Screening for neurocognitive impairment in HIV-positive adults aged 50 years and older: Montreal Cognitive Assessment relates to self-reported and clinician-rated everyday functioning

Select Dietary Components Are Associated With Better Global Cognition in U.S. Adults With HIV: A Pilot Study

ABSTRACT

People with HIV (PWH) are at an increased risk for cognitive impairment. Lifestyle factors can have protective effects on cognition; little work has examined diet and cognitive function in PWH. In this cross-sectional pilot study, 86 PWH (mean age 56 years) completed diet recalls and a neurocognitive assessment. Correlations were conducted between diet and cognitive function, adjusting for total calories, sex, and education (multiple comparison correction p values are reported). Diet quality of the sample was poor. Greater calories per day ( r = 0.28, p =.08) and greater percentage of calories from saturated fatty acids (SFAs; r = 0.26, p = 0.08) were associated with better cognition. Higher intake of SFAs ( r s 0.30-0.31, p s = 0.07), amino acids ( r s = 0.27, p s = 0.08), and phosphorus ( r = 0.29, p = .07) and magnesium ( r = 0.25, p = .08) were associated with better cognition. A diet reflecting higher protein and fat relative to carbohydrates was associated with better cognition. Targeting individual nutrients, improving diet quality, and adequate caloric intake may preserve cognition in PWH.

Moderate-to-severe cognitive impairment is associated with both recent and chronic alcohol misuse in people with HIV: The New Orleans alcohol use in HIV (NOAH) study

BACKGROUND

Human immunodeficiency virus (HIV) profoundly impacts the nervous system, leading to neurological deficits including HIV-associated neurocognitive disorder (HAND). HAND represents the most common neurological comorbidity among people with HIV (PWH), and alcohol use may exacerbate cognitive deficits, especially in vulnerable populations. This study investigated relationships between alcohol use and cognition in an underserved cohort of PWH, on the hypothesis that alcohol misuse exacerbates cognitive deficits.

METHODS

Data collected from participants (n = 259; 66.7% male; mean age 52 ± 10 years) enrolled in the New Orleans Alcohol Use in HIV (NOAH) study were utilized for cross-sectional analysis. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA), and alcohol use was comprehensively measured using four metrics: the Alcohol Use Disorders Identification Test (AUDIT), 30-day timeline follow back (TLFB), lifetime drinking history, and phosphatidylethanol (PEth) levels.

RESULTS

The average MoCA score among participants was 20.7 ± 4.5, with 86.5% demonstrating cognitive impairment (MoCA < 26). Individuals with MoCA scores below 18 (moderately or severely cognitively impaired) had a higher frequency of recent severe alcohol misuse and greater lifetime alcohol consumption. Participants at increased risk for AUD (AUDIT ≥ 16) also had worse global cognition and memory task performance than those with lower AUDIT scores; this was particularly true among those aged 50 and older. Analysis of the MoCA sub-score data indicated that participants with increased AUD risk had impairments in the cognitive domains of language and memory.

CONCLUSIONS

Our findings demonstrate a high prevalence of cognitive impairment in the NOAH cohort and suggest that alcohol misuse contributes to global cognitive deficits in PWH, especially among individuals aged 50 and older. Further exploration of the impact of alcohol use on specific cognitive domains, including memory and language, should incorporate additional cognitive tasks. These findings highlight the importance of considering alcohol use and AUD risk as significant factors that may exacerbate cognitive deficits in vulnerable populations, including older PWH.

Frailty and Aging in HIV- Status Post 13 Years of National Awareness

The People aged 50 years and above comprise over 50% of people living with HIV (PLWH) in the US. Despite the advances made with anti-retroviral therapy in increasing their life span, PLWH are plagued with non-AIDS associated conditions which increase their risk for morbidity and mortality. Frailty, a decline in physical and functional reserve, is one of the manifestations of aging, has a prevalence of 5-30%, and occurs up to 2 decades earlier in people aging with HIV (PAWH). The majority of providers for PAWH have minimal experience with the concept of gerontology, frailty, and aging. Hence, there is a gap in clinicians' knowledge on how to address frailty and aging in PAWH. This review will focus on the clinical interventions that mitigate frailty and aging in PAWH as well as highlight areas of investigation towards achieving these mediations. Beyond the identification of the roles of exercise and nutrition, more studies are needed on the pragmatic approach to apply these resources to routine care. There should be continued reinforcement of the proven strategy of combination antiretroviral therapy as well as treatment of co-infections and age-appropriate health and cancer screening in PAWH.

Neurocognitive performance and quality of life of older adults with HIV on antiretroviral treatment in Northern Thailand

Introduction

With virologic suppression and longer life expectancy, older adults with HIV (OAHIV) are at risk for neurocognitive impairment (NCI). This study investigated neurocognitive performance, quality of life (QOL) and the association between OAHIV determinants.

Methods

This cross‐sectional study was conducted in OAHIV aged ≥ 50 years on antiretroviral treatment at community hospitals in Northern Thailand between September and November 2020. The Montreal Cognitive Assessment Thai Version (MoCA‐T) and the Thai‐validated Medical Outcomes Study HIV (MOS‐HIV) were used. NCI was defined as MoCA‐T scores <25: 16–24 for amnestic mild cognitive impairment (aMCI) and <16 for dementia. For QOL, higher scores meant better QOL; a physical health summary T‐score ≥50 was defined as good QOL.

Results

Overall, 269 OAHIV were enrolled; 59% were female and 99% had virologic suppression. The current median age was 61.8 years (interquartile range [IQR] 58.9–65.7). The median duration of antiretroviral treatment was 10.5 years (IQR 8.5–13.5). The current median CD4 count (234 tested) was 484 cells/mm³ (IQR 339–634), and 99% had plasma HIV RNA <40 copies/ml (229 tested). The median MoCA‐T score was 20.0 (IQR 16.3–23.0). There were 234 OAHIV (87.3%) with NCI: 182 (67.9%) with aMCI and 52 (19.4%) with dementia. A hundred and ninety (70.6%) had good QOL. Bivariate analysis revealed no correlation between MoCA‐T scores and QOL. Multivariable linear regression analysis revealed that MoCA‐T score was associated with older age (r = –0.144, p = 0.002), lower education (r = 0.629, p < 0.001), lower income (r = 0.797, p = 0.040) and shorter treatment duration (r = 0.189, p = 0.006).

Conclusions

The vast majority of OAHIV with virologic suppression had NCI. Approximately two‐thirds had a mild impairment and one‐fifth had dementia. Neurocognitive performance and QOL were not correlated. Addressing mild NCI would enable more targeted monitoring. Early intervention and support could minimize functional impairment with increased age.

Self-Reported Cognitive Function in Persons with Nonneurological Chronic Diseases: A Systematic Review

Background

Globally, one in three adults has a chronic condition. Many chronic diseases that are not neurological in nature (e.g., diabetes and heart failure) are increasingly associated with cognitive symptoms. However, the instruments used to assess cognitive symptoms in those with nonneurologic chronic illness are heterogeneous, and questions remain as to how cognitive symptoms may be related to demographic and clinical outcome variables, neurocognitive test performance, and other patient-reported outcomes. In this review, we describe associations among self-reported cognitive function, cognitive performance, and additional patient-reported outcomes as well as how cognitive symptoms are measured in nonneurologic chronic illness.

Method

Multiple databases (PubMed, Medline, CINAHL, PsycInfo, EMBASE, SCOPUS, the Cochrane Library, and Academic Search Complete) were searched for studies from 1990 to 2020 that provided data on self-reported cognitive symptoms in those with nonneurological chronic conditions. Initial search yielded 304 articles, of which 32 met inclusion criteria. Quality assessment was conducted using the Critical Appraisal Skills Programme.

Results

Thirty-two total studies were included: twenty cross-sectional, 10 longitudinal, and 2 randomized controlled trials. The tools used to assess self-reported cognitive function in the studies were heterogeneous: 28 unique tools were used. Thirty studies examined associations among self-reported cognitive function and other patient-reported outcomes. In 19 there were significant associations. Six studies showed no significant associations between neuropsychological tests and self-reported cognitive function; another 6 studies found a significant association.

Conclusion

Tools to assess cognitive symptoms were heterogeneous. In most studies, self-reported cognitive symptoms were not correlated with neuropsychological test results, but the majority of studies found a strong association between self-reported cognitive function and other patient-reported outcomes. Implications. Consensus on measuring cognitive symptoms would facilitate cross-study comparisons and facilitate scientific progress in those with nonneurological chronic conditions. Based on these results, there is a need to establish a standardized approach for self-reported cognitive function measurement in patients with nonneurologic chronic illness.

Factors associated to neurocognitive impairment in older adults living with HIV

OBJECTIVE

The HIV infection is a chronic disease that causes neurocognitive impairment (NI) and has been related with early development of frailty. We aimed to study the main risk factors for neurocognitive disorders and frailty in HIV older adults.

MATERIALS AND METHODS

Cross-sectional study with 40 HIV individuals older than 65 years under antiretroviral therapy in Hospital del Mar (Barcelona) recruited between November 2019 and October 2020. Data has been obtained through clinical scores and a blood sample to evaluate NI and frailty and has been analyzed with non-parametric tests and a multivariate logistic regression model.

RESULTS

Among the 40 patients admitted for the study, 14 (35%) had positive screening for NI. We found that HIV individuals with nadir CD4+ T-cell count lower than 350 cells/mm³ had 39.7 more risk for NI (95% CI 2.49-632.10; p = 0.009). Those with a lower education level had 22.78 more risk for neurocognitive disorders (95% CI 2.13-242.71; p = 0.01) and suffering any comorbidity with a punctuation ≥ 1 in the Charlson Comorbidity index had an increased risk of 18.26 of developing NI and frailty (95% CI 1.30-256.33; p = 0.031), among them diabetes was significantly more frequent in NI.

CONCLUSION

We observed that the main risk factors for a positive NI screening in HIV older adults were low education level, a nadir CD4+ T-cell count < 350 cells/mm³ and the presence of any comorbidity, highlighting diabetes among them.

International HIV Dementia Scale for HIV-Associated Neurocognitive Disorders: A Systematic Review and Meta-Analysis

The present study aims to systematically review the evidence on the accuracy of the International HIV Dementia Scale (IHDS) test for diagnosing human immunodeficiency virus (HIV)-associated neurocognitive disorders (HAND) and outline the quality and quantity of research evidence available on the accuracy of IHDS in people living with HIV. We conducted a systematic literature review, searching five databases from inception until July 2020. We extracted dichotomized positive and negative test results at various thresholds and calculated the sensitivity and specificity of IHDS. Quality assessment was performed according to the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) criteria. Fifteen cross-sectional studies, published between 2011 and 2018, met the inclusion criteria for meta-analysis. Overall, 3760 patients were included, but most studies recruited small samples. We assessed most studies as being applicable to the review question, though we had concerns about the selection of participants in three studies. The accuracy of IHDS was investigated at thirteen cut-off points (scores 6-12). The threshold of 10 is the most useful for optimal HAND screening (including asymptomatic neurocognitive disorder, symptomatic HAND, and HIV-associated dementia) with fair diagnostic accuracy.

Robot-Based Assessment of HIV-Related Motor and Cognitive Impairment for Neurorehabilitation

There is a pressing need for strategies to slow or treat the progression of functional decline in people living with HIV. This paper explores a novel rehabilitation robotics approach to measuring cognitive and motor impairment in adults living with HIV, including a subset with stroke. We conducted a cross-sectional study with 21 subjects exhibiting varying levels of cognitive and motor impairment. We tested three robot-based tasks – trajectory tracking, N-back, and spatial span – to assess if metrics derived from these tasks were sensitive to differences in subjects with varying levels of executive function and upper limb motor impairments. We also examined how well these metrics could estimate clinical cognitive and motor scores. The results showed that the average sequence length on the robot-based spatial span task was the most sensitive to differences between various cognitive and motor impairment levels. We observed strong correlations between robot-based measures and clinical cognitive and motor assessments relevant to the HIV population, such as the Color Trails 1 (rho = 0.83), Color Trails 2 (rho = 0.71), Digit Symbol – Coding (rho = 0.81), Montreal Cognitive Assessment – Executive Function subscore (rho = 0.70), and Box and Block Test (rho = 0.74). Importantly, our results highlight that gross motor impairment may be overlooked in the assessment of HIV-related disability. This study shows that rehabilitation robotics can be expanded to new populations beyond stroke, namely to people living with HIV and those with cognitive impairments.

HIV and three dimensions of Wisdom: Association with cognitive function and physical and mental well-being: For: Psychiatry Research

Wisdom is a unique human personality trait with cognitive, affective or compassionate, and reflective dimensions. We evaluated relationships of three specific dimensions of wisdom with cognitive function and physical and mental well-being in people with HIV (PWH) and HIV-negative (HIV-) participants. Subjects included 138 adults (61 PWH, 77 HIV-) from the San Diego community. Validated measures were used to assess wisdom and well-being. Cognitive function was assessed via the Montreal Cognitive Assessment. We conducted multivariate linear regressions to evaluate the associations of wisdom dimensions with cognitive function and physical and mental well-being. Compared to the HIV- group, PWH had lower mean scores on cognitive function, and physical and mental well-being, and cognitive and reflective dimensions of wisdom, but similar scores on affective or compassionate wisdom. Among PWH, higher total wisdom scores were associated with older age, lower likelihood of substance dependence, greater mental well-being, better cognitive function, higher resilience, social support, and optimism scores, as well as lower levels of perceived stress and nadir CD4 count. Our findings of an association of different dimensions of wisdom with physical and/or mental well-being in PWH would point to a possibility that enhancing these dimensions of wisdom might improve health outcomes in PWH.

Robot-based assessment of HIV-related motor and cognitive impairment for neurorehabilitation

There is a pressing need for strategies to slow or treat the progression of functional decline in people living with HIV. This paper explores a novel rehabilitation robotics approach to measuring cognitive and motor impairment in adults living with HIV, including a subset with stroke. We conducted a cross-sectional study with 21 subjects exhibiting varying levels of cognitive and motor impairment. We developed three robot-based tasks – trajectory tracking, N-back, and spatial span – to assess if metrics derived from these tasks were sensitive to differences in subjects with varying levels of executive function and upper limb motor impairments. We also examined if these metrics could estimate clinical cognitive and motor scores. The results showed that the average sequence length on the robot-based spatial span task was the most sensitive to differences between subjects’ cognitive and motor impairment levels. We observed strong correlations between robot-based measures and clinical cognitive and motor assessments relevant to the HIV population, such as the Color Trails 1 (rho = 0.83), Color Trails 2 (rho = 0.71), Digit Symbol – Coding (rho = 0.81), Montreal Cognitive Assessment – Executive Function subscore (rho = 0.70), and Box and Block Test (rho = 0.74). Importantly, our results highlight that gross motor impairment may be overlooked in the assessment of HIV-related disability. This study shows that rehabilitation robotics can be expanded to new populations beyond stroke, namely to people living with HIV and those with cognitive impairments.

An Exploratory Study of Correlates of Allostatic Load in Older People Living With HIV

BACKGROUND

Older people living with HIV (PLWH) experience poorer outcomes than seronegative counterparts. Allostatic load (AL) markers have shown utility as indicators of cumulative wear-and-tear of stress on biological systems. However, little is known about correlates of AL in PLWH.

METHODS

Ninety-six PLWH aged 50+ completed a comprehensive neurobehavioral assessment and blood draw. Select AL markers (ie, 10 blood markers) were available for a subset (n = 75) of seronegative controls. AL was operationalized as a sum of markers in the highest risk quartile for: cortisol, DHEA, IL-6, TNF-alpha, C-reactive protein, glucose, total cholesterol, high-density lipoprotein cholesterol, triglycerides, albumin, systolic and diastolic blood pressure, and body mass index.

RESULTS

PLWH had higher risk levels than seronegatives with small-medium effect sizes for several biomarkers. Among HIV+ African Americans (84% of PLWH), higher AL was associated with lower psychological resilience (rho = -0.27, P = 0.02), less physical activity (rho = -0.29, P < 0.01), poorer neurocognitive functioning (rho = -0.26, P = 0.02), greater basic activity of daily living complaints (P < 0.01), and diabetes (P < 0.01). Multivariable regressions within African American PLWH for significant AL-outcome associations (ie, neurocognitive function, basic activity of daily living complaints, diabetes) showed that associations with AL remained significant when adjusting for relevant covariates. Mediation analysis suggested that the association between socioeconomic status and neurocognitive function was mediated by AL.

CONCLUSIONS

These exploratory findings are consistent with the larger aging literature, suggesting that lower AL may serve as a pathway to better health and functional outcomes, particularly in African American PLWH. Furthermore, resilience and physical activity may reduce AL in this population.

Neurocognitive evaluation using the International HIV Dementia Scale (IHDS) and Montreal Cognitive Assessment Test (MoCA) in an HIV-2 population

OBJECTIVES

We aimed to characterize neurocognitive impairment (NI) in an HIV-2 population using an observational cross-sectional study in four Portuguese hospitals.

METHODS

Adult HIV-2-infected patients were included. Montreal Cognitive Assessment Test (MoCA) and International HIV Dementia Scale (IHDS) scales were applied for screening of NI. Patient Health Questionnaire-9 (PHQ-9) and Instrumental Activities of Daily Living (IADL) scales were used for assessment of depression and functionality. A multivariate analysis was performed to assess for risk factors for NI.

RESULTS

Eighty-one patients were included, 50.6% of African origin (n = 41) and 49.4% of Portuguese origin (n = 40). The MoCA scale showed alterations in 81.5% of patients (100% of migrants vs. 62.5% of non-migrants, P < 0.001) and the IHDS scale showed alterations in 42%. Both scales were altered simultaneously in 35.8%. Variables independently associated with NI were age [odds ratio (OR) = 0.885] and migrant status (OR = 9.150).

CONCLUSIONS

Neurocognitive impairment (both scales altered) was present in 35.8%, which is comparable to what is described for HIV-1. The MoCA performed worse in the migrant population and might not be applicable in this setting.

Cognitive Reserve Over the Lifespan: Neurocognitive Implications for Aging With HIV

Approximately 59% of adults living with HIV experience HIV-associated neurocognitive disorder, a collection of symptoms and cognitive deficits in various cognitive domains. As the HIV population ages, the prevalence and severity of such cognitive deficits are expected to grow. Understanding how these cognitive deficits manifest is important for nurses and health care providers. This article provides an overview of cognitive reserve and evidence of how it is compromised by HIV, aging, and individual characteristics. Within this context of cognitive reserve, the role of neuroinflammation, neurotoxicity, substance use, comorbidities, depression and anxiety, social isolation, and sedentary lifestyle is reviewed. From this, strategies used to address cognitive deficits are provided, including topics such as psychostimulants, cognitive training, multimodal lifestyle interventions, and compensation strategies. Scenarios of successful and unsuccessful cognitive aging are presented to provide a lifespan perspective of cognitive reserve. Implications for clinical practice and research are provided, as it relates to aging.

Absence of peripapillary retinal nerve-fiber-layer thinning in combined antiretroviral therapy-treated, well-sustained aviremic persons living with HIV

Purpose

To compare peripapillary retinal nerve-fiber–layer (pRNFL) thickness, total retina macular volume, and ganglion-cell-layer (GCL) macular volume and thickness between persons living with HIV (PLHIVs) with well-controlled infections and good immune recovery, and sex- and age-matched HIV-uninfected controls (HUCs).

Methods

This prospective cross-sectional study (www.clinicaltrials.gov identifier: NCT02003989) included 56 PLHIVs, infected for ≥10 [median 20.2] years and with sustained plasma HIV-load suppression on combined antiretroviral therapy (cART) for ≥5 years, and 56 matched HUCs. Participants underwent spectral-domain optical coherence tomography (SD-OCT) with thorough ophthalmological examinations and brain magnetic resonance imaging (MRI). Their overall and quadrant pRNFL thicknesses, total macular volumes, and GCL macular volumes and thicknesses were compared. Cerebral small-vessel diseases (CSVD) complied with STRIVE criteria.

Results

Median [interquartile range, IQR] ages of PLHIVs and HUCs, respectively, were 52 [46–60] and 52 [44–60] years. Median [IQR] PLHIVs’ nadir CD4+ T-cell count and current CD4/CD8 T-cell ratio were 249/μL [158–350] and 0.95 [0.67–1.10], respectively; HIV-seropositivity duration was 20.2 [15.9–24.5] years; cART duration was 16.8 [12.6–18.6] years; and aviremia duration was 11.4 [7.8–13.6] years. No significant between-group pRNFL thickness, total macular volume, macular GCL-volume and -thickness differences were found. MRI-detected CSVD in 21 (38%) PLHIVs and 14 (25%) HUCs was associated with overall thinner pRNFLs, and smaller total retina and GCL macular volumes, independently of HIV status.

Conclusions

SD-OCT could not detect pRNFL thinning or macular GCL-volume reduction in well-sustained, aviremic, cART-treated PLHIVs who achieved good immune recovery. However, CSVD was associated with thinner pRNFLs and GCLs, independently of HIV status.

Functional deficits and other psychiatric associations with abnormal scores on the Montreal Cognitive Assessment (MoCA) in older HIV-infected patients

OBJECTIVE

The authors assessed the association of physical function, social variables, functional status, and psychiatric co-morbidity with cognitive function among older HIV-infected adults.

DESIGN

From 2012-2014, a cross-sectional study was conducted among HIV-infected patients ages 50 or older who underwent comprehensive clinical geriatric assessment.

SETTING

Two San Francisco HIV clinics.

PARTICIPANTS

359 HIV-infected patients age 50 years or older.

MEASUREMENTS

Unadjusted and adjusted Poisson regression measured prevalence ratios and 95% confidence intervals for demographic, functional and psychiatric variables and their association with cognitive impairment using a Montreal Cognitive Assessment (MoCA) score < 26 as reflective of cognitive impairment.

RESULTS

Thirty-four percent of participants had a MoCA score of < 26. In unadjusted analyses, the following variables were significantly associated with an abnormal MoCA score: born female, not identifying as homosexual, non-white race, high school or less educational attainment, annual income < $10,000, tobacco use, slower gait speed, reported problems with balance, and poor social support. In subsequent adjusted analysis, the following variables were significantly associated with an abnormal MoCA score: not identifying as homosexual, non-white race, longer 4-meter walk time, and poor social support. Psychiatric symptoms of depressive, anxiety, and post-traumatic stress disorders did not correlate with abnormal MoCA scores.

CONCLUSIONS

Cognitive impairment remains common in older HIV-infected patients. Counter to expectations, co-morbid psychiatric symptoms were not associated with cognitive impairment, suggesting that cognitive impairment in this sample may be due to neurocognitive disorders, not due to other psychiatric illness. The other conditions associated with cognitive impairment in this sample may warrant separate clinical and social interventions to optimize patient outcomes.

NEU Screen Shows High Accuracy in Detecting Cognitive Impairment in Older Persons Living With HIV

The NEUrocognitive (NEU) Screen is a practical tool proposed to screen for HIV-associated cognitive impairment in the clinical setting. This is a pencil-and-paper method that can be applied rapidly (≤10 minutes for administration) and has no copyright limitations. In this study, we aimed at investigating its diagnostic accuracy in an older population of persons living with HIV (PLWH), with cutoffs set at 30, 40, 50, and 60 years. Data were collected from a sample of 368 PLWH who underwent a comprehensive neuropsychological tests battery (gold standard). Results of statistical tests showed that accuracy of the NEU Screen increased with age of the participants. The highest degree of precision, with a sensitivity of 91% and specificity of 92%, was obtained for people ages 60 years or older (correct classification: 91%). These optimal results point to the great potential of the NEU Screen as a tool for detecting cognitive disorders in older PLWH.

Screening for HIV-Associated Neurocognitive Impairment: Relevance of Psychological Factors and Era of Commencement of Antiretroviral Therapy

Neurocognitive impairment (NCI) is common in people aging with HIV and can adversely affect health-related quality of life. However, early NCI may be largely asymptomatic and neurocognitive function is rarely assessed in the context of routine clinical care. In this study, we considered the utility of two assessment tools as screens for NCI in patients attending a community-based clinic (N = 58; mean age = 57 years): the Montreal Cognitive Assessment (MoCA) and a 3-item cognitive concerns questionnaire derived from the HIV Dementia Scale. Health-related quality of life and depression/anxiety were also measured. Indication of NCI using the MoCA was more prevalent compared to the 3-item questionnaire and was associated with the patients' initial antiretroviral therapy commencing between the years of 1997 and 2001, independently of age. Findings of the MoCA were not confounded by existing mood disorders, unlike the 3-item questionnaire. Therefore, we suggest implementing the MoCA as an initial screen for NCI.

Montreal Cognitive Assessment (MoCA) for HIV-Associated Neurocognitive Disorders

This study aims to systematically review the evidence on the accuracy of the Montreal Cognitive Assessment (MoCA) test for diagnosing HIV-associated neurocognitive disorders (HAND) and to outline the quality and quantity of research evidence available about the accuracy of MoCA in populations infected with HIV. We conducted a systematic literature review, searching five databases from inception until January 2019. We extracted dichotomized positive and negative test results at various thresholds and calculated the sensitivity and specificity of MoCA. Quality assessment was performed according to the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) criteria. Eight cross-sectional studies met the inclusion criteria for meta-analysis. Overall, 1014 patients were included but most studies recruited small samples. Recruitment period ranged from 2009 to 2015. We assessed most studies as being applicable to the review question though we had concerns about the selection of participants in three studies. The accuracy of MoCA for diagnosing HAND was reported at six cut-off points (scores 22-27). The MoCA test provides information about general cognitive functioning disturbances that contribute to a diagnosis of HAND. A lower threshold than the original cut-off of 26 is probably more useful for optimal screening of HAND, as it lowers false positive rates and improves diagnostic accuracy. Nonetheless, the choice of cut-off always comes with a sensitivity-specificity trade-off, the preferred cut point depending on whether sensitivity or specificity is more valuable in a given context.

Critical, and not functional, health literacy is associated with missed HIV clinic visits in adults and older adults living with HIV in the Deep South

Engagement in care is a key component of the HIV treatment cascade and is influenced by biopsychosocial factors. Little is known about the association of health literacy with this impactful outcome in people living with HIV (PLWH). Ninety-five PLWH completed a comprehensive battery including health literacy measures covering several domains (i.e., numeracy, reading, self-efficacy, and ability to appraise and access health information). Engagement in care was operationalized as missed clinic visits (i.e., proportion of clinic visits in the prior 24 months where the participant did not attend and did not cancel or reschedule). The ability to appraise health information (measured by the Newest Vital Sign [NVS]) was the only significant health literacy predictor of missed clinic visits. Hierarchical linear regression including clinico-demographics and all health literacy variables showed that age, depression, neurocognition, and NVS were significant (p < 0.05) correlates of missed clinic visits. The ability to appraise health information was a strong and independent predictor of missed clinic visits in PLWH, even in the context of traditional correlates. Such measures may be useful in identifying PLWH with low health literacy who may be at risk for poorer engagement in care. Future research developing interventions targeting this health literacy dimension are warranted.

HIV and aging: A primer for NPs

Estimates indicate 70% of all individuals with HIV will be age 50 or older by 2030. Chronic conditions, including cardiovascular disease, diabetes mellitus, kidney disease, malignancies, neurocognitive disorders, and osteopenia or osteoporosis, occur more frequently in patients with HIV and have become the leading cause of morbidity in this population. NPs play an integral role in helping this population age healthfully.

Resilience attenuates the association between neurocognitive functioning and everyday functioning in individuals aging with HIV in the Deep South

OBJECTIVES

Adults aging with HIV are at risk for poorer neurocognitive and daily functioning. Identifying factors to protect such outcomes is a significant research priority. The aim of this study was to explore the role of resilience in cognitive and everyday functioning in a largely African American and low socioeconomic status sample of adults and older adults with HIV in the Deep South.

METHODS/DESIGN

In this cross-sectional study 100 HIV+ middle-aged and older adults (range 40-73; 61% aged 50+) completed a comprehensive neurocognitive battery along with self-reported measures of resilience and everyday functioning.

RESULTS

Higher resilience was associated with better global neurocognitive functioning (rho = 0.31, P < 0.01), as well as better functioning in all domains (verbal fluency, executive functioning, speed of information processing, learning, working memory) except recall and motor skills. Resilience was also significantly associated with instrumental activities of daily living (IADL) dependence, with lower resilience observed in those with IADL dependence compared with those who were IADL independent (P < 0.01). In a multiple regression adjusting for data-driven covariates (verbal IQ, income, depression), and global neurocognitive impairment, resilience was the only significant (P = 0.02) correlate of IADL dependence. A follow-up mediation showed that the direct relationship between neurocognitive functioning and IADL declines was fully attenuated after accounting for shared variance with resilience.

CONCLUSIONS

Resilience is associated with better cognitive and functional outcomes in people aging with HIV. While further work is needed to understand these associations over time, results suggest interventions to build resilience may promote successful aging in this vulnerable population.

Diagnostic accuracy of new and old cognitive screening tools for HIV-associated neurocognitive disorders

OBJECTIVES

Considering the similarities between HIV-associated neurocognitive disorders (HAND) and neurodegenerative dementias and the frequency of executive dysfunctions among HIV-positive patients, we evaluated the accuracy of the Frontal Assessment Battery and Clock-Drawing Test together with the Three Questions Test and International HIV Dementia Scale to screen for HAND.

METHODS

A cross-sectional monocentric study was conducted from 2010 to 2017. The index tests were represented by the four screening tools; the reference standard was represented by a comprehensive neurocognitive battery used to investigate 10 cognitive domains. Patients were screened by a trained infectious diseases physician and those showing International HIV Dementia Scale scores ≤ 10 and/or complaining of neurocognitive symptoms were then evaluated by a trained neuropsychologist.

RESULTS

A total of 650 patients were screened and 281 received the full neurocognitive evaluation. HAND was diagnosed in 140 individuals. The sensitivity, specificity, correct classification rate and area under the receiver operating characteristic curve (AUROC) were, respectively, as follows: Frontal Assessment Battery, 40.7%, 95.1%, 68.3% and 0.81; International HIV Dementia Scale, 74.4%, 56.8%, 65.4% and 0.73; Clock-Drawing Test, 30.9%, 73.4%, 53.8% and 0.56; and Three Questions Test, 37.3%, 54.1% and 45.7%. Raising the Frontal Assessment Battery's cut-off to ≤ 16 improved its sensitivity, specificity and correct classification rate to 78.0%, 63.9% and 70.8%, respectively.

CONCLUSIONS

We observed poor screening performances of the Three Questions and Clock-Drawing Tests. While the International HIV Dementia Scale showed a poor specificity, the Frontal Assessment Battery showed the highest correct classification rate and a promising performance at different exploratory cut-offs.

Examining the effectiveness of a cognitive intervention to improve cognitive function in a population of older adults living with HIV: a pilot study

OBJECTIVE

The purpose of this randomized-controlled pilot study was to explore the effectiveness of a home-based computerized cognitive training intervention in improving cognitive function in a population of older adults with mild cognitive impairment who are living with HIV.

METHODS

In all, 24 participants were enrolled in this study. All study participants were impaired [defined as Montreal Cognitive Assessment (MoCA) score < 26]; 12 were randomly assigned to a computer-training intervention group and 12 to a control group. The intervention group used a home-based computerized cognitive training program for 8 weeks, while the control group received health-related newsletter via email and follow-up phone calls. Cognitive function was measured at study entry, immediately post intervention, and 8 and 16 weeks post intervention.

RESULTS

This study achieved a 92% retention rate, losing two persons from the intervention group. Participants in the intervention group scored significantly higher on cognitive testing immediately post intervention compared to the control group: F(1, 19) = 4.92, p = 0.04. The partial Eta squared of 0.32 indicates a small to moderate effect size.

DISCUSSION

Cognitive improvement was seen immediately after the intervention, and cognitive improvement was still evident 16 weeks post intervention. Cognitive training could be considered as an option for older adults with HIV experiencing mild cognitive impairment.