Monica Rivera Mindt

HIV-associated neurocognitive disorders before and during the era of combination antiretroviral therapy: differences in rates, nature, and predictors.

Combination antiretroviral therapy (CART) has greatly reduced medical morbidity and mortality with HIV infection, but high rates of HIV-associated neurocognitive disorders (HAND) continue to be reported. Because large HIV-infected (HIV+) and uninfected (HIV−) groups have not been studied with similar methods in the pre-CART and CART eras, it is unclear whether CART has changed the prevalence, nature, and clinical correlates of HAND. We used comparable methods of subject screening and assessments to classify neurocognitive impairment (NCI) in large groups of HIV + and HIV − participants from the pre-CART era (1988–1995; N = 857) and CART era (2000–2007; N = 937). Impairment rate increased with successive disease stages (CDC stages A, B, and C) in both eras: 25%, 42%, and 52% in pre-CART era and 36%, 40%, and 45% in CART era. In the medically asymptomatic stage (CDC-A), NCI was significantly more common in the CART era. Low nadir CD4 predicted NCI in both eras, whereas degree of current immunosuppression, estimated duration of infection, and viral suppression in CSF (on treatment) were related to impairment only pre-CART. Pattern of NCI also differed: pre-CART had more impairment in motor skills, cognitive speed, and verbal fluency, whereas CART era involved more memory (learning) and executive function impairment. High rates of mild NCI persist at all stages of HIV infection, despite improved viral suppression and immune reconstitution with CART. The consistent association of NCI with nadir CD4 across eras suggests that earlier treatment to prevent severe immunosuppression may also help prevent HAND. Clinical trials targeting HAND prevention should specifically examine timing of ART initiation.

Neuropsychological, Cognitive, and Theoretical Considerations for Evaluation of Bilingual Individuals

As the number of bilinguals in the USA grows rapidly, it is increasingly important for neuropsychologists to be equipped and trained to address the unique challenges inherent in conducting ethical and competent neuropsychological evaluations with this population. Research on bilingualism has focused on two key cognitive mechanisms that introduce differences between bilinguals and monolinguals: (a) reduced frequency of language-specific use (weaker links), and (b) competition for selection within the language system in bilinguals (interference). Both mechanisms are needed to explain how bilingualism affects neuropsychological test performance, including the robust bilingual disadvantages found on verbal tasks, and more subtle bilingual advantages on some measures of cognitive control. These empirical results and theoretical claims can be used to derive a theoretically informed method for assessing cognitive status in bilinguals. We present specific considerations for measuring degree of bilingualism for both clients and examiners to aid in determinations of approaches to testing bilinguals, with practical guidelines for incorporating models of bilingualism and recent experimental data into neuropsychological evaluations. This integrated approach promises to provide improved clinical services for bilingual clients, and will also contribute to a program of research that will ultimately reveal the mechanisms underlying language processing and executive functioning in bilinguals and monolinguals alike.

INCREASING CULTURALLY COMPETENT NEUROPSYCHOLOGICAL SERVICES FOR ETHNIC MINORITY POPULATIONS: A CALL TO ACTION

US demographic and sociopolitical shifts have resulted in a rapidly growing need for culturally competent neuropsychological services. However, clinical neuropsychology as a field has not kept pace with the needs of ethnic minority clients. In this discussion we review: historical precedents and the limits of universalism in neuropsychology; ethical/professional guidelines pertinent to neuropsychological practice with ethnic minority clients; critical cultural considerations in neuropsychology; current disparities germane to practice; and challenges to the provision of services to racial/ethnic minority clients. We provide a call to action for neuropsychologists and related organizations to advance multiculturalism and diversity within the field by increasing multicultural awareness and knowledge, multicultural education and training, multicultural neuropsychological research, and the provision of culturally competent neuropsychological services to racial/ethnic minority clients. Lastly, we discuss strategies for increasing the provision of culturally competent neuropsychological services, and offer several resources to meet these goals.

Motor Function and Human Immunodeficiency Virus-Associated Cognitive Impairment in a Highly Active Antiretroviral Therapy-Era Cohort

BACKGROUND Cognitive impairment has long been recognized as a manifestation of human immunodeficiency virus (HIV) infection. However, highly active antiretroviral therapy (HAART) has altered the neurologic manifestations of HIV. OBJECTIVES To develop a measure to quantify the motor abnormalities included in the original descriptions of HIV-associated dementia (HAD); to determine whether motor, affective, and behavioral dysfunction predict cognitive impairment; and to determine whether quantitative motor testing is a helpful adjunct in the diagnosis of HAD in a complex population from the HAART era. DESIGN Neurologic and neuropsychological data were collected from the Manhattan HIV Brain Bank, a longitudinal cohort study of patients with advanced HIV. The HIV-Dementia Motor Scale (HDMS) was developed and validated and cognitive and affective or behavioral function was quantified using global neuropsychological T scores, the Beck Depression Inventory (BDI), and an independent assessment of apathy. Relationships among cognitive, motor, affective, and behavioral performance were examined using correlation, linear regression, and analyses of variance. SETTING An urban AIDS research center. PARTICIPANTS A total of 260 HIV-positive, predominantly minority patients. MAIN OUTCOME MEASURES The HDMS scores and global neuropsychological T scores. RESULTS The HDMS and BDI scores were independent predictors of cognitive impairment. Significant cognitive impairment was found in patients with motor dysfunction. Patients diagnosed as having HAD had a greater degree of motor impairment than those with other neurocognitive diagnoses. CONCLUSIONS Motor, affective, and behavioral abnormalities predict cognitive impairment in HIV-positive patients in this HAART-era cohort. The HDMS may be useful in the assignment of HIV-associated neurocognitive impairment in HIV populations in which normative data or neuropsychological test design is not optimal.

Effects of Stereotype Threat, Perceived Discrimination, and Examiner Race on Neuropsychological Performance: Simple as Black and White?

The purpose of the current study was to examine the predictive roles of stereotype threat and perceived discrimination and the mediating role of examiner-examinee racial discordance on neuropsychological performance in a non-clinical sample of African American and Caucasian individuals. Ninety-two African American (n = 45) and Caucasian (n = 47) adults were randomly assigned to either a stereotype threat or non-threat condition. Within each condition, participants were randomly assigned to either a same race or different race examiner. All participants underwent neuropsychological testing and completed a measure of perceived discrimination. African Americans in the stereotype threat condition performed significantly worse on global NP (Mz = -.30, 95% confidence interval [CI] [-0.07, -0.67] than African Americans in the non-threat condition (Mz = 0.09, CI [0.15, 0.33]. African Americans who reported high levels of perceived discrimination performed significantly worse on memory tests when tested by an examiner of a different race, Mz = -1.19, 95% CI [-1.78, -.54], than African Americans who were tested by an examiner of the same race, Mz = 0.24, 95% CI [-0.24, 0.72]. The current study underscores the importance of considering the role of contextual variables in neuropsychological performance, as these variables may obscure the validity of results among certain racial/ethnic groups.

The Functional Impact of HIV-Associated Neuropsychological Impairment in Spanish-Speaking Adults: A Pilot Study

Among English-speaking adults, HIV-associated neuropsychological (NP) impairments have been associated with problems in everyday functioning, including ability to function at work and drive an automobile. Latinos account for a disproportionate number of HIV/AIDS cases nationwide, and a significant segment of this population is primarily Spanish speaking. We have previously developed an assessment that evaluates English-speakers on a variety of instrumental activities of daily living. In this pilot study, we used Spanish-language translations of our functional battery to investigate the cultural relevance of such measures, and to explore relationships between NP status and ability to perform important everyday tasks in HIV-infected Spanish-speakers. Sixteen HIV-infected monolingual Spanish-speaking adults received comprehensive, Spanish language NP testing and functional assessments included the following domains: Medication Management, Cooking, Finances, Shopping, and Restaurant Scenario. Results revealed that most of the functional tasks appeared culturally relevant and appropriate with minor modifications. NP-impaired participants were significantly more functionally impaired compared to NP-normals (88% vs. 13%, p <.01). Performances on the functional assessment and the NP battery were also related to indicators of real world functioning, including employment status and quality of life. These results, though preliminary, suggest that Spanish language functional assessments are potentially valid tools for detecting everyday functioning deficits associated with NP impairments in HIV-infected Spanish-speakers.

Characterization and Sociocultural Predictors of Neuropsychological Test Performance in HIV+ Hispanic Individuals

Hispanic individuals in the U.S. have been disproportionately impacted by HIV/AIDS, yet little is known regarding the neuropsychological sequelae of HIV within the Hispanic population. This study characterized neuropsychological (NP) test performance of HIV+ English-speaking Hispanic participants (n = 51) and investigated the combined roles of sociocultural factors (e.g., ethnicity, socioeconomic status [SES] proxy, and reading level) on NP test performance among our HIV+ Hispanic and non-Hispanic White participants (n = 49). Results revealed that the pattern of NP impairment in HIV+ Hispanic participants is consistent with the frontal-striatal pattern observed in HIV-associated CNS sequelae, and the overall prevalence of global NP impairment was high compared to previous reports with more ethnically homogeneous, non-Hispanic White cohorts. Multivariate prediction models that considered both sociocultural factors and CD4 count revealed that reading level was the only unique predictor of global NP functioning, learning, and attention/working memory. In contrast, ethnicity was the only unique predictor of abstraction/executive functioning. This study provides support for the use of neuropsychological evaluation in detecting HIV-associated NP impairment among HIV+ Hispanic participants and adds to the growing literature regarding the importance of considering sociocultural factors in the interpretation of NP test performance.

Isolating Cognitive and Neurologic HIV Effects in Substance-Dependent, Confounded Cohorts: A Pilot Study

Controversy exists as to whether effects of HIV infection can be detected in the cognitive profiles of substance users, with methodological differences in degree of control for confounding factors a major contributor to empirical discrepancies. To address this shortcoming, we conducted a small but well-controlled study aimed at isolating HIV neurocognitive (NC) effects in a group of chronic substance users. Thirty HIV-negative substance users were individually matched to 30 HIV-positive substance users on relevant medical and demographic factors, including reading level and methadone therapy status. Results revealed that reading level, methadone maintenance therapy, and positive urine toxicology each exerted significant influence on NC function, and that HIV status was a significant predictor of learning and speeded processing after these control factors were considered. The HIV-positive group also displayed significantly more neurologically assessed motor impairment (p < .05), which was specifically related to impaired cognition in this group and independent of degree of immunocompromise. These data demonstrate the need for increased attention to clinical/demographic characteristics of groups under study. They also show that with applied methodological rigor, the deleterious effects of HIV on cognition can be parsed from substance use, even in small samples with chronic and active use histories.

Cognitive functioning during highly active antiretroviral therapy interruption in human immunodeficiency virus type 1 infection

Although no longer considered therapeutically beneficial, antiretroviral treatment interruptions (TIs) still occur frequently among patients with human immunodeficiency virus (HIV) infection for a variety of reasons. TIs typically result in viral rebound and worsening immunosuppression, which in turn are risk factors for neurocognitive decline and dementia. We sought to determine the extent of neurocognitive risk with TIs and subsequent reintroduction of highly active antiretroviral therapy (HAART) by using a comprehensive, sensitive neuropsychological assessment and by concurrently determining changes in plasma and cerebrospinal fluid (CSF) viral load and CD4 counts. Prospective, serial, clinical evaluations including neuropsychological (NP) testing and measurement of plasma HIV RNA and CD4 count and mood state were performed on HIV-1—infected individuals (N=11) at three time points: (1) prior to a TI, while on HAART; (2) after TIs averaging 6 months; and (3) after reinitiating HAART therapy. During TI, plasma HIV RNA increased and CD4 counts declined significantly, but NP performance did not change. Following reinitiation of HAART, viral loads fell below pre-TI levels, and CD4 counts rose. Improved viral suppression and immune restoration with reinitiation of HAART resulted in significant improvement in neurocognitive performance. No changes on comprehensive questionnaires of mood state were observed in relation to TI. NP performance and mood state remained stable during TIs despite worsened viral loads and CD4 counts. Because “practice effects” are generally greatest between the first and second NP testing sessions, improvement at the third, post-TI time point was unlikely to be accounted for by practice. TIs of up to 6 months appear to be neurocognitively and psychiatrically safe for most patients.

Socioeconomic Status and Neuropsychological Functioning: Associations in an Ethnically Diverse HIV+ Cohort

Objective: There is limited research examining the relationship between socioeconomic status (SES) and neuropsychological functioning, particularly in racial/ethnic minority and HIV+ populations. However, there are complex associations between poverty, education, HIV disease, race/ethnicity, and health outcomes in the US. Method: We explored these relationships among an ethnically diverse sample of 134 HIV+ adults using a standardized SES measure (i.e., the Hollingshead scale), a comprehensive NP test battery, and a functional evaluation (i.e., Patient’s Assessment of Own Functioning Inventory and Modified Instrumental Activities of Daily Living Scale). Results: Bivariate analyses showed that adult SES was significantly, positively correlated with neuropsychological performance on specific tests within the domains of verbal fluency, attention/concentration, learning, memory, processing speed, and executive functioning, and childhood SES was significantly linked to measures of verbal fluency, processing speed, and executive functioning. In a series of linear regressions, controlling for SES significantly attenuated group differences in NP test scores between racial/ethnic minority individuals and non-Hispanic White individuals. Finally, SES scores significantly differed across HIV-Associated Neurocognitive Disorder (HAND) diagnoses. In a binary logistic regression, SES was the only independent predictor of HAND diagnosis. Conclusions: HIV+ individuals with lower SES may be more vulnerable to HIV-associated neuropsychological sequelae due to prominent health disparities, although the degree to which this is influenced by factors such as test bias remains unclear. Overall, our results suggest that SES is significantly linked to neuropsychological test performance in HIV+ individuals, and is an important factor to consider in clinical practice.