title: Navigation skill impairment: Another dimension of the driving difficulties in minimal hepatic encephalopathy.
abstract: Patients with minimal hepatic encephalopathy (MHE) have attention, response inhibition, and working memory difficulties that are associated with driving impairment and high motor vehicle accident risk. Navigation is a complex system needed for safe driving that requires functioning working memory and other domains adversely affected by MHE. The aim of this study was to determine the effect of MHE on navigation skills and correlate them with psychometric impairment. Forty-nine nonalcoholic patients with cirrhosis (34 MHE+, 15 MHE-; divided on the basis of a battery of block design, digit symbol, and number connection test A) and 48 age/education-matched controls were included. All patients underwent the psychometric battery and inhibitory control test (ICT) (a test of response inhibition) and driving simulation. Driving simulation consisted of 4 parts: (1) training; (2) driving (outcome being accidents); (3) divided attention (outcome being missed tasks); and (4) navigation, driving along a marked path on a map in a "virtual city" (outcome being illegal turns). Illegal turns were significantly higher in MHE+ (median 1; P = 0.007) compared with MHE-/controls (median 0). Patients who were MHE+ missed more divided attention tasks compared with others (median MHE+ 1, MHE-/controls 0; P = 0.001). Similarly, accidents were higher in patients who were MHE+ (median 2.5; P = 0.004) compared with MHE- (median 1) or controls (median 2). Accidents and illegal turns were significantly correlated (P = 0.001, r = 0.51). ICT impairment was the test most correlated with illegal turns (r = 0.6) and accidents (r = 0.44), although impairment on the other tests were also correlated with illegal turns.
  
  
  CONCLUSIONS
  Patients positive for MHE have impaired navigation skills on a driving simulator, which is correlated with impairment in response inhibition (ICT) and attention. This navigation difficulty may pose additional driving problems, compounding the pre-existing deleterious effect of attention deficits.
authors.affiliation: Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI 53226, USA. jbajaj@mcw.edu
authors.forename: Jasmohan S
authors.initials: JS
authors.lastname: Bajaj
authors.forename: Muhammad
authors.initials: M
authors.lastname: Hafeezullah
authors.forename: Raymond G
authors.initials: RG
authors.lastname: Hoffmann
authors.forename: Rajiv R
authors.initials: RR
authors.lastname: Varma
authors.forename: Jose
authors.initials: J
authors.lastname: Franco
authors.forename: David G
authors.initials: DG
authors.lastname: Binion
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Hammeke
authors.forename: Kia
authors.initials: K
authors.lastname: Saeian
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001288:Attention; D001334:Automobile Driving; D006501:Hepatic Encephalopathy / Q000150:complications* / Q000503:physiopathology / Q000523:psychology; D006801:Humans; D008569:Memory Disorders / Q000209:etiology; D008875:Middle Aged; D009043:Motor Activity / Q000502:physiology*; D009069:Movement Disorders / Q000209:etiology* / Q000523:psychology; D018579:Patient Selection; D012016:Reference Values; D011795:Surveys and Questionnaires; D014584:User-Computer Interface