Evaluating the accuracy of self-report for the diagnosis of HIV-associated neurocognitive disorder (HAND): defining “symptomatic” versus “asymptomatic” HAND

Abstract

The criteria for differentiating symptomatic from asymptomatic HIV-associated neurocognitive disorder require evaluation of (1) cognitive impairment, (2) daily functioning declines, and (3) whether the functional declines are attributable to cognitive versus physical problems. Many providers rely only on self-report to evaluate these latter criteria. However, the accuracy of patient-provided information may be limited. This study evaluated the validity of self-assessment for HIV-associated neurocognitive disorder (HAND) diagnoses by comparing objective findings with self-report of criteria 2 and 3 above. Self-reports were used to stratify 277 cognitively impaired HIV+ individuals into functionally dependent (n = 159) and independent (n = 118) groups, followed by group comparisons of objective functional problems. The dependent group was then divided into those who self-attributed their functional dependence to only cognitive (n = 80) versus only physical (n = 79) causes, for further comparisons on objective findings. The functionally dependent group was significantly worse than the independent group on all objective disability characteristics except severity of cognitive impairment, while those who attributed their dependence to physical (versus cognitive) factors were similar on all objective physical, cognitive, and functioning variables. Of note, 28 % of physical attributors showed no physical abnormalities on neuromedical examinations. Results suggest that patient report is consistently associated with objective measures of functional loss; in contrast, patient identification of physical versus cognitive causes is poorly associated with objective criteria. These findings caution against relying solely on patient self-report to determine whether functional disability in cognitively impaired HIV+ individuals can be attributed to strictly physical causes.

Self-Reported Decline in Everyday Function, Cognitive Symptoms, and Cognitive Function in People With HIV

“…[7][8][9][10] In 290 PLWH over 50 years in Great Britain and Ireland and 97 seronegative controls, other patient-reported outcome measures, including depression, falls, sexual function, and general health, correlated poorly with cognitive impairment. 8 Thames et al 36 divided 107 HIV-positive patients into 4 groups, on the basis of whether they were impaired or unimpaired, and whether they were accurate or inaccurate in their selfassessment of this.…”

“…Although patients were able to rate their own overall level of ability, they were poor at correctly attributing their difficulties to cognitive versus physical problems. 7 Patients' symptoms are important because they guide clinical decisions, but clearly there are reasons other than neurological disease why patients and study participants may report symptoms. First, PLWH may have psychiatric problems, excessive substance use, or some other reversible cause for their symptoms.…”

“…The first outcome measure was defined, using the IADLS, as self-reported decline in 2 or more ADLs of the possible 16 (designated "functionally dependent" by Obermeit et al 7 ) and attribution to cognitive problems by the participant. To harmonize our results with Obermeit and others, we included ADLs that had been omitted in our previous analysis, 11 namely planning social activities, reading/watching television, and childcare.…”

“…[7][8][9][10] But even if symptoms are only weakly correlated with cognitive impairment, they are in some sense highly important to the patient. There are likely to be psychological and other factors underlying reported symptoms and understanding these factors may steer the clinician away from investigations such as brain imaging and lumbar puncture and toward the patients' more pertinent needs.…”

HIV-associated neurocognitive disorder

“…Commonly self-report is the only evidence used, but recent evaluations suggest that this is an insecure determination. [17] Given the serious lack of sensitivity of full neuropsychological batteries for HIV-associated deficits[18], the requirement that biomarkers with pathophysiological significance be found seems urgent.…”