Dementia Diagnosis: Don't Miss the Hidden Liver Connection

This study published in the journal JAMA Network Open found that up to 10% of veterans with dementia may have undiagnosed cirrhosis, based on elevated FIB-4 (Fibrosis-4) scores. This undiagnosed cirrhosis could lead to missed treatment for hepatic encephalopathy (HE), which mimics dementia symptoms and worsens cognitive decline. The study suggests screening dementia patients for cirrhosis using a simple blood test to enable early detection and treatment, potentially improving patient outcomes. However, further research is needed to confirm the link between cirrhosis, HE, and dementia.

Key Findings:

• High Prevalence: Among veterans with dementia, 5.3% had a FIB-4 score suggestive of cirrhosis, and 10.3% had a score suggestive of advanced fibrosis.

• Missed Opportunities: These findings suggest that undiagnosed cirrhosis, potentially leading to hepatic encephalopathy (HE), might be present in some dementia patients.

• HE and dementia: HE can mimic dementia symptoms, making it challenging to distinguish between the two conditions. Undiagnosed HE could lead to missed treatment opportunities and worsen cognitive decline.

• Risk Factors: The study identified several factors associated with higher FIB-4 scores, including older age, male gender, certain medical conditions like viral hepatitis and congestive heart failure, and alcohol use.

Implications:

• Screening Importance: The study suggests that clinicians treating dementia patients should consider screening for potential undiagnosed cirrhosis using the FIB-4 score, a simple blood test.

• Early Detection: Early detection and treatment of cirrhosis and HE could improve cognitive function and overall outcomes for dementia patients.

• Further Research: More research is needed to explore the link between cirrhosis, HE, and dementia, and to develop optimal screening and treatment strategies for this patient population.

Limitations:

• Observational Study: This study was observational, meaning it cannot establish a causal relationship between cirrhosis and dementia.

• Veteran Population: The study focused on veterans, and the findings might not be generalizable to the entire population.

Cirrhosis, hepatic encephalopathy (HE), and dementia present significant challenges in the increasingly aging veteran population. A recent national cohort study sheds light on the prevalence and implications of high FIB-4 scores, indicating potential undiagnosed cirrhosis, particularly in patients with dementia. This comprehensive analysis explores the intricate relationship between these conditions, emphasizing the need for heightened awareness, early detection, and targeted interventions to improve cognitive function and overall quality of life among veterans.

Prevalence and Risk Factors

The study revealed that 10.3% of veterans with dementia exhibited high FIB-4 scores, suggesting underlying cirrhosis. Notably, non-white and Hispanic patients, as well as urban dwellers, exhibited a higher prevalence of potentially undiagnosed cirrhosis. Furthermore, patients with comorbidities such as alcohol use disorder (AUD) and viral hepatitis were at increased risk. These findings underscore the importance of considering liver disease as a potential contributor to cognitive impairment in patients with dementia, particularly those with additional risk factors.

Diagnostic Challenges and Screening Tools

Diagnosing cirrhosis and HE in the context of dementia poses significant challenges due to overlapping symptoms and the lack of clinically applicable biomarkers. However, the FIB-4 index emerges as a valuable screening tool, offering scalability, affordability, and ease of interpretation. Primary care physicians are increasingly utilizing FIB-4 scores for screening purposes, enhancing the likelihood of early detection and intervention.

Disparities and Implications

The study highlights racial and geographic disparities in the diagnosis of cirrhosis among veterans with dementia. Black and Hispanic veterans, as well as those residing in urban areas, are disproportionately affected, indicating potential gaps in access to quality healthcare. Addressing these disparities is crucial to ensuring equitable diagnosis and management of liver disease in vulnerable populations.

Novel Findings and Considerations

Interestingly, the study observed differences in the factors associated with high FIB-4 scores compared to the general population. While traditional risk factors like AUD and viral hepatitis remained significant, other comorbidities, such as diabetes and hyperlipidemia, did not exhibit the same association. This suggests unique pathophysiological mechanisms underlying cirrhosis in patients with dementia, necessitating tailored approaches to diagnosis and management.

• Data Source: VHA Corporate Data Warehouse (CDW) from 2009 to 2019.

• Inclusion Criteria: Veterans with 2 or more dementia diagnoses, no prior cirrhosis diagnosis, and sufficient lab values for calculating the FIB-4 score.

• Exclusion Criteria: Existing cirrhosis diagnosis, missing lab values, or abnormally low platelet count.

• FIB-4 Score: Used to assess liver fibrosis/cirrhosis risk, with higher scores indicating increased risk.

• Cutoffs: FIB-4 > 3.25 suggests cirrhosis, and FIB-4 > 2.67 suggests advanced fibrosis.

• Validation: Conducted using medical record reviews from Richmond VAMC.

Findings:

• Prevalence:

  • 5.3% of veterans had a FIB-4 score > 3.25, suggesting undiagnosed cirrhosis.

  • 10.3% had a FIB-4 score > 2.67, suggesting advanced liver fibrosis.

• Characteristics Associated with High FIB-4:

  • Older age

  • Male gender

  • Certain medical conditions (e.g., viral hepatitis, congestive heart failure)

  • Alcohol use disorder

  • Non-White race (except White)

Implications:

• Undiagnosed cirrhosis might be present in a significant portion of veterans with dementia.

• High FIB-4 scores suggest the potential for undiagnosed advanced liver disease.

• Screening for cirrhosis using FIB-4 could be valuable in this population.

• Early detection and treatment of cirrhosis might improve cognitive function and overall outcomes.

Limitations and Future Directions

Despite the strengths of the study, including its national scope and diverse veteran population, there are notable limitations. The reliance on coding for diagnoses and the lack of granularity in cirrhosis and dementia classifications warrant caution in interpreting the findings. Future research should focus on refining diagnostic criteria, elucidating underlying mechanisms, and addressing healthcare disparities to optimize outcomes for veterans with dementia and liver disease.

Conclusion

In conclusion, the study underscores the importance of recognizing and addressing liver disease as a potential contributor to cognitive impairment in veterans with dementia. Early detection of cirrhosis through tools like the FIB-4 index is crucial for timely intervention and improved outcomes. By enhancing awareness, promoting targeted screening, and addressing healthcare disparities, we can strive towards better management of liver disease in this vulnerable population.

Journal Reference

Bajaj, J. S., Silvey, S. G., Rogal, S., O’Leary, J. G., Patton, H., Morgan, T. R., Kanagalingam, G., Gentili, A., Godschalk, M., & Patel, N. (2024, January 31). Undiagnosed Cirrhosis and Hepatic Encephalopathy in a National Cohort of Veterans With Dementia. JAMA Network Open, 7(1), e2353965. https://doi.org/10.1001/jamanetworkopen.2023.53965

Related
https://healthnewstrend.com/fatty-liver-disease-and-obesity-alarming-link-and-essential-steps-to-manage

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