Why People With Dementia Should Get Screened for Liver Disease

Fact checked by Nick Blackmer

Key Takeaways

• New research suggests that some patients with a dementia diagnosis may actually have advanced liver disease that’s causing cognitive changes.

• Hepatic encephalopathy can cause signs and symptoms of dementia.

• While it can be treated with medication, hepatic encephalopathy can be deadly if left unchecked.

About 5.8 million people in the United States have Alzheimer’s disease and related dementias. A dementia diagnosis can be devastating, but new research suggests that some people who have been diagnosed with the condition may not actually have it—and their symptoms could even be reversible.

A study published in JAMA Network Open looked at data on 177,422 veterans who had been diagnosed with dementia. The researchers found that up to 10% of the patients in the study may have had liver disease advanced enough to cause scarring (cirrhosis), even though they hadn’t been diagnosed with the condition previously.

Untreated cirrhosis can cause a nervous system disorder called hepatic encephalopathy, which is characterized by signs and symptoms of cognitive decline, study co-author Jacqueline G. O’Leary, MD, professor of internal medicine at UT Southwestern Medical Center, told Verywell. If patients are not diagnosed correctly, they won’t know that it could be possible to reverse the cognitive decline by treating the underlying liver disease that’s causing it.

Related: Types of Liver Disease and How to Treat Them

When Liver Disease Causes Cognitive Symptoms

When the liver doesn’t work properly, toxins can build up in the blood and travel to the brain. The resulting hepatic encephalopathy can happen suddenly or develop over time.

The condition can be caused by a severe hepatitis B or C infection, alcohol use, autoimmune hepatitis, bile duct disorders, nonalcoholic fatty liver disease, and certain medications. It may develop in patients with undiagnosed liver disease that advances, as well as people who already know that they have chronic liver disease, according to lead study author Jasmohan Bajaj, MD, a professor of internal medicine at Virginia Commonwealth University.

“Due to the aging population overall and specifically with cirrhosis, as well as the obesity and diabetes epidemic, there is a higher risk for dementia in patients with cirrhosis,” Bajaj told Verywell.

Once the toxins that are building up in the blood start to reach the brain, they can affect cognitive function. Some of the signs and symptoms can look and feel a lot like the cognitive and even motor symptoms of dementia.

For example, early symptoms of the condition can include musty or sweet-smelling breath, changes in sleep patterns, mild confusion, personality or mood changes, poor concentration, and worsening handwriting.

More severe symptoms can include agitation or excitement, shaking hands or arms, disorientation, drowsiness, confusion, behavior or personality changes, slurred speech, and slowed or sluggish movement. Certain factors can also make these symptoms worse, like a diet that’s too rich in protein, surgery, dehydration, or infections.

Related: Everything to Know About Alcoholic Liver Disease

Why It’s Hard to Tell Dementia From Hepatic Encephalopathy

With so many overlapping symptoms, it’s easy to see why hepatic encephalopathy could be missed as the culprit behind a patient’s cognitive dysfunction. But while Alzheimer’s is the most common cause of dementia, it’s not the only possibility. And we don’t yet have highly specific diagnostic tools to help providers feel more confident about either diagnosis.

“There are no simple blood tests for dementia or hepatic encephalopathy—and they can look very similar,” said O’Leary.

However, there might be some clues in the nuances of each patient’s cognitive function. A provider just has to look a little closer and take their full health into account.

“In my practice, I’m often asked to distinguish between Alzheimer’s disease and hepatic encephalopathy,” Holly Westervelt, PhD, an associate professor of clinical neurology and director of Neuropsychological Services at Vanderbilt University Medical Center, told Verywell.

She said both conditions can make patients seem “very forgetful,” but the main symptoms seen in patients with hepatic encephalopathy affect attention and information processing.

“When information isn’t processed well, it isn’t remembered well, and patients with hepatic encephalopathy can show a lot of absentminded forgetfulness,” said Westervelt. “In a dementia-like Alzheimer’s disease, patients may process well, especially in early disease, but they can’t store new memories for later. It is a true disorder of memory.”

Westervelt added that patients with either condition can be forgetful, “but we are actually able to distinguish between these conditions fairly well with detailed cognitive testing, as is done in a neuropsychological evaluation.”

When tested, patients with hepatic encephalopathy typically have more trouble paying attention than those with Alzheimer’s disease do.

Is Cognitive Decline From Hepatic Encephalopathy Treatable?

While it’s a serious condition, hepatic encephalopathy is treatable and can even be reversible.

“In most cases, with adequate recognition and treatment, it can be reversed to the point of improvement in mental status,” said Bajaj.

The medications used to treat it, like lactulose and rifaximin, are commonly prescribed for conditions that affect the gut, like constipation and irritable bowel syndrome (IBS).

Hepatic encephalopathy is definitely treatable, emphasized O’Leary. Lactulose is a synthetic sugar that’s “very cheap and readily available.” The syrup can be taken once or twice a day and binds to the built-up toxins so they can clear out of the body in the stool. Rifaximin is an antibiotic pill that works on the gut microbiome to potentially prevent hepatic encephalopathy.

Westervelt said that providers should consider hepatic encephalopathy when patients are diagnosed with dementia under the age of 65. It’s also important to consider when a patient already has liver problems and starts having cognitive problems, too.

“When there is known liver disease, it is important for families to let the patient’s hepatologist know if the patient is showing abrupt changes in thinking, whether or not there is a diagnosis of dementia,” said Westervelt.

Even if someone has not been diagnosed with liver disease, Bajaj said people should be aware of the condition and consider whether a loved one with cognitive changes could have it.

What This Means for You

Severe liver disease can cause cognitive changes that look like dementia and may even be misdiagnosed as the condition. While the symptoms can overlap, hepatic encephalopathy is treatable and the cognitive decline even reversible with medication.

Read Next: Liver Disease Is Becoming More Common. Here Are Common Risk Factors

Read the original article on Verywell Health.