Firesetting is a unique manifestation of HAD. Cohen and Alfonso (1998) have described several cases of fire-setting behavior among persons with cognitive impairment and HIV infection and suggest a multifactorial etiology for the behavior. Accidental firesetting often occurs in the context of cigarette smoking by persons both with and without cognitive impairment. The cognitive impairment concomitant with HAD exaggerates the lapses in attention, memory, or judgment that may lead to accidental firesetting from lit cigarettes. HAD is characterized by motor abnormalities such as tremor and bradykinesia, which may contribute to fine motor dyscontrol, thereby increasing the risk of, for example, dropping a lit cigarette. In addition to encephalopathy, persons with HIV may have HIV-associated neuropathy, which may further increase the likelihood of an accident by decreasing the perception of heat. A person with visual acuity limited by cytomegalovirus (CMV) retinitis would have further difficulty in not being able to perceive a dangerous situation until it is too late.
It is important that caregivers be aware of this potentially dangerous behavior among persons with HIV. We strongly recommend programs of smoking cessation. Ideally, all health care environments should be smoke free for fire prevention and for the health of both patients and staff. Smoking should be prohibited except with direct staff supervision and preferably out of doors with supervision. Staff education and frequent fire drills are important. Warning signs of unsafe smoking include severe dementia, delirium, visual impairment, and neuropathy. Specific measures that can be taken to decrease the risk of firesetting include limiting unsupervised cigarette smoking, providing flame-retardant clothing, and encouraging smoking cessation.
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