HIV-associated dementia: symptoms, stages and treatment

Even today HIV infection and AIDS are a global pandemic. If more and more prevention policies are implemented and the existing pharmacotherapy now makes it possible to stop being a death sentence in a few years to be a chronic disease in a large number of cases, the truth is that ‘she is always top notch. problem in much of the globe that requires much more research in the face of finding a cure.

Although most people know what HIV and AIDS are (although they are often identified even though they are not exactly the same) and their effects on weakening the immune system, the fact that in in some cases it can cause a type of dementia in advanced stages. This is the dementia associated with HIV, Which we will talk about throughout this article.

    HIV and AIDS: basic definition

    Before continuing to discuss what HIV-associated dementia is, it is necessary to take a brief look at what HIV and AIDS are (and to mention that they are not synonymous and HIV is not synonymous with HIV). does not necessarily imply the onset of AIDS).

    The acronym HIV refers to the human immunodeficiency virus, a retrovirus whose action affects and attacks the human immune system, particularly affecting CD4 + T lymphocytes (causing, among other things, the cells of the intestinal mucosa that make them deteriorate and disappear) and causing progressive deterioration of this system as the virus multiplies.

    AIDS refers to the acquired immunodeficiency syndrome, in which the immune system is so damaged that it is no longer able to respond to infections and pathogens effectively. This is an advanced stage of HIV infection, but it may not appear. And it is that the HIV infection may not progress to this point.

    The onset of neurological symptoms during HIV infection or AIDS is not unknown, and certain nervous disorders may occur (with symptoms ranging from hypotonia, loss of sensation, paraesthesia, physical slowing, changes in behavior) or mental retardation among others) at different points in the system at any time during the infection.

    In some cases it can cause cognitive impairment following HIV infection or derived from opportunistic infections. The presence of cognitive impairment is generally more typical of the advanced stages, usually already during AIDS. There may be minimal cognitive impairment that does not present with serious complications, but a much larger complication may also arise: HIV-associated dementia.

    HIV-associated dementia: basic characteristics and symptoms

    By dementia associated with HIV, or dementia-AIDS complex, is meant this neurological disorder characterized by progressive neurodegeneration which causes the progressive loss of faculties and cognitive and motor capacities, resulting from the affectation produced by infection with HIV. The weakened immune system and the action of viruses eventually damage the nervous system, especially in areas such as the basal ganglia and frontal lobe.

    The mechanism by which they do this is not fully known, although the hypothesis is release of neurotoxins and cytokines from infected lymphocytes, Especially in the cerebrospinal fluid, which in turn would lead to an excessive increase in the release of glutamate which would generate excitotoxicity, damaging the neurons. The involvement of the dopaminergic system is also suspected since the most damaged areas initially correspond to pathways linked to this neurotransmitter and the symptoms resemble other dementias in which there are alterations.

    We are faced with an insidious but rapidly evolving dementia in which the abilities derived from neurological impairment are lost, with a profile that begins in a fronto-subcortical fashion (i.e. the impairment would begin in the internal parts of the brain located in the frontal, and not in the cortex). We would speak of a primary type of dementia, characterized by the presence of cognitive impairment, behavioral changes and motor dysfunctions. The type of symptomatology is similar to the dementia that can appear with Parkinson’s or Huntington’s disease.

    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 characteristic symptoms), although at first the ability to reason and plan is preserved. As the disease progresses, problems with memory and concentration appear as well as visuospatial and visuoconstructive deficits, depressive symptoms such as listlessness and motor slowdown. Reading and problem solving are also changed.

    In addition to this, it is common for them to introduce themselves apathy and loss of spontaneity, Delusions and hallucinations (especially in the final stages), as well as confusion and disorientation, language alterations and progressive isolation. Autobiographical memory can be impaired, but this is not an essential criterion. In verbal memory, they usually have an effect on the level of evocation, in addition to also appearing alterations in procedural memory (how to do things, like walking or cycling).

    And not only does it affect cognitive functions, but neurological disorders such as hyperreflexia, muscle hypertension, tremors and ataxia, seizures and incontinence also occur. Altered eye movements may occur.

    Another point to note especially is that the appearance of this type of dementia usually implies the existence of AIDS, being typical of the final stages of this syndrome. Unfortunately, the course of this disorder is surprisingly rapid: the subject loses his 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 should be noted that children can also develop this dementia, with delays in the development of maturation and microcephaly in addition to the above symptoms.

    Stages of HIV-associated dementia

    Dementia associated with HIV usually develops and changes rapidly over time. However, it is possible to distinguish different phases or stages of development of this type of dementia.

    step 0

    It is called stage 0 when the person becomes infected with HIV he does not yet present symptoms at the neurodegenerative level. The subject would maintain cognitive and motor skills and could carry out normal daily activities.

    step 0.5

    This is when some anomalies start to appear. Alterations may be detected in certain activities of daily living, or appear some kind of symptom like a slight slowing down although there are no day-to-day difficulties.

    Step 1

    At this stage, they are already beginning to manifest alterations in the patient’s abilities. Activities of daily living and neurological examinations reflect a slight impairment. The subject is able to tackle most activities except those involving greater demand. He does not need help moving, although there are signs of cognitive and motor impairment.

    2nd step

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

    step 3

    Severe dementia. The subject is no longer able to understand complex situations and conversations, and / or needs help to move at all times. Slowdown is common.

    step 4

    Final and most serious stage, the person retains only the most basic abilities, it is not possible to perform any type of neuropsychological assessment. Paraplegia and incontinence appear, as well as mutism. It is practically in the vegetal state, until death.

    Treatment of this rare dementia

    Treatment for this type of dementia requires a rapid response in the form of treatment, as symptoms develop and progress rapidly. As with other dementias there is no cure, but it is possible to prolong the functionality and improve the quality of life of the patient. The treatment of this dementia is complex. First of all, keep in mind that dementia is caused by the viral effects of human immunodeficiency on the brainBy becoming peremptory, reduce and inhibit the viral load in the cerebrospinal fluid as much as possible.

    Pharmacology

    If there is no specific pharmacological treatment for this type of dementia, it should be noted that routine antiretroviral therapy will always be necessary, although it will not be sufficient to slow the progression of the dementia. It is recommended to use those that can best penetrate the blood-brain barrier. Several antiretrovirals (at least two or three) are used in combination, this treatment is known as combination retroviral therapy or Targa.

    One of the most widely used and obvious drugs to reduce 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 for the onset of this dementia (which has diminished over time).

    The use of neuroprotectors such as calcium channel blockers, NMDA glutamate receptor antagonists and inhibitors of free radical oxygen production is also recommended. Selegiline, an irreversible MAOI, Has been found useful in this regard, as well as nimodipine. In addition, the use of psychostimulants, anxiolytics, antipsychotics and other drugs is also recommended in order to reduce the manifestations of hallucinations, anxiety, depression, mania or other disorders that may occur. .

    Other aspects to work on and take into account

    Beyond medical and pharmacological treatmentIt is very useful that the patient is in a protected environment that offers support, as well as the presence of aids that facilitate his guidance and stability. Following a routine greatly facilitates the person to maintain a certain sense of security and facilitates the preservation of memory, and it is also necessary to be warned in advance of any changes.

    Physiotherapy and occupational therapy can make it easier to maintain skills longer and promote independence. Psychotherapy can be useful, especially in terms of expressing fears and doubts both by the subject and by his immediate environment.

    While dementia will reappear over time and gradually progress, the truth is that treatment it can encourage a really big improvement and prolong the maintenance of the patient’s capacities and autonomy.

    Bibliographical references:

    • López, OL and Becker, JT (2013). Dementia associated with acquired immunodeficiency syndrome and dopaminergic hypothesis. Behavioral neurology and dementia. Spanish Society of Neurology
    • Custodi, N .; Escobar, J. and Altamirano, J. (2006). Dementia associated with infection with human immunodeficiency virus type 1. Annals of the Faculty of Medicine; 67 (3). Enlarged National University of San Marcos.

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