Covert hepatic encephalopathy: the cirrhosis patient who keeps falling

Covert (minimal) hepatic encephalopathy has no obvious confusion but impairs attention, reaction time and psychomotor speed. It is common in cirrhosis with portal hypertension and is linked to falls, road traffic accidents and poor quality of life. Simple bedside tests — the animal naming test (fewer than 15 animals in a minute suggests impairment) or a Stroop smartphone app — can detect it in clinic. Ask about falls, near-misses and driving difficulties at every review.

• Ask every patient with cirrhosis about falls and near-falls.
• Use the animal naming test in clinic: fewer than 15 in one minute suggests covert encephalopathy.
• Review sedatives, opioids and alpha-blockers that add to fall risk.
• Discuss driving safety when covert encephalopathy is suspected.

Why it matters

Covert encephalopathy is common, treatable and routinely missed because the patient looks normal.

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