In patients with suspected CHE and major confounders (e.g., OSA, alcohol-related cognitive impairment, early dementia), what is your practical stopping rule for escalating HE-directed therapy before pivoting to a primary non-HE evaluation (sleep/medication/neurocognitive workup)?

I think it's reasonable to give the lactulose/rifaximin combination a reasonable try in this patient population without going overboard as to cause side effects. Achieving requisite bowel movements with lactulose should eliminate any HE component of AMS within 24-48 hours, and the guidelines suggest...