Source

Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA. jsbajaj@vcu.edu.

Abstract

Background: Psychiatric disorders and medications may affect cognitive performance in cirrhosis and complicate the diagnosis and prediction of hepatic encephalopathy (HE). Aims: to study the association of psychoactive medications with cognitive performance and their effect on the ability of tests to predict HE development in cirrhotics referred for transplant evaluation. Methods: Cirrhosis details, psychiatric disorders, psychoactive medications and history of prior HE were recorded for cirrhotics in two transplant centers. Patients were followed until HE development. Five cognitive tests [Number connection-A/B(NCT), Digit symbol(DST), block design, inhibitory control test (ICT)]were administered. A high lure and low ICT target score indicates poor performance. Cognitive performance between those with/without psychiatric disorders/medications was compared. A proportional-hazards model with time to HE as the outcome using demographics, psychoactive medications, cirrhosis details and individual cognitive scores was performed. Patients with/without prior HE were then studied separately. Results: 155 patients (57.5±6.2years,15.1±6.2 MELD, 48% prior HE, 34% diabetes, 32% on selective serotonin-reuptake inhibitors(SSRI), 19% on opioids, 10% on antipsychotics) were included. Prior HE and anti-psychotics, but not opioids or diabetes were associated with worse cognition. SSRI users had better NCT-A and DST performance. 148 patients were followed for 182.5 days(median); 58 developed HE 99 days(median) post-inclusion. Using the entire group, the model showed that prior HE(HR:4.13), MELD(HR:1.07), high lures(HR:1.04) decreased while use of SSRIs(HR:0.42), high targets(HR:0.95) and high sodium(HR:0.89) increased time to HE. In those without prior HE, MELD score(HR:1.25) and lures(HR:1.09) predicted time to HE. Lures(HR:1.03), targets(HR:0.96) and sodium(HR:0.87) were associated with time to HE in those with prior HE. Conclusion: Cognitive tests, particularly ICT, remain valid as predictors of HE in the face of psychiatric diseases and medications. SSRI use is associated with better cognitive performance and reduced likelihood of developing HE.