1 Virginia Commonwealth University Medical Center and Hunter Holmes McGuire VA Medical Center, Richmond, Virginia. Electronic address: email@example.com.
2 University of Arkasas School of Medical Sciences, Little Rock, Arkansas.
3 Virginia Commonwealth University Medical Center and Hunter Holmes McGuire VA Medical Center, Richmond, Virginia.
4 Mayo Clinic, Arizona.
BACKGROUND & AIMS: Patients with cirrhosis are growing older. The overlap between minimal hepatic encephalopathy (MHE) and pre-dementia mild cognitive impairment (MCI) could affect quality of life (QOL). We investigated the performance of elderly patients with cirrhosis on tests for MHE and MCI and their effects on QOL.
METHODS: We recruited outpatients with cirrhosis (n=109) and without cirrhosis (controls, n=100), 65 y or older, at 4 centers (derivation cohort). All study participants were assessed for psychometric hepatic encephalopathy score (PHES), EncephalApp score, and QOL. MCI was tested in patients with cirrhosis using the repeatable battery for assessment of neuropsychological status and assigned to the following groups: unimpaired, MCI-only, MHE-only, and MCI+MHE. We created adjusted norms to detect MHE using PHES and EncephalApp scores from the controls. Findings were validated using data from a separatecohort of 77 patients with cirrhosis (mean age, 69.49±4.36y; 72% men) at the same study sites.
RESULTS: Controls were older but were more educated, performed better cognitively, and had better QOL. Among patients with cirrhosis, age, education, model for end-stage liver disease score, EncephalApp score, and QOL were similar but PHES and repeatable battery for assessment of neuropsychological status differed among sites. In the derivation cohort, presence of MHE, with or without MCI, associated with poor QOL, which was lowest in the MCI+MHE group. When we adjusted for age, sex, and education, 49% of patients with cirrhosis had MHE based on the EncephalApp and 8% had MHE based on the PHES. A similar pattern (49% MHE based on EncephalApp and 6% MHE based on PHES) was found in a validation cohort.
CONCLUSIONS: In a multi-center study of patients with cirrhosis (older than 65 y) and controls, the presence of MHE, regardless of MCI, associated with poor cognition and QOL. We created adjusted norms that defined the high sensitivity of EncephalApp for detection of MHE in older individuals and validated it in a separate cohort.