Minimal encephalopathy is associated with motor vehicle crashes: The reality beyond the driving test (original) (raw)
Related papers
Hepatology, 2009
Patients with minimal hepatic encephalopathy (MHE) have impaired driving skills, but association of MHE with motor vehicle crashes is unclear. Standard psychometric tests (SPT) or inhibitory control test (ICT) can be used to diagnose MHE. The aim was to determine the association of MHE with crashes and traffic violations over the preceding year and on 1-year follow-up. Patients with cirrhosis were diagnosed with MHE by ICT (MHEICT) and SPT (MHESPT). Self and department-of-transportation (DOT)-reports were used to determine crashes and violations over the preceding year. Agreement between self and DOT-reports was analyzed. Patients then underwent 1-year follow-up for crash/violation occurrence. Crashes in those with/without MHEICT and MHESPT were compared. 167 patients with cirrhosis had DOT-reports, of which 120 also had self-reports. A significantly higher proportion of MHEICT patients with cirrhosis experienced crashes in the preceding year compared to those without MHE by self-report (17% vs 0.0%, P = 0.0004) and DOT-reports (17% vs 3%, P = 0.004, relative risk: 5.77). SPT did not differentiate between those with/without crashes. A significantly higher proportion of patients with crashes had MHEICT compared to MHESPT, both self-reported (100% vs 50%, P = 0.03) and DOT-reported (89% vs 44%, P = 0.01). There was excellent agreement between self and DOT-reports for crashes and violations (Kappa 0.90 and 0.80). 109 patients were followed prospectively. MHEICT patients had a significantly higher future crashes/violations compared to those without (22% vs 7%, P = 0.03) but MHESPT did not. MHEICT (Odds ratio: 4.51) and prior year crash/violation (Odds ratio: 2.96) were significantly associated with future crash/violation occurrence. Conclusion: Patients with cirrhosis and MHEICT have a significantly higher crash rate over the preceding year and on prospective follow-up compared to patients without MHE. ICT, but not SPT performance is significantly associated with prior and future crashes and violations. There was an excellent agreement between self- and DOT-reports. (HEPATOLOGY 2009.)
Patients With Minimal Hepatic Encephalopathy Have Poor Insight Into Their Driving Skills
Clinical Gastroenterology and Hepatology, 2008
Background & Aims: Minimal hepatic encephalopathy (MHE) is associated with impaired driving skills. It is not clear whether patients have insight into this. The Driving Behavior Survey (DBS) is a validated self-or observeradministered questionnaire. DBS consists of a total score (maximum, 104) and an attention-related driving skills section (maximum, 40). DBS was used to compare self-assessment with observer-assessment of driving skills in cirrhotic patients tested for MHE. Methods: Forty-seven nonalcoholic cirrhotic patients and 40 controls underwent psychometric tests, DBS, and driving simulation with navigation/ driving tasks. An adult familiar with the subject's driving completed the DBS independently. Simulator performances, total DBS scores, and driving skill scores were compared between/within groups (MHE؉, MHE؊, and controls) with respect to self-assessment and observer assessment. Results: Thirty-six patients were MHE؉ and 11 were MHE؊. MHE؉ had a significantly higher simulator crash (MHE؉, 3; MHE؊, 1.2; controls, 1.7; P ؍ .001) and illegal turn rate (MHE؉, 1.2; MHE؊, 0.3; controls, 0.1; P ؍ .0001). Despite this worse performance, MHE؉ patients rated themselves similar to MHE؊ patients and control groups on total (P ؍ .28) and driving skills scores (P ؍ .19). Observer assessment in MHE؉ was significantly lower for total (P ؍ .0001) and driving skills (P ؍ .0001) compared with observer assessment for MHE؊ patients and control groups. MHE؉ patients were rated significantly lower on driving skills (34 vs 37; P ؍ .02) and trended lower in the total score (P ؍ .08) by observers compared with self-ratings. In contrast, MHE؊ and control groups rated themselves similar to their observers on driving skills and total DBS scores. Conclusions: MHE patients have poor insight into their driving skills. A part of the MHE patient's clinical interview should be to increase awareness of this driving impairment. Methods Consecutive nonalcoholic patients with cirrhosis who were car drivers and were tested for MHE were included. 13 Cirrhotic patients on psychoactive drugs (including psychiatric and seizure medications, ADHD therapy, and interferon), those
PubMed, 2009
Introduction: Minimal hepatic encephalopathy (mHE) has been reported in up to 84 percent of cirrhotics. The natural history of mHE has not been well-described. We designed a three-year prospective cohort study to determine the prevalence and natural history of mHE among cirrhotic patients. Methods: The patient cohort comprising 62 consecutive outpatients with cirrhosis were assessed at baseline and followed-up with a repeat assessment three years later. The assessments include: (1) Neuropsychometric analysis (digit-symbol substitution test, block-design test, number-connection test A); (2) Clinical, biochemical assessment; and (3) Quality of life (QOL) assessment (abbreviated sickness impact profile). Results: Baseline characteristics were: age 52.9 +/- 11.0 years; Child's A:B:C was 46:14:2. mHE was detected in 33.9 percent of the cohort. Older age, a higher Child-Pugh score and female gender were independently associated with mHE. mHE was associated with a poorer QOL. Follow-up assessment three years later showed that seven patients had died, while six were lost to follow-up; these patients had significantly higher baseline Child's scores. Of the remaining patients, 36/49 (73 percent) agreed to a repeat evaluation. In this group, none had mHE. QOL remained impaired despite the resolution of mHE. Conclusion: It has been shown for the first time that mHE can revert to a normal state in a significant proportion of patients with well-compensated cirrhosis.
Role of minimal hepatic encephalopathy in road traffic accidents
The Egyptian Journal of Neurology, Psychiatry and Neurosurgery, 2019
Background: The term minimal hepatic encephalopathy (MHE) is defined as encephalopathy that does not lead to clinically overt cognitive dysfunction but can have an impact on quality of life, risk of involvement in road traffic accidents, and ability to function in daily life. Objective: To identify the incidence of minimal hepatic encephalopathy in patients actively involved in a road traffic accident and its role in the increased incidence of road traffic accidents. Patients and methods: We included 74 patients presented in road traffic accidents (drivers, history of fall, pedestrians whom accidents occur during crossing the road) with clinically proven hepatic cirrhosis, without clinical manifestation of hepatic encephalopathy (HE). Thorough history taking, clinical examinations, routine laboratory investigations, serum IL-6 and ammonia in blood were done. Diagnosis of MHE is based on psychometric hepatic encephalopathy score (PHES) which includes digit symbol test (DST), number connection test-A (NCT-A), number connection test-B (NCT-B), serial dotting test (SDT), and line drawing test (LDT). Results: The mean age was 52.0 ± 7.47 in MHE patients. Most of the MHE patients were males. Most of the patients with MHE were working other jobs and were not drivers (63.2% vs 36.8%). MHE was observed in 19 patients (25.7%). Albumin, interleukin-6 (IL-6), and ammonia were statistically significantly different between both groups. Conclusion: Minimal hepatic encephalopathy (MHE) was observed in 25.7% of patients which points that we must give attention in the screening of MHE as road traffic accident is considered the main cause of mortality in our community with high incidence of liver disease.
Hepatology, 2007
Patients with minimal hepatic encephalopathy (MHE) have attention, response inhibition, and working memory difficulties that are associated with driving impairment and high motor vehicle accident risk. Navigation is a complex system needed for safe driving that requires functioning working memory and other domains adversely affected by MHE. The aim of this study was to determine the effect of MHE on navigation skills and correlate them with psychometric impairment. Forty-nine nonalcoholic patients with cirrhosis (34 MHE؉, 15 MHE؊; divided on the basis of a battery of block design, digit symbol, and number connection test A) and 48 age/education-matched controls were included. All patients underwent the psychometric battery and inhibitory control test (ICT) (a test of response inhibition) and driving simulation. Driving simulation consisted of 4 parts: (1) training; (2) driving (outcome being accidents); (3) divided attention (outcome being missed tasks); and (4) navigation, driving along a marked path on a map in a "virtual city" (outcome being illegal turns). Illegal turns were significantly higher in MHE؉ (median 1; P ؍ 0.007) compared with MHE؊/controls (median 0). Patients who were MHE؉ missed more divided attention tasks compared with others (median MHE؉ 1, MHE؊/controls 0; P ؍ 0.001). Similarly, accidents were higher in patients who were MHE؉ (median 2.5; P ؍ 0.004) compared with MHE؊ (median 1) or controls (median 2). Accidents and illegal turns were significantly correlated (P ؍ 0.001, r ؍ 0.51). ICT impairment was the test most correlated with illegal turns (r ؍ 0.6) and accidents (r ؍ 0.44), although impairment on the other tests were also correlated with illegal turns. Conclusion: Patients positive for MHE have impaired navigation skills on a driving simulator, which is correlated with impairment in response inhibition (ICT) and attention. This navigation difficulty may pose additional driving problems, compounding the pre-existing deleterious effect of attention deficits. (HEPATOLOGY 2008;47:596-604.) Abbreviations: BDT, block design test; DBQ, driving behavior questionnaire; DST, digit symbol test; ICT, inhibitory control test; MHE, minimal hepatic encephalopathy; NCT-A, number connection test A. From the
Hepatology (Baltimore, Md.), 2017
Over 40% of patients with cirrhosis will develop hepatic encephalopathy (HE). HE is associated with decreased survival, falls, motor vehicle accidents, and frequent hospitalization. Accordingly, we aimed to develop a tool to risk-stratify patients for HE development. We studied a population-based cohort of all patients with cirrhosis without baseline HE (N=1,979) from the Veterans Administration from Michigan, Indiana, and Ohio (1/1/2005-12/31/10) using demographic, clinical, laboratory, and pharmacy data. The primary outcome was the development of HE. Risk-scores were constructed with both baseline and longitudinal data (annually updated parameters) and validated using bootstrapping. The cohort had mean age of 58.0±8.3 years, 36% had hepatitis C, 17% had ascites. Opiates, benzodiazepines, statins, and nonselective beta-blockers were taken at baseline by 24%, 13%, 17%, and 12%. Overall, 863(43.7%) developed HE within 5 years. In multivariable models, risk factors (HR, 95%CI) for HE ...
Assessment of minimal hepatic encephalopathy (with emphasis on computerized psychometric tests)
Clinics in liver disease, 2012
Minimal hepatic encephalopathy (MHE) is associated with a high risk of development of overt hepatic encephalopathy, impaired quality of life, and driving accidents. The detection of MHE requires specialized testing because it cannot, by definition, be diagnosed on standard clinical examination. Psychometric and neurophysiologic techniques are often used to test for MHE. Paper-pencil psychometric batteries and computerized tests have proved useful in diagnosing MHE and predicting its outcomes. Neurophysiologic tests also provide useful information. The diagnosis of MHE is an important issue for clinicians and patients alike. Testing strategies depend on the normative data available, patient comfort, and local expertise.
Zagazig University Medical Journal, 2020
Background: Minimal hepatic encephalopathy (MHE) has a mild neurocognitive impairment that includes neuropsychological and neurophysiological alterations that can not be detected by clinical examination. This study aims to assess the frequency and risk factors for developing minimal hepatic encephalopathy in patients with compensated cirrhosis. Methods: This cross sectional study was conducted on 60 patients with compensated cirrhosis in Zagazig University Hospital and elmatarya Teaching Hospital from December 2017 to June 2018, diagnosis of minimal hepatic encephalopathy was established by using mini mental status examination test and psychometric studies, they underwent full history, laboratory investigations and abdominal doppler ultrasonography by professional radiologist assessing the presence of any porto systemic shunts and measuring serum ammonia level. Results: About 37% had MHE. Female represented 65% with mean age 49.82 years. There is statistically significant relation between MHE and smoking, comorbid diabetes, hypertension, high ammonia level and portosystemic shunt. Smoking, being single, illiterate, portosystemic shunt, comorbid diabetes and hypertension increased risk of MHE by 4.57, 3.05, 2.31, 25.94, 3.29 and 3.55 folds. Male gender and normal ammonia level were protective factors. There is significant relation between MHE and age, platelet count, serum albumin, ammonia and INR. Older patients, low platelet count and serum albumin, high ammonia level and INR were detected among patients with MHE. Increasing ammonia level was significant independent risk factor for MHE. Conclusions: MHE is a prevalent condition among patients with compensated cirrhosis with high ammonia level and portosystemic shunts as a strong risk factors for its development.