Human immunodeficiency virus (HIV) has been shown to affect the brain directly by crossing the blood-brain barrier on two types of immune cells—monocytes and macrophages. Cells within the central nervous system (CNS) have been found to have express CD4 receptor sites for HIV entry into cells. Although several hypotheses have been proposed, it is not known exactly by what mechanism neurological dysfunction occurs. Neuropsychiatric symptoms may range from barely perceptible changes in a person’s normal psychological presentation to acute delirium to profound dementia. Because of the associated immune dysfunction, secondary brain infections may cause further damage.
Studies have shown CNS abnormalities in a large percentage of clients, with 3 people in 10 who are HIV-symptomatic exhibiting symptoms of dementia. Recent studies suggest symptoms can occur prior to an acquired immunodeficiency syndrome (AIDS) diagnosis, as they are the first clinical symptoms of progression.
CLIENT ASSESSMENT DATA BASE
Activity/Rest
- Low energy level, constant fatigue
- Insomnia, change in sleep patterns
- Yawning frequently
- Wakefulness at night
Ego Integrity
- Emotional lability (e.g., irritability, anxiety, agitation, combativeness, and panic attacks)
- Reports feeling like he or she is losing his or her mind
- Feelings of powerlessness, worthlessness
Elimination
- Constipation/diarrhea
- Increasing frequency of incontinence
Food/Fluid
- Decreased interest in food
- Apraxia (inability to carry out motor functions of chewing and swallowing despite intact sensory function)
- Agnosia (failure to recognize foods despite intact sensory function); may report change in taste/smell
- Weight loss
Hygiene
- Unable to do simple/difficult tasks of activities of daily living (ADL)
- Deficits in many/all personal care areas
- No concern for hygiene; disheleved, unkempt appearance
Neurosensory
- Changes in mental status, forgetfulness, poor concentration/decreased alertness, apathy; impaired impulse control (loss of mental acuity/ability to problem-solve)
- Unrealistic expectations, free-floating anxiety, paranoid ideation
- Organic psychosis (hallucinations, delusions)
- Psychomotor retardation/slowed responses, decreased grip strength, decreased pinprick sensation, ataxic gait
- Impaired sensation or sense of position
- Numbness, tingling of feet (paresthesias)
- Deterioration in handwriting, decreased verbal comprehension, aphasia, mutism
- Seizure activity; falls/accidental fractures
- Antisocial personalities (drug users)
Pain/Discomfort
- Headache
- Pain in lower extremities, burning in feet
- Guarding behavior (posturing, withdrawal), request not to be touched
Safety
- Decline in general strength; muscle tremors, sense of lack of balance; spastic weakness, changes in gait/ataxia, hemiparesis
- Bruises, burns/lesions
- Not completing tasks (e.g., not turning off stove/burning food)
- Needle marks on skin (injection drug use)
Sexuality
- Decreased interest in sexual activity; withdrawal from others (intimacy)
- Decreased ability/inability to obtain arousal
- Unsafe sexual practices related to drug abuse
Social Interactions
- Disinterest in friends/social interaction; loss of social responsiveness; withdrawal
- Labile personality, increased anger
- Slurred speech/aphasia, mutism (late)
- Disorganized activities
- Chaotic lives owing to drug use (e.g., homelessness, unemployment)
DIAGNOSTIC STUDIES
- Choice of studies depends on individual situation to rule out conditions with symptoms mimicking HIV dementia, especially depression.
- Weschsler Adult Intelligence Scale (WAIS-R): Used to screen for the presence of HIV-induced brain damage; a low score may indicate memory loss or sensorimotor deficit (may be influenced by depression, anxiety, and hostile states).
- Minnesota Multiphasic Personality Inventory (MMPI): Identifies degree of depression, presence of personality disorders.
- Picture Drawing: Differentiates depression from dementia (depressed person can draw, demented person cannot).
- Tumor Necrosis Factor (TNF): Elevated levels may account for white matter pallor.
- Mental Status Examinations (e.g., Galveston Orientation and Amnesia Scale [GOAT]; Neurobehavioral Rating Scale [NRS, Freeman]; Self-Rating Depression Scale; Cognitive Evaluation): Identify specific deficits.
- CBC: May show anemia, affecting cerebral oxygenation/mentation.
- Blood Chemistries: Rule out metabolic causes (e.g., diabetes mellitus, hypoglycemia, hypothyroid) and electrolyte deficiencies.
- B12: Identifies diminished levels (affects synaptic responses and biochemical interactions).
- Albumin: Provides a measure of nutritional status.
- Arterial Blood Gases (ABGs): Rule out/determine contribution of hypoxia on mentation.
- Serology Rapid Plasma Reagin (RPR)/Screens: May reveal infection by STD, requiring treatment.
- Alcohol/Drug Screen: Rules out acute drug intoxication, drug or alcohol withdrawal.
- CT/MRI/Positron Emission Tomography (PET): Determine changes in brain mass (lesions or atrophy) and activity (expect to find cerebral atrophy mainly in the subcortical regions, white matter pallor, and ventricular enlargement).
- Lumbar Puncture: Rule out tumors, identify CNS infections; may show increased protein (60%), glucose, elevated white blood count (WBC) (which may reflect cytomegalovirus [CMV]); with culture/sensitivity done to identify/rule out specific infective agents/treatment options.
NURSING PRIORITIES
- Promote socially acceptable responses, limit inappropriate behavior.
- Prevent injury/complications.
- Support SO/family involvement in care.
- Provide information about condition, prognosis, and treatment.
DISCHARGE GOALS
- Maximal level of independent functioning achieved.
- Injury prevented/minimized, complications resolved.
- SO/family effectively participating in care.
- Condition, prognosis, and therapeutic regimen understood at level of ability.
- Plan in place to meet needs after discharge.
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