Metabolic Burden, Metabolic Dysfunction-Associated Steatotic Liver Disease, and Cognitive Performance Among Older Adults: Analysis of 1,387 Participants from the National Health and Nutrition Examination Survey.

Background

Metabolic dysfunction-associated steatotic liver disease (MASLD) is prevalent in older adults, yet its independent contribution to cognitive decline beyond cardiometabolic risk factors remains uncertain.

Methods

We performed a cross-sectional analysis of 1,387 NHANES 2011-2014 participants aged ≥60 years. MASLD was defined using hepatic steatosis index ≥36 plus ≥1 cardiometabolic risk factor, excluding excessive alcohol use. Cognitive performance across memory, verbal fluency, and processing speed was summarized as a global z-score composite. Advanced fibrosis likelihood was assessed using validated non-invasive scores. Weighted multivariable linear regression adjusted for demographic, lifestyle, and cardiometabolic covariates.

Findings

MASLD was not associated with global cognition (β = 0.027; p=0.526) or individual domains after full adjustment. Advanced fibrosis risk was unrelated to cognition except for lower CERAD memory with high FIB-4 (β = -0.319; p=0.016). Greater metabolic risk factor burden showed graded associations with poorer cognition: ≥2 risk factors linked to lower global cognition (β = -0.23; p=0.036) and memory (β = -0.33; p=0.003); ≥3 showed borderline memory impairment (β = -0.24; p=0.049). In MASLD participants, ≥2 risk factors were associated with lower global cognition (β = -0.19; p=0.021) and ≥3 with reduced verbal fluency (β = -0.27; p=0.045). Processing speed declined only at highest metabolic burden in fibrosis-stratified models (e.g., DSST β = -0.51; p=0.015).

Conclusion

MASLD and related fibrosis risk were not independently linked to cognitive impairment. Metabolic risk factor burden primarily drove poorer cognition, especially memory, in both the overall sample and those with MASLD, with processing speed affected only at the highest burden.