Minimal hepatic encephalopathy is associated with motor vehicle crashes: The reality beyond the driving test

✍ Scribed by Jasmohan S. Bajaj; Kia Saeian; Christine M. Schubert; Muhammad Hafeezullah; Jose Franco; Rajiv R. Varma; Douglas P. Gibson; Raymond G. Hoffmann; R. Todd Stravitz; Douglas M. Heuman; Richard K. Sterling; Mitchell Shiffman; Allyne Topaz; Sherry Boyett; Debulon Bell; Arun J. Sanyal

• Publisher: John Wiley and Sons
• Year: 2009
• Tongue: English
• Weight: 378 KB
• Volume: 50
• Category: Article
• ISSN: 0270-9139
• DOI: 10.1002/hep.23128

✦ Synopsis

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 selfreported (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;50: 1175-1183.) See Editorial on Page 1007. M inimal hepatic encephalopathy (MHE) is a prevalent neurocognitive complication of cirrhosis that is diagnosed in up to 80% of patients with cirrhosis. It is associated with increased progression to overt hepatic encephalopathy (OHE) and impaired driving skills. 1-3 MHE patients have impaired attention, visuomotor coordination, psychomotor speed, and response inhibition. 4 Paper-pencil standard psychometric tests (SPT) or the computerized inhibitory control test (ICT) can be used to diagnose MHE. 5 The ICT has