Psychiatric Disorders in HIV-infected Patients
Delirium
Delirium is the clinical manifestation of a CNS metabolic disturbance. Systemic illness, CNS infection or neoplasm, and medications may cause delirium in advanced HIV disease. Hypoxia, dehydration, sepsis, renal failure, hyponatremia, hypercalcemia, and hypoglycemia can cause delirium. Delirium may be caused by HIV encephalopathy, cryptococcal meningitis, neurosyphilis, progressive multifocal leukoencephalopathy, herpes encephalitis, cytomegalovirus encephalitis, disseminated toxoplasmosis, lymphoma, and trauma.
Medications associated with delirium. Anticholinergics, antihistamines, sedatives, opioids and antibiotics (cephalosporins and amphotericin B, antineoplastics) can cause delirium. Delirium may be the result of intoxication or withdrawal from abused substances, including alcohol, stimulants, hallucinogens, sedatives, and opiates.
Early symptoms of delirium include irritability and sleep-wake cycle alterations. A later symptom of delirium is rapid onset of fluctuating level of consciousness, with markedly poor attention and disorganized thought and speech. Orientation and memory are often impaired. Illusions may be present. The patient may be agitated or apathetic.
Treatment of delirium
Treatment consists of treatment of the underlying disease process and identification of medications contributing to the confusional state.
Olanzapine ( Zyprexa), an “atypical” neuroleptic with a very low incidence of extrapyramidal symptoms, is effective for treatment of agitation accompanying delirium. Treatment should start at 2.5 mg bid or 5 mg qhs, and increasing up to 20 mg po qhs as needed. Olanzapine can lower seizure thresholds, but otherwise is well tolerated.
Risperidone ( Risperdal)is also effective and well-tolerated, starting at 0.5 twice a day or 1 mg at bedtime, increasing up to 3 mg twice a day if necessary.
Haloperidol ( Haldol)may be used at low doses (0.5 to 2.0 mg 2 times a day) when intravenous administration is necessary. Extrapyramidal side effects are common. Additional sedation can be obtained with lorazepam ( Ativan), starting at 0.5 to 1.0 mg every 3 to 8 hours as needed.
Nonpharmacologic treatments include assisting with orientation by having a calendar and clock in the patient’s room, and keeping the patient’s room well lit when the patient is awake.
Cognitive impairment and dementia
Neurocognitive impairment is common in persons with advanced HIV disease. Early symptoms include poor concentration, psychomotor slowing, difficulty with complex sequential motor activity, apathy, and withdrawal. Advanced dementia may manifest as severe cognitive deficits, disinhibition, mutism and/or catatonia, ataxia, and incontinence.
Treatment of dementia consists of treatment of the underlying organic cause. Multidrug regimens to lower serum viral load, which include protease inhibitors, often will slow progression and may even reverse HIV encephalopathy and improve cognitive impairment. Highly-active antiretroviral treatment is recommended, preferably including ZDV.
Psychostimulants, such as methylphenidate, may improve cognitive performance. The initial dosage is 5 mg orally twice a day.
Olanzapine ( Zyprexa) (2.5 mg bid or 5mg qhs, increasing to 10 to 20 mg qhs if necessary), or risperidone ( Risperdal) (starting at 0.5 mg bid, increasing up to 3 mg bid if necessary) may be useful for control of agitation, disinhibition, or psychosis. Neuroleptics can be augmented with lorazepam, 0.5 mg 2 to 3 times daily.
Fluoxetine ( Prozac) or Venlafaxine ( Effexor XR), stimulating antidepressants, are is often effective for apathy accompanying dementia. Methylphenidate ( Ritalin), 5 mg twice a day, may also reduce apathy.
Major depressive disorder is a common psychiatric diagnosis in HIV-infected patients. Symptoms include depressed mood, changes in sleep and/or appetite and weight, fatigue, loss of interest or pleasure in daily activities, psychomotor slowing or agitation, feelings of worthlessness or guilt, poor concentration, indecisiveness, and recurrent thoughts of death or suicide.
Treatment with a selective serotonin reuptake inhibitor (SSRI), such as fluoxetine ( Prozac), sertraline ( Zoloft ), paroxetine ( Paxil ), or fluvoxamine ( Luvox ) is recommended. SSRIs are very safe in overdose and lack the anticholinergic and orthostatic side effects of tricyclic antidepressants (TCAs). Initial treatment consists of 10 mg of paroxetine or fluoxetine, or 50 mg sertraline, increasing as necessary to 40 mg paroxetine or fluoxetine or 200 mg sertraline.
SSRIs are generally well tolerated, but they may cause nausea, jitteriness, weight loss, insomnia, and sexual dysfunction. These side effects frequently diminish if dosage is reduced or with time.
Bupropion ( Wellbutrin) is a stimulating antidepressant, without the sexual dysfunction of SSRI’s, but with a small risk of seizures. The slow release form (Wellbutrin SR) has reduced seizure risk, and is well tolerated. Wellbutrin SR (dose 100 to 200 mg bid) is often used in SSRI nonresponders and in patients who discontinue SSRIs due to sexual dysfunction.
Venlafaxine ( Effexor) has a side effect profile similar to SSRIs, but may be useful in SSRI nonresponders (starting dose 37.5 bid, or 75 mg qd of the slow release form, Effexor XR).
Tricyclic antidepressant agents are useful for treating peripheral neuropathy pain and depression. They may be effective for those patients who cannot tolerate or who do not respond to SSRIs. TCAs with greater anticholinergic and orthostatic side effects (amitriptyline [ Elavil ]) should be avoided. A TCA with lower incidence of side effects, such as desipramine ( Norpramin) and nortriptyline ( Pamelor), is recommended. Side effects of TCAs may include dry mouth, constipation, urinary retention, orthostatic hypotension, increased heart rate, and cognitive impairment. TCAs may cause lethal cardiac effects on overdose.
Nortriptyline ( Pamelor) is mildly sedating; dosage is 50 to 150 mg at bedtime. Desipramine ( Norpramin) is somewhat stimulating; its 100- to 300-mg dose may be taken either in the morning or at bedtime.
Insomnia associated with depression often responds to trazodone ( Desyrel, 50 mg every night, increasing if necessary to 150 to 300 mg every night). Side effects of morning grogginess and orthostatic hypotension. In depressed patients with persistent insomnia, trazodone should be used at bedtime in conjunction with a morning dose of fluoxetine, sertraline, or paroxetine.
Apathetic withdrawal in patients with advanced HIV disease may improve with methylphenidate ( Ritalin ), 5 mg twice a day. Buy other pills on Online Canadian Pharmacy - Discount Canada Drugs Online.