Impaired cognition predicts the risk of hospitalization and death in cirrhosis

Objective: Cognitive impairment, detected in up to 80% of patients with liver cirrhosis, is associated with negative health outcomes but is underdiagnosed in the clinical setting due to the lack of practical testing method. This single-center prospective observational study aimed to test the feasibility and prognostic utility of in-clinic cognitive assessment of patients with liver cirrhosis using the NIH Toolbox cognition battery (NIHTB). Methods: Patients recruited from a hepatology/transplant clinic underwent cognitive assessments using West-Haven Grade (WHG) and NIHTB between November 2016 and August 2018 and were prospectively followed until December 2018. The primary outcome was a composite end point of hospitalization related to overt hepatic encephalopathy (OHE) and all-cause mortality during follow-up, evaluated by a Cox proportional hazards regression model that adjusted for a priori covariates (age and MELD-Na). Results: Among 127 patients (median age 60 years, 48 [38%] women) assessed, cognitive performance was significantly impaired in 82 [78%] patients with WHG 0 and 22 [100%] patients with WHG 1 and 2. Over a median of 347 days follow-up, 18 OHE and 8 deaths were observed. Lower cognitive performance was associated with an increased risk of OHE/death adjusting for age and MELD-Na. Subclinical cognitive impairment detected by NIH Toolbox in WHG 0 patients was significantly associated with greater mortality. Median time to complete the two prognostically informative NIH Toolbox tests was 9.4 min. Interpretation: NIH Toolbox may enable a rapid cognitive screening in the outpatient setting and identify patients at high risk for death and hospitalization for severe encephalopathy.