Gupta Salil, Venugopal Nirmala
Department of Neurology, Army Hospital Research and Referral, New Delhi, India.
Department of Internal Medicine, Military Hospital Bagdogra, Darjeeling District, West Bengal, India.
J Neurosci Rural Pract. 2020 Apr;11(2):230-236. doi: 10.1055/s-0040-1702799. Epub 2020 May 2.
Asymptomatic neurocognitive impairment (ANI) in people living with HIV (PLWH) can lower quality of life, reduce drug compliance, increase unemployment, and reduce life expectancy. This study was aimed to identify risk factors of ANI in PLWH in an Indian cohort and explore the usefulness of Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment Score (MoCA) as screening tools. PLWH under follow-up at an antiretroviral treatment center who were 18 to 60 years were included in this study. Patients were excluded if they had any cognitive symptoms, previous history of any central nervous system (CNS) pathology, or any systemic illness. Included patients were subjected to domain wise standardized neuropsychological battery. Six domains were screened including language, attention, speed, memory, sensory motor skills, and executive. Abnormal dysfunctional scores in at least two domains were taken as suggestive of ANI. The two groups thus created, ANI and normal cognition, were evaluated for differences. Variables evaluated as risk factors included age, sex, handedness, education, presence of at least one vascular risk factor, duration of disease, biochemical profile, cluster of differentiation 4 (CD4) count (both current and nadir) HIV viral load, and use of antiretroviral therapy (ART) and its CNS penetration effectiveness (CPE). MMSE and MoCA were also done in all patients. Regression analysis was used to find out significant variables. MMSE and MoCA scores were correlated using Spearman's correlation coefficient. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were also determined Three hundred and eighty-four patients were included out of which 185 (48%) had ANI. In the multivariate regression analysis, female sex with odds Ratio (OR) of 1.89 (95% confidence interval [CI]: 1.21-2.79, < 0.01), education below 10 years with OR = 2.43 (95% CI: 1.56-3.80, < 0.01) and presence of at least one vascular risk factor with OR = 2.52 (95% CI: 1.67-3.80, < 0.01) were found to be significant. Both MMSE and MoCA had a high PPV (0.99 and 0.97, respectively) but poor NPV (0.64 and 0.75) below a score of 25 with MoCA scoring slightly better. Both, MMSE and MoCA correlated well with each other. Nearly half of our patients had ANI, despite being on ART. Majority of patients were on ART with CPE > 7 and had relatively preserved immune status. Female HIV patients with at least one vascular risk factor and less than 10 years of formal education were found to be at risk for ANI. MMSE and MoCA are not good screening tools to identify this condition.
艾滋病毒感染者（PLWH）的无症状神经认知障碍（ANI）会降低生活质量、降低药物依从性、增加失业率并缩短预期寿命。本研究旨在确定印度队列中PLWH发生ANI的危险因素，并探讨简易精神状态检查表（MMSE）和蒙特利尔认知评估量表（MoCA）作为筛查工具的有效性。本研究纳入了在抗逆转录病毒治疗中心接受随访的18至60岁的PLWH。如果患者有任何认知症状、既往有任何中枢神经系统（CNS）病变史或任何全身性疾病，则将其排除。纳入的患者接受了按领域标准化的神经心理测试组。筛查了六个领域，包括语言、注意力、速度、记忆、感觉运动技能和执行能力。至少两个领域的功能异常得分被视为提示ANI。由此创建的ANI组和正常认知组进行了差异评估。评估为危险因素的变量包括年龄、性别、利手、教育程度、至少存在一种血管危险因素、疾病持续时间、生化指标、分化簇4（CD4）计数（当前和最低点）、艾滋病毒病毒载量以及抗逆转录病毒疗法（ART）的使用及其CNS渗透效率（CPE）。所有患者也进行了MMSE和MoCA测试。使用回归分析来找出显著变量。MMSE和MoCA得分使用斯皮尔曼相关系数进行相关性分析。还确定了敏感性、特异性、阳性预测值（PPV）和阴性预测值（NPV）。共纳入384例患者，其中185例（48%）有ANI。在多变量回归分析中，发现女性的优势比（OR）为1.89（95%置信区间[CI]：1.21 - 2.79，P < 0.01），教育年限低于10年的OR = 2.43（95%CI：1.56 - 3.80，P < 0.01），至少存在一种血管危险因素的OR = 2.52（95%CI：1.67 - 3.80，P < 0.01）具有显著性。MMSE和MoCA的PPV都很高（分别为0.99和0.97），但得分低于25分时NPV较差（分别为0.64和0.75），MoCA得分略好。MMSE和MoCA彼此相关性良好。尽管接受了ART治疗，但我们近一半的患者仍有ANI。大多数患者接受的ART治疗CPE > 7，免疫状态相对良好。发现至少有一个血管危险因素且正规教育年限少于10年的女性艾滋病毒患者有发生ANI的风险。MMSE和MoCA不是识别这种情况的良好筛查工具。
