Study finds 1 in 10 veterans with dementia may suffer cognitive decline due to cirrhosis

Up to 10% of older U.S. veterans diagnosed with dementia may suffer from reversible cognitive decline caused by dementia, according to an analysis from the Virginia Commonwealth University School of Medicine and the Richmond VA Medical Center. advanced liver disease.

It can be difficult for doctors to differentiate dementia from cognitive decline caused by cirrhosis, called hepatic encephalopathy. If undetected, patients may not receive appropriate treatment that can reverse or stop the deficiency. The study, published in the journal Open JAMA Network, sought to learn more about the prevalence and risk factors for undiagnosed cirrhosis and potential encephalopathy in veterans with dementia.

The findings suggest that physicians treating veterans with dementia, even without a diagnosis of cirrhosis, should consider evaluating their patients for liver disease. Early identification of cirrhosis may reveal reversible causes of cognitive impairment, potentially improving the lives of these patients.

“This unexpected link between dementia and liver health highlights the importance of screening patients for potentially treatable contributors to cognitive decline,” said lead author Jasmohan Bajaj, MD, a gastroenterologist and hepatic encephalopathy expert at the VCU Stravitz-Sanyal Institute for Liver Disease and Metabolic Health and Richmond VA Medical Center.

The researchers believe the findings would apply to nonveterans with dementia, but more research is needed. Bajaj urges clinicians, especially those who encounter patients with dementia, to incorporate liver assessments into their patients’ routine care.

“Early detection of liver problems enables targeted interventions and paves the way to address treatable factors contributing to cognitive decline,” he said.

Hepatic encephalopathy is a nervous system disorder caused by cirrhosis, an advanced form of liver disease in which patients develop severe liver scarring. When the liver is not functioning properly, toxins build up in the blood. These toxins can travel to the brain and affect brain function, leaving patients confused or delirious. Widely available medications can easily rid the body of toxins and reverse this condition, but without treatment, patients can slip into a coma or die.

Bajaj said the study was sparked by the cases of two elderly men suspected of having dementia and Parkinson’s disease, but whose symptoms improved significantly after being treated for hepatic encephalopathy. One of the men recovered to the point where he resumed driving. Bajaj and colleagues continued to study this link between dementia and cirrhosis, publishing findings in 2023 that found about 8% of U.S. veterans with cirrhosis had dementia.

To look at the other side of the coin, the authors of the new study examined the medical records of 177,422 U.S. veterans diagnosed with dementia but not cirrhosis between 2009 and 2019. The veterans studied were patients from across the VA medical system. About 30% of veterans suffer from some form of liver disease.

Participants were predominantly men, with an average age of 78 years, and assessed using the Fibrosis-4, or FIB-4, score. The FIB-4 score, an initial screening index for most liver diseases based on several measures including age, is recommended by major liver, gastroenterology, and endocrinology associations as a first-line test to screen for liver fibrosis in the general population.

The FIB-4 score was developed by VCU Health hepatologist Richard Sterling, MD, who is the clinical director of the Stravitz-Sanyal Institute for Liver Disease and Metabolic Health.

The study found that 10.3% of veterans with dementia had high FIB-4 scores, meaning they were very likely to have cirrhosis. Factors that increase the risk of cirrhosis include older age, being male, congestive heart failure, viral hepatitis, alcohol use, and certain health conditions.

Notably, data showed that dementia disproportionately affected Black and Hispanic veterans, who were also more likely to be diagnosed later in the disease course. Non-Hispanic white veterans who did not use tobacco or had diabetes were less likely to have high FIB-4 scores.

Researchers conducted a follow-up study at the Richmond VA Medical Center to validate their findings and found similar results, with up to 11.2% of patients having elevated FIB-4 scores.

“The next step is to ensure that health care providers who care for patients with cirrhosis and dementia are aware of a potential overlap with hepatic encephalopathy, which is treatable,” said Bajaj, who spent the last few years focusing on hepatic encephalopathy and the gut-brain axis.

“Systematic use of the FIB-4 index to assess dementia could help a significant number of patients, families and physicians by providing the opportunity to treat and potentially reverse cognitive impairment caused by liver disease.” , he added.