Abstract
Few adult patients with HIV/AIDS are evaluated for communication disorders. A broad inventory of the communication disorders was obtained in a convenience sample of 82 adult HIV/AIDS patients who presented for medical appointments. Each participant underwent a head and neck exam and a communications skills evaluation. Speech, language, and cognition were assessed using a 10-item test battery. A 14-item hearing test battery was conducted in a separate session. The primary outcomes were the presence and degree of communication disorders. Head and neck exams revealed 40% with ear-related issues. Only 2 participants showed normal findings on all 24 communication skills assessments. Four demonstrated normal findings on all speech-language-cognitive assessments, whereas 8 had normal findings on the complete hearing test battery. A relatively high prevalence of cognitive and language deficits and central auditory disturbances were found. Clinicians must recognize the potential for communication deficits even in a relatively healthy patient with HIV.
Introduction
Communication is essential for human interaction. Yet, few adult patients with HIV/AIDS are tested for communication disorders. There are no comprehensive studies of the speech–language and hearing abilities in adults living with HIV/AIDS. Our study’s purpose was to obtain a broad inventory of the communication disorders (ie, speech, language, cognition, and hearing) in an adult population living with HIV/AIDS.
Cognitive impairment is one manifestation of the central nervous system complications associated with HIV/AIDS. 1 HIV-associated neurocognitive defects are seen in about half of the patients with HIV infection. Cognitive changes may be seen early in the course of the infection even in patients who are otherwise asymptomatic. 2 –4 Common cognitive changes include problems with abstract reasoning, learning difficulties, slow information processing, and retardation of the spontaneity of speech. Although a decrease in the incidence of cognitive impairment has been reported with antiretroviral therapy, the prevalence has increased because of patients surviving longer. 5
HIV infection may damage the cochlea, eighth nerve, or both, sometimes resulting in sensorineural hearing loss. It may also compromise neural pathways and centers in the brain, resulting in central auditory disturbance. 2,6,7 Most neuro-otological disorders in patients living with HIV/AIDS have a central origin; both central auditory disorders and peripheral auditory disorders are more common in advanced stages of HIV/AIDS. 6,8 –10 Central auditory disorders may also be more common in adults with HIV-associated dementia. 11
Adults with HIV/AIDS may show head, neck, and otologic symptoms from opportunistic infections, including otalgia, otorrhea, tinnitus, “muffled” hearing, aural fullness, facial nerve palsy, vertigo, and central vestibular and ocular–motor disturbance. 2,6,7,9,12 –20 Some middle ear infections in adults living with HIV/AIDS are as common as in those without HIV/AIDS and often respond to medical treatment. 7,14 Sensorineural hearing loss, which often cannot be treated medically, is more common among adults living with HIV/AIDS than adults without HIV/AIDS. 7,16,18,21,22 Sensorineural hearing losses occurred in approximately one- to two-thirds of patients. Finally, common risk factors for hearing loss in adults in general (eg, excessive noise exposure or aging) can impact the prevalence and severity of auditory problems in adults with HIV/AIDS.
Methods
A cross-sectional design was used to investigate communication disorders in a sample of patients living with HIV/AIDS. The study was approved by the university’s institutional review board.
Patients
The eligibility criteria for study participants include patients from the KU Wichita Internal Medicine Midtown clinic in Wichita, Kansas, aged 18 years and older, diagnosed with HIV/AIDS, and capable of giving consent. The vast majority of patients were diagnosed with HIV-1 but not subtyped. A convenience sample of English-speaking patients was recruited for the study as they presented for medical appointments. Each received a small stipend of US$50 for participation in the study.
Procedures
Each patient received an in-depth evaluation of communication skills that included a medical chart review for history and a brief head and neck examination. Table 1 lists the speech, language, cognitive, and hearing assessments. The speech–language test battery consisted of 10 assessments evaluating speech, language, and cognition. The speech–language and physical examinations took approximately 1 hour. The 14-item hearing test battery was scheduled at a second visit to avoid patient fatigue. The hearing evaluation took approximately 2.5 hours and was performed in a soundproof hearing booth. These assessments were selected because they broadly covered the range of speech, language, cognitive, and hearing skills and were used routinely by professionals in communication disorders, although not specifically with an HIV population. Thus, they are readily available in most speech–language and hearing clinics.
Speech–Language, Cognitive, and Hearing Assessments Conducted.
a Some overlap exists between speech–language and cognitive/neural function assessments.
The primary outcomes were presence of a communication disorder; a positive result from any of the examinations performed within the complete test battery; and degree of disorder; positive results on a greater number of examinations indicated a higher degree of the communication disorder.
All speech–language and cognitive assessments were conducted by 1 of the 2 licensed speech–language pathologists. All hearing assessments were conducted or supervised by 1 licensed audiologist. Medical chart reviews and physical examinations were conducted by resident physicians.
Results
Eighty-two eligible patients completed the speech–language–cognitive assessments. One patient could not complete the hearing assessments because of the confined space within the hearing booth. The average age of the patients was 46 years (range 20-67 years). Two-thirds (67%) were white; three-fourths (74%) were men. Forty-five percent completed college. The year of HIV/AIDS diagnosis ranged from 1984 to 2010; the median year of diagnosis was 2000.
At diagnosis, 34 (41%) patients manifested AIDS (CD4 < 200 cells/µL, HIV infection stage 3 according to US Centers for Disease Control and Prevention criteria 23 ), 23 were in stage 2 (CD4 200-499 cells/mm3), and 25 were in stage 1 (CD4 ≥ 500). 23 The average nadir CD4 count was 242 cells/mm3, ranging from 4 to 765 cells/mm3. At the time of the study, however, 52 were in stage 1, 26 were in stage 2, and 4 were in stage 3. The average CD4 count at study time was 620 cells/mm3, ranging from 74 to 1256 cells/mm3. The average viral load was 7057 copies/mL, ranging from 0 to 166 470 copies/mL. Nine (11%) took no HIV-related medications. In all, 35 (43%) patients took 3 or more HIV-related medications (combination drugs were counted as 1 medication).
Examinations of the head and neck revealed 40% with positive ear findings. Impacted cerumen was the most frequent finding and was cleaned before the hearing examination. In all, 21% had oropharyngeal issues (mostly dental abnormalities), 14% had nasal issues (mostly swollen turbinates), and 4% had neck issues (mostly lymphadenopathy).
Only 2 patients manifested normal findings on the 24 speech–language–cognitive–hearing assessments. Even in this relatively healthy patient sample, 80 (98%) patients manifested a positive finding on at least 1 assessment. Only 4 patients manifested normal findings on all speech–language–cognitive assessments. Patients revealed a variety of cognitive and language issues mostly related to integrating information on the picture description task (45%), timed word generation (44%), and memory-related story retelling (35%). Reading fluency and word retrieval each revealed 28% of patients with positive findings. Twenty-four percent revealed the possibility of dementia on the Modified HIV Dementia Scale. Seventy-eight percent reported a history of speech–language or cognitive difficulties. Seventy percent showed positive oral anomalies potentially related to speech production, mostly dental abnormalities.
Eight patients manifested normal findings on all of the hearing assessments. Fifty-four percent of patients noted a history of hearing difficulties. Forty-one percent manifested positive findings on 3 or more hearing assessments. Peripheral auditory impairment (ie, outer, middle, and inner ear) was noted in 71.6% of patients. Central auditory impairment (ie, brain stem and cortex) was noted in 23.5% of patients. Seventh cranial nerve impairment was seen in 3.7%.
Discussion
Speech–language, cognitive, and/or hearing findings are common in a sample of HIV/AIDS patients, 24 yet infrequently tested in the medical setting. A battery of tests, commonly available to professionals in communication disorders, can identify communication deficits within this population. Physicians must recognize the potential for communication deficits even in a relatively healthy patient with HIV.
Hearing issues are common in adults living with HIV. A recent study of HIV-infected patients in Tanzania concluded that HIV is associated with hearing problems. 25 Hearing problems had more to do with the brain than with the ear. Similarly, our study found a relatively high prevalence of central auditory disturbance (particularly brain stem disturbance). A South African study reported peripheral involvement of up to 50% and the central involvement even greater. 6 Another South African study found a higher prevalence of auditory findings than that of our study. 22 They also reported an increase in sensorineural hearing loss at more advanced stages of the disease.
Our study noted a relatively high prevalence of cognitive and language deficits. Cognitive and language deficits in HIV-infected patients should be expected. A large US study found 52% had neuropsychological impairment; however, severe dementia was rare. 26 Most patients had milder forms of impairment. Our results were similar as our patients lead mostly functional daily lives with their cognitive impairments. A Swiss study found that only 16.6% of patients had completely normal neurocognitive testing. 27
Interestingly, speech deficits (ie, voice, fluency, or sound and intelligibility deficits) were infrequent in our study, even with a large percentage of dental abnormalities. Few studies have examined speech errors. A small Indian study reported a variable pattern of voice, swallowing, and oral motor function in HIV-infected patients. 28 No patients in our study were impacted to any large extent by speech deficits.
In summary, the status of speech–language, cognition, and hearing has the potential to impact communication abilities and social interactions. As a prevalence study, no direct connection between our study results and HIV/AIDS status was made. We did not assess the risk of communication disorder in this sample. With the high prevalence noted, however, physicians should consider this possibility in their examination of patients. Communication disorders are seen frequently, and available tests can identify them.
Footnotes
Acknowledgments
Souha Haydoura, MD, Dany Saad, MD, Amanda Valliant, MD, Ronnie Moussa, MD, and Rami Jambeih, MD, performed medical chart reviews and completed head and neck examinations as part of the procedures for this study. Their role is gratefully acknowledged.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Wichita Center for Graduate Medical Education through a grant from the Kansas Biosciences Authority.