New research reveals that approximately 10% of older U.S. veterans diagnosed with dementia may actually be suffering from reversible cognitive decline due to advanced liver disease. These findings were noted in an analysis conducted by Virginia Commonwealth University’s School of Medicine and Richmond VA Medical Center.
Distinguishing between dementia and cognitive decline caused by cirrhosis, known as hepatic encephalopathy, can be a challenge for physicians.
If hepatic encephalopathy goes undetected, patients may miss out on appropriate treatment that could potentially reverse or halt the cognitive impairment. The study, reported in the journal JAMA Network Open, aimed to investigate the prevalence and risk factors associated with undiagnosed cirrhosis and potential encephalopathy in veterans with dementia.
The research findings suggest that healthcare professionals treating veterans with dementia, even in the absence of a cirrhosis diagnosis, should consider assessing their patients for liver disease. Detecting cirrhosis early may reveal treatable causes of cognitive impairment, potentially enhancing the quality of life for these patients.
Lead author Dr. Jasmohan Bajaj, a gastroenterologist and renowned expert in hepatic encephalopathy, emphasized the significance of screening patients for treatable contributors to cognitive decline, stating, “This unexpected link between dementia and liver health emphasizes the importance of screening patients for potentially treatable contributors to cognitive decline.”
While the study focused on veterans, the researchers believe the findings could apply to non-veterans with dementia, although further research is required. Dr. Bajaj encourages clinicians, particularly those dealing with dementia patients, to incorporate liver assessments into their routine care practices.
Hepatic encephalopathy is a nervous system disorder that results from cirrhosis, an advanced form of liver disease characterized by severe liver scarring. When the liver functions improperly, toxins accumulate in the bloodstream, and these toxins can reach the brain, affecting brain function and causing confusion or delirium. There are readily available medications that can eliminate toxins from the body and reverse this condition. Without treatment, patients can progress to a coma or face fatal consequences.
The inspiration for this study came from two cases involving older men initially diagnosed with dementia and Parkinson’s disease. Their symptoms dramatically improved after treatment for hepatic encephalopathy, with one individual even regaining the ability to drive. Building on this link between dementia and cirrhosis, the researchers previously published findings in 2023, indicating that around 8% of U.S. veterans with cirrhosis also had dementia.
In the current study, the authors reviewed the medical records of 177,422 U.S. veterans diagnosed with dementia but not cirrhosis between 2009 and 2019. These veterans were drawn from various VA medical facilities. Approximately 30% of veterans suffer from some form of liver disease.
The participants in the study were primarily male, with an average age of 78, and were assessed using the Fibrosis-4 (FIB-4) score. The FIB-4 score, a screening index for most liver diseases, takes into account multiple factors, including age, and is recommended by leading liver, gastroenterology, and endocrinology associations as an initial test to screen for liver fibrosis. The FIB-4 score was developed by Dr. Richard Sterling, the chief clinical officer of the Stravitz-Sanyal Institute for Liver Disease and Metabolic Health at VCU Health.
The study uncovered that 10.3% of veterans with dementia had high FIB-4 scores, indicating a high likelihood of cirrhosis. Risk factors for cirrhosis included older age, male gender, congestive heart failure, viral hepatitis, alcohol use, and specific health conditions.
Interestingly, the data indicated that Black and Hispanic veterans were disproportionately affected by dementia and were more likely to receive a diagnosis at a later stage of the disease. Non-Hispanic white veterans who did not use tobacco or had diabetes were less likely to have elevated FIB-4 scores.
The researchers conducted a follow-up study at the Richmond VA Medical Center, which yielded similar results, with as many as 11.2% of patients having high FIB-4 scores.
Dr. Bajaj emphasized the importance of healthcare providers being aware of the potential overlap between cirrhosis and hepatic encephalopathy in patients with cirrhosis and dementia. Routine use of the FIB-4 index for dementia evaluation could benefit a significant number of patients, families, and physicians by offering the opportunity to treat and potentially reverse cognitive impairment caused by liver disease.