Up to 10% of veterans with dementia have FIB-4 scores that suggest undiagnosed cirrhosis
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Key takeaways:
- Results showed 10.3% of veterans had a FIB-4 score greater than 2.67 and 5.3% had a score greater than 3.25.
- A higher score was associated with history of viral hepatitis and alcohol use disorder, among other factors.
Physicians treating older veterans with dementia “should consider underlying cirrhosis” and use Fibrosis-4 as a screening tool to uncover reversible factors, such as hepatic encephalopathy, that may be associated with cognitive decline.
“Up to 10% of patients with dementia — without a preexisting cirrhosis diagnosis — could have cirrhosis and potential for underlying hepatic encephalopathy (HE), either as a cause or a contributing factor toward their mental dysfunction,” Jasmohan S. Bajaj, MD, from the division of gastroenterology, hepatology and nutrition at Virginia Commonwealth University, told Healio. “HE is very easily treatable, unlike dementia, and should be looked for in case cirrhosis is suspected.”
Using data from the Veterans Health Administration from 2009 to 2019, Bajaj and colleagues conducted a retrospective cohort study of 177,422 U.S. veterans (mean age, 78.35 years; 97.1% men; 80.7% white) with dementia. Researchers compared results with two separate validation cohorts from the Richmond Veterans Affairs Medical Center.
Studied outcomes included prevalence and risk factors associated with undiagnosed cirrhosis and potential HE, with FIB-4 scores greater than 2.67 (n = 10.3%) suggestive of advanced fibrosis and greater than 3.25 (n = 5.3%) suggestive of cirrhosis.
According to results published in JAMA Network Open, multivariable analysis showed FIB-4 greater than 3.25 was associated with older age (OR = 1.07; 95% CI, 1.06-1.09), male sex (OR = 1.43; 95% CI, 1.26-1.61), congestive heart failure (OR = 1.48; 95% CI, 1.43-1.54), viral hepatitis (OR = 1.79; 95% CI, 1.66-1.91), Alcohol Use Disorders Identification Test score (OR = 1.56; 95% CI, 1.44-1.68) and chronic kidney disease (OR = 1.11; 95% CI, 1.04-1.17).
Conversely, a high score was inversely associated with white race (OR = 0.79; 95% CI, 0.73-0.85), diabetes (OR = 0.78; 95% CI, 0.73-0.84), hyperlipidemia (OR = 0.84; 95% CI, 0.79-0.89), stroke (OR = 0.85; 95% CI, 0.79-0.91), tobacco use disorder (OR = 0.78; 95% CI, 0.7-0.87) and rural residence (OR = 0.92; 95% CI, 0.87-0.97).
According to continuous variable analysis, the odds for a FIB-4 score greater than 3.25 independently increased by 1.07 for a 1-unit increase in age and Charlson Comorbidity Index, while a 1-unit increase in BMI decreased the odds for this score by 0.97.
Researchers noted “findings were similar” when using a FIB-4 cutoff of 2.67; however, hypertension (OR = 1.03; 95% CI, 0.98-1.08) was no longer a significant risk factor in the multivariable model, while peripheral vascular disease (OR = 1.07; 95% CI, 1.07-1.12) and PTSD (OR = 0.92; 95% CI, 0.86-0.97) “became significant.”
Further, results from the validation cohort demonstrated a “similar percentage” of high FIB-4 scores, ranging from 4.4% to 11.2%.
“Providers, family members and patients should consider underlying cirrhosis in patients with dementia, which could in turn help not only treat HE as a specific contributor but also ensure patients get screening for liver cancer and other non-HE complications of cirrhosis,” Bajaj said. “Better biomarkers to differentiate the two conditions or identify overlaps and validation in non-veteran cohorts are needed. We are in the process of performing these investigations.”
Perspective
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William Carey, MD
When caring for individuals with altered mental status or dementia but no history of liver disease, the possibility of cirrhosis as a contributing factor is often overlooked.This study reminds us to think of cirrhosis in every person with apparent dementia and uses FIB-4 as a simple tool to identify those with cirrhosis. In such cases, additional testing and treatment for hepatic encephalopathy may be useful.
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