Neuropsychological assessment of hepatic encephalopathy: ISHEN practice guidelines

Abstract

Low-grade or minimal hepatic encephalopathy (MHE) is characterised by relatively mild neurocognitive impairments, and occurs in a substantial percentage of patients with liver disease. The presence of MHE is associated with a significant compromise of quality of life, is predictive of the onset of overt hepatic encephalopathy and is associated with a poorer prognosis for outcome. Early identification and treatment of MHE can improve quality of life and may prevent the onset of overt encephalopathy, but to date, there has been little agreement regarding the optimum method for detecting MHE. The International Society on Hepatic Encephalopathy and Nitrogen Metabolism convened a group of experts for the purpose of reviewing available data and making recommendations for a standardised approach for neuropsychological assessment of patients with liver disease who are at risk of MHE. Specific recommendations are presented, along with a proposed methodology for further refining these assessment procedures through prospective research.

Minimal Hepatic Encephalopathy: The Reality Beyond Our Eyes

“…33,36 The PHES has been recently recommended by the International Society on Hepatic Encephalopathy and Nitrogen Metabolism for the neuropsychological assessment of patients with liver disease. 33 Only this battery has been specifically developed for the diagnosis of MHE. 5 The PHES combines five easily applicable paper-andpencil psychometric tests: the Number Connection Test-A, the Number Connection Test-B, the Digit Symbol Test, the Serial Dotting Test and the Line Drawing Test.…”

“…33,34,36,41,42 Comparing with the other approaches, the psychometric testing is the most robust diagnostic method because it directly assesses the cognitive functions which are impaired in MHE and is more extensively validated. 33,36 The PHES has been recently recommended by the International Society on Hepatic Encephalopathy and Nitrogen Metabolism for the neuropsychological assessment of patients with liver disease. 33 Only this battery has been specifically developed for the diagnosis of MHE.…”

“…33,34 Several tools to detect MHE have been proposed, including neuropsychological testing (such as Psychometric Hepatic Encephalopathy Score (PHES), 33 Repeatable Battery for Assessment of Neuropsychological Status (RBANS), 33 Inhibitory Control Test, 35 Continuous Reaction Time Test 34,36 ), electroencephalogram spectral analysis/evoked potentials 33,[37][38][39][40] and critical flicker frequency. 33,34,36,41,42 Comparing with the other approaches, the psychometric testing is the most robust diagnostic method because it directly assesses the cognitive functions which are impaired in MHE and is more extensively validated. 33,36 The PHES has been recently recommended by the International Society on Hepatic Encephalopathy and Nitrogen Metabolism for the neuropsychological assessment of patients with liver disease.…”

Effects of Illness Severity and Alcohol Use on Cognition in End Stage Liver Disease after Controlling for General Intelligence and Mood——Cognition in End Stage Liver Disease

“…Many patients experience milder cognitive dysfunction, commonly referred to as minimal hepatic encephalopathy (MHE). MHE is primarily characterized by a deficit in cognitive processing speed that is apparent on select neuropsychological tests rather than standard mental status exam (for review, see Randolph et al [7]). Early detection and management of patients with MHE is important because of the increased risk of developing overt hepatic encephalopathy and gross cognitive impairment.…”

“…In their practice guidelines [7] the commission recommended two specific batteries, the PSE-Syndrom-Test [8] and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) [9]. The PSE-SyndromTest consists of five measures of psychomotor speed.…”