HAND DIAGNOSTIC ISSUES OHTN HIV End Game October 26, 2016 Reuben - - PowerPoint PPT Presentation

HAND DIAGNOSTIC ISSUES

OHTN HIV End Game October 26, 2016 Reuben N. Robbins, PhD

New York State Psychiatric Institute and Columbia University

Disclosures

• No financial conflicts of interest to disclose
• Funded by NIH: NIMH, NIAID, NINR, NICHD

Clinical Presentation

• Memory problems
• Slowed thinking
• Concentration problems
• Planning difficulties
• Multitasking difficulties

Consequences

• Disrupt ADLs/IADLs
• Work/employment difficulties
• Mild symptoms can predict further decline
• Lower quality of life
• Greater need for social services
• Neurocognitive deficits linked to greater HIV

risk behaviors and poor decision making

• Neuropsychological Assessment/Evaluation
• Detailed history: medical, psychiatric, psychosocial,

education, work/employment/functional status

• Series of tests to evaluate domains of cognitive

functioning (usually multiple tests per domain):

• Verbal and visual learning and memory
• Working memory/attention
• Motor functioning
• Speed of information processing
• Executive functions (set-shifting, problem solving,

abstract thinking)

• And measures for psychological/emotional functioning

Clinical Assessment

HAND Nosology

• Developed primarily for research to describe

the cognitive effects of HIV

• Where cognitive effects not better explained by

factors/co-morbidities other than HIV

• Asymptomatic Neurocognitive Impairment (ANI)
• Mild Neurocognitive Disorder (MND)
• HIV-Associated Dementia (HAD)

HAND Criteria

ANI

Abnormality in two or more cognitive abilities (≥ 2 cognitive domains, each 1 SD below mean) No functional impairment

MND

Abnormality in two or more cognitive abilities (≥ 2 cognitive domains, each 1 SD below mean) With mild functional impairment

HAD

Marked cognitive impairment (2 cognitive domains, 2 SD below mean) With marked functional impairment

Screening for HAND

• In absence of a neuropsychological evaluation,

screening tests can assist in detecting HAND

• Recommended for routine and ongoing care/monitoring

(e.g., at HIV diagnosis, at regular check-ups, and/or use algorithms to screen most at risk for HAND)

• Commonly used tests in HIV, such HDS, MoCA, and

MMSE, relatively brief and easier to administer than a neuropsychological battery

• However, these tests often lack adequate sensitivity

and/or specificity to detect mild HAND

Screening for HAND

• Computerized/tablet-based screening tests may be

better at detecting milder forms of HAND

• CogState
• CAMCI
• Brain Baseline
• NeuroScreen
• Easy to administer by non-specialized personnel
• Hold potential to be scale-able and more easily

implementable than paper-and-pencil tests

• ‘Connected’ technology can integrate into EMRs,

databases/big data platforms

Screening for HAND

• Ongoing research to evaluate screening tests sensitivity

and specificity to detect mild impairment in a variety of HIV populations

• Older age
• Co-morbidities
• Different countries/languages
• Resource limited settings, e.g., inner New York City and sub-

Saharan Africa

• Still very important to know the normative sample used

to validate the test

• Computerized tests, at least currently, do not include

measures of mental health (e.g., depression) or daily functioning

Screening for HAND

• Important caveats for screening tests:
• Not definitive – trying to find patients most likely to

have HAND/impairment

• Test subject to false positives and false negatives
• In absence of definitive biomarker, must work with

these short comings

• Often not done with a detailed history
• Positive result on a screening test should trigger

follow-up evaluation

Challenges

• Is it normal aging?
• How bad is it?
• Do I have Alzheimer’s?
• What can I expect?
• Level if impairment in HIV can fluctuate over time
• Pre-ART/post-ART
• Is it due to HIV?
• Is it ART toxicity?
• What role are co-morbidities playing?
• What do we do?

• Research has identified numerous challenges to

neurocognitive testing:

• Education
• Language
• Cultural acceptance
• Test exposure
• Norms
• Provider and patient awareness/concern

Other Challenges