1 Delete figure and replace with below, “Prevalence of ...



Table 1 Current AAN criteria (1991 definition)

1

2 Criteria for clinical diagnosis of central nervous system disorders in HIV-infected adults and adolescents

HIV-1 associated cognitive/motor complex

All of the following diagnoses require laboratory evidence for systemic HIV-1 infection (ELISA test confirmed by Western blot, polymerase chain reaction, or culture)

1 I. Sufficient for diagnosis of AIDS

A. HIV-1-associated dementia complex*

Probable (must have each of the following):

1. Acquired abnormality in at least two of the following cognitive abilities (present for at least 1 month): attention/concentration, speed of processing information, abstraction/reasoning, visuospatial skills, memory/learning, and speech/language. The decline should be verified by reliable history and mental status examination. In all cases, when possible, history should be obtained from an informant, and examination should be supplemented by neuropsychological testing.

Cognitive dysfunction causing impairment of work or activities of daily living** (objectively verifiable or by report of a key informant). This impairment should not be attributable solely to severe systemic illness.

2. At least one of the following:

a. Acquired abnormality in motor function or performance verified by clinical examination (e.g., slowed rapid movements, abnormal gait, limb incoordination, hyperreflexia, hypertonia, or weakness), neuropsychological tests (e.g., fine motor speed, manual dexterity, perceptual motor skills), or both.

b. Decline in motivation or emotional control or change in social behavior. This may be characterized by any of the following: change in personality with apathy, inertia, irritability, emotional lability, or new onset of impaired judgment characterized by socially inappropriate behavior or disinhibition.

3. Absence of clouding of consciousness during a period long enough to establish the presence of #1.

4. Evidence of another etiology, including active CNS opportunistic infection or malignancy, psychiatric disorders (e.g., depressive disorder), active alcohol or substance use, or acute or chronic substance withdrawal, must be sought from history, physical and psychiatric examination, and appropriate laboratory and radiologic investigation (e.g., lumbar puncture, neuroimaging). If another potential etiology (e.g., major depression) is present, it is not the cause of the above cognitive, motor, or behavioral symptoms and signs.

Possible (must have one of the following):

1. Other potential etiology present (must have each of the following):

a. As above (see Probable) #1, 2, and 3.

b. Other potential etiology is present but the cause of #1 above is certain.

2. Incomplete clinical evaluation (must have each of the following):

a. As above (see Probable) #1, 2, and 3.

b. Etiology cannot be determined (appropriate laboratory or radiologic investigations no performed).

NB: HIV-associated myelopathy is not included in this table for brevity, but was in the original 1991 definition.

II. Not sufficient for diagnosis of AIDS

HIV-1-associated minor cognitive/motor disorder

Probable (must have each of the following):

1. Cognitive/motor/behavioral abnormalities (must have each of the following):

a. At least two of the following acquired cognitive, motor, or behavioral symptoms (present for at least 1 month) verified by reliable history (when possible, from an informant):

1) Impaired attention or concentration

2) Mental slowing

3) Impaired memory

4) Slowed movements

5) Incoordination

6) Personality change, or irritability or emotional lability

b. Acquired cognitive/motor abnormality verified by clinical neurologic examination or neuropsychological testing (e.g., fine motor speed, manual dexterity, perceptual motor skills, attention/concentration, speed of processing of information, abstraction/reasoning, visuospatial skills, memory/learning, or speech/language).

2. Disturbance from cognitive/motor/behavioral abnormalities (see #1) causes mild impairment of work or activities of daily living (objectively verifiable or by report of a key informant).

3. Does not meet criteria for HIV-1-associated dementia complex or HIV-1-associated myelopathy.

4. No evidence of another etiology, including active CNS opportunistic infection or malignancy, or severe systemic illness determined by appropriate history, physical examination, and laboratory and radiologic investigation (e.g., lumbar puncture, neuroimaging). The above features should not be attributable solely to the effects of active alcohol or substance use, acute or chronic substance withdrawal, adjustment disorder, or other psychiatric disorders.

Possible (must have one of the following):

1. Other potential etiology present (must have each of the following):

a. As above (see Probable) #1, 2, and 3.

b. Other potential etiology is present and the cause of the cognitive/motor/behavioral abnormalities is uncertain.

2. Incomplete clinical evaluation (must have each of the following):

a. As above (see Probable) #1, 2, and 3.

b. Etiology cannot be determined (appropriate laboratory or radiologic investigations not performed).

*For research purposes, HIV-1 associated dementia complex can be coded to describe the major features:

HIV-1-associated dementia complex requires criteria 1, 2a, 2b, 3 and 4.

HIV-1-associated dementia complex (motor) requires criteria 1, 2a, 3, and 4.

HIV-1-associated dementia complex (behavior) requires criteria 1, 2b, 3, and 4.

**The level of impairment due to cognitive dysfunction should be assessed as follows:

Mild: Decline in performance at work, including work in the home that is conspicuous to others. Unable to work at usual job, although may be able to work at a much less demanding job. Activities of daily living or social activities are impaired but not to a degree making the person completely dependent on others. More complicated daily tasks or recreational activities cannot be undertaken. Capable of basic self-care such as feeding, dressing, and maintaining personal hygiene, but activities such as handling money, shopping, using public transportation, driving a car, or keeping track of appointments or medications is impaired.

Moderate: Unable to work, including work in the home. Unable to function without some assistance of another in daily living, including dressing, maintaining personal hygiene, eating, shopping, handling money, and walking, but able to communicate basic needs.

Severe: Unable to perform any activities of daily living without assistance. Requires continual supervision. Unable to maintain personal hygiene, nearly or absolutely mute.

Table 2 (Appendix). Outline of criteria for classifying HIV-related neurocognitive disorders

| |Neuropsychological (NP) Testing is available|NP Testing not available |

|Asymptomatic |NP impairment in > 2 cognitive domains that |Mental Status Exam (MSE) impairment involving >2 |

|Neurocognitive |cannot be explained by opportunistic CNS |cognitive domains, that cannot be explained by |

|Impairment (ANI) |disease, systemic illness, psychiatric |opportunistic CNS disease, systemic illness, |

| |illness, substance use disorders, or |psychiatric illness, substance use disorders, or |

| |medications with CNS effects. No reported |medications with CNS effects. |

| |or demonstrated functional decline. |No reported or demonstrated functional decline. |

|Mild Neurocognitive Disorder (MND) |At least mild NP impairment (>1 SD below a |At least mild MSE impairment (>1SD below a |

| |demographically appropriate normative mean),|demographically appropriate normative mean), involving|

| |involving >2 cognitive domains that cannot |>2 cognitive domains, that cannot be explained by |

| |be explained by confounding conditions. |confounding conditions. |

| | |AND |

| |AND |Reported or demonstrated |

| |Reported or demonstrated mild functional |mild functional decline that cannot be explained by |

| |decline that cannot be explained by |confounding conditions. |

| |confounding conditions. | |

|HIV-Associated Dementia (HAD) |> Moderate NP impairment (>2SD below a |> Moderate MSE impairment |

|Note: Severity of NP impairment and |demographically appropriate normative mean) |(>2SD below a demographically appropriate normative |

|functional decline must both meet these |on > 2 cognitive domains.* Impairment cannot|mean), involving >2 cognitive domains, that cannot be |

|standards in order to diagnose the person |be explained by confounding conditions (see |explained by confounding conditions. |

|as having HAD. If either NP impairment or|Table 2). |AND |

|functional decline is mild, the condition |AND |Reported or demonstrated |

|should be classified as MND. |Reported or demonstrated major functional |major functional decline that |

| |decline that cannot be explained by |cannot be explained by confounding conditions. |

| |confounding conditions. *Alternatively, one | |

| |domain could be more severely impaired (>2.5| |

| |SD below the mean) and another less severely| |

| |impaired (>1 SD below the mean) -–see | |

| |Woods et al., 2004 (7). | |

Table 3 (Appendix). Examples of NP tests that may be used to document impairments in

ability domains.

Fluency

Controlled Oral Word Association Test (FAS) (1, 2)

Thurstone Word Fluency Test (3)

Category Fluency (4)

Action Fluency (5)

Design Fluency Tests (6, 7)

Executive Functions

Stroop Color and Word Test (8)

Trailmaking Test – Part B (3, 9)

Color Trails –II (10)

Wisconsin Card Sorting Test (11)

Halstead Category Test (3, 9)

Odd Man Out Test (12-14)

Tower Tests (15-17)

Delis-Kaplan Executive Function System (7)

Speed of Information Processing

WAIS-III Digit Symbol Subtest (18)

WAIS-III Symbol Search Subtest (18)

Symbol Digit Modalities Test (19)

Trailmaking Test – Part A (3, 9)

Color Trails – I (10)

Digit Vigilance Test (3, 20)

Stroop Color Naming (8)

Reaction Time Tests, e.g., California Computerized Assessment Battery (21)

Attention/Working Memory

WAIS-III Digit Span Subtest (18)

WAIS-III Letter-Number Sequencing Subtest (18)

WMS-III Spatial Span Subtest (22)

Paced Auditory Serial Addition Test (23)

Digit Vigilance Test (error component) (3, 20)

Verbal and Visual Learning

Verbal:

California Verbal Learning Test (Original and Revised; Total Learning) (24)

Rey Auditory Verbal Learning Test (Total Learning) (25)

Story Memory Test (Learning component) (3)

Hopkins Verbal Learning Test- Revised (Total Learning) (26)

Buschke Selective Reminding Test (27)

WMS-III Logical Memory I (22)

WMS-III Paired Associates I (22)

Visual:

WMS-III Visual Reproduction-I (22)

WMS-III Family Pictures-I (22)

Brief Visuospatial Memory Test – Revised (Total Learning) (28)

Figure Memory Test (Learning component) (3)

Rey-Osterreith Complex Figure Test (Immediate Recall) (29, 30)

Verbal and Visual Memory

Delayed recall scores of the 12 learning/memory tests listed above, with interpretation also guided by results on any normed, forgetting/savings scores and delayed recognition scores.

Motor Skills

Grooved Pegboard Test (3, 31)

Purdue Pegboard Test (32, 33)

Arendt Central Motor Test Battery (34, 35)

Finger Tapping Test (3)

Timed Gait (36)

The area of quantitative testing of motor function needs further exploration, but data from Arendt et al seem promising measures that track with cognitive improvements with HAART. The predictive value of quantitative motor test abnormalities for evolving cognitive impairment needs further delineation.

NOTE: WAIS-III is Third Edition of the Wechsler Adult Intelligence Scale; WMS-III is the Third Edition of the Wechsler Memory Scale.

   

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