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Prevalence and Incidence of Cognitive Impairment and Dementia in Heart Failure – A Systematic Review, Meta-Analysis and Meta-Regression
Abstract
INTRODUCTION
The burden of cognitive impairment in HF patients is significant and leads to longer hospital stay, higher readmission rates, and increased mortality. This review seeks to synthesize the available studies to determine the prevalence and incidence of cognitive impairment and dementia in HF patients.
METHODS
PubMed, Embase, PsychoINFO and Cochrane databases were systematically searched from their inception through to 3 May 2021. Study and population characteristics, total patients with HF, prevalence of cognitive impairment and dementia in HF patients and cognitive assessment tool were abstracted by two reviewers.
RESULTS
In heart failure patients, overall prevalence for cognitive impairment and dementia was 41.42% (CI) and 19.79% (dementia) respectively. We performed a meta-regression analysis which demonstrated that the risk of cognitive impairment and dementia increased with age.
DISCUSSION
Further research should investigate whether HF accelerates the rate of cognitive decline and the progression of dementia.
... Moreover, reports on the frequency of CI in persons with heart failure (HF) are varied, being between 25% and 75% [15,16]. Further, a recent meta-analysis of 119 studies has established the overall prevalence of CI and dementia in patients with HF as 41.42% and 19.79%, respectively [17]. Research has also shown that patients with HF report up to a four-fold higher risk of presenting with cognitive dysfunction, particularly in attentional and memory domains, when compared with the general population, and that the overall prevalence of CI in outpatients with HF is as high as 50% [18]. ...
... Items are rated using a 4-point (0-3) scale, with greater scores indicating elevated distress. Scores for each subscale range from 0 to 21 and can be categorized as normal (0-7), mild (8-10), moderate (11)(12)(13)(14), or severe (15)(16)(17)(18)(19)(20)(21). ...
Executive attention as a frontal domain ability that is effective in potentially blocking distracting information, reconciling conflicts among simultaneous attentional demands, and regulating impulsive behavior may be impaired in individuals with obesity and cardiovascular disease (CVD). This study aimed (i) to explore the presence of selected cognitive (global cognitive impairment , sensitivity to interference, and attention) and psychological (quality of life, depression, anxiety, and impulsivity) dimensions and (ii) to examine the interactive relationship between attentional dyscontrol-both as a psychological and as a cognitive measure-and the above-mentioned variables in a sample of patients with CVD attending a cardiac rehabilitation program across different body mass index (BMI) levels. Clinical information of 104 patients with CVD was retrospectively collected. Participants were classified into three groups according to their BMI as follows: normal weight (NW = 30), overweight (OW = 19), and obese (OB = 55). Individuals with CVD and a higher BMI showed problems in controlling executive attention-through both neuropsychological and behavioral measures. Specifically, OB patients demonstrated reduced sensitivity to cognitive interference, lower capabilities in divided attention during visual-tracking tasks, and greater impulsivity compared to NW patients. This behavioral characteristic was also found to be correlated with higher levels of anxiety and depression and a lower quality of life. Implications for cognitive rehabilitation were discussed to offer directions for better management of patients with CVD and obesity.
... Thus, the issue of HF-related depressive and anxiety disorders began to be investigated and further larger studies ensued on this important topic. In addition, other studies examined the occurrence of various other neuropsychological disorders in patients with HF, including sleep disorders, personality disorders, and cognitive impairment, which may further amplify depression and anxiety [19,20]. All these issues are herein reviewed. ...
... Cognitive function is important for effective self-care and compliance with HF therapies. However, there is evidence that cognitive impairment (CI) and dementia may be encountered in ~ 40% and ~ 20% respectively in HF patients, and the risk of cognitive dysfunction may increase with age [20,71]. Patients with HF and CI have poorer functional independence, self-care and QoL, more frequent rehospitalizations, as well as increased mortality. ...
Among various neuropsychiatric disorders, depression and anxiety are commonly encountered in patients with heart failure (HF), reported in ≥ 50% of patients attending a HF clinic, but may frequently elude clinician’s attention. Both disorders are associated with the development and progression of HF, incurring higher rates of morbidity/mortality, probably via physiologic and behavioral mechanisms. Patients with devices and/or advanced HF are more severely affected, especially early following device receipt. In addition, various other neuropsychiatric and neuropsychological disorders and symptoms of these and other disorders occur in and impact HF patients, including sleep disorders and cognitive impairment, which further interact with and amplify depression and anxiety. Mechanisms involved in the link between neuropsychiatric/neuropsychological disorders and HF may relate to pathophysiological processes, lifestyle factors, and behavioral patterns. Among the pathophysiological factors, inflammation, autonomic dysfunction, endothelial dysfunction, thrombotic mechanisms, and dysregulation of the hypothalamic–pituitary–adrenal axis may play a significant role as they are implicated in the pathogenesis, progression, and prognosis of HF. Multimodal psychiatric management strategies with flexible approaches, using antidepressants/anxiolytics/atypical antipsychotics and various psychotherapies such as cognitive behavioral therapy combined with exercise adjusted to patients’ care and needs, appear promising in this patient group. Choosing agents with a higher efficacy/safety profile is a prudent strategy. Although depression and anxiety are risk factors for mortality in HF patients, indiscriminate use of psychiatric medications may not improve or even worsen survival when one neglects to closely monitor for potential proarrhythmic and other side effects. Newer meta-analytic data in HF patients indicate no increase in mortality for newer antidepressants, while secondary analyses show improved survival in patients who achieved remission of depressive symptoms.
... Важными факторами, дополнительно способствующими развитию повреждений ткани головного мозга у пациентов с ХСН, могут быть изменение реактивности сосудов в результате нейрогуморальных нарушений, тромбоэмболические осложнения и падение перфузии в результате неадекватного снижения артериального давления [18,20]. Выявленные в настоящем исследовании КН у пациентов пожилого возраста с ХСН также характеризовались снижением концентрации внимания, семантической памяти, Таблица 6. Корреляционная связь между показателями значений нейропсихологических тестов, фракции выброса левого желудочка, NT-proBNP Table 6. ...
Introduction. Next to neurodegenerative disorders, cardiovascular diseases are now the most common cause of cognitive impairment. The combination of factors such as older age and chronic heart failure is a corner-stone of a greater risk for developing vascular cognitive impairment.
Aim. To study the relationship between the parameters of the left ventricular ejection fraction and the concentration of NT-proBNP with the results of neuropsychological testing in patients with chronic heart failure in old age.
Materials and methods. The study included 200 elderly patients with CHF II–III FC. The neuropsychological examination included tests: tracking, Schulte tables, verbal associations, the Montreal Cognitive Function Assessment Scale (МоСА test). Laboratory tests included determination of the concentration of NT-proBNP in serum.
Results. During neuropsychological testing, reduced indicators were obtained: during the MOS test in patients with left ventricular ejection fraction (LVEF) values < 40% and ≥ 40% and < 50% and with a concentration of NT-proBNP 7230 [3325; 8830] pg/ml; in the Schulte test, an increase in execution time was noted in patients with LVEF values < 40% and ≥ 40% and < 50% and with a concentration of NT-proBNP 2900 [700; 7500] pg/ml; in the tracking test – an increase in time in part A in patients with LVEF values < 40% and ≥ 40% and < 50% and with a concentration of NT-proBNP 5385 [2125; 8675] pg/ml and part B in patients with LVEF values < 40% and ≥ 40% and < 50% and with a concentration of NT-proBNP 6947 [3325; 9310] pg/ml, in the verbal association test – in patients with LVEF values < 40% and ≥ 40% and < 50% and with a concentration of NT-proBNP 2090 [608; 7126] pg/ml. Correlation analysis showed the presence of a significant relationship between LVEF indicators, the concentration of NT-proBNP and the results of neuropsychological testing (p < 0.001), while, according to the Rea&Parker classification, the connection was assessed as relatively strong and medium strength.
Conclusion. The cognitive impairments identified in this study in elderly patients with chronic heart failure were characterized by a decrease in concentration, memory, executive functions and the overall integrative index of cognitive functions. These disorders were significantly associated with a decrease in the left ventricular ejection fraction and a high concentration of NT-proBNP.
... HCP, healthcare professional; maxHR, predicted maximal heart rate according to age (ie, 220-age). [69][70][71][72][73][74][75][76][77][78][79] To establish a clear causal association between sports participation early in life and cognitive impairment or dementia late in life or to quantify that association, future well-designed case-control and cohort studies, that include as many individual risk-modifying and confounding factors as possible, are needed. ...
For over two decades, the Concussion in Sport Group has held meetings and developed five international statements on concussion in sport. This 6th statement summarises the processes and outcomes of the 6th International Conference on Concussion in Sport held in Amsterdam on 27–30 October 2022 and should be read in conjunction with the (1) methodology paper that outlines the consensus process in detail and (2) 10 systematic reviews that informed the conference outcomes. Over 3½ years, author groups conducted systematic reviews of predetermined priority topics relevant to concussion in sport. The format of the conference, expert panel meetings and workshops to revise or develop new clinical assessment tools, as described in the methodology paper, evolved from previous consensus meetings with several new components. Apart from this consensus statement, the conference process yielded revised tools including the Concussion Recognition Tool-6 (CRT6) and Sport Concussion Assessment Tool-6 (SCAT6, Child SCAT6), as well as a new tool, the Sport Concussion Office Assessment Tool-6 (SCOAT6, Child SCOAT6). This consensus process also integrated new features including a focus on the para athlete, the athlete’s perspective, concussion-specific medical ethics and matters related to both athlete retirement and the potential long-term effects of SRC, including neurodegenerative disease. This statement summarises evidence-informed principles of concussion prevention, assessment and management, and emphasises those areas requiring more research.
... the apolipoprotein E genotype, [139][140][141][142][143] and usually did not consider or control for known and potential confounding factors related to brain injury and brain health in the general population, such as socioeconomic status, educational attainment, cognitive reserve, smoking, hypertension and cardiovascular disease, diabetes, sleep apnoea, substance abuse, white matter hyperintensities, social isolation, diet, physical activity or exercise. [144][145][146][147][148][149][150][151][152][153][154] The one study that did examine genetic factors in a subanalysis reported that it did not affect the lack of association between exposure to football and worse mental health or cognitive functioning in older age. 134 To establish a clear causal association between sports participation, cognitive impairment and dementia, or to quantify that association, it is important to consider and control for factors that could confound these associations. ...
Objective
Concern exists about possible problems with later-in-life brain health, such as cognitive impairment, mental health problems and neurological diseases, in former athletes. We examined the future risk for adverse health effects associated with sport-related concussion, or exposure to repetitive head impacts, in former athletes.
Design
Systematic review.
Data sources
Search of MEDLINE, Embase, Cochrane, CINAHL Plus and SPORTDiscus in October 2019 and updated in March 2022.
Eligibility criteria
Studies measuring future risk (cohort studies) or approximating that risk (case-control studies).
Results
Ten studies of former amateur athletes and 18 studies of former professional athletes were included. No postmortem neuropathology studies or neuroimaging studies met criteria for inclusion. Depression was examined in five studies in former amateur athletes, none identifying an increased risk. Nine studies examined suicidality or suicide as a manner of death, and none found an association with increased risk. Some studies comparing professional athletes with the general population reported associations between sports participation and dementia or amyotrophic lateral sclerosis (ALS) as a cause of death. Most did not control for potential confounding factors (eg, genetic, demographic, health-related or environmental), were ecological in design and had high risk of bias.
Conclusion
Evidence does not support an increased risk of mental health or neurological diseases in former amateur athletes with exposure to repetitive head impacts. Some studies in former professional athletes suggest an increased risk of neurological disorders such as ALS and dementia; these findings need to be confirmed in higher quality studies with better control of confounding factors.
PROSPERO registration number
CRD42022159486.
... Пациенты с сердечной недостаточностью хуже выполняют все когнитивные тесты и имеют повышенный риск когнитивных нарушений. Как показало недавно опубликованное международное исследование, клинически значимые когнитивные нарушения у пациентов с сердечной недостаточностью приводят к более длительному пребыванию в стационаре, более высокой частоте повторных госпитализаций и увеличению смертности [45,46]. ...
Heart failure is of major clinical and economic importance and remains a major public health problem worldwide. Despite existing treatment approaches, morbidity and mortality in these patients remains high. The progression of heart failure is accompanied by an increase in the metabolism of ketone bodies. The use of exogenous ketones may become a new therapeutic approach to increase cardiac efficiency, reduce energy deficit and improve cardiac function in patients with heart failure. The review presents the available data on ketone body metabolism in patients with heart failure, preclinical and clinical studies demonstrating the beneficial effects of exogenous ketone therapy in animal models and human studies with heart failure, and describes the potential pros and cons of using this therapeutic approach.
... The 5 categories other than cognitive function are content normally provided in Human Services management and nursing care for patients with chronic HF. [14][15] Another key issue for older patients with HF is cognitive impairment, which has an estimated incidence between 3.1% and 90.0% (average 41.4%) in patients with HF. [16][17][18] share patient information, especially among multiple facilities. 11) The present study also found a lack of opportunities to obtain such information on patients' illnesses. ...
This study aimed to clarify the information required by hospital nurses (HN), home-visiting nurses (HVN), and long-term care insurance facility nurses (LFN) for continuous home care support for community-dwelling older patients with heart failure (HF). Semi-structured interviews with HN, HVN, and LFN involved in HF nursing were used to collect empirical data during August 2019–March 2020. The interview data were organized as narratives about the information necessary for continuing home-care support for older patients with HF, and categories were generated by content analysis. A total of 13 categories were discovered. Among these, 6 were in common for HN, HVN, and LFN: disease management, medication management, activities, diet, family/supporters, and cognitive function. The other 7 categories included 1 in common for HN and HVN, hopes of the patient/family; 1 in common for HVN and LFN, anxiety/stress; 1 for HN, social resources; 1 for HVN, cooperation status of medical institutions; and 3 for LFN, sleep, defecation, and difficult behaviors. This study found that HN, HVN, and LFN had common information items determined necessary for continuous home care support for community-dwelling patients with HF, and each type of nurse also had different informational item requirements.
Claims data are a valuable resource for studying Alzheimer's disease and related dementias (ADRD). Alzheimer's disease and related dementias is often identified using a list of claims codes and a fixed lookback period of 3 years of data. However, a 1-year lookback or an approach using all-available lookback data could be beneficial based on different research questions. Thus, the purpose of this study was to compare 1-year and all-available lookback approaches to ascertaining ADRD compared to the standard 3-year approach. Using a cohort of Veterans hospitalized for heart failure (N = 373, 897), our results suggested high agreement (93% or greater) between the lookback periods. The 1-year lookback period had lower sensitivity (60%) and underestimated the prevalence of ADRD. These results suggest that 1-year and all-available lookback periods are viable approaches when using claims data.
We previously reported that apoptosis is responsible for cognitive impairment in rats with myocardial infarction (MI). Acute administration of an apoptosis inhibitor (Z-vad) effectively reduced brain inflammation in rats with cardiac ischemia/reperfusion injury. However, the beneficial effects of Z-vad on cognitive function, brain inflammation, mitochondrial function, cell death pathways, and neurogenesis in MI rats have not been investigated. Male rats were divided into sham or MI groups (left anterior descending coronary ligation). A successful MI was determined by a reduction of ejection fraction <50 %. Then, MI rats were allocated to receive vehicle, enalapril (10 mg/kg, a positive control), and Z-vad (1 mg/kg) for 4 weeks. Cardiac function, cognitive function, and molecular analysis were investigated. MI rats exhibited cardiac dysfunction, cognitive impairment, blood brain barrier (BBB) breakdown, dendritic spine loss, which were accompanied by an upregulation of oxidative stress, mitochondrial dysfunction, and apoptosis. Chronic treatment with Z-vad attenuated cardiac dysfunction following MI to the same extent as enalapril. Z-vad successfully improved cognitive function and restored dendritic spine density in MI rats through a reduction of systemic oxidative stress and brain mitochondrial dysfunction similar to enalapril. Moreover, Z-vad provided greater efficacy than enalapril in enhancing mitophagy, neurogenesis, synaptic proteins and reducing apoptosis in hippocampus of MI rats. Nevertheless, neither Z-vad nor enalapril increased BBB tight junction protein. In conclusion, treatment with an apoptosis inhibitor reduced cognitive impairment in MI rats via reducing oxidative stress, mitochondrial dysfunction, apoptosis, and restoring dendritic spine density, together with enhancing mitophagy and neurogenesis.
The relationship between the Charlson comorbidity index (CCI) and short-term readmission is as yet unknown. Therefore, we aimed to investigate whether the CCI was independently related to short-term readmission in patients with heart failure (HF) after adjusting for other covariates. From December 2016 to June 2019, 2008 patients who underwent HF were enrolled in the study to determine the relationship between CCI and short-term readmission. Patients with HF were divided into 2 categories based on the predefined CCI (low < 3 and high > =3). The relationships between CCI and short-term readmission were analyzed in multivariable logistic regression models and a 2-piece linear regression model. In the high CCI group, the risk of short-term readmission was higher than that in the low CCI group. A curvilinear association was found between CCI and short-term readmission, with a saturation effect predicted at 2.97. In patients with HF who had CCI scores above 2.97, the risk of short-term readmission increased significantly (OR, 2.66; 95% confidence interval, 1.566–4.537). A high CCI was associated with increased short-term readmission in patients with HF, indicating that the CCI could be useful in estimating the readmission rate and has significant predictive value for clinical outcomes in patients with HF.
Background: Healthcare is currently struggling to provide access and coverage for an increasingly diverse aging population who frequently have multiple co-morbid conditions complicating their care and medical management. Methods: This retrospective study analyzed the prevalence and distribution of common co-morbid conditions (hypertension, dyslipidemia, dementia, and diabetes mellitus) in 316 elderly heart failure patients (age range 80–103; mean 87 ±4.9). Results: Chart review analysis showed a racial distribution of 65 African American versus 251 Caucasian patients (21 vs. 79%). Hypertension was comparable in both groups (98.5% African American vs. 92.4% Caucasian). Dyslipidemia, diabetes and dementia diagnoses were all approximately 20% higher in African American versus Caucasian patients. The concurrent presence of all four conditions was approximately three times more prevalent in African Americans (18.5%) versus Caucasians (7.2%). Conclusion: Our study is unique for studying disparity in octogenarian and nonagenarians residing in a rural setting. Our results also highlight the importance of making a special effort to engage older African American patients in seeking healthcare. In addition, strategies must be designed to reduce barriers that impede access and availability of resources and clinical care, especially in economically underserved regions of the country.
Background:
Cognitive impairment (CI) is common in patients with heart failure (HF), but the association between CI and biomarkers related to HF or cognitive decline in patients with HF remains unclear.
Methods:
This prospective observational study investigated the incidence of CI, subsequent cognitive changes, and the association between CI and novel biomarkers in patients with left ventricular ejection fraction < 40% who were hospitalized for acute decompensated HF. Patients were evaluated for CI, depressive symptoms, and quality of life with the Mini-Mental State Examination (MMSE) and the Mini-Cog, Beck Depression Inventory (BDI)-II, and Kansas City Cardiomyopathy Questionnaire (KCCQ), respectively. The primary endpoint was a composite of all-cause mortality or hospitalization for HF at one year.
Results:
Among the 145 patients enrolled in this study, 54 had CI (37.2%) at baseline. The mean MMSE increased significantly at the 3-month and 1-year follow-up, accompanied by decreased BDI-II and increased KCCQ scores. The improvement in the MMSE scores mainly occurred in patients with CI. Among the biomarkers assayed, only growth/differentiation factor (GDF)-15 > 1621.1 pg/mL was significantly associated with CI (area under the curve = 0.64; P = 0.003). An increase in GDF-15 per 1000 units was associated with an increased risk of the primary endpoint (hazard ratio = 1.42; 95% confidence interval: 1.17-1.73; P < 0.001).
Conclusions:
In patients with HF with CI, cognitive function, depression, and quality of life measures improved at the 3-month and 1-year follow-up. GDF-15 predicted CI with moderate discrimination capacity and was associated with worse HF outcomes.
Aim:
Heart failure (HF) outcomes are disproportionately worse in patients discharged to skilled nursing facilities (SNF) as opposed to home. We hypothesized that dementia and delirium were key factors influencing these differences. Our aim was to explore the associations of dementia and delirium with risk of hospital readmission and mortality in HF patients discharged to SNF.
Methods and results:
The study population included Veterans hospitalized for a primary diagnosis of HF and discharged to SNFs between 2010 and 2015. Pre-existing dementia was identified based on International Classification of Diseases-9 codes. Delirium was determined using the Minimum Data Set 3.0 Confusion Assessment Method algorithm. Proportional hazard regression analyses were used to model outcomes and were adjusted for covariates of interest. Patients (n = 21 655) were older (77.0 ± 10.5 years) and predominantly male (96.9%). Four groups were created according to presence (+) or absence (-) of dementia and delirium. Relative to the dementia-/delirium- group, the dementia-/delirium+ group was associated with increased 30 day mortality [adjusted hazard ratio (HR) = 2.2, 95% confidence interval (CI) = 1.7, 3.0] and 365 day mortality (adjusted HR = 1.5, 95% CI = 1.3, 1.7). Readmission was highest in the dementia-/delirium+ group after 30 days (HR = 1.2, 95% CI = 1.0, 1.5). In the group with dementia (delirium-/dementia+), 30 day mortality (12.8%; HR = 0.7, 95% CI = 0.7, 0.8) and readmissions (5.3%; HR = 1.0, 95% CI = 0.8, 1.1) were not different relative to the reference group.
Conclusions:
Delirium, independent of pre-existing dementia, confers increased risk of hospital readmission and mortality in HF patients discharged to SNFs. Managing HF after hospitalization is a complex cognitive task and an increased focus on mental status in the acute care setting prior to discharge is needed to improve HF management and transitional care, mitigate adverse outcomes, and reduce healthcare costs.
Aims:
Although evidence suggests that cognitive decline and physical frailty in elderly patients with heart failure (HF) are associated with prognosis, the impact of concurrent physical frailty and cognitive impairment, that is, cognitive frailty, on prognosis has yet to be fully investigated. The current study sought to investigate the prevalence and prognostic impact of cognitive frailty in elderly patients with HF.
Methods and results:
This study is a sub-analysis of FRAGILE-HF, a prospective multicentre observational study involving patients aged ≥65 years hospitalized for HF. The Fried criteria and Mini-Cog were used to diagnose physical frailty and cognitive impairment, respectively. The association between cognitive frailty and the combined endpoint of mortality and HF rehospitalization within 1 year was then evaluated. Among the 1332 patients identified, 1215 who could be assessed using Mini-Cog and the Fried criteria were included in this study. Among those included, 279 patients (23.0%) had cognitive frailty. During the follow-up 1 year after discharge, 398 combined events were observed. Moreover, cognitive frailty was determined to be associated with a higher incidence of combined events (log-rank: P = 0.0146). This association was retained even after adjusting for other prognostic factors (hazard ratio: 1.55, 95% confidence interval: 1.13-2.13). Furthermore, a sensitivity analysis using grip strength, short physical performance battery, and gait speed to determine physical frailty instead of the Fried criteria showed similar results.
Conclusions:
This cohort study found that 23% of elderly patients with HF had cognitive frailty, which was associated with a 1.55-fold greater risk for combined events within 1 year compared with patients without cognitive frailty.
Aims:
A patient's understanding of his or her own comorbidities is part of the recommended patient education for those with heart failure. The accuracy of patients' understanding of their comorbidities and its prognostic impact have not been reported.
Methods and results:
Patients hospitalized for heart failure (n = 1234) aged ≥65 years (mean age: 80.1 ± 7.7 years; 531 females) completed a questionnaire regarding their diagnoses of diabetes, malignancy, stroke, hypertension, chronic obstructive pulmonary disease (COPD), and coronary artery disease (CAD). The patients were categorized into three groups based on the number of agreements between self-reported comorbidities and provider-reported comorbidities: low (1-2, n = 19); fair (3-4, n = 376); and high (5-6, n = 839) agreement groups. The primary outcome was a composite of all-cause mortality or heart failure rehospitalization at 1 year. The low agreement group had more comorbidities and a higher prevalence of a history of heart failure. The agreement was good for diabetes (κ = 0.73), moderate for malignancy (κ = 0.56) and stroke (κ = 0.50), and poor-to-fair for hypertension (κ = 0.33), COPD (κ = 0.25), and CAD (κ = 0.30). The fair and low agreement groups had poorer outcomes than the good agreement group [fair agreement group: hazard ratio (HR): 1.25; 95% confidence interval (CI): 1.01-1.56; P = 0.041; low agreement group: HR: 2.74: 95% CI: 1.40-5.35; P = 0.003].
Conclusions:
The ability to recognize their own comorbidities among older patients with heart failure was low. Patients with less accurate recognition of their comorbidities may be at higher risk for a composite of all-cause mortality or heart failure rehospitalization.
Background:Heart failure in elderly people causes physical and cognitive dysfunction and often requires long-term care insurance (LTCI); however, among patients with left ventricular (LV) systolic dysfunction, the incidence and risk factors of future LTCI requirements need to be elucidated.
Methods and Results:The study included 1,852 patients aged ≥65 years with an echocardiographic LV ejection fraction (LVEF) ≤50%; we referred to their LTCI data and those of 113,038 community-dwelling elderly people. During a mean 1.7-year period, 332 patients newly required LTCI (incidence 10.7 per 100 person-years); the incidence was significantly higher than that for the community-dwelling people (hazard ratio [HR], 1.47; 95% confidence interval [CI], 1.32–1.64). On multivariate analysis, the risk factors at the time of echocardiography leading to future LTCI requirement were atrial fibrillation (HR, 1.588; 95% CI, 1.279–1.971), history of stroke (HR, 2.02; 95% CI, 1.583–2.576), osteoporosis (HR, 1.738; 95% CI, 1.253–2.41), dementia (HR, 2.804; 95% CI, 2.075–3.789), hypnotics (HR, 1.461; 95% CI, 1.148–1.859), and diuretics (HR, 1.417; 95% CI, 1.132–1.773); however, the LVEF was not a risk factor (HR, 0.997; 95% CI, 0.983–1.011).
Conclusions:In elderly patients with LV systolic dysfunction, the incidence of LTCI requirement was more common than that for community-dwelling people; its risk factors did not include LVEF, but included many other non-cardiac comorbidities and therapies, suggesting the need for interdisciplinary cooperation to prevent disabilities.
Background:
The aim of this study was to validate our previous finding that frailty predicts early mortality in patients with advanced heart failure (AHF) and that including cognition in the frailty assessment enhances the prediction of mortality.
Methods:
Patients with AHF referred to our Transplant Unit between November 2015 and April 2020 underwent physical frailty assessment using the modified Fried physical frailty (PF) phenotype as well as cognitive assessment using the Montreal Cognitive Assessment (MOCA) to identify patients who were cognitively frail (CogF). We assessed the predictive value of the 2 frailty measures (PF ≥ 3 of 5 = frail; CogF ≥ 3 of 6 = frail) for pretransplant mortality.
Results:
313 patients (233 male, 80 female; age 53 ± 13 years) were assessed. Of these, 224 patients (72%) were nonfrail and 89 (28%) were frail using the PF. The cognitive frailty assessment identified an additional 30 patients as frail: 119 (38%). Frail patients had significantly increased mortality as compared to nonfrail patients. Ventricular assist device and heart transplant-censored survival at 12 months was 92 ± 2 % for nonfrail and 69 ± 5% for frail patients (p < 0.0001) using the CogF instrument.
Conclusions:
This study validates our previously published findings that frailty is prevalent in patients with advanced heart failure referred for heart transplantation. Physical frailty predicts early mortality. The addition of cognitive assessment to the physical assessment of frailty identifies an additional cohort of patients with a similarly poor prognosis.
Background:
Atrial fibrillation (AF) and heart failure (HF) frequently co-occur in older individuals. Among patients with AF, HF increases risks for stroke and death, but the associations between HF and incident cognition and physical impairment remain unknown. We aimed to examine the cross-sectional and prospective associations between HF, cognition, and frailty among older patients with AF.
Methods:
The SAGE-AF (Systematic Assessment of Geriatric Elements in AF) study enrolled 1244 patients with AF (mean age 76 years, 48% women) from five practices in Massachusetts and Georgia. HF at baseline was identified from electronic health records using ICD-9/10 codes. At baseline and 1-year, frailty was assessed by Cardiovascular Health Survey score and cognition was assessed by the Montreal Cognitive Assessment.
Results:
Patients with prevalent HF (n = 463, 37.2%) were older, less likely to be non-Hispanic white, had less education, and had greater cardiovascular comorbidity burden and higher CHA2DS2VASC and HAS-BLED scores than patients without HF (all P's < 0.01). In multivariable adjusted regression models, HF (present vs. absent) was associated with both prevalent frailty (adjusted odds ratio [aOR]: 2.38, 95% confidence interval [CI]: 1.64-3.46) and incident frailty at 1 year (aOR: 2.48, 95% CI: 1.37-4.51). HF was also independently associated with baseline cognitive impairment (aOR: 1.60, 95% CI: 1.22-2.11), but not with developing cognitive impairment at 1 year (aOR 1.04, 95%CI: 0.64-1.70).
Conclusions:
Among ambulatory older patients with AF, the co-existence of HF identifies individuals with physical and cognitive impairments who are at higher short-term risk for becoming frail. Preventive strategies to this vulnerable subgroup merit consideration.
Aims
Heart failure (HF) is a complex clinical syndrome with multiple comorbidities. Cognitive impairment, stress, anxiety, depression, and lower quality of life are prevalent in HF. Herein, we explore the interplay between these parameters and study their value to predict major adverse cardiovascular events (MACEs) and health‐related quality of life (HrQoL) in patients with HF with reduced ejection fraction using guideline recommended assessment tools.
Methods and results
We conducted a longitudinal study using a sample of 65 patients from two hospitals. A battery of tests was applied to assess cognition [Montreal Cognitive Assessment (MoCA)], stress (Perceived Stress Scale‐10), anxiety, and depression (Hospital Anxiety and Depression Scale) at baseline. MACEs were registered using clinical records. HrQoL was estimated using the Kansas City Cardiomyopathy Questionnaire (KCCQ). A descriptive statistical analysis was conducted, and multiple linear and Cox regression models conducted to determine the predictive value of neurocognitive parameters and HrQoL in MACE. Both MoCA [hazard ratio = 0.906 (0.829–0.990); P = 0.029] and KCCQ scores were predictors of MACE, but not of overall mortality. Anxiety, depression, and stress scores did not predict MACE. However, anxiety (β = −0.326; P = 0.012) and depression levels (β = −0.309; P = 0.014) were independent predictors of the KCCQ score.
Conclusions
The MoCA score and HrQoL were predictors of MACE‐free survival. Anxiety and depression were good predictors of HrQoL, but not of MACE‐free survival.
Background:
Evidence has shown that serum uric acid (UA) is associated with cognitive function, but this finding remains debatable. Serum UA is commonly elevated in patients with chronic heart failure (CHF), especially in men. However, the relationship between serum UA and cognitive function in CHF populations and stratified by sex are unclear. We aimed to examine whether serum UA was independently associated with cognitive function in CHF populations after controlling for demographic, medical and psychological variables and whether there was a sex difference in the association between serum UA and cognitive function among male and female CHF patients.
Methods:
One hundred ninety-two hospitalized patients with CHF underwent an assessment of cognitive function using the Montreal Cognitive Assessment (MoCA) and the determination of serum UA. Hyperuricemia was defined as serum UA ≥7 mg/dl in men and ≥ 6 mg/dl in women. Multiple linear hierarchical regression analyses were conducted to examine the independent association between serum UA and cognitive function in CHF populations and stratified by sex.
Results:
The mean serum UA concentration of participants was 7.3 ± 2.6 mg/dL. The prevalence of hyperuricemia was 54.7% (105 of 192) in CHF patients, 52.9% (64 of 121) in men, and 57.7% (41 of 71) in women. In the total sample, higher serum UA was associated with poorer cognitive function independent of demographic, medical and psychological variables (β = - 0.130, ΔR2 = 0.014, p = 0.015). In sex-stratified groups, elevated serum UA was independently associated with worse cognitive function in men (β = - 0.247, ΔR2 = 0.049, p = 0.001) but not in women (β = - 0.005, ΔR2 = 0.000, p = 0.955).
Conclusions:
Higher serum UA is independently associated with poorer cognitive function in CHF populations after adjusting for confounding variables. Furthermore, elevated serum UA is independently related to worse performance on cognitive function in men but not in women. More longitudinal studies are needed to examine the association between serum UA and cognitive function in CHF populations and stratified by sex.
Background:Elderly patients admitted to hospital with heart failure (HF) often have cognitive impairment, but the association between these conditions is unclear.
Methods and Results:We enrolled 43 patients admitted to a geriatric hospital with HF. We evaluated echocardiography, Mini Mental State Examination (MMSE), and extracellular water/total body water (ECW/TBW) ratio (Inbody S10). Mean age was 85.1±8.0 years (range, 60–99 years) and 44.2% of the patients were men. Mean MMSE score was 20.5±5.4, with 66.7% of the patients showing cognitive impairment (MMSE ≤23). There was a significant negative correlation of MMSE score with age (r=−0.344, P=0.032), regular alcohol drinking (r=0.437, P=0.007), uric acid level (r=0.413, P=0.010), and ECW/TBW ratio (r=−0.437, P=0.007). On stepwise regression analysis including these covariates, MMSE score was significantly associated with the ECW/TBW ratio (β=0.443, P=0.009). When several echocardiography parameters (i.e., end-diastolic left ventricular volume, r=0.327, P=0.048; left atrial volume index, r=−0.411, P=0.012; and transmitral inflow A wave velocity, r=−0.625, P=0.001) were added to the model, MMSE score was found to be related to the A wave (P=0.001) and to atrial volume index (P=0.015), which are measures of diastolic function.
Conclusions:In elderly patients with HF, cognitive function might be influenced by body water distribution and diastolic heart function.
Background:
There are differences among the outcomes regarding cognitive impairment in heart failure (HF) because the evidence is fragmented and sample size is small. Therefore we aimed to systematically review and analyze the available evidence about the association between HF and dementia.
Methods:
In the present study, we searched for articles published until August 2019 in the following databases: PubMed, Web of Science, EMBASE, Medline and Google Scholar. The pooled multivariate odds ratio (OR) or relative risk (RR) and 95% confidence intervals (CI) were obtained by the use of STATA 12.0 software.
Results:
The meta-analysis showed a positive association between HF and risk of all-cause dementia (OR/RR = 1.28, 95% CI 1.15 to 1.43, I = 70.0%, P < 0.001). Additionally, the study showed no significant association between HF and risk of Alzheimer's disease (AD) (OR/RR = 1.38, 95% CI 0.90 to 2.13, I = 74.8%, P = 0.008).
Conclusion:
In conclusion, HF was associated with an increased risk of developing dementia. In addition, large scale prospective studies are essential to explore the associations between HF and risk of AD.
Background
The prevalence and impact of cognitive impairment in heart failure is increasingly recognized. Converging evidence points to global cognitive function as predictive of prognosis in adults with heart failure when assessed with screening tools. Additional work is needed to understand which domains of cognitive function are most relevant for prognosis.
Aims
The present study sought to examine associations between domains of cognitive function and mortality risk in adults with heart failure.
Methods
In the present prospective, observational cohort study, global cognitive function, attention, executive function, and memory were assessed by means of a comprehensive neuropsychogical battery in adults with systolic heart failure. Mortality data were obtained from the National Death Index (median follow-up 2.95 years). Relationships among each cognitive domain and mortality were assessed with Cox regression. Covariates included age, sex, heart failure severity, comorbidity and depressive symptoms.
Results
Participants were 325 patients with systolic heart failure with a mean age of 68.6 years (59% men, 73% Caucasian). Following covariate adjustment, better global cognitive function, attention, and executive function were related to decreased mortality risk.
Conclusions
Future research is needed to clarify the underlying mechanisms of the association between cognitive impairment and mortality.
Background:
Recent systematic review and meta-analysis showed that the prevalence of cognitive impairment was significantly increased in patients with heart failure (HF) when compared to the general population. However, the effect of cognitive impairment on cardiovascular outcome in this population is still unclear. We performed a systematic review and meta-analysis to assess whether cognitive impairment associated with worse outcome in patients with HF.
Methods:
We comprehensively searched the databases of MEDLINE and EMBASE from inception to October 2018. Included studies were published cohort (prospective or retrospective) or randomized control trials that evaluate the effect of cognitive impairment mortality in HF patients. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate pooled hazard ratios (HR) and 95% confidence intervals (CI).
Results:
Eight studies were included in the analysis involving 3318 participants (951 participants had cognitive impairment). In a random-effects model, our analysis demonstrated that cognitive impairment significantly increased the risk of mortality in HF patients (pooled HR = 1.64, 95% CI = 1.42-1.88, I2 = 0.0%, p < 0.001).
Conclusion:
Our systematic review and meta-analysis showed that the presence of cognitive impairment is strongly associated with an increased mortality risk in the HF population. Further research is needed to explore the pathophysiology of this association.
Cognitive impairment is a prevalent condition and important barrier to self-care behaviors in patients with heart failure (HF). HF patients with depression or physical frailty are more likely to have reduced cognitive function. However, it remains unclear if combined depression and physical frailty increased the risk of cognitive impairments among HF populations. This study aimed to identify the influence of combined depression and physical frailty on cognitive impairments in HF. This cross-sectional study was included 289 patients with HF in outpatient cardiology clinics at a tertiary care university hospital in Cheonan, South Korea. We obtained patients’ characteristics including depression, physical frailty, and cognitive function with Korean validated tools using a face-to-face interview. The prevalence rate of cognitive impairment was approximately 27.3% in HF outpatients. We found that the combined influence of depression and physical frailty increased the risk of cognitive impairments in both unadjusted (odds ratio (OR) 4.360; 95% confidence interval (CI) (2.113, 8.994)) and adjusted models (OR 3.545; 95% CI (1.448, 8.681)). Our findings highlight that healthcare professionals need to be more aware of the vulnerable population who suffer from both depression and physical frailty at the same time. Future prospective studies should examine the causal relationships among depression, physical frailty and cognitive impairment during the HF illness trajectories.
Heart failure (HF)-related cognitive decline is a common condition and may be associated with health literacy. However, gender differences in this context have not been explored fully. This secondary data analysis aimed to identify gender differences in the impact of cognitive function on health literacy among older patients with HF. A total of 135 patients (75 men and 60 women) with a mean age of 73.01 ± 6.45 years were recruited. Older women with HF had higher cognitive impairment (15%) and inadequate health literacy (56.7%) compared to men. Cognitive function was the strongest predictor of health literacy in men (β = 3.668, p < 0.001) and women (β = 2.926, p = 0.004). Notably elderly women are likely to face double the burden of the influence of cognitive function on health literacy in comparison with men. It is necessary to assess cognitive function and health literacy during HF illness trajectories on a regular basis. Healthcare professionals working with patients with HF should be aware of gender differences in cognitive function and health literacy and the importance of assessing these factors.
Aims
The utility of combined assessment of both frailty and cognitive impairment in hospitalized heart failure (HF) patients for incremental post‐discharge risk stratification, using handgrip strength and Mini‐Cog as feasible representative parameters, was investigated.
Methods and results
A prospective, single‐centre cohort study of older adults (age ≥65) hospitalized for HF being discharged to home was performed. Pre‐discharge, grip strength was assessed using a dynamometer (Jamar hydrolic hand dynamometer, Lafayette Instruments, Lafayette, IN, USA) and was defined as weak if the maximal value was below the gender‐derived and body mass index‐derived cut‐offs according to Fried criteria. Cognition was assessed using the Mini‐Cog. The presence of impairment was defined as a score of <2. Outcome measures were all‐cause readmission or emergency department visit (primary) or all‐cause mortality (secondary) at 6 months. A total of 56 patients (mean age 77 ± 7 years, 73% male) were enrolled. The majority (n = 33, 59%) had weak grip strength, either with (n = 5) or without (n = 28) cognitive impairment. The highest risk for both readmission and mortality occurred in those with weak grip strength and cognitive impairment in combination (log‐rank P < 0.0001 and P = 0.01, respectively).
Conclusions
Patients who are frail by grip strength assessment and cognitively impaired according to severely reduced Mini‐Cog performance show the worst midterm post‐discharge outcomes after HF hospitalization.
Background:
Cognitive impairment is highly prevalent among older adults (aged ≥65 years) hospitalized for heart failure and has been associated with poor outcomes. Poor medication self-management skills have been associated with poor outcomes in this population as well. The presence and extent of an association between cognitive impairment and poor medication self-management skills in this population has not been clearly defined.
Objective:
We assessed the cognition of consecutive older adults hospitalized for heart failure, in relation to their medication self-management skills.
Methods:
We conducted a cross-sectional study of older adults (aged ≥65 years) who were hospitalized for heart failure and were being discharged home. Prior to discharge, we assessed cognition using the Mini-Cog. We also tested patients' ability to read a pill bottle label, open a pill bottle safety cap, and allocate mock pills to a pill box. Pill allocation performance was assessed quantitatively (counts of errors of omission and commission) and qualitatively (patterns suggestive of knowledge-based mistakes, rule-based mistakes, or skill-based slips).
Results:
Of 55 participants, 22% were found to have cognitive impairment. Patients with cognitive impairment tended to be older as compared to those without cognitive impairment (mean age = 81 vs 76 years, p = NS). Patients with cognitive impairment had a higher prevalence of inability to read pill bottle label (prevalence ratio = 5.8, 95% confidence interval = 3.2-10.5, p = 0.001) and inability to open pill bottle safety cap (prevalence ratio = 3.3, 95% confidence interval = 1.3-8.4, p = 0.03). While most patients (65%) had pill-allocation errors regardless of cognition, those patients with cognitive impairment tended to have more errors of omission (mean number of errors = 48 vs 23, p = 0.006), as well as more knowledge-based mistakes (75% vs 40%, p = 0.03).
Conclusion:
There is an association between cognitive impairment and poor medication self-management skills. Medication taking failures due to poor medication self-management skills may be part of the pathway linking cognitive impairment to poor post-discharge outcomes among patients with heart failure transitioning from hospital to home.
Background: Evidence suggests that HF patients do not consistently engage in self-care. One possible reason may be the presence of undetected mild cognitive deficits (MCD). The primary objective of this study was to prospectively evaluate whether MCD measured with the Montreal Cognitive Assessment (MoCA) test in HF patients aged ≥60 years at hospital discharge is associated with impaired ability to self-care (measured with the Self-Care Heart Failure Index (SCHFI), patient is considered adequate if score ≥70/100).
Methods /
Results: We prospectively recruited HF patients within 48 hours from hospital discharge. In addition to the assessment of cognitive function, we measured baseline intelligence (NAART35), depression (Geriatric Depression Scale, GDS15 ), caregiver burden (modified Oberst Caregiver Burden Scale), activities of daily living (Barthel index), and frailty (Clinical Frailty Scale, CFS). We have recruited 51 patients (mean age 78, SD 7 years, 51% male) in this study. Sixty eight percent of patients have a high school education or less, 45% are married, 42% widowed, and 64% of patients have a total household income of <$40,000. Fifty three percent of patients have a left ventricular ejection fraction >45%. The mean number of medications at hospital discharge is 10 (SD 4). The mean MoCA score at baseline was 22 (SD 4) and 87% of patients had a MoCA score <26 (indicating cognitive impairment). The SCHFI at baseline was 64 for self-maintenance, 46 for self-management, and 63 for self-confidence. Caregiver burden was low for the 2 subscales (Demand: 1.9, Difficulty: 1.3). The mean score for the GDS15 was 4/15 (no depression: 0-4/15), Barthel index was 82/100 indicating that the patients are not fully independent for ADLs. The mean CFS score was 4/7 indicating that these individuals are limited by symptoms during their activities.
Conclusion: To our knowledge, this is the first prospective study at hospital discharge indicating a high prevalence of cognitive impairment. These results suggest that older HF patients have significant undetected cognitive deficits which may impact on their ability to self-care, which may in turn potentially lead to re-hospitalization early after hospital discharge.
Background:
Cognitive function is essential to effective self-management of heart failure (HF). Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) can coexist with HF, but its exact prevalence and impact on health care utilization and death are not well defined.
Methods:
Residents from 7 southeast Minnesota counties with a first-ever diagnosis code for HF between January 1, 2013 and December 31, 2018 were identified. Clinically diagnosed AD/ADRD was ascertained using the Centers for Medicare and Medicaid (CMS) Chronic Conditions Data Warehouse algorithm. Patients were followed through March 31, 2020. Cox and Andersen-Gill models were used to examine associations between AD/ADRD (before and after HF) and death and hospitalizations, respectively.
Results:
Among 6336 patients with HF (mean age [SD] 75 years [14], 48% female), 644 (10%) carried a diagnosis of AD/ADRD at index HF diagnosis. The 3-year cumulative incidence of AD/ADRD after HF diagnosis was 17%. During follow-up (mean [SD] 3.2 [1.9] years), 2618 deaths and 15,475 hospitalizations occurred. After adjustment, patients with AD/ADRD before HF had nearly a 2.7 times increased risk of death, but no increased risk of hospitalization compared to those without AD/ADRD. When AD/ADRD was diagnosed after the index HF date, patients experienced a 3.7 times increased risk of death and a 73% increased risk of hospitalization compared to those who remain free of AD/ADRD.
Conclusions:
In a large, community cohort of patients with incident HF, the burden of AD/ADRD is quite high as more than one-fourth of patients with HF received a diagnosis of AD/ADRD either before or after HF diagnosis. AD/ADRD markedly increases the risk of adverse outcomes in HF underscoring the need for future studies focused on holistic approaches to improve outcomes.
Funding Acknowledgements
Type of funding sources: None.
Background
Dementia, in the setting of heart failure (HF), portends poorer outcomes and poses great challenges in its clinical management.
Purpose
We investigated the incidence, types, clinical correlates, and the prognostic impact of dementia in a population-based cohort of patients with HF. Further, we examined the interactions of age and sex, and education status with dementia incidence.
Methods
The previously validated Hong Kong Clinical Data Analysis Reporting System (CDARS), a territory-wide database was interrogated to identify patients with HF (N= 202,121) from 1995 to 2018. Associations of clinical correlates with incident dementia and its risk with all-cause mortality were assessed using competing risk/multivariable Cox regression models where appropriate.
Results
Among a total cohort aged ≥18 years with HF (mean age: 75.3 ± 13.0 years, 51.3% women), new-onset dementia occurred in 22,145 (11.0%) over a median follow-up of 5.5 years. Alzheimer’s disease occurred in 27.0%; vascular dementia (18.1%) and unspecified dementia (in 55.1%). Age-standardized rate of dementia incidence in women was 1297 (95%CI, 1276-1318) (vs. 744, 95%CI, 723-765) per 10000 population in men. Other independent predictors of dementia include: Increasing age (HR 1.08), Female sex (HR 1.19), Nil/< primary (vs tertiary) education (HR 1.29), Parkinson’s disease (HR 1.73), head injury (HR 1.37), peripheral vascular disease (HR 1.31), stroke (HR 1.29), depression (HR 1.18), alcohol intake (HR1.17), anaemia (HR 1.14), hypertension (HR 1.08), among other common comorbidities in HF (Figure 1A).
Notably, a significant interaction (p < 0.001) between age and sex on dementia incidence was observed, such that women in all age groups were observed to have higher sHR compared to men (Figure 1B). After accounting for competing risk, dementia was not associated with adjusted hazard of all-cause mortality.
Conclusions
Female sex, lower socioeconomic status, increasing age and common comorbidities were associated with higher hazards of incident dementia. Abstract Figure 1A and Figure 1B
Background
We assessed the prevalence and clinical characteristics of patients with acute decompensated heart failure (ADHF) who live alone and how they were different from patients who lived with someone else.
Methods
We analyzed patients in the REHAB-HF Trial. Patients were ≥60 years with preserved or reduced ejection fraction who were hospitalized with ADHF.
Results
Of 202 patients, 67 (33.2%) lived alone. Patients who lived alone had a mean age of 72.4±7.8 years, 64% (n=43) of whom were female, 52% (n=35) were non-white and had a mean 6.1±5.5 comorbidities. Patients living alone were largely similar in baseline characteristics, comorbid burden and prescribed medications to patients living with someone else. However, patients living alone were more likely to be female than patients living with someone else (63% [n=43] vs. 49% [n=66], p=0.04). Patients living alone had severe impairments in physical function and QoL. Cognitive dysfunction was present in 81% of those living alone. However, after adjusting for sex, no differences in physical function, depression, cognitive dysfunction or QoL were noted between patients who lived alone or those who lived with someone else.
Conclusions
In this diverse population of older ADHF patients, 33% lived alone (versus 26% in the general population). Those living alone were more often female, non-white, and had >6 comorbidities. Treatment strategies for older ADHF patients should consider the potential impact of social determinants.
Introduction: The domain management approach to caring for heart failure patients outlines the importance of considering deficits from multiple health domains including: medical, mental and emotional, physical, and social. The extent to which these deficits exist in patients with HFpEF is unknown. We sought to characterize deficits across multiple domains among patients seen in an outpatient HFpEF program.
Hypothesis: We hypothesized that HFpEF patients would have a high prevalence of deficits across multiple domains.
Methods: We conducted a retrospective study of 134 patients with HFpEF seen between July 2018 and December 2019 in the Weill Cornell HFpEF Program, which incorporates the domain management approach through several assessments. The medical domain includes an assessment of multimorbidity (≥ 2 comorbid conditions), polypharmacy (≥ 5 medications), malnutrition (Mini Nutritional Assessment < 12), and hearing and vision impairment (self-report). The mental and emotional domain includes cognitive impairment (Mini-Cog < 3), depression (PHQ-9 ≥ 10), and anxiety (GAD-7 ≥ 10). The physical function domain includes frailty (Short Physical Performance Battery < 10), functional impairment (Katz Index < 6), and fall within the past year (self-report). The social domain includes loneliness (UCLA 3-Item Loneliness Scale ≥ 6) and living situation (self-report).
Results: The median age was 75 years (IQR 69-82), 60% were women, and 64% were White. The Figure shows the prevalence for each deficit across the four domains. The most common deficits were multimorbidity (100%), polypharmacy (98%), frailty (79%), and loneliness (62%). Notably, 13% of patients had deficits in all four domains, 31% in three domains, 47% in two domains, and 9% in one domain.
Conclusions: HFpEF patients have deficits spanning multiple domains. This supports the importance of considering issues such as multimorbidity, polypharmacy, frailty, and loneliness when caring for these patients.
Introduction: Symptom self-management is important in heart failure (HF) but challenging given the high prevalence of associated cognitive impairment. Visualizations may support symptom self-management by improving recognition of meaningful changes in symptoms over time. The purpose of this study was to evaluate whether visualizations of self-reported symptom status were associated with recognition of worsening symptoms (risk perception) and intention to act on worsening symptoms (behavioral intention) .
Methods: We recruited hospitalized, English-speaking adults with HF from 2 inpatient cardiac units at an urban academic medical center. A professional designer developed 4 visualizations of simulated changes in self-reported symptoms (e.g., fatigue; Figure 1 ) using best practices for displaying health information to adults with cognitive impairment. Using the participants’ favorite visualization of the 4, we evaluated risk perception and behavioral intention using validated scales. We also collected demographics, health literacy, and cognitive status using the Montreal Cognitive Assessment (MoCA).
Results: Participants (n=40) had an average age of 61.3 years (±12.5) and were 22% female, 52% White, and 38% Latino. More than half (55%) had low health literacy. Most (88%) had mild/moderate cognitive impairment (MoCA score < 26). The favorite visualization (selected by 42%) was the number line. Regarding risk perception, 70% reported it was very/extremely likely their HF was getting worse and 54% reported they were very/extremely worried about their HF getting worse based on the visualization. Regarding behavioral intention, most (82%) were very/extremely likely to act based on the visualization.
Conclusion: Visualizations of symptoms over time communicated risk to most patients who in turn reported being more likely to act, and may be an effective tool to support symptom self-management among HF patients with mild/moderate cognitive impairment.
Background:
Older adults with acute decompensated heart failure (ADHF) have persistently poor clinical outcomes. Cognitive impairment (CI) may be a contributing factor. However, the prevalence of CI and the relationship of cognition with other patient-centered factors such a physical function and quality-of-life (QOL) that also may contribute to poor outcomes are incompletely understood.
Methods:
Older (≥60 years) hospitalized patients with ADHF were assessed for cognition [Montreal Cognitive Assessment (MoCA)], physical function [(short physical performance battery (SPPB), 6-minute walk distance (6MWD)], and QOL [Kansas City Cardiomyopathy Questionnaire (KCCQ), Short Form-12 (SF-12)].
Results:
Among patients (N=198, 72.1±7.6 years), 78% screened positive for CI (MoCA <26) despite rare medical record documentation (2%). Participants also had severely diminished physical function (SPPB 6.0±2.5 units, 6MWD 186±100m) and QOL (scores <50). MoCA positively related to SPPB (ß=0.47, p<0.001), 6MWD ß=0.01, p=0.006) and inversely related to KCCQ Overall Score (ß=-0.05, p<0.002) and SF-12 Physical Component Score (ß=-0.09, p=0.006). MoCA was a small but significant predictor of SPPB, 6MWD, and KCCQ.
Conclusion:
Among older hospitalized patients with ADHF, CI is highly prevalent, is underrecognized clinically, and is associated with severe physical dysfunction and poor QOL. Formal screening may reduce adverse events by identifying patients who may require more tailored care.
Epidemiologic research often involves meta-analyses of proportions. Conventional two-step methods first transform each study's proportion and subsequently perform a meta-analysis on the transformed scale. They suffer from several important limitations: the log and logit transformations impractically treat within-study variances as fixed, known values and require ad hoc corrections for zero counts; the results from arcsine-based transformations may lack interpretability. Generalized linear mixed models (GLMMs) have been recommended in meta-analyses as a one-step approach to fully accounting for within-study uncertainties. However, they are seldom used in current practice to synthesize proportions. This article summarizes various methods for meta-analyses of proportions, illustrates their implementations, and explores their performance using real and simulated datasets. In general, GLMMs led to smaller biases and mean squared errors, and higher coverage probabilities than two-step methods. Many software programs are readily available to implement these methods.
Readmission to the hospital is a major issue in clinical care for patients with heart failure (HF). However, the impact of the number of hospital admissions due to worsened HF is not fully understood. We sought to clarify the association between the number of hospital admissions due to worsened HF and patient outcomes. We studied 331,259 patients (median age was 81 years, and 175,286 patients (52.9%) were men) hospitalized for HF between January 2010 and March 2018 using the Japanese Diagnosis Procedure Combination Database, a national inpatient database. Patients were categorized into four groups based on the number of times they were admitted: once (n = 264,583), twice (n = 42,385), three times (n = 13,205), four times (n = 5347), and five or more times (n = 5739). The patients with larger numbers of admissions were more likely to have comorbidities and to use inotropic agents. The interval period between hospitalizations was shortened with an increasing number of hospital admissions, whereas the length of hospital stay was prolonged with an increasing number of hospital admissions. Multivariable logistic regression analysis fitted with a generalized estimating equation showed that an increased number of hospital admissions was independently associated with higher in-hospital mortality. In conclusion, readmission to the hospital due to worsened HF was still common, and in-hospital mortality was higher in those with larger numbers of readmissions, suggesting a clinical significance of the number of readmissions in patients with HF.
The objective of this study is to determine the prevalence of cognitive impairment (CogI) in patients hospitalized for congestive heart failure, and the influence of CogI on mortality and hospital readmission. This is a multicenter cohort study of patients hospitalized for congestive heart failure enrolled in the RICA registry. The patients were divided into 3 groups according to their Short Portable Mental Status Questionnaire score: 0–3 errors (no CogI or mild CogI), 4–7 (moderate CogI) and 8–10 (severe CogI). A total of 3845 patients with a mean (SD) age of 79 (8.6) years were included; 2038 (53%) were women. A total of 550 (14%) patients had moderate CogI and 76 (2%) had severe CogI. Factors independently associated with severe CogI were age (OR 1.09, 95% CI 1.05–1.14 p < 0.001), male sex (OR 0.57, 95% CI 0.34–0.95, p = 0.031), heart rate (OR 1.01, 95% CI 1.00–1.02, p = 0.004), Charlson index (OR 1.16, 95% CI 1.06–1.27, p = 0.002), and history of stroke (OR 2.67, 95% CI 1.60–4.44, p < 0.001). Severe CogI was associated with higher mortality after one year (HR 3.05, 95% CI 2.25–4.14, p < 0.001). The composite variable of death/hospital readmission was higher in patients with CogI (log rank p < 0.001). Patients with heart failure and severe CogI are older and have a higher comorbidity burden, lower survival, and a higher rate of death or readmission at 1 year, compared to patients with no CogI.
Purpose
Cognitive impairment and mood deviation often occurs in patients with heart failure. Frailty and sarcopenia have been widely studied in patients with heart disease, but cognitive frailty has been little explored. High complexity of patients referred for heart transplantation connected with socioeconomic characteristics in a developing country underlines the importance to investigate cognitive and mood conditions in this population. The aim of the study is to evaluate the prevalence of cognitive impairment and depression symptoms in patients with heart failure in waiting list for heart transplantation (HTx).
Methods
Cognition was assessed with the Montreal Cognitive Assessment (MoCA) and Wechsler Abbreviated Scale of Intelligence (WASI), depression symptoms was assessed with Beck Depression Inventory (BDI). Patients included in waiting-list from Nov/2018 to Sep/2019 in our institution had its cognitive assessment in four weeks.
Results
36 patients were evaluated; 28 (77%) were male; 45,6 was the average age; Chagas disease was the main etiology (36%), followed by dilated cardiomyopathy (25%), ischemic cardiomyopathy (11%) and other etiologies (28%). 9,1 was the average of school years; 20 (55,5%) belong to social class “E” according to monthly family income and 9 (25%) reported history of mental health treatment or psychotropic use. Considering scales described above, 14 (38,8%) had mild symptons for depression; 31 (86,1%) denoted frailty on the brief cognitive screening test (MoCA) and 32 (88,8%) in the global intelligence scale (WASI), with emphasis on lower scores on non-verbal tasks over verbal tasks.
Conclusion
In our cohort, the prevalence of cognitive frailty in patients in heart transplant waiting list was alarming. Socioeconomic conditions seem to be a crucial issue in worse performance of candidates reflecting specific features and challenges regarding heart transplantation in a developing country.
Background: The effective self-management of heart failure (HF) is highly dependent on cognitive function. Dementia frequently coexists with HF, but its exact prevalence and impact on health care utilization and death is not well understood.
Methods: Residents from 7 southeast Minnesota counties with a first-ever code for HF (ICD-9 428 and ICD-10 I50) between 1/1/2012 and 12/31/2017 were identified. Dementia before and after the HF diagnosis was ascertained with codes recommended by the US Department of Health and Human Services. Patients were followed through 12/31/2018 for death and hospitalizations. Cox and Andersen-Gill models were used to examine associations between dementia (prior and post HF) and death and hospitalizations, respectively. Dementia after HF was analyzed as a time-dependent variable.
Results: Among 6,312 patients with HF (mean age 75 years, 49% female), 636 (10%) had a prior diagnosis of dementia. After a mean (SD) follow-up of 3.1 (1.8) years, 601 (9.5%) patients were diagnosed with dementia post HF. The median time from HF to dementia was 1.3 years, with 43% of dementia cases occurring within 1 year and 64% within 2 years post HF. During follow-up, 2,678 deaths and 15,095 hospitalizations occurred. After adjustment, patients with dementia before HF had nearly a 2-times increased risk of death and 10% increased risk of hospitalization compared to those that did not have dementia (Table). Dementia after HF was associated with a 78% increased risk of death and 63% increased risk of hospitalization compared to those that did not have dementia.
Conclusions: Approximately 10% of patients had dementia prior to HF and 10% develop dementia shortly after HF diagnosis. Patients with HF and dementia have an increased risk of death and hospitalization compared to dementia-free counterparts. These data underscore the importance of recognizing the presence and impact of dementia on outcomes in HF to optimize care delivery.
Objectives:
This study sought to characterize cognitive decline (CD) over time and its predictors in patients with systolic heart failure (HF).
Background:
Despite the high prevalence of CD and its impact on mortality, predictors of CD in HF have not been established.
Methods:
This study investigated CD in the WARCEF (Warfarin versus Aspirin in Reduced Ejection Fraction) trial, which performed yearly Mini-Mental State Examinations (MMSE) (higher scores indicate better cognitive function; e.g., normal score: 24 or higher). A longitudinal time-varying analysis was performed among pertinent covariates, including baseline MMSE and MMSE scores during follow-up, analyzed both as a continuous variable and a 2-point decrease. To account for a loss to follow-up, data at the baseline and at the 12-month visit were analyzed separately (sensitivity analysis).
Results:
A total of 1,846 patients were included. In linear regression, MMSE decrease was independently associated with higher baseline MMSE score (p < 0.0001), older age (p < 0.0001), nonwhite race/ethnicity (p < 0.0001), and lower education (p < 0.0001). In logistic regression, CD was independently associated with higher baseline MMSE scores (odds ratio [OR]: 1.13; 95% confidence interval [CI]: 1.07 to 1.20]; p < 0.001), older age (OR: 1.37; 95% CI: 1.24 to 1.50; p < 0.001), nonwhite race/ethnicity (OR: 2.32; 95% CI: 1.72 to 3.13 for black; OR: 1.94; 95% CI: 1.40 to 2.69 for Hispanic vs. white; p < 0.001), lower education (p < 0.001), and New York Heart Association functional class II or higher (p = 0.03). Warfarin and other medications were not associated with CD. Similar trends were seen in the sensitivity analysis (n = 1,439).
Conclusions:
CD in HF is predicted by baseline cognitive status, demographic variables, and NYHA functional class. The possibility of intervening on some of its predictors suggests the need for the frequent assessment of cognitive function in patients with HF. (Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction [WARCEF]; NCT00041938).
Background and Purpose—
Patients with cardiovascular disease are at increased risk for cognitive decline. We studied the occurrence and profile of cognitive impairment in 3 patient groups as exemplar conditions of hemodynamic disturbances at different levels of the heart-brain axis, including patients with heart failure (HF), carotid occlusive disease (COD), and patients with cognitive complaints and vascular brain injury on magnetic resonance imaging (possible vascular cognitive impairment [VCI]).
Methods—
In 555 participants (160 HF, 107 COD, 160 possible VCI, 128 reference participants; 68±9 years; 36% F; Mini-Mental State Examination 28±2), we assessed cognitive functioning with a comprehensive test battery. Test scores were transformed into z -scores. Compound z -scores were constructed for: memory, language, attention/psychomotor speed, executive functioning, and global cognitive functioning. We rated cognitive domains as impaired when z -score≤−1.5. Based on the number of impaired domains, patients were classified as cognitively normal, minor, or major cognitive impairment. We used general linear models and χ ² tests to compare cognitive functioning between patient groups and the reference group.
Results—
Age, sex, and education adjusted global cognitive functioning z-score was lower in patients with COD (β [SE]=−0.46 [0.10], P <0.001) and possible VCI (β [SE]=−0.80 [0.09], P <0.001) compared with reference participants. On all domains, z -scores were lower in patients with COD and possible VCI compared with reference participants. Patients with HF had lower z-scores on attention/speed and language compared with reference participants. Cognitive impairment was observed in 18% of HF, 36% of COD, and 45% possible VCI. There was no difference in profile of impaired cognitive domains between patient groups. Memory and attention-psychomotor speed were most commonly affected, followed by executive functioning and language.
Conclusions—
A substantial part of patients with HF and COD had cognitive impairment, which warrants vigilance for the occurrence of cognitive impairment. These results underline the importance of an integrative approach in medicine in patients presenting with disorders in the heart-brain axis.
Background
Cognitive impairment is a prevalent, independent marker of readmission in heart failure (HF), but the screening is time-consuming. This study sought (1) to identify HF patients at low risk of cognitive impairment (obviating screening) and (2) to simplify a predictive model of HF outcomes by only using cognitive domains that are most predictive.
Methods and Results
The Montreal Cognitive Assessment was performed in 1152 Australian patients with HF who were followed for 12 months. One-third (376/1152) of the patients were enrolled into an HF disease management plan to reduce early readmission. Postdischarge outcomes in HF included 30- and 90-day readmission or death and days alive and out of hospital within 12 months of discharge. Cognitive impairment—present in 54% of patients—independently predicted HF outcomes. Normal cognition could be predicted with common clinical and sociodemographic factors with good discrimination (C statistic=0.74 [0.69–0.78]). The visuospatial/executive and orientation domains were most predictive of HF postdischarge outcomes. Using either Montreal Cognitive Assessment score or these 2 domains provided similar incremental values ( P =0.0004 and P =0.0008, respectively) in predicting HF outcomes (both C statistic=0.76) and could similarly identify a group of high-risk patients who benefited most from an HF disease management plan.
Conclusions
Cognitive function independently predicts HF outcomes and may also contribute to how a patient responds to intervention. The time and resources spent on cognitive assessment for risk-stratification in HF may be minimized by (1) identifying patients with low risk of cognitive impairment and (2) simplifying the screening instrument to include only the domains that are most predictive of postdischarge outcomes in HF.
OBJECTIVE: The aim of this study was to assess the prevalence of multimorbidity and co-existed diseases in hospitalized patients with heart failure (HF) in relation to age and gender. METHODS: The nationwide cross-sectional survey had been conducted in Poland (April-November 2013), in 260 randomly selected hospital wards. A trained nurse contacted with one physician, drawn from the list of all doctors working in the selected hospital's wards, who completed the study questionnaires regarding to clinical characteristics of the last five HF patients, who were discharged from an internal or cardiology ward. RESULTS: Mean age ± SD of the patients was 72.1 ± 10.1 years, 50% were female but the women were significantly older than men. Criterion of multimorbidity met almost 100% of the HF patients. There were no significant differences in the number of co-existed cardiovascular (CV) and non-CV diseases according to gender, but different clinical profile of HF men and women was observed. Women more frequently had thyroid disease, peripheral artery disease and cognitive impairment, whereas men was characterized by higher prevalence of cardiac, pulmonary and hepatic diseases. The co-morbidity significantly increased with age, notably due to increasing prevalence of non-CV diseases. Diabetes, chronic kidney disease, hypercholesterolemia and anemia were the most common non-CV diseases. Among HF patients, 83% suffered from three or more co-morbidities. CONCLUSIONS: The study confirms, that multimorbidity is a considerable problem in patients with HF. Besides age, multimorbidity pattern is strongly dependent on gender. The multidisciplinary approach is warranted in particular in elderly subjects who su er from HF.
Introduction
Mild cognitive impairment (MCI) is regarded as a prodrome to dementia. Various cognitive tests can help with diagnosis; meta‐analysis of diagnostic accuracy studies would assist clinicians in choosing optimal tests.
Methods
We searched online databases for “mild cognitive impairment” and “diagnosis” or “screening” from 01/01/1999 to 01/07/2017. Articles assessing the diagnostic accuracy of a cognitive test compared with standard diagnostic criteria were extracted. Risk of bias was assessed. Bivariate random‐effects meta‐analysis was used to evaluate sensitivity and specificity.
Results
Eight cognitive tests (ACE‐R, CERAD, CDT‐Sunderland, IQCODE, Memory Alteration Test, MMSE, MoCA, and Qmci) were considered for meta‐analysis. ACE‐R, CERAD, MoCA, and Qmci were found to have similar diagnostic accuracy, while the MMSE had lower sensitivity. Memory Alteration Test had the highest sensitivity and equivalent specificity to the other tests.
Discussion
Multiple cognitive tests have comparable diagnostic accuracy. The Memory Alteration Test is short and has the highest sensitivity. New cognitive tests for MCI diagnosis should not be compared with the MMSE.
Background:
Cognitive impairment (CI) is estimated to be present in 25%-80% of heart failure (HF) patients, but its prevalence at diagnosis is unclear. To improve our understanding of cognition in HF, we determined the prevalence of CI among adults with incident HF in the REGARDS study.
Methods and results:
REGARDS is a longitudinal cohort study of adults ≥45 years of age recruited in the years 2003-2007. Incident HF was expert adjudicated. Cognitive function was assessed with the Six-Item Screener. The prevalence of CI among those with incident HF was compared with the prevalence of CI among an age-, sex-, and race-matched cohort without HF. The 436 participants with incident HF had a mean age of 70.3 years (SD 8.9), 47% were female, and 39% were black. Old age, black race, female sex, less education, and anticoagulation use were associated with CI. The prevalence of CI among participants with incident HF (14.9% [95% CI 11.7%-18.6%]) was similar to the non-HF matched cohort (13.4% [11.6%-15.4%]; P < .43).
Conclusions:
A total of 14.9% of the adults with incident HF had CI, suggesting that the majority of cognitive decline occurs after HF diagnosis. Increased awareness of CI among newly diagnosed patients and ways to mitigate it in the context of HF management are warranted.
Objectives
Although cognitive impairment is common among patients with chronic heart failure (HF), the accuracy with which caregivers can recognize it is unknown. This study aimed to examine the degree to which subjective and objective evaluations coincide.
Methods
Cognitive function was evaluated subjectively and objectively in 184 hospitalized patients aged 65 or older (82 ± 7.2 years old and 49% male) with HF, who were divided into three groups: (i) normal; (ii) mild cognitive impairment; and (iii) severe cognitive impairment.
Results
The intrapatient agreement of the results of subjective and objective evaluations was tested, and weighted κ coefficients showed poor agreement (0.54, 95% confidence interval: 0.42–0.66, P < 0.001).
Conclusion
Subjective and objective cognitive function evaluations in older patients with HF are poorly concordant.
Background:
In our prior study of 250 outpatient veterans with heart failure (HF), 58% had unrecognized cognitive impairment (CI) which was linked to worsened medication adherence. Literature suggests HF patients with CI have poorer clinical outcomes including higher mortality.
Objective:
The study is to examine mortality rates in outpatients with HF and undiagnosed CI compared to their cognitively intact peers.
Methods:
This is a retrospective study for all-cause mortality.
Results:
During the 3-year follow up, 64/250 (25.6%) patients died: 20/106 (18.9%) with no CI, 29/104 (27.9%) with mild CI, and 15/40 (37.5%) with severe CI. Patients with CI were at increased risk for mortality (hazard ratio 1.82, p = 0.038). Those with severe CI had the worst outcome (hazard ratio 2.710, p = 0.011).
Conclusions:
CI was an independent risk factor for mortality in patients with heart failure when controlling for age and markers of disease severity. Cognitive screening should be performed routinely to identify patients at greater risk for adverse outcomes.
Background:
Symptoms of anxiety, depression, and cognitive impairment are common in heart failure (HF) patients, but there are inconsistencies in the literature regarding their relationship and effects on exercise capacity.
Objectives:
The aim of this study was to explore the relationships between exercise capacity and anxiety, depression, and cognition in HF patients.
Methods:
This was a secondary analysis on the baseline data of the Italian subsample (n = 96) of HF patients enrolled in the HF-Wii study. Data was collected with the 6-minute walk test (6MWT), Hospital Anxiety and Depression Scale, and Montreal Cognitive Assessment.
Results:
The HF patients walked an average of 222 (SD 114) meters on the 6MWT. Patients exhibited clinically elevated anxiety (48%), depression (49%), and severe cognitive impairment (48%). Depression was independently associated with the distance walked on the 6MWT.
Conclusions:
The results of this study reinforced the role of depression in relation to exercise capacity and call for considering strategies to reduce depressive symptoms to improve outcomes of HF patients.
Objectives:
This study sought to determine the spectrum of brain lesions seen in heart failure (HF) patients and the extent to which lesion type contributes to cognitive impairment.
Background:
Cognitive deficits have been reported in patients with HF.
Methods:
A total of 148 systolic and diastolic HF patients (mean age 64 ± 11 years; 16% female; mean left ventricular ejection fraction 43 ± 8%) were extensively evaluated within 2 days by cardiological, neurological, and neuropsychological testing and brain magnetic resonance imaging (MRI). A total of 288 healthy, sex- and age-matched subjects sampled from the Austrian Stroke Prevention Study served as MRI controls.
Results:
Deficits in reaction times were apparent in 41% of patients and deficits in verbal memory in 46%. On brain MRI, patients showed more advanced medial temporal lobe atrophy (MTA) (Scheltens score) compared to controls (2.1 ± 0.9 vs. 1.0 ± 0.6; p < 0.001). The degree of MTA was strongly associated with the severity of cognitive impairment, whereas the extent of white matter hyperintensities was similar in patients and controls. Moreover, patients had a 2.7-fold increased risk for presence of clinically silent lacunes.
Conclusions:
HF patients exhibit cognitive deficits in the domains of attention and memory. MTA but not white matter lesion load seems to be related to cognitive impairment.
Introduction:
Cardiovascular risk factors are closely linked with dementia risk, but whether heart disease predisposes to dementia is uncertain.
Methods:
We systematically reviewed the literature and meta-analyzed risk estimates from longitudinal studies reporting the association of coronary heart disease (CHD) or heart failure (HF) with risk of dementia.
Results:
We identified 16 studies (1,309,483 individuals) regarding CHD, and seven studies (1,958,702 individuals) about HF. A history of CHD was associated with a 27% increased risk of dementia (pooled relative risk [RR] [95% confidence interval, CI]: 1.27 [1.07-1.50]), albeit with considerable heterogeneity across studies (I2 = 80%). HF was associated with 60% increased dementia risk (pooled RR 1.60 [1.19-2.13]) with moderate heterogeneity (I2 = 59%). Among prospective population-based cohorts, pooled estimates were similar (for CHD, RR 1.26 [1.06-1.49], nine studies; and HF, RR 1.80 [1.41-2.31], four studies) and highly consistent (I2 = 0%).
Conclusion:
CHD and HF could be associated with an increased risk of dementia.
Background:
Heart failure (HF) is common among skilled nursing facility (SNF) residents, yet patients with HF in the SNF setting have not been well described.
Methods:
Using Minimum Data Set 3.0 cross-linked to Medicare data (2011-2012), we studied 150,959 HF patients admitted to 13,858 SNFs throughout the USA. ICD-9 codes were used to differentiate patients with HF with preserved ejection fraction (HFpEF), reduced ejection fraction (HFrEF), or unspecified HF.
Results:
The median age of the study population was 82 years, 68% were women, 34% had HFpEF, and 27% had HFrEF. HFpEF patients were older than those with HFrEF. Moderate/severe physical limitations (82%) and cognitive impairment (37%) were common, regardless of HF type. The burden and pattern of common comorbidities, with the exception of coronary heart disease, were similar among all groups, with a median of five comorbidities. One half of patients with HF had been prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 39% evidence-based β-blockers.
Conclusions:
SNF residents with HF are old and suffer from significant physical limitations and cognitive impairment and a high degree of comorbidity. These patients differ substantially from HF patients enrolled in randomized clinical trials and that might explain divergence from treatment guidelines.
Background:
Reliable data are necessary if the burden of early readmissions following hospitalization for heart failure (HF) is to be addressed. We studied unplanned 30-day readmissions, their causes and timing over an 11-year period, using population-based linked data.
Methods:
All hospitalizations from 2003 to 2013 were analyzed by using administrative linked data based on the Minimum Basic Set discharge registry of the Department of Health (Region of Murcia, Spain). Index hospitalizations with HF as principal diagnosis (n=27,581) were identified. Transfers between centers were merged into one discharge. Readmissions were defined as unplanned admissions to any hospital within 30-days after discharge.
Results:
In the 2003-2013 period, 30-day readmission rates had a relative mean annual growth of +1.36%, increasing from 17.6% to 22.1%, with similar trends for cardiovascular and non-cardiovascular causes. The figure of 22.1% decreased to 19.8% when only same-hospital readmissions were considered. Most readmissions were due to cardiovascular causes (60%), HF being the most common single cause (34%). The timing of readmission shows an early peak on the fourth day post discharge (+13.29%) due to causes other than HF, followed by a gradual decline (-3.32%); readmission for HF decreased steadily from the first day (-2.22%). Readmission for HF (12.7%) or non-cardiovascular causes (13.3%) had higher in-hospital mortality rates than the index hospitalization (9.2%, p<0.001). Age and comorbidity burden were the main predictors of any readmission, but the performance of a predictive model was poor.
Conclusion:
These findings support the need for population-based strategies to reduce the burden of early-unplanned readmissions.
Background:
Little is known about guideline-directed pharmacotherapy use in patients with heart failure and reduced ejection fraction (HFrEF) discharged to skilled nursing facilities (SNFs). This study aimed to describe the use of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) and evidence-based β-blocker (EBBB) among older patients with HFrEF within 90 days after the SNF admission and to identify factors associated with receipt of these medications.
Methods and results:
Using Minimum Data Set 3.0 cross-linked to Medicare data (2011-2012), we studied 35,792 Americans aged ≥ 65 years with HFrEF admitted to 10,333 SNFs. The median age was 82 years, 59% were women, 81% had at least moderate physical limitations, and 39% had moderate/severe cognitive impairment. Fifty-six percent received an ACEI/ARB and 53% an EBBB; one quarter received neither. In a multivariable log-binomial model, advanced age, severe physical limitations, and greater number of comorbid conditions not associated with heart failure were inversely associated with ACEI/ARB and EBBB receipt.
Conclusions:
Use of standard pharmacotherapy among patients with HFrEF after a SNF stay is higher than reported previously. In the absence of evidence demonstrating the effectiveness of ACEIs/ARBs and EBBBs in this population, whether or not improvements in prescribing are warranted remains unknown.
Background:
Cognitive impairment and dementia are associated with a range of cardiovascular conditions including hypertension, coronary artery disease and atrial fibrillation. We aimed to describe the association with heart failure, summarising published data to give estimates around prevalence, incidence and relative risk of cognitive impairment/dementia in heart failure.
Methods:
We searched multidisciplinary databases including MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO), PsychINFO (EBSCO), Web of Science (Thomson Reuters) and CENTRAL (Cochrane Library) from inception until 31(st) May 2015. All relevant studies looking at cognitive impairment/dementia in heart failure were included. Studies were selected by two independent reviewers using pre-specified inclusion/exclusion criteria. Where data allowed we performed meta-analysis and pooled results using random effects models.
Results:
From 18,000 titles 37 studies were eligible (n=8411 participants). Data from 4 prospective cohorts (n= 2513 participants) suggest greater cognitive decline in heart failure compared to non-heart failure over the longer term. These data were not suitable for meta-analysis. In case-control studies describing those with and without heart failure (n=4 papers, 1414 participants) the odds ratio for cognitive impairment in the heart failure population was 1.67 (95% confidence interval 1.15 -2.42). Prevalence of cognitive impairment in heart failure cohorts (n=26 studies, 4176 participants) was 43% (95% confidence interval 30-55%).
Conclusions:
This review suggests a substantial proportion of patients with heart failure have concomitant cognitive problems. This has implications for planning treatment and services. These data do not allow us to comment on causation and further work is needed to describe the underlying pathophysiology.