person to maintain some sense of security and facilitates the preservation of memory, and it is also necessary to be notified in advance of possible changes.

Physiotherapy and occupational therapy can facilitate the maintenance of capacities for a longer time and favor a certain autonomy. Psychological therapy can be useful, especially with regard to the expression of fears and doubts both on the part of the subject and his immediate environment.

Although dementia will reappear over time and will progressively evolve, the truth is that treatment can foster a really considerable improvement and prolong the maintenance of the patient's capacities and autonomy.

Bibliographic references:

• Lopez, O. L. and Becker, J.T. (2013). Dementia Associated with Acquired Immunodeficiency Syndrome and the Dopaminergic Hypothesis. Behavioral neurology and dementias. Spanish Society of Neurology
• Custodio, N.; Escobar, J. and Altamirano, J. (2006). Dementia associated with human immunodeficiency virus type 1 infection. Annals of the Faculty of Medicine; 67 (3). National University of San Marcos.