HIV-associated dementia

Symptoms

The onset of primary dementia may be slow, taking months or years. Memory deficits, impaired abstract thinking, poor judgment, and clouding of consciousness and orientation are not present until the terminal stages; depression, agitation, sleeplessness, and paranoid ideation may be present. Patients become dependent for activities of daily living and typically die from complications of immobility in the terminal stage.

Etiology

Dementia may result from many illnesses, including AIDS, chronic alcoholism, Alzheimer disease, vitamin B₁₂ deficiency, carbon monoxide poisoning, cerebral anoxia, hypothyroidism, subdural hematoma, or multiple brain infarcts (vascular dementia).

Treatment

Some medications, e.g., donepezil, nemantidine, and tacrine, improve cognitive function in some patients.

Patient care

Demented patients deserve respectful and dignified care at all stages of their disease. Caregivers assist the demented with activities of daily living and with the cognitive and behavioral changes that accompany the disease. A variety of nursing interventions may reduce the risk of inadvertently precipitating behavioral symptoms. Health care professionals should reinforce the patient's abilities and successes rather than disabilities and failures. Caregivers can help the patient make optimal use of his or her abilities by reducing the adverse effects of other health conditions, sensory impairments, and cognitive defects while maximizing social and environmental factors that support functional capacity. Daily routines should be adjusted to focus on the person rather than the task, e.g., the comfort of bathing rather than the perceived need to bathe in a certain way at a certain time.

Interaction and communication strategies should be adjusted to ensure that the message delivered is the one perceived (obtain attention, make eye contact, speak directly to the individual, match nonverbal communication and gestures to the message, slow the pace of speech, use declarative sentences, use nouns instead of pronouns). Commands including the word “don’t” and questions beginning with “why” should be avoided. Tasks should be broken down into manageable steps. Reassurance and encouragement are provided to assist the patient to act more independently. Reality grounding is not necessary for such a patient; thus, if the patient asks to see his mother (who is dead), reminding him of her death may reinforce the pain of that loss. It may be better to redirect the conversation, asking the patient to talk about his mother, instead. Written agreements and reminders may not be as useful as they would be in the care of other patients, for a demented patient may not remember what has been negotiated and agreed upon in the past. The patient’s environment should be adjusted to provide needed safety. Finding the correct balance between doing too much or too little may be difficult for the caregiver, who should recognize that the balance may shift day to day and that patience and flexibility are more helpful. Caregivers must be aware that the patient will have moments of lucidity, which should be treasured but not considered evidence that the patient is exaggerating or feigning his or her disease to obtain attention. Family members who provide care must be aware that they, too, have emotional needs and can become angry, frustrated, and impatient and that they need help to learn to forgive themselves as well as the loved one they are caring for. Finally, such caregivers must learn how to accept help and should not fear to admit that they cannot carry the burden of care by themselves.