Signs and symptoms (S&S) of HAND experienced by PLHIV that can indicate changes in cognition may be a new behaviour (e.g. poorer memory). S&S may be so subtle that they are missed or the PLHIV may attribute the changes to something else, such as being tired, stressed, or busy. If the person has always misplaced keys, this is considered their usual behaviour. It is more important to take note of new changes in behaviour.
The person’s usual behaviour may be different, which could indicate that they are experiencing some cognitive change, for example, change affecting the person’s ability to perform activities of daily living (preparing meals, managing finances, remembering doctor’s appointments, and driving ability). Cognitive changes may also impact social relationships and the ability to retain employment or work at a higher level.
Key areas affected are motor skills, memory, concentration, and social engagement. In addition, executive function can also be affected whereby the person may experience changes in their ability to plan, organise and to solve complex or new problems (see Table 1). The person may also experience less language fluency.
Nurses working in a wide range of settings – sexual health, viral hepatitis and HIV, primary care, community health, custodial settings, the drug and alcohol sector and homelessness services can play key roles in increasing awareness of cognitive impairment and assisting PLHIV with developing induvial strategies and discussing and validating the person’s experience.
Table 1: Areas affected by HIV-associated neurocognitive disorder (HAND) and nursing strategies.
*Source Dementia Australia (14) and HAND Poslife NSW Resources (35, 44).
| Area affected.
|
Signs and Symptoms | Strategies |
|
Motor Skills
|
Increasing fatigue
Unsteady gait Increased clumsiness Fine motor coordination Slowed motor speed. Driving deficits Difficulty typing, texting |
Provide information slowly.
Give ample opportunity for response. May need assistance to complete activities |
|
Memory |
Forgetting dates (e.g. birthdays), where placed keys, phone
Memory affecting cooking and shopping. Missing appointments and medications Forgetting to send emails and issues for meetings.
|
Write down instructions relating to important information and check understanding.
Encourage use of memory aids (e.g. diaries, calendars, Post-it notes) Repeat and write down new information. Provide reminders of appointments Encourage a routine. Pay more deliberate attention to what the person is trying to remember |
| Concentration | How the person becomes receptive to stimuli and how he or she begins to process information Problems include:
Difficulty taking simple information and following directions. Difficulty keeping track of conversations. Short attention span May have to re-read things. Difficulty completing activities. Difficulty following plots of movies and books. Becoming mentally fatigued easily |
Present information in small amounts at a time
Present information in a manner that is clear, simple, and concrete. Limit distractions (e.g. TV) Provide prompts and reorient to task if distracted. Determine the time of day at which the person is most alert and encourage completion of difficult tasks at that point |
|
Behavioural (social) changes |
The person can experience one of two areas of behaviour change:
1: Apathy and listlessness Withdrawal Lack of motivation Impulsivity and disinhibition 2: Hypomania Change in personality. Increased agitation, aggression, and irritability (e.g. stealing, swearing, overfamiliarity) Emotional lability |
Identify the person’s change of mood, ask if he or she is aware of changes; are there any reasons for becoming withdrawn.
Arrange a psychiatric assessment to exclude depression. If not, depression assist the person to have small achievable goals. Check in with the person frequently to encourage engagement with the service. Identify changes in mood Ask the person what he or she has noticed whether there are any specific reasons for increased irritability for example. Arrange a psychiatric review (possible prescription of medications) Develop strategies to reduce elevated mood or irritability. Refer to other services to support changes in mood outcomes to life |
|
Executive function
|
The person may experience difficulty in:
Initiation of a task Planning Problem-solving Cognitive flexibility Decision-making Concept formation and abstraction Judgment- (poor judgement and assessment of situations etc) Feedback utilisation and monitoring behaviour |
Encourage client to work through problems with a trusted person and to write down alternative solutions for later referral.
Try to break complex tasks down into smaller components. Provide a structure or plan where possible. Guide the client through complex decisions step-by-step |
Consider the clinical picture and how it impacts on the person:
Which S&S are the PLHIV experiencing? Are there recent changes in behaviour or mood? Has there been an impact on their quality of life (QoL)?
It is important to ask the person (and caregiver, if they have one) questions relating to changes they may have noticed.
A question to start the conversation can simply be: “Have you noticed any changes?” acknowledge any concerns whilst not creating fear and try to normalise the next steps. This may also validate what they are feeling.