Dementia associated with HIV: symptoms, stages and treatment
HIV infection and AIDS are, even today, a global pandemic. In spite of the fact that more and more prevention policies are being established and that the existing pharmacotherapy allows us 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 It remains a major problem in much of the globe that requires much more research in order to try to find a cure.
Although most people know what HIV and AIDS are (although they often identify themselves despite not being exactly the same) and its effects on the level of weakening of the immune system, less known is the fact that in some cases it can cause, in advanced stages, a type of dementia. It is the dementia associated with HIV , of which we are going to talk throughout this article.
- Related article: "Types of dementia: the 8 forms of loss of cognition"
HIV and AIDS: Basic definition
Before going into a discussion about what is the dementia associated with HIV, it is necessary to briefly review what HIV and AIDS are (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 CD4 + T lymphocytes (causing among other things that the cells of the intestinal mucosa that generate them deteriorate and disappear) and causing a progressive deterioration of said system as the virus multiplies.
AIDS would refer to the Acquired Immune Deficiency 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 HIV infection, but it may still not appear. And 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 there may be some nervous disorder (with symptoms that can range from hypotonia, loss of sensation, paresthesias, physical slowness, behavioral changes or mental retardation). among others) in different points of the system at any time of the infection.
In some cases Cognitive impairment may result from HIV infection or derived from opportunistic infections. The presence of cognitive deterioration is generally more typical of advanced stages, usually during AIDS. It is possible that a minimal cognitive deterioration appears that does not present serious complications, but a much more important complication can also occur: the dementia associated with HIV.
Dementia associated with HIV: basic characteristics and symptoms
Dementia associated with HIV, or dementia-AIDS complex, is understood to be that neurological disorder characterized by a progressive neurodegeneration that causes the progressive loss of cognitive and motor faculties and abilities, derived from the affectation produced by HIV infection. The affectation 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 that 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 the 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 resemble other dementias in which there are alterations in this.
We are facing a dementia of insidious onset but of rapid evolution in which abilities derived from a neurological affectation are lost, 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 frontal , and not in the cortex). We would be talking about 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 in Huntington's Korea.
It usually starts with a loss of the ability to coordinate different tasks , as well as a mental slowdown or bradypsychia (which is one of the most characteristic symptoms), despite the fact that in the beginning the capacity for reasoning and planning remains preserved.As the disease progresses, problems of memory and concentration appear, as well as visuo-spatial and visuoconstructive deficits, depressive-type symptoms such as apathy and motor slowing down. Reading and solving problems are also altered.
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. The autobiographical memory may be altered, but it is not an essential criterion. In verbal memory tend to affect the level of evocation, in addition to also appear alterations with regard to procedural memory (how to do things, such as walking or cycling).
And not only affects the level of cognitive functions, but also often appear neurological disorders such as hyperreflexia, muscle hypertension, tremors and ataxia, seizures and incontinence. Alteration of the movement of the eyes may appear.
Another point that should be emphasized especially 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 high speed until his death, which usually occurs around six months after the onset of symptoms if not subjected to any treatment.
Finally, it is worth mentioning that children can also develop this dementia, with delays in maturational development and microcephaly, as well as previous symptoms.
Stages of dementia associated with HIV
The dementia associated with HIV 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 the temporary moment when the person infected with HIV still does not present any type of symptom at the neurodegenerative level . The subject would maintain their cognitive and motor skills, being able to perform daily activities normally.
Stadium 0.5
This is the point at which some anomalies begin to appear. Alterations may be detected in some activity of daily life, or appear some kind of symptom as a slight slowdown although there are no difficulties in day to day.
Stadium 1
At this stage, alterations in the patient's capacities begin to manifest themselves. Activities of daily living and neurological examinations reflect mild involvement. The subject is able to face the majority of activities except those that suppose a greater demand. He does not need help to move, although there are signs of cognitive and motor impairment.
Stadium 2
In this stage dementia is in a moderate phase. Although you 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 stops being able to understand complex situations and conversations, and / or requires help to move at all times. Deceleration is usual.
Stadium 4
The final and most serious stage, the person only maintains the most basic abilities, It is not possible to perform any kind of neuropsychological evaluation . Paraplegia and incontinence appear, as well as mutism. It is practically in plant state, until death.
Treatment of this rare dementia
The treatment of this type of dementia requires a rapid response in the form of treatment, given that the symptomatology evolves and progresses rapidly. As with other dementias there is no curative treatment, but it is possible to prolong the functionality and improve the quality of life of the patient. Treating this dementia is complex. First, you have to keep in mind that dementia is caused by the effects of the human immunodeficiency virus on the brain , making it necessary to reduce and inhibit as much as possible the viral load in the cerebrospinal fluid.
Pharmacology
Although there is no specific pharmacological treatment for this type of dementia, it is necessary to take into account that the usual treatment with antiretrovirals will still be necessary, although it will not be enough to stop the evolution of dementia. It is recommended the use of those that can better reach penetrate the blood-brain barrier. Several antiretroviral drugs (at least two or three) are used in combination, this treatment being known as retroviral or Targa combination therapy.
One of the most used drugs and with greater 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 the neuropsychological performance and serve as a prophylactic for the appearance of this dementia (which has decreased over time).
It is also recommended the use of neuroprotectants such as calcium channel blockers, glutamate NMDA receptor antagonists and inhibitors of the production of oxygen free radicals. Selegiline, an irreversible MAOI , has been seen as useful in this sense, as well as the nimodipine. In a complementary manner, the use of psychostimulants, anxiolytics, antipsychotics and other drugs is also recommended in order to reduce the hallucinatory, anxious, depressive, manic or other disorders that may arise.
Other aspects to work and take into account
Beyond medical and pharmacological treatment , it is very useful that the patient is in a protected environment that provides support, as well as the presence of aids that facilitate their orientation and stability. Following a routine greatly facilitates the person to maintain a certain sense of security and facilitates the preservation of memory, being necessary also to be notified in advance of possible changes.
Physical therapy and occupational therapy can facilitate the maintenance of skills for longer and favor a certain autonomy. Psychological therapy can be useful, especially in regard to the expression of fears and doubts both by the subject and their immediate environment.
Although dementia will reappear over time and progressively evolve, the truth is that the treatment can encourage a really considerable improvement and prolong the maintenance of the capabilities and autonomy of the patient.
Bibliographic references:
- López, O.L. and Becker, J.T. (2013). Dementia Associated with Acquired Immunodeficiency Syndrome and the Dopaminergic Hypothesis. Neurology of behavior and dementias. Spanish Society of Neurology
- Custodio, N .; Escobar, J. and Altamirano, J. (2006). Dementia associated with infection by human immunodeficiency virus type 1. Anales de la Faculty of Medicine; 67 (3). National University of San Marcos.
