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Book Review -- AIDS and the Impact of Cognitive Impairment:
A Treatment Guide for Mental Health Providers by Penelope Zeifert, PhD; Mark Leary, MD; and Alicia A. Boccellari, PhD
UCSF AIDS Health Project, 1995, 84 Pages, $7.95, Paper

Reviewed by Cheryl S. Weinstein

June 1996

AIDS and the Impact of Cognitive Impairment is an excellent resource for mental health providers in understanding all relevant biological, psychological, neurocognitive, and social factors associated with HIV-related illness. The tenet of this book is that "the provider is in a powerful position from which to mitigate the impact of cognitive impairment and improve the quality of life." The authors then carefully and clearly present diagnostic and management tools that mental health workers must have in their repertoire.

The book introduces an important two-part paradigm: One, when the mental health worker connects empathically with a patient with HIV-related illness at his or her cognitive level, there is significant improvement in the quality of care and the quality of life for the patient. Two, the mental health worker coordinates patient care and helps family members understand the appropriate treatments at each stage of HIV-related illness.

A major strength of this monograph is the concise and straightforward presentation of complex information such as the direct effect of HIV infection on the brain and the subsequent chemical sabotage of nerves; the spectrum of neuropsychiatric impairment; descriptions of opportunistic diseases; organic affective illness; and transient impairments including potential causes of delirium. The presentation provides the mental health worker with simple language to present complicated and painful information to family members, employers, and other members of the treatment team. The case presentations are excellent and address difficult differential diagnostic questions such as organic mania versus bipolar mania. Moreover, case examples help one to understand the individual's experience of delirium and the importance communicating immediately with the primary care doctor.

Specific diagnosis guidelines are provided, and there is a solid review of neurocognitive functions (level of consciousness, orientation, attention and concentration, memory, visual-spatial information, abstraction, insight and judgment, etc) and the elements of a neuropsychiatric interview. The reader is instructed to observe changes in motor functions, concentration, memory, emotions, and complex reasoning such as managing money, planning meals, and working.

I hesitate to say anything negative about this monograph, but I was disappointed that specific diagnostic tools or questionnaires (eg, Neuropsychiatric Symptom Questionnaire) were not included. While the book has excellent guidelines for a general evaluation -- for example, observation of changes in handwriting or difficulty following the plot of a book -- mental health workers could provide more accurate diagnoses with specific measures under the supervision of a "friendly" clinical neuropsychologist.

The authors do a superb job discussing the treatment and management of cognitive impairment. The data they present are valuable not only for people with HIV/AIDS but for all individuals with neuropsychiatric disorders. They present two psychotherapeutic models for managing HIV-related cognitive impairment: "Adaptation and Compensation" for use with mild cognitive impairment, and "Environmental Engineering" which is used with moderate to severe impairment.

The authors' goals for the patient management are twofold: "to treat aggressively the acute causes of cognitive impairment, such as opportunistic infections and delirium; and to attenuate through psychopharmacology and psychotherapy the effects of organic affective disorders and the ongoing, and progressive impairment caused by HIV infection of the brain."

The authors demonstrate how the framework of psychotherapy shifts with neurocognitive decline -- a subject that is rarely addressed. In a cogent description of personality and emotional changes, they write: "Emotions as well as thinking become simplified. As a result of cognitive deficits, there is a loss of ability to distinguish among the fine nuances of emotional states and a decreased ability to sustain emotional states. Thus, although individuals with dementia can become distressed -- particularly with regard to threatened changes in living situation -- they lack the depth to their emotions that is seen in cognitively intact individuals."

When caregivers and family members fail to appreciate this basic principle, there can be unfortunate miscommunications and misinterpretation of the behavior of an individual with HIV (eg, "He/She doesn't care about me any more" versus "Increased impairment in functions associated with the frontal network lead to a apathetic state"). Thus, this book is an essential tool to help the mental health worker improve the quality of life for everyone who lives with HIV-related illness -- the individual with HIV/AIDS; lovers, partners, and friends; the extended family including children, and healthcare workers of all disciplines. The authors are to be commended for creating this valuable teaching tool.


Cheryl S. Weinstein is a diplomate in Clinical Neuropsychology, the American Board of Professional Psychology and works as a clinical neuropsychologist at the New England Deaconess Hospital. She teachs Neuropsycho-logy Fellows in the combined Massachusetts Mental Health/Deaconess Hospital Program of the Harvard Medical School. She is also a part of a HIV-teaching program headed by Drs. Marshall Forstein and Steven Brady.




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