Key result
MMSE demonstrates poor diagnostic accuracy for overt hepatic encephalopathy and fails to detect minimal disease.
Why the study?
The usefulness of Mini-Mental State Examination (MMSE) in the evaluation of hepatic encephalopathy (HE) in patients with liver cirrhosis has never been properly assessed.
Does the Mini-Mental State Examination accurately detect hepatic encephalopathy in patients with liver cirrhosis?
Cross-Sectional (n=101)
No
Does the Mini-Mental State Examination accurately detect hepatic encephalopathy in patients with liver cirrhosis?
Effect estimate: AUC 0.64 (95% CI 0.528-0.752)
p-value: p=0.018
The Mini-Mental State Examination is not a useful tool for assessing minimal hepatic encephalopathy in patients with liver cirrhosis.
MMSE should not guide hepatic encephalopathy assessment in cirrhosis; leaves open validation of accurate alternative cognitive tools.
BACKGROUND: Mini-Mental State Examination (MMSE) is one of the most commonly used methods in the assessment of cognitive mental status. MMSE has been used in hepatology but its usefulness in the evaluation of hepatic encephalopathy (HE) has never been properly assessed. The aim of the study was to investigate the value of MMSE in detection of HE in patients with cirrhosis. METHODS: One hundred and one consecutive patients with liver cirrhosis underwent neurological examination, MMSE and electroencephalography (EEG). Spectral analysis of EEG was done with calculation of mean dominant frequency (MDF) and relative power of delta, theta, alpha and beta rhythms. Minimal HE was diagnosed in patients with normal neurological status and alterations in spectral EEG. Statistical analysis included Fisher's exact and Anova analysis. Categorical data were compared using Levene's test for equality of variances. Correlation-coefficient analysis was performed by the Pearson's r or Z-test, as needed. Tests performance was assessed by the calculating the area under the ROC curve (AUC) and evaluating its difference from reference area (AUC=0.5). A p value <0.05 was considered statistically significant. RESULTS: Overt HE was identified in 49 (48.5%) and minimal HE in 22 (21.8%) patients. Although there were significant correlations between both severity of liver disease (Child-Pugh classification), overt HE (West-Haven criteria) and various MMSE items, MDF showed no correlation with any of MMSE items as well as MMSE summary score. MMSE (score and items) did not discriminate patients without HE and minimal HE. The only significant differences between patients without HE and with overt HE were seen in respect of MMSE score (p<0.02), orientation to place (p<0.003), repetition (p<0.01) and complex commands-understanding (p<0.02). Test performance analysis has shown that MMSE has no value as a prediction method in determining minimal HE and in respect of overt HE has a sensitivity of 63% and specificity of 52% by a cut-off level at 27.5 points to diagnose overt HE. CONCLUSIONS: In conclusion, although MMSE score and single items are altered in patients with overt HE, MMSE has no value in the assessment of minimal HE. Because MMSE could be impaired in several cognitive dysfunctions, more specific test should be used for measuring HE.
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Koziarska et al. (2013) conducted a cross-sectional in Hepatic encephalopathy and liver cirrhosis (n=101). Mini-Mental State Examination (MMSE) vs. Standard clinical and EEG evaluation was evaluated on Diagnostic accuracy (Area Under the ROC Curve) for overt hepatic encephalopathy (AUC 0.64, 95% CI 0.528-0.752, p=0.018). The Mini-Mental State Examination demonstrated poor diagnostic accuracy for overt hepatic encephalopathy (AUC 0.64, sensitivity 63%, specificity 52%) and had no predictive value for detecting minimal hepatic encephalopathy.
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