Dementia Frequently Coexists With Hepatic Encephalopathy but Not Other Cirrhosis Complications in US Veterans

Abstract

INTRODUCTION: Hepatic encephalopathy (HE) is a common decompensating event in patients with cirrhosis. Because of the aging population of patients with cirrhosis, differentiating HE from nonhepatic etiologies of cognitive impairment, such as dementia, is increasingly important. METHODS:Veterans with cirrhosis were identified via International Classification of Diseases-10 codes between October 1, 2019, and September 30, 2021, using the VA Corporate Data Warehouse. Baseline characteristics were compared between cohorts based on the presence vs absence of dementia. Factors associated with having a diagnosis of dementia were evaluated using multivariate logistic regression models, adjusting for demographics, comorbid illnesses, cirrhosis etiology, and cirrhosis complications. RESULTS:A total of 71,552 veterans with cirrhosis were identified, of which, 5,647 (7.89%) veterans had a diagnosis of dementia. Veterans with dementia were older, more frequently White, urban located, and diagnosed with alcohol-related cirrhosis, metabolic syndrome, brain trauma, and cerebrovascular disease more frequently. On multivariable analysis, the presence of any decompensating event was associated with dementia. Multivariable analysis of individual decompensating events revealed HE to be associated with a dementia diagnosis, but not ascites, independent of other risk factors analyzed. DISCUSSION:Dementia is commonly diagnosed in patients with cirrhosis and correlates with a diagnosis of HE, independent of alcohol use, brain injury, age, and other metabolic risk factors. Dementia did not correlate with other decompensating events. Increased awareness of the overlap between dementia and HE, as well as reliable diagnostic and treatment strategies, is needed for the aging population of veterans with cirrhosis.

Undiagnosed Cirrhosis and Hepatic Encephalopathy in a National Cohort of Veterans With Dementia

“…Cirrhosis, HE, and dementia are prevalent in the rapidly increasing older veteran population, creating the potential for overlap and diagnostic confusion . In older patients with risk factors for both cirrhosis and dementia, the lack of clinically applicable biomarkers and diagnostic tests complicates accurate diagnoses and treatment .…”

“…The FIB-4 index is a scalable, inexpensive, and useful approach to identify patients with possible advanced liver fibrosis or cirrhosis . We used several validated methods to exclude previously diagnosed cirrhosis in this population . However, the large number of people with diagnosed dementia and diagnosed cirrhosis represent another population of interest; these have challenges in comanagement because HE and dementia overlap .…”

“…We used validated International Classification of Diseases, 9th Revision ( ICD-9 ) and International Statistical Classification of Diseases and Related Health Problems, 10th Revision ( ICD-10 ) codes to identify patients with 2 or more dementia diagnoses at different dates . We then collected the index date, considered to be the second date of diagnosis, and removed patients with evidence of an outpatient or inpatient cirrhosis diagnosis or complication from cirrhosis using validated ICD-9 and ICD-10 codes, and/or lactulose or rifaximin prescriptions during the study period (eAppendix in Supplement 1).…”

“…Many veterans receiving Veterans Administration care are aging and often have comorbid conditions that affect cognitive function, such as AUD, posttraumatic stress disorder (PTSD), and head injuries, in addition to risk factors for cirrhosis . Among veterans with cirrhosis, concomitant dementia is common and is challenging to distinguish from HE, but the extent to which patients with diagnoses of dementia also have undiagnosed cirrhosis and HE is unknown . Undiagnosed cirrhosis among veterans with dementia could raise the possibility that part of their cognitive impairment may be due to reversible HE .…”

Exploring GI Diseases Across the Lifespan

“…A randomized control trial studied the utility of endoscopic POEMs for pyloric stenosis, with positive results (12). On the other extreme, 1 article found a substantial overlap of dementia with hepatic encephalopathy in Veterans with cirrhosis, which was much higher than the baseline prevalence across the general population (26).…”