title: Driving simulation can improve insight into impaired driving skills in cirrhosis.
abstract: BACKGROUND
  Minimal hepatic encephalopathy (MHE) is associated with poor driving skills and insight. Increasing insight may improve receptiveness for therapy or driving restrictions.
  
  
  OBJECTIVE
  To evaluate the change in the self-assessment of driving skills (SADS) using a driving simulator.
  
  
  METHODS
  Cirrhotic patients and age/education-matched controls underwent MHE testing with inhibitory control (ICT) and the psychometric hepatic encephalopathy score (PHES). SADS, a Likert scale from 0 to 10, was administered just before and after a standardized driving simulation comprising testing and navigation tasks. The percentage SADS change from baseline was compared within/between groups.
  
  
  RESULTS
  A total of 84 patients (60% men, age 55 years) and 12 controls were included. Controls were significantly better than cirrhotics on cognitive/simulator testing. The baseline SADS was similar between the groups. The baseline patient SADS was only correlated with ICT lures (r = -0.4, P = 0.001). Post-simulation, 60% of patients improved their insight, i.e., reduced SADS (from 8 to 6.5, P = 0.0001) compared to 25% of controls (P = 0.02). The mean percentage SADS reduction was also higher in cirrhotics (18% vs. 8%, P = 0.03). MHE on ICT patients had a significantly higher SADS improvement (P = 0.004) compared to the other patients; no difference was seen in those with/without MHE due to the PHES. The percentage SADS reduction in patients was correlated with getting lost (r = 0.468, P < 0.0001), crashes (P = 0.002), and centerline/road-edge excursions (P = 0.01). There was a significantly higher percentage SADS reduction in cirrhotics who got lost (25%) compared to those who did not get lost (12%) and controls (8%, P = 0.014).
  
  
  CONCLUSIONS
  Insight into driving skills in cirrhosis improves after driving simulation and is highest in those with navigation errors and MHE on ICT. Driving simulator-associated insight improvement may be the first step towards the cognitive rehabilitation of driving skills in cirrhosis.
authors: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA 23249, USA. jsbajaj@vcu.edu
authors: Jasmohan S
authors: JS
authors: Bajaj
authors: Leroy R
authors: LR
authors: Thacker
authors: Douglas M
authors: DM
authors: Heuman
authors: Douglas P
authors: DP
authors: Gibson
authors: Richard K
authors: RK
authors: Sterling
authors: R Todd
authors: RT
authors: Stravitz
authors: Michael
authors: M
authors: Fuchs
authors: Arun J
authors: AJ
authors: Sanyal
authors: James B
authors: JB
authors: Wade
mesh_terms: D001334:Automobile Driving; D003072:Cognition Disorders / Q000175:diagnosis / Q000209:etiology / Q000534:rehabilitation; D005260:Female; D006501:Hepatic Encephalopathy / Q000175:diagnosis / Q000209:etiology; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications; D008297:Male; D008875:Middle Aged; D011594:Psychometrics; D013647:Task Performance and Analysis