Diagnosing symptomatic HIV-associated neurocognitive disorders: self-report versus performance-based assessment of everyday functioning

Abstract

Three types of HIV-associated neurocognitive disorders (HAND) exist that are distinguished by presence and severity of impairment in cognitive and everyday functioning. Although well-validated neurocognitive measures exist, determining impairment in everyday functioning remains a challenge. We aim to determine whether Self-Report measures of everyday functioning are as effective in characterizing HAND as Performance-Based measures. We assessed 674 HIV-infected participants with a comprehensive neurocognitive battery; 233 met criteria for a HAND diagnosis by having at least mild neurocognitive impairment. Functional decline was measured via Self-Report and Performance-Based measures. HAND diagnoses were determined according to published criteria using three approaches to assess functional decline: (1) Self-Report measures only, (2) Performance-Based measures only, and (3) Dual-method combining Self-Report and Performance-Based measures. The Dual-method classified the most symptomatic HAND, compared to either singular method. Singular method classifications were 76% concordant with each other. Participants classified as Performance-Based functionally impaired were more likely to be unemployed and more immunosuppressed, whereas those classified as Self-Report functionally impaired had more depressive symptoms. Multimodal methods of assessing everyday functioning facilitate detection of symptomatic HAND. Singular Performance-Based classifications were associated with objective functional and disease-related factors; reliance on Self-Report classifications may be biased by depressive symptoms.

Figure 1

CONSORT flow chart indicating participant selection procedure; boxes in bold signify those subjects included in analyses.

Figure 2

HAND classification flow chart via the self-report, performance-based, and dual assessment approaches. Definitions and abbreviations: NCI = neurocognitive impairment; ANI = Asymptomatic Neurocognitive Impairment; MND = Mild Neurocognitive Disorder; HAD = HIV-Associated Dementia; Mild-to-moderate NCI: global rating = 5 or 6; Moderate-to-severe NCI = global rating ≥ 7.

Figure 3

The Dual classification method yielded the lowest prevalence of ANI and largest prevalence of symptomatic diagnoses compared to either singular method. Each row represents the proportion of specific HAND diagnoses by assessment method among the participants with HIV-associated neurocognitive impairment. Abbreviations: NCI = neurocognitive impairment; ANI = Asymptomatic Neurocognitive Impairment; MND = Mild Neurocognitive Disorder; HAD = HIV-associated Dementia.

Figure 4

Frequency of discrepant Self-Report versus Performance-Based classifications. Agree: No functional impairment = 67% (156/233); Agree: Functional impairment = 9% (20/233); Discrepancy: Impaired by Self-Report only = 16% (37/233); Discrepancy: Impaired by Performance-Based only = 9% (20/233). Abbreviations: NCI = neurocognitive impairment.