The Aging Liver
In October, the American Journal of Gastroenterology published “Considerations in the Diagnoses and Management of Hepatic Disease in Older Adults,” written by gastroenterologist Jasmohan Bajaj, M.D., of the Institute and the Richmond Veterans Administration Medical Center, and Cristal L. Brown, M.D., a transplant hepatologist at the University of Texas at Austin.
As people get older, every organ slows down a little, but the liver changes in ways that can quietly affect nearly every part of the body. It shrinks, blood flow drops, and its ability to filter toxins and process medicines declines.
By age 75, blood flow through the liver drops by about 30 percent, and the organ itself can shrink by up to 40 percent. The number of healthy liver cells falls, and the ones that remain don’t work as efficiently. The liver also produces less albumin, a protein that helps carry medicines and nutrients through the bloodstream.
All of these changes make older adults more sensitive to drugs and alcohol. A normal medication dose for a younger person might build up to harmful levels in an older body. And when the liver struggles to recover from stress or injury, the risk of chronic disease rises.
When Liver Trouble Looks Like Dementia
For some, these changes cause fatigue or poor appetite. For others, they can lead to something more alarming: confusion and memory loss that looks like dementia.
Doctors say that for many older adults, those symptoms are actually caused by hepatic encephalopathy, or HE — a buildup of toxins in the brain that happens when the liver can’t clean the blood as it should.
HE often starts with mild forgetfulness, slower thinking, or daytime sleepiness. As it worsens, a person may become disoriented, struggle to speak clearly, or seem suddenly confused. It’s most common in people with cirrhosis, severe scarring of the liver that develops after years of damage from conditions like fatty liver disease or alcohol misuse.
Because HE can look like dementia, older adults are often misdiagnosed. Families might assume a loved one has Alzheimer’s when the real problem is the liver. Blood tests, ammonia levels, and liver scans can help doctors tell the difference.
When treated early, HE is often reversible. The main treatment, lactulose, is a type of laxative that helps remove toxins through the stool. Some patients also take antibiotics like rifaximin to reduce the bacteria that create those toxins. With proper care, many people regain clear thinking and normal daily function.
(This topic will be covered in a ticketed presentation by the Institute’s Jasmohan Bajaj, M.D., on Nov. 8 at The Liver Meeting 2025.)
Other Common Liver Conditions in Older Adults
While HE may grab attention because it affects the brain, other liver diseases are also growing more common with age.
Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as fatty liver disease, is now the leading cause of chronic liver problems in older adults. It’s tied to obesity, diabetes, and high cholesterol. Doctors recommend screening people at risk, especially those with diabetes or a family history of liver disease. In 2024, the FDA approved Resmetirom, the first medication for treating MASLD with moderate scarring.
Alcohol-associated liver disease is also on the rise among seniors. Even moderate drinking can harm an aging liver. Short screening tools like AUDIT-C or CAGE can help identify alcohol misuse. Naltrexone is the preferred first-line medication for older adults struggling with alcohol dependence.
Cholestatic liver diseases, such as primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC), interfere with bile flow and often cause fatigue and itching. Cholestyramine can relieve itching, but antihistamines should be used carefully because they can worsen confusion in older adults. New medications, elafibranor and seladelpar, were recently approved for people with PBC who don’t respond to standard treatment.
Cirrhosis, Liver Cancer and Transplant
Cirrhosis is the end stage of many liver diseases and can cause dangerous complications such as internal bleeding, fluid buildup in the belly, and muscle wasting, known as sarcopenia. These problems make older adults weaker and more likely to fall. Managing salt intake, adjusting diuretics, and performing procedures to drain excess fluid can help, but care must be taken to protect the kidneys.
Cirrhosis also increases the risk of hepatocellular carcinoma, the most common type of liver cancer. Screening every six months with an ultrasound and a blood test can catch it early, but only patients who are strong enough for treatment are usually screened.
When liver damage becomes severe, a liver transplant may be an option. There’s no upper age limit, and selected older adults can do as well as younger patients after surgery. Doctors evaluate overall strength, heart and kidney health, and support at home before approving a transplant. Older recipients need close follow-up, since a weaker immune system increases the risk of infection.
Talking About Care and Quality of Life
Not everyone can or should pursue aggressive treatments. That’s why experts emphasize serious illness communication: open, ongoing conversations between doctors, patients and families about what matters most. These discussions help match treatment to a person’s goals, whether that’s living longer, staying comfortable or avoiding hospitalizations.
Palliative care can begin early in liver disease and focuses on managing pain, fatigue and anxiety. Hospice care is available when life expectancy is less than six months. Both approaches can improve comfort and help families make informed decisions.
Bear in Mind
The aging liver doesn’t just affect digestion or medication use, it can affect the brain. When an older person seems confused, forgetful, or different from their usual self, liver disease may be part of the reason. Asking doctors to check liver function can lead to answers and treatments that restore clarity and quality of life.
With early diagnosis, healthy lifestyle choices and honest discussions about care, many older adults can manage liver disease and stay mentally sharp and independent for years to come.