Screening for Neurocognitive Impairment in HIV Patients
Screening for Neurocognitive Impairment in HIV Patients
Objective: Practical screening methods are necessary to detect neurocognitive impairment (NCI) in HIV-infected patients. We aimed to find a brief and feasible paper-based tool to facilitate the diagnosis of an HIV-associated neurocognitive disorder.
Methods: A total of 106 HIV-infected outpatients with variable clinical characteristics were recruited in a multicenter investigation. NCI was diagnosed using a standardized neuropsychological tests battery (7 areas, 21 measures, ~2 hours). Multiple score combinations were compared to find a paper-based method that took ≤10 minutes to apply. The presence of NCI was considered the gold standard for comparisons, and the sensitivity and specificity were calculated.
Results: Subjects were mostly middle-aged (median, 44 years) men (87%) on antiretroviral treatment. NCI was detected in 51 individuals (48%) and was associated with lower nadir CD4 count (P < 0.001), receiving antiretroviral therapy (P = 0.004), fewer years of education (P = 0.009), and presence of comorbidities (P < 0.001). The score combination that showed the highest sensitivity (74.5%) and specificity (81.8%) detecting NCI included 3 measures of attention/working memory, executive functioning, and verbal fluency (part A of Trail Making Test, part B of Trail Making Test, and Controlled Oral Word Association Test scores). A broader paper-based selection of measures covering 7 areas indicated a sensitivity of 100% and a specificity of 96.3% (7 measures, ~35 minutes).
Conclusions: The combination of the 3 measures presented in this study seems to be a rapid and feasible screening mean for NCI in HIV-infected patients. This approach, combined with screening for potential comorbidities and daily functioning interference, could help in the initial stages of a HIV-associated neurocognitive disorder diagnosis and in settings with limited access to neuropsychological resources.
Neurocognitive impairment (NCI) is a frequent complication that is reported to affect 30%–60% of HIV-infected patients. It has detrimental consequences for quality of life and daily functioning and has been associated with more complex patient management involving poorer adherence, more frequent virological failure, and higher mortality rates in individuals with previous mild neurocognitive changes.
Standard comprehensive neuropsychological test batteries are recommended for the assessment of NCI in HIV-infected patients. However, these tests provide broad information on neurocognitive functioning rather than useful data on the initial stages of the diagnosis of an HIV-associated neurocognitive disorder (HAND). Thus, brief and sensitive screening methods for the detection of NCI are desirable in clinical practice. Given that access to neuropsychological resources is problematic in many settings, such a screening method should be readily available. In addition, any individual with HIV infection could be at risk of developing HAND; therefore, not only those with more evident suspicion or at high risk should be tested. Nonetheless, although several methods to screen for NCI have been proposed, they are difficult to apply in clinical practice. There are several reasons for this discrepancy. First, these tools are not traditionally used in HIV infection; therefore, clinical experience is limited. Second, widespread application is affected by copyright restrictions and instrumental requirements. And third, their accuracy for detecting NCI is variable, and they generally present better properties when detecting marked impairment, rather than mild forms of HAND.
Hence, we developed the NEUrocognitive HIV study (NEU), a multicenter investigation aimed at finding a brief, feasible, and sensitive instrument to screen for NCI in HIV-infected patients. After administering a comprehensive neuropsychological test battery including paper-based, computerized, and instrumental tests to a population of HIV-infected outpatients, we compared the accuracy of score combinations enabling the detection of NCI to develop a short paper-based instrument that could prove useful in screening for HAND in routine clinical practice.
Abstract and Introduction
Abstract
Objective: Practical screening methods are necessary to detect neurocognitive impairment (NCI) in HIV-infected patients. We aimed to find a brief and feasible paper-based tool to facilitate the diagnosis of an HIV-associated neurocognitive disorder.
Methods: A total of 106 HIV-infected outpatients with variable clinical characteristics were recruited in a multicenter investigation. NCI was diagnosed using a standardized neuropsychological tests battery (7 areas, 21 measures, ~2 hours). Multiple score combinations were compared to find a paper-based method that took ≤10 minutes to apply. The presence of NCI was considered the gold standard for comparisons, and the sensitivity and specificity were calculated.
Results: Subjects were mostly middle-aged (median, 44 years) men (87%) on antiretroviral treatment. NCI was detected in 51 individuals (48%) and was associated with lower nadir CD4 count (P < 0.001), receiving antiretroviral therapy (P = 0.004), fewer years of education (P = 0.009), and presence of comorbidities (P < 0.001). The score combination that showed the highest sensitivity (74.5%) and specificity (81.8%) detecting NCI included 3 measures of attention/working memory, executive functioning, and verbal fluency (part A of Trail Making Test, part B of Trail Making Test, and Controlled Oral Word Association Test scores). A broader paper-based selection of measures covering 7 areas indicated a sensitivity of 100% and a specificity of 96.3% (7 measures, ~35 minutes).
Conclusions: The combination of the 3 measures presented in this study seems to be a rapid and feasible screening mean for NCI in HIV-infected patients. This approach, combined with screening for potential comorbidities and daily functioning interference, could help in the initial stages of a HIV-associated neurocognitive disorder diagnosis and in settings with limited access to neuropsychological resources.
Introduction
Neurocognitive impairment (NCI) is a frequent complication that is reported to affect 30%–60% of HIV-infected patients. It has detrimental consequences for quality of life and daily functioning and has been associated with more complex patient management involving poorer adherence, more frequent virological failure, and higher mortality rates in individuals with previous mild neurocognitive changes.
Standard comprehensive neuropsychological test batteries are recommended for the assessment of NCI in HIV-infected patients. However, these tests provide broad information on neurocognitive functioning rather than useful data on the initial stages of the diagnosis of an HIV-associated neurocognitive disorder (HAND). Thus, brief and sensitive screening methods for the detection of NCI are desirable in clinical practice. Given that access to neuropsychological resources is problematic in many settings, such a screening method should be readily available. In addition, any individual with HIV infection could be at risk of developing HAND; therefore, not only those with more evident suspicion or at high risk should be tested. Nonetheless, although several methods to screen for NCI have been proposed, they are difficult to apply in clinical practice. There are several reasons for this discrepancy. First, these tools are not traditionally used in HIV infection; therefore, clinical experience is limited. Second, widespread application is affected by copyright restrictions and instrumental requirements. And third, their accuracy for detecting NCI is variable, and they generally present better properties when detecting marked impairment, rather than mild forms of HAND.
Hence, we developed the NEUrocognitive HIV study (NEU), a multicenter investigation aimed at finding a brief, feasible, and sensitive instrument to screen for NCI in HIV-infected patients. After administering a comprehensive neuropsychological test battery including paper-based, computerized, and instrumental tests to a population of HIV-infected outpatients, we compared the accuracy of score combinations enabling the detection of NCI to develop a short paper-based instrument that could prove useful in screening for HAND in routine clinical practice.