Hepatic encephalopathy tool detects minimal impairment in the elderly
BOSTON — In a multicenter study of older patients with cirrhosis, the EncephalApp tool accurately diagnosed cognitive impairment and hepatic encephalopathy, according to a presenter at The Liver Meeting 2019.
“Patients with cirrhosis are growing older and increasing survival means that these patients are often diagnosed with cirrhosis at a later age,” Jasmohan S. Bajaj, MD, from the Virginia Commonwealth University, said during his presentation. “Cirrhosis-associated altered cognition and impaired health-related quality of life is most likely related to hepatic encephalopathy.”
Bajaj explained that some patients may have minimal hepatic encephalopathy (MHE), in which patients have never developed clinical encephalopathy, but show cognitive impairment with certain tests. Additionally, with advancing age, it is important to account for the potential overlap with age-related mild cognitive impairment (MCI).
To determine the performance tests focused on MHE and MCI and the impact of cognitive impairment on quality of life, Bajaj and colleagues enrolled 109 patients with cirrhosis and 100 controls aged 65 years to 95 years. Both groups had similar demographics and education and no current presentation of hepatic encephalopathy or dementia.
Patients and controls completed the following tests: psychometric hepatic encephalopathy score (PHES), EncephalApp Off+On, and QOL: Sickness Impact Profile. Patients with cirrhosis also completed the Repeatable Battery for the Assessment of Neuropsychological Status for MCI which tests immediate memory, delayed memory, language, visuo-spatial and attention.
While the control participants were older, they performed better than the patients with cirrhosis on the PHES (2.9 vs. 12.4; P < .001) and EncephalApp Off+On (181.4 vs. 218.2; P = .03), and had better QOL outcomes (SIP total: 3.8 vs. 7.9; Psych: 3.3 vs. 7.2; Phys: 3 vs. 6.7; P < .001).
Bajaj highlighted that among patients with cirrhosis, those who had both MHE and MCI had the worst health-related QOL results.
“In fact, any group with MHE regardless of MCI had poor health-related quality of life,” he said.
Finally, Bajaj and colleagues developed age, sex and education-adjusted norms for PHES and EncephalApp based on the controls: 6% patients with cirrhosis were positive for MHE on PHES compared with controls, while 48% were positive on EncephalApp, giving a 55% concordance rate. Taking PHES as the gold standard, EncephalApp had a sensitivity of 1 (95% CI, 0,93-1) and a specificity of 0.5 (95% CI, 0.92-1).
“While MHE and MCI coexist in almost a quarter of patients with cirrhosis, MHE had a greater impact than MCI on health-related quality of life,” Bajaj said. “EncephalApp was able to detect cognitive impairment adjusted for age, [sex] and educational attainment in this population.” – by Talitha Bennet
Reference: Bajaj JS. Abstract 0053. Presented at: The Liver Meeting; Nov. 7-12, 2019; Boston.
Disclosure: Bajaj reports he is consultant for Norginie and has received grant or research support from Grifols, Kaleido, Synlogic and Valeant.