Minimal hepatic encephalopathy impairs fitness to drive

Wein, Christian; Koch, Horst; Popp, B; Oehler, G.; Schauder, P.

doi:10.1002/hep.20095

Cited by 269 publications

(186 citation statements)

References 30 publications

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“…Similar results were reported in a study by Watanabe et al 65 However, a pilot study of 9 MHE patients using real road driving found no impairment in driving performance of these patients. 66 In a landmark study involving 48 patients with cirrhosis, Wein and his colleagues 67 had shown that MHE patients had impairment of driving using a standardized 90 min on-road driving test. Compared to NMHE patients, MHE patients showed most impairment in categories like car handling, maneuvering, adaptation and cautiousness compared to NMHE patients.…”

Section: Driving and Navigational Skills In Minimal Hepatic Encephalomentioning

confidence: 99%

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Minimal Hepatic Encephalopathy Impairs Quality of Life

Agrawal

Umapathy

Dhiman

2015

Journal of Clinical and Experimental Hepatology

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Minimal hepatic encephalopathy (MHE) is the mildest form of the spectrum of neurocognitive impairment in cirrhosis. It is a frequent occurrence in patients of cirrhosis and is detectable only by specialized neurocognitive testing. MHE is a clinically significant disorder which impairs daily functioning, driving performance, work capability and learning ability. It also predisposes to the development of overt hepatic encephalopathy, increased falls and increased mortality. This results in impaired quality of life for the patient as well as significant social and economic burden for health providers and care givers. Early detection and treatment of MHE with ammonia lowering therapy can reverse MHE and improve quality of life. ( J CLIN EXP HEPATOL 2015;5:S42-S48) H epatic encephalopathy (HE) is a neurocognitive disorder in which brain function is impaired and is associated with both acute and chronic liver dysfunction. 1 It is a major complication that develops in some form and at some stage in a majority of patients with liver cirrhosis. Minimal HE (MHE) is the mildest form of spectrum of HE which is characterized by subtle cognitive and psychomotor deficits in the absence of recognizable clinical symptoms of HE. 2 It occurs in patients with liver dysfunction and/or portosystemic shunts. In MHE, neurocognitive abnormalities primarily affect attention, speed of information processing, executive control, motor ability and coordination in an individual. 3 In 1970, Zeegen et al 4 first described this condition when they discovered that 38% of patients who had undergone portal decompression surgery scored abnormal in Reitan trail making test (number connection test). Eight years later, the term subclinical HE 5 was introduced to describe these patients. Since then, this condition was described under various names like early HE, latent HE, subclinical HE and finally minimal HE. The latest classification combines MHE and grade 1 HE into covert HE while higher grades are classified as overt HE, thus simplifying the clinical schema so that HE can be uniformly diagnosed. 6 Covert HE means that the mental defect is not detectable by the clinician using conventional testing and is not noticeable to the patient. However, it is significant because these patients usually have neuropsychiatric and neurophysiological abnormalities on advanced testing which are not enough to cause disorientation or asterixis. MHE is regarded as a preclinical stage of HE and ammonia and systemic inflammation plays an important role in its pathogenesis similar to HE. Ammonia lowering therapies were used in the treatment of MHE and found to be effective.MHE is clinically significant as it impairs daily functioning, health related quality of life (HRQOL) and driving skills, predicts the development of overt HE and is associated with poor survival. 7-11 Overt HE develops in >50% of MHE patients within three years. 10 These patients pose a significant burden to their care givers depending on the severity of cognitive dysfunction. 2,12 Considering all ...

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Section: Driving and Navigational Skills In Minimal Hepatic Encephalomentioning

confidence: 99%

“…Intervention required by the driving instructor to avoid accidents were more in MHE patients. 67 Increased risk of accidents was attributed to decline in cognitive function in MHE patients. 68 They also reported to have difficulties in following a map.…”

Section: Driving and Navigational Skills In Minimal Hepatic Encephalomentioning

confidence: 99%

Minimal Hepatic Encephalopathy Impairs Quality of Life

Agrawal

Umapathy

Dhiman

2015

Journal of Clinical and Experimental Hepatology

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“…Five of the 14 with MHE had the on-theroad performance test stopped by the driving instructor who was blinded to their cognitive test results. 6 There were no significant differences for individual components of the driving test, only for driving cessation. In a desktop driving simulator test, subjects with MHE made more wrong turns when performing a route following task, missed more divided attention tasks, and had more collisions than drivers with cirrhosis without MHE and compared to normal controls.…”

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confidence: 85%

Minimal Hepatic Encephalopathy and Driving† ‡

Dubinsky

Stein

2009

Hepatology

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O perating a motor vehicle is an overlearned motor task involving aspects of divided attention and visual perception (surveillance of roadway, traffic, and regulatory and informational signage), and time-on-task, accomplished by multiple limb-coordinated motions. Driving is a privilege granted by the government based on age (reflecting driver maturity), minimal performance standards (corrected vision, passing a written and a performance test under low workload conditions), and restricted based on bad experience (moving violations and collisions). Society tolerates the increased risk of the immature driver, because the only way their driving skills improve and the risk of collisions decrease is with practice. A trained driving examiner makes the licensing decision for the immature driver on behalf of the State. Society, through the legislative process, has restricted driving for certain conditions or driving violations. For example, States have progressively tightened the permissible level of breath alcohol concentration of drivers to a uniform 0.08 mg/dL. Through the same mechanism, some jurisdictions have increased the frequency of testing of older drivers and required physician reporting of potentially impaired drivers.Physicians are not trained to determine fitness-todrive. Thus, when called upon by a patient or their family to answer the question "can they drive?" the physician has no basis on which to base a decision. Previously, we addressed this question for drivers with dementia, through a systematic literature review. 1 This evidence-based medicine practice parameter reported that there was an increased risk of collisions for drivers with a clinical dementia rating scale score of 0.5 (possible Alzheimer's disease) and 1 (probable Alzheimer's disease) compared to nondemented drivers. The clinical dementia rating is a complex rating scale, based on a structured interview, encompassing many domains, and not easily adaptable to a brief clinical encounter. Of the many psychometric tests used in the studies of driving in people with dementia, only Trails A (as part of a regression analysis including age, sex, and driving history) and the Sternberg Test (a triarchic memory test) were partially predictive of future crash risk. 2,3 Thus far, no simple psychometric test has been found to have a threshold level robust enough to reliably divide drivers into high or low risk for future crashes. This is because driving is a complex task involving many cognitive domains, and collisions are rare events that involve both capable and impaired drivers.Bajaj and colleagues present an interesting report of motor vehicle crashes in drivers with cirrhosis, with and without minimal hepatic encephalopathy (MHE) over a 2-year period. 4 After measuring cognition with a brief psychometric test battery, and the inhibitory control test (ICT), the drivers were assigned to either the MHE cohort or the non-MHE cohort. Collision and violation data were collected by self-report and from the Department of Transportation for the year befor...

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“…64,65 Studies have consistently shown that patients with MHE have a diminished quality of life, cognitive function, daily function, and driving impairment. [3][4][5][6][7][8][9][10] While it was once thought that cognitive impairment with CHE or OHE was reversible, data from studies evaluating medical treatment or liver transplantation suggest that the associated cognitive changes may not be totally reversible. [66][67][68] Moreover, it has been demonstrated that even after therapy and improvement to normal mental status, a single episode of OHE may continue to have residual negative effects on cognitive function.…”

Section: Management Guidelines For Covert Hepatic Encephalopathymentioning

confidence: 99%