A percentage of people who suffer cognitive decline likely have undiagnosed liver disease, not dementia, according to a study that a Virginia Commonwealth University-led research team published Wednesday.
The upside of having liver disease and not Alzheimer’s is that slowing mental capacity can be treated and reversed. One patient who was in a nursing home recovered so well he began driving again.
In a study of 177,000 patients with symptoms of dementia over 10 years, roughly 1 in 10 had undiagnosed cirrhosis, or scarring, of the liver, according to the study, published in the Journal of the American Medical Association Network Open.
The results should change the way doctors think about diagnosing dementia, said Dr. Jasmohan Bajaj, the study’s lead author.
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“We need to expand our horizons when we look at patients with dementia,” he said.
Liver disease has long been linked to brain dysfunction. When cirrhosis causes mental decline, the condition is known as hepatic encephalopathy, or H.E.
The liver’s job is to rid the body of toxins. When the liver ceases to function, those toxins travel to the brain, causing confusion or delirium. Without treatment, patients can fall into a coma or die.
As the causes of cirrhosis increase, liver disease has become a growing problem in the United States. Obesity, alcoholism, hepatitis B and C and auto immune disorders can contribute to a loss of liver function.
But H.E. can be treated with relative ease. Doctors often prescribe a laxative or antibiotic to rid the body of the toxin.
A major complicating factor of liver disease is that many patients don’t know they have it. It can spread for years without displaying symptoms. If the patient’s first symptom of liver disease is cognitive decline, a doctor can easily mistake it for incurable dementia.
Liver disease “only comes to our attention when they actually have a complication, which is a little too late,” Bajaj said.
177,000 patients studied at hospitals
Years ago, Bajaj analyzed a patient who had been diagnosed with Parkinson’s disease. The man was 71 years old, had tremors and hallucinations and could not remember his birthday. Doctors diagnosed him with Parkinson’s disease.
But when he came to the emergency room with abdominal pain, health care providers discovered cirrhosis in his liver. After he was treated for H.E., his memory made a stunning return. Another patient with a similar condition had been in a nursing home. After he was treated for H.E., he was able to resume driving.
“It boggles my mind that there could be other patients like this,” Bajaj said.
To find out how many, he and his team studied 177,000 patients at Veterans Affairs hospitals who suffered cognitive decline but had not been diagnosed with cirrhosis. The study, which collected data from 2009 to 2019, is believed to be the first of its kind.
Roughly 1 in 10 patients in the study had a lab test that indicated cirrhosis. About half of patients who have cirrhosis develop the cognitive decline known as H.E., meaning somewhere between 5% and 10% of the patients in the study likely had treatable liver disease.
Last year, Bajaj’s team conducted a follow-up study at the Richmond VA Medical Center, where they analyzed an additional 80 veterans who had possible dementia. Again, about 1 in 10 displayed a lab result indicating liver disease.
Cirrhosis is not reversible
There were limitations to what Bajaj and his team could learn from the study. It is impossible to know how many patients had cirrhosis but not H.E., meaning their cognitive decline was caused by something other than their disease and was not treatable. And it is possible some patients had the bad luck of suffering both H.E. and another form of dementia. For these patients, treating the H.E. would likely still improve their quality of life, even if the dementia persisted, Bajaj said.
Here’s the bad news for these patients: the cirrhosis itself is not reversible, and patients who suffer scarring on their liver have a high rate of developing cancer. The only treatment is a liver transplant.
The study’s other limitation was that it was conducted on veterans at VA hospitals, and most of the participants were white men. The participants in the study had higher rates of alcohol consumption and obesity, which leads to cirrhosis.
But Bajaj believes the study’s results are meaningful for a general population. Undiagnosed cirrhosis was higher in Black and Latino patients, and the participants had higher-than-usual risks for cognitive decline, such as post-traumatic stress syndrome.
“I think the results are extremely significant because (of) whatever we can do to help improve a patient’s quality of life, and if there’s a reversible cause of brain dysfunction, we should explore it in people with dementia,” Bajaj said.
In 2022, VCU started a standalone institute for the research and treatment of liver disease, the Stravitz-Sanyal Institute for Liver Disease and Metabolic Health.