Given the nation’s aging population, skilled nursing clinicians must be prepared to make proper identification and management of liver disease. Nonalcoholic fatty liver disease (NAFLD) is common in the elderly and common comorbid factors such as diabetes and obesity can create progression of more substantial liver disease, such as nonalcoholic steatohepatitis (NASH), cirrhosis and hepatocellular carcinoma, as well as the development of cardiovascular disease.   

Not simply a result of alcohol consumption, NAFLD is the most common type of liver disease in the Western world — associated with obesity, insulin resistance, diabetes and other metabolic risk factors and directly related to an inflammatory process from free fatty acids or too much fat in the liver cells. The American Diabetes Association has recommended the evaluation of comorbidities that may impact management like NAFLD. For patients in long-term care, the identification of advanced fibrosis and cirrhosis is essential for risk factor reductions, medical management and improvement in daily activities and quality of life.  

Fortunately, NAFLD can be reversible if caught in the early stages and accompanied by lifestyle changes. What’s more, simple screening and early detection with available non-invasive technologies can help to prevent more serious conditions, such as end-stage liver disease or liver cancer. 

Understanding NAFLD

NAFLD among elderly individuals is linked to frailty, multimorbidity and dementia. Additionally, age-adjusted readmittance rates for Type 2 diabetes compared to the non-diabetic population (95% confidence intervals) varied between 1.27 (1.04-1.55) for autoimmune liver disease and 5.36 (4.41-6.51) for NAFLD. 

An optimized treatment strategy for NAFLD requires a multidisciplinary approach. A non-pharmacological approach to treatment, such as diet, proper calorie intake and physical exercise, should be tailored individually and encompass the physical limitations of most elderly people. 

Furthermore, drug treatment must be balanced with the benefits and risks to mitigate adverse events and pharmacological interactions. More accurate understanding of the molecular mechanisms of geriatric NAFLD can help in identifying the most appropriate diagnostic and therapeutic approach for individual elderly patients. 

Identifying At-Risk Patients

An interim look at an ongoing study of 10,000 patients with no history of liver disease was conducted in community-based endoscopy centers by the Florida Research Institute, a division of Florida Digestive Health Specialists.  Only 43% of patients evaluated had what is considered normal livers based on a FibroScan® assessment alone, while the remainder had some form of liver abnormality, ranging from elevated liver fat to liver fibrosis, including 13% suspected of having undiagnosed liver fibrosis or cirrhosis.

It’s important to note that the vast majority of patients had no symptoms. While further workup is recommended to confirm the extent of liver disease in these patients, this analysis of 367 patients suggests a significant rate of undiagnosed NAFLD in the population studied. 

This prospective study evaluated patients with no history of liver disease, who were undergoing routine endoscopic procedures between June 2017 and January 2018 versus a matched control of patients not undergoing a liver health assessment. Patients were risk stratified based on FibroScan®, which utilizes VCTE™ and CAP™, surrogate scores of liver fibrosis and liver fat, respectively. The study team examined electronic medical records within 90 days after the procedure to determine and compare the prevalence of NAFLD. 

Results showed 53% of patients studied had excess fat in their livers as identified by the CAP™, of which 64% likely had grade 3 liver fat, as identified by a CAP™ score of ≥279 dBmMore concerning, only 43% of patients evaluated had what would be considered normal livers.  These results underscore the importance of identifying long-term care, asymptomatic patients who may be at risk for advancing disease and targeted for earlier intervention. Keep in mind that this research noted dramatic rise in liver disease compared with the previous decade and indicated a growing need for ongoing assessment.

Non-invasive methods to assess liver health

A growing number of healthcare providers, including those associated with long-term care populations, have started adopting non-invasive screening methods that can detect NAFLD in the absence of indications or warning signs.

FibroScan®, for example, is a 10-minute assessment that offers quick insight into liver health – measuring liver fat content and liver stiffness – associated with fibrosis and cirrhosis. Test scores provide immediate information to help guide treatments and/or referral to a specialist. In fact, a yearly NAFLD screening may become standard practice similar to A1C blood sugar testing. FibroScan® is covered by Medicare, Medicaid and other insurance plans. 

The point of these tools is that they can quickly and easily measure the amount of liver stiffness and fat to better target more expensive or more invasive diagnostic procedures – saving time and resources for skilled nursing clinicians by eliminating patients who don’t need additional assessment.

Scott Howell, D.O., MPH&TM, CPE, is an advisor for Echosens, The Liver Company.