Navigation skill impairment: Another dimension of the driving difficulties in minimal hepatic encephalopathy

Bajaj, Jasmohan S.; Hafeezullah, Muhammad; Hoffmann, Raymond G.; Varma, Rajesh; Franco, José; Binion, David G.; Hammeke, Thomas A.; Saeian, Kia

doi:10.1002/hep.22032

Cited by 140 publications

(107 citation statements)

References 38 publications

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“…MHE patients had impairment in navigation leading to more number of illegal turns and accidents which correlated with abnormal inhibitory control test. 73 Treatment of MHE with rifaximin improves driving performance of these patients in a driving simulator, which correlates with improvement in cognition. 51 Impaired driving performance in MHE patients is attributed to poor insight 74 of their driving skills, prolonged reaction time, impaired navigational skills and worsening fatigue.…”

Section: Driving and Navigational Skills In Minimal Hepatic Encephalomentioning

confidence: 93%

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: 93%

Minimal Hepatic Encephalopathy Impairs Quality of Life

Agrawal

Umapathy

Dhiman

2015

Journal of Clinical and Experimental Hepatology

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“…[6][7][8][9][10] Further treatment of MHE patients with lactulose or rifaximin show significant improvement in health-related quality of life and driving simulator performance. 2,4,29,30 PHES is a reliable and preferred tool for the diagnosis of MHE which has been recommended by the working party of the 11th World Congress of Gastroenterology 1 and by the consensus statement of a working party of the Indian National Association for Study of the Liver.…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3] It is associated with cognitive impairment that may have a detrimental effect on HRQOL 4,5 and is likely to affect driving abilities. [6][7][8][9][10] In view of its socio-medical relevance, simple and reproducible tests are required for routine diagnosis. But in the absence of a "gold standard", psychometric and neurophysiological methods have been the most trusted and widely used tests to diagnose this condition.…”

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confidence: 99%

Inhibitory Control Test for the Detection of Minimal Hepatic Encephalopathy in Patients with Cirrhosis of Liver

Taneja¹,

Dhiman²,

Khatri³

et al. 2011

Journal of Clinical and Experimental Hepatology

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Background & aims: Minimal hepatic encephalopathy (MHE) has significant impact on future clinical outcomes, such as occurrence of overt HE (OHE) and survival in patients of cirrhosis. In the absence of a 'gold standard', psychometric hepatic encephalopathy score (PHES) is widely used for the diagnosis of MHE. This cross-sectional and prospective study was carried out to determine the usefulness of inhibitory control test (ICT) for the diagnosis of MHE. Methods: One hundred and two patients with cirrhosis and without a history of OHE were enrolled in to the study and were subjected to PHES and ICT. MHE was diagnosed when the PHES was # À5. ICT was considered abnormal when the numbers of ICT lures were more than 14. Results: Forty-one (40.2%) patients had MHE. There were 40 patients with normal PHES and ICT, 32 with abnormal PHES and ICT, 9 with abnormal PHES and normal ICT, and 21 with abnormal ICT and normal PHES score. ICT had 78% sensitivity and 65.6% specificity and an areaunder-the-curve value of 0.735 (95% CI = 0.632-0.830) for the diagnosis of MHE. In patients with cirrhosis, ICT did not correlate with severity of liver disease as measured by CTP score (r = 0.044, P = 0.658) and MELD score (r = 0.176, P = 0.077). ICT did not predict survival as well as PHES; while 6 (11.3%) patients died among those who had altered ICT compared to 4 (8.2%) patients who did not have altered ICT (P = 0.74), 8 (19.5%) patients died among those who had altered PHES compared to 2 (3.3%) patients who did not have altered PHES (P = 0.013). Conclusion: ICT is not as useful as PHES in diagnosing MHE in patients with cirrhosis of the liver. It does not correlate with disease severity and predict survival as well as PHES. ( J CLIN EXP HEPATOL 2012;2:306-314)

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“…Minimal hepatic encephalopathy impairs daily functioning and health-related quality of life (HRQOL), 5,6 it predicts the development of overt HE, 7,8 it is associated with poor prognosis, 9,10 and these patients experience higher rates of accidents, driving problems, and falls. [11][12][13][14] Furthermore, treatment with lactulose or rifaximin improves cognitive functions as well as HRQOL and driving simulator performance in these patients. 6,15,16 Neuropsychological tests are commonly applied to detect MHE in patients with liver cirrhosis, 5 but they provide no information about the cerebral regions involved.…”

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confidence: 99%