HAND diagnosis

Clinical features

HIV-associated neurocognitive disorders (HAND) encompass a spectrum of neurological problems involving the brain or spinal cord. HAND can impact memory, mood, mobility, and problem-solving. Persistent HIV activation of pro-inflammatory immune cells within the CNS is believed to cause a decline in cognitive function and memory even when the virus is undetectable by lab tests.

The reports of the prevalence of HAND vary widely, but most studies indicate that HIV associated dementia (HAD) has decreased since the introduction of antiretroviral treatment (ART). C.J. Hoffmann of the Johns Hopkins reports the U.S. prevalence of HIV associated dementia (HAD) to be 2%, 12% for mild neurocognitive disorder (MND), and 33% for asymptomatic neurocognitive impairment (ANI). ANI is only detectable with neurologic and neurocognitive testing), (Hoffmann n.d.).

Diagnosis of HAND requires differentiating it from the slowing of thought, memory, and mobility that can accompany many other conditions with neurologic effects, e.g., normal aging, cerebral vascular disease, Alzheimer's disease, Parkinson's disease, etc. The results of aging can overlap with mild symptoms of HAND. The CDC believes that 70 percent of people living with HIV reached 50 years and older by 2020. As a result, the mild effects of HAND are increasing in prevalence. Some other treatable causes of neurocognitive disorders include depression, thyroid disease, B12 deficiency, syphilis, an opportunistic infection, and cancer (Cournos n.d.).

A 2020 study by Prabhakar, Martin, and Muller-Oehring, et al. compared motor and cognitive capabilities of 36 chronically treated HIV+ persons, 28 persons with mild to moderate Parkinson's disease, and 28 healthy controls.  Motor function was assessed with the Unified Parkinson Disease Rating Scale (MDS-UPDRS-III) and a rapid alternating finger tapping (RAFT) task on a (two keyed) engineered keyboard known as Quantitative Digitography (QDG). Executive function, verbal memory, and visuospatial processing were assessed using standard neuropsychological tests.  The study found:

• People with chronically treated HIV infection display progressive bradykinesia in fine motor control and worse performance in executive, verbal memory, and visuospatial cognitive measures than healthy controls.
• The patterns of cognitive and motor disturbances in the HIV group were similar but inverted compared to a group with moderate Parkinson's Disease (PD): the HIV group demonstrated worse cognitive performance in more domains than healthy controls, and the PD group demonstrated motor impairment in more aspects to healthy controls.

HAND Symptoms

Cognitive: 

• diminished concentration and attention that interferes with routine tasks, planning, and problem solving
• diminished recall of words, phone numbers, appointments, medication schedules, agreements, or previous conversations
• generalized slowing of mental functions (difficulty understanding and responding to questions, loss of sense of humor or wit)

Motor:

• Reduced coordination
• Extremity weakness
• Loss of fine motor control like handwriting
• Loss of balance
• Bowel and bladder incontinence

Behavioral:

• Personality changes: increased irritability, apathy toward loved ones or life in general, loss of initiative, withdrawal from social contact
• Mood swings: depression, excitability, emotional outbursts
• Impaired judgment: impulsive decision-making, loss of inhibitions
• Occasional symptoms of psychosis: hallucinations, paranoia, disorientation, sudden rages

Patient complaints

Mild to moderate complaints:

• Slower thinking Brain fog (feeling fuzzy headed)
• Trouble concentrating or paying attention
• Difficulty recalling facts, names or new information
• Difficulty remembering things that happened in the past
• Trouble learning new tasks
• Sleep disturbances
• Slower reflexes Impaired coordination
• Unsteady walking or moving
• Depression, anxiety or irritability

More serious complaints (HAD)

• Mental confusion and disorientation
• Trouble solving problems or handling complex tasks
• Inability to concentrate
• Severe memory loss
• Difficulty with speech and communication
• Difficulty with vision and spatial ability
• Insomnia
• Difficulty standing or walking
• Muscle weakness
• Loss of bladder control
• Mood changes including mania, paranoia (excessive fearfulness), or agitation
• Personality and behavior changes Isolation and withdrawing from life.

Differential Diagnosis

Currently, no single test is determinative for HAND. Diagnosis begins with a thorough history for pre-existing trauma, delirium, depression, substance use disorder, etc., as well as comorbidities including Progressive multifocal leukoencephalopathy, CNS toxoplasmosis, primary CNS lymphoma, cytomegalovirus encephalitis, neurosyphilis, vitamin B12 or thiamine deficiency, or other causes of dementia. HAND differs from delirium in that there is no alteration of consciousness or attention (Hoffmann n.d.).

Workup for HAND may include brain MRI, neuropsychological testing, serologic testing as needed to rule out vitamin deficiency and syphilis because the diagnosis is one of exclusion. MRI usually shows atrophy and ill-defined white matter hyperintensities on T2-weighted scans. CSF analysis not essential but may be needed to rule out opportunistic infection (OI) (Hoffmann n.d.).

Reference

Cournos F., Budak J.Z. (n.d.) Screening for Mental Health Conditions. National HIV Curriculum.
Updated 9/2020. Retrieved 5/9/21
https://www.hiv.uw.edu/go/basic-primary-care/screening-mental-disorders/
core-concept/all#neurocognitive-disorders-persons-living-hiv

Hoffman C. (n.d.) HIV-associated neurocognitive disorder (HAND). Johns Hopkins HIV Guide. Reviewed 2016.
Retrieved from https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_HIV_Guide
/545054/all/HIV_associated_neurocognitive_disorder__HAND_

Prabhakar, V., Martin, T., Müller-Oehring, E. M., Goodcase, R., Schulte, T., Poston, K. L., & Brontë-Stewart, H. M. (2020). Quantitative Digitography Measures Fine Motor Disturbances in Chronically Treated HIV Similar to Parkinson's Disease. Frontiers in aging neuroscience, 12, 539598. https://doi.org/10.3389/fnagi.2020.539598