Fitness to drive in patients with cirrhosis and portal-systemic shunting: a pilot study evaluating driving performance

doi:10.1016/S0168-8278(05)80612-9

Journal of Hepatology

Volume 21, Issue 6, 1994, Pages 1023-1028

https://doi.org/10.1016/S0168-8278(05)80612-9 Get rights and content

It has been suggested that some patients with cirrhosis are unfit to operate a motor vehicle. However, performance while driving a motor vehicle has not been evaluated in such patients. In this pilot study, we assessed the fitness to drive of stable individuals with cirrhosis and clinical evidence of portal hypertension, portal-systemic shunting and no prior history of hepatic encephalopathy. We examined 15 ambulatory patients with cirrhosis together with 15 age-, educational level- and driving experience-matched healthy controls. Neuropsychological testing was performed with the Reitan trail test, block design and digit symbol tests as well as visual reaction time. A driving test in the laboratory used a film to measure complex visual reaction time (reaction to road symbols) and threat recognition (accident avoidance). Driving on the road was assessed by a licensed Illinois state driving evaluator. Penalty points were given according to 11 standardized driving categories. As a group, patients with cirrhosis had no significant differences in their performance on a simulator or during actual driving conditions when compared to matched controls. Sixty-six percent of the subjects with cirrhosis had two or more abnormal neuropsychological tests, a criterion used to define the presence of subclinical encephalopathy. No deficiencies in simulated or real driving performance was seen when compared to patients with cirrhosis with normal neuropsychological tests. In this study, stable subjects with cirrhosis and evidence of portal hypertension, portal-systemic shunting, abnormal neuropsychological tests and no prior history of overt encephalopathy did not exhibit a major impairment in their fitness to drive.

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Cited by (80)

Social Impact of Hepatic Encephalopathy
2024, Clinics in Liver Disease
EASL Clinical Practice Guidelines on the management of hepatic encephalopathy
2022, Journal of Hepatology
Citation Excerpt :
Patients with cirrhosis and cognitive impairment have more documented traffic accidents and violations compared to unimpaired patients with cirrhosis179 and may overestimate their driving competence.176,180 Two studies found no increased rate of accidents in patients with cirrhosis and covert HE181,182 and patients with covert HE may not be unsafe drivers in reality.183 Nevertheless, treatment with rifaximin in a randomised trial has been shown to improve driving simulator performance in patients with covert HE.184,185
The EASL Clinical Practice Guidelines (CPGs) on the management of hepatic encephalopathy (HE) present evidence-based answers to a set of relevant questions (where possible, formulated in PICO [patient/population, intervention, comparison and outcomes] format) on the definition, diagnosis, differential diagnosis and treatment of HE. The document does not cover the pathophysiology of HE and does not cover all available treatment options. The methods through which it was developed and any information relevant to its interpretation are also provided.
Gut-liver-brain axis in chronic liver disease with a focus on hepatic encephalopathy
2021, The Complex Interplay Between Gut-Brain, Gut-Liver, and Liver-Brain Axes
Hepatic encephalopathy (HE) or brain dysfunction due to liver insufficiency and/or portosystemic shunting is one of the determinants of prognosis and outcome of liver cirrhosis. It is a key parameter in liver cirrhosis severity and organ transplantation scores. HE remains a clinical diagnosis, yet there are forms of HE, where mental or motor defect is usually not yet recognizable and specific tests need to be performed to assess this covert HE. Pathophysiologically, hyperammonemia remains the crucial factor in the pathogenesis of HE leading to astrocyte swelling and a glial edema which accounts for psychological and psychomotor abnormalities through impaired glioneuronal communication. The treatment of HE includes the management of triggering causes and the use of different therapeutic strategies of ammonia-scavenging in the gut and the circulation. Besides that, liver cirrhosis is associated with a chronic inflammatory milieu and recent works have established alterations of the gut microbiome that seem to be specific for HE patients in comparison to control populations and liver cirrhosis patients without overt HE. These are associated with distinct neuroimaging profiles of astroglial and neuronal injury. Therapeutically, strategies to target the gut microbiome via antibiotic treatment (rifaximine) or experimental therapies based on fecal microbiota transplantation have shown beneficial effects on HE and support the concept of microbiome-specific effects on HE in the sense of a gut–liver–brain axis.
The psychomotor vigilance task: Role in the diagnosis of hepatic encephalopathy and relationship with driving ability
2019, Journal of Hepatology
Citation Excerpt :
However, it remains difficult to predict driving ability at an individual patient level,4 because driving is a complex competence that depends on a variety of factors, including natural inclination, experience and practice. Indeed, in one of the first studies on driving and HE, Srivastava and colleagues described the case of a taxi driver with cirrhosis and significant neuropsychological impairment whose on-the-road performance remained excellent.55 Both relaxed and strict approaches to HE and driving might lead to problems: on the one hand, one would not want dangerous drivers within the community but, on the other hand, it would be unfair to impinge on patients’ earning ability and their social lives by depriving them of their licence unnecessarily.
Hepatic encephalopathy (HE) is a syndrome of decreased vigilance and has been associated with impaired driving ability. The aim of this study was to evaluate the psychomotor vigilance task (PVT), which is used to assess both vigilance and driving ability, in a group of patients with cirrhosis and varying degrees of HE.
A total of 145 patients (120 males, 59 ± 10 years, model for end-stage liver disease [MELD] score 13 ± 5) underwent the PVT; a subgroup of 117 completed a driving questionnaire and a subgroup of 106 underwent the psychometric hepatic encephalopathy score (PHES) and an electroencephalogram (EEG), based on which, plus a clinical evaluation, they were classed as being unimpaired (n = 51), or as having minimal (n = 35), or mild overt HE (n = 20). All patients were followed up for an average of 13 ± 5 months in relation to the occurrence of accidents and/or traffic offences, HE-related hospitalisations and death. Sixty-six healthy volunteers evenly distributed by sex, age and education served as a reference cohort for the PVT.
Patients showed worse PVT performance compared with healthy volunteers, and PVT indices significantly correlated with MELD, ammonia levels, PHES and the EEG results. Significant associations were observed between neuropsychiatric performance/PVT indices and licence/driving status. PVT, PHES and EEG results all predicted HE-related hospitalisations and/or death over the follow-up period; none predicted accidents or traffic offences. However, individuals with the slowest reaction times and most lapses on the PVT were often not driving despite having a licence. When patients who had stopped driving for HE-related reasons (n = 6) were modelled as having an accident or fine over the subsequent 6 and 12 months, PVT was a predictor of accidents and traffic offences, even after correction for MELD and age.
The PVT is worthy of further study for the purposes of both HE and driving ability assessment.
Hepatic encephalopathy (HE) is a complication of advanced liver disease that can manifest as excessive sleepiness. Some patients with HE have been shown to have difficulty driving. Herein, we used a test called the Psychomotor Vigilance Task (PVT), which measures sleepiness and can also be used to assess driving competence. We showed that PVT performance is fairly stable in healthy individuals. We also showed that PVT performance parallels performance in tests which are commonly used in cirrhotic patients to measure HE. We suggest that this test is helpful in quantifying HE and identifying dangerous drivers among patients with cirrhosis.
Neuropsychiatric performance in patients with cirrhosis: Who is “normal”?
2017, Journal of Hepatology
In patients with cirrhosis a normal neuropsychiatric performance has been traditionally defined by the absence of any degree of hepatic encephalopathy and/or the absence of psychometric or neurophysiological abnormalities, compared with data from the healthy population. As the understanding and management of end-stage liver disease continues to change, it is our impression that the concept of normal neuropsychiatric performance also needs updating. This review explores novel and more pragmatic interpretations of neuropsychiatric “normality” compared with top personal performance, in terms of risk of overt hepatic encephalopathy or brain failure and in relation with events such as liver transplantation, decompensation, acute-on-chronic liver failure and transjugular intrahepatic portosystemic shunt placement.
Minimal hepatic encephalopathy: A review
2016, Neuroscience Research
Citation Excerpt :
In fact, attention deficit reduces an individual's ability to react to unexpected traffic conditions (Schomerus et al., 1982; Watanabe et al., 1995; Bajaj et al., 2008a,b, 2009b). Driving fitness and ability have been examined since the mid-1990s (Srivastava et al., 1994; Watanabe et al., 1995). In a study from 2004 on MHE and driving four global driving categories (car handling, adaptation to traffic situation, cautiousness, maneuvering), 17 specific driving actions (e.g., changing lanes, overtaking, etc.), and a total score of driving performance have been evaluated.
Minimal hepatic encephalopathy (MHE) is the earliest form of hepatic encephalopathy and can affect up to 80% of patients with liver cirrhosis. By definition, MHE is characterized by cognitive function impairment in the domains of attention, vigilance and integrative function, but obvious clinical manifestation are lacking. MHE has been shown to affect daily functioning, quality of life, driving and overall mortality. The diagnosis can be achieved through neuropsychological testing, recently developed computerized psychometric tests, such as the critical flicker frequency and the inhibitory control tests, as well as neurophysiological procedures. Event related potentials can reveal subtle changes in patients with normal neuropsychological performances. Spectral analysis of electroencephalography (EEG) and quantitative analysis of sleep EEG provide early markers of cerebral dysfunction in cirrhotic patients with MHE. Neuroimaging, in particular MRI, also increasingly reveals diffuse abnormalities in intrinsic brain activity and altered organization of functional connectivity networks. Medical treatment for MHE to date has been focused on reducing serum ammonia levels and includes non-absorbable disaccharides, probiotics or rifaximin. Liver transplantation may not reverse the cognitive deficits associated with MHE. We performed here an updated review on epidemiology, burden and quality of life, neuropsychological testing, neuroimaging, neurophysiology and therapy in subjects with MHE.

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Regular PaperFitness to drive in patients with cirrhosis and portal-systemic shunting: a pilot study evaluating driving performance

J Hepatol

J Hepatol

Lancet

J Hepatol

Latent portasystemic encephalopathy. I. Nature of cerebral functional defects and their effect on fitness to drive

Dig Dis Sci

Advance report of final mortality statistics, 1989

Monthly Vital Statistics Report

Pathogenesis of hepatic enceophalopathy

Driving safety after brain damage: follow-up of twenty-two patients with matched controls

Arch Phys Med Rehab

Wechsler adult intelligence scale-revised (WAIS-R) Manula

Manual for administration of neuropsychological test batteries for adults and children

Regular Paper
Fitness to drive in patients with cirrhosis and portal-systemic shunting: a pilot study evaluating driving performance