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Lan H, Hawkins LA, Kashner M, Perez E, Firek CJ, Silvet H. Cognitive impairment predicts mortality in outpatient veterans with heart failure. Heart Lung 2018; 47:546-552. [PMID: 30143364 DOI: 10.1016/j.hrtlng.2018.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 06/12/2018] [Accepted: 06/14/2018] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Howard Lan
- Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354, USA; VA Loma Linda Healthcare System, 11201 Benton St, Loma Linda, CA 92357, USA.
| | - Lee Ann Hawkins
- Indiana Wesleyan University, 4201 S Washington St, Marion, IN 46953, USA.
| | - Michael Kashner
- VA Loma Linda Healthcare System, 11201 Benton St, Loma Linda, CA 92357, USA.
| | - Elena Perez
- VA Loma Linda Healthcare System, 11201 Benton St, Loma Linda, CA 92357, USA.
| | - Christopher J Firek
- VA Loma Linda Healthcare System, 11201 Benton St, Loma Linda, CA 92357, USA.
| | - Helme Silvet
- VA Loma Linda Healthcare System, 11201 Benton St, Loma Linda, CA 92357, USA.
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Abstract
BACKGROUND Cognitive impairment is prevalent in heart failure (HF) with severe consequences, including increased risk of mortality and reduced ability to self-manage HF symptoms. Identifying cognitive impairment through screening would assist clinicians in managing HF and comorbid cognitive impairment. However, the accuracy of cognitive screening instruments for HF has not been adequately determined. OBJECTIVE The aim of this study was to determine the diagnostic accuracy of cognitive screening instruments in screening for mild cognitive impairment (MCI) in HF patients. METHODS A systematic review of major electronic bibliographic databases was searched from January 1999 to June 2013. Inclusion criteria were as follows: primary studies examining cognitive impairment in HF, administration of a cognitive screening instrument and neuropsychological test battery, and cognitive impairment indicated by performance on neuropsychological tests 1.5 SDs less than that of normative data. Methodological rigor of included publications was evaluated using 2 bias risk instruments: QUality Assessment of Diagnostic Accuracy Studies and STAndards for the Reporting of Diagnostic accuracy studies. The precision, accuracy, and receiver operating characteristic curves of the Mini Mental State Examination were computed. RESULTS From 593 citations identified, 8 publications met inclusion criteria. Risk of bias included selective HF patient samples, and no study examined the diagnostic test accuracy of the cognitive screening instruments. The Mini Mental State Examination had low sensitivity (26%) and high specificity (95%) with a score of 28 or less as the optimal threshold for MCI screening. CONCLUSIONS Screening for cognitive impairment in HF is recommended; however, future studies need to establish the diagnostic accuracy of screening instruments of MCI in this population.
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Albabtain M, Brenner MJ, Nicklas JM, Hummel SL, McCormick MP, Pawlowski JL, Remington TL, Gure TR, Dorsch MP, Bleske BE. Hyponatremia, Cognitive Function, and Mobility in an Outpatient Heart Failure Population. Med Sci Monit 2016; 22:4978-4985. [PMID: 27988787 PMCID: PMC5193121 DOI: 10.12659/msm.898538] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background The association of hyponatremia with cognitive impairment and mobility in heart failure (HF) patients is unknown. The purpose of this study was to determine if hyponatremia is associated with cognitive and mobility impairment as measured by simple, validated, and time-sensitive tests. Material/Methods This was a prospective study in patients with reduced and preserved ejection fraction (HFrEF, HFpEF) seen in outpatient HF clinics. Hyponatremia was defined as sodium level ≤136 mEq/L. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA) tool, and mobility was measured with the Timed Up and Go test (TUG-t). Results A total of 121 patients were evaluated; 30% were hyponatremic (134±1.9 mEq/l, range 128–136 mEq/l). Overall, 92% of hyponatremic patients had cognitive impairment (MoCA <26) compared to 76% of the non-hyponatremic patients [relative risk 1.2 (confidence interval: 1.02–1.4, p=0.02)]. In regard to mobility, 72% of hyponatremic patients and 62% of non-hyponatremic patients (p=0.4) had TUG-t times that were considered to be worse than average. A total of 84% (N=76) of HFrEF and 71% (N=22) of HFpEF patients had cognitive impairment (p=0.86). HFrEF patients had significantly lower overall MoCA scores (21.2±3.7 vs. 23.3±3.6, p=0.006) and similar TUG-t times compared to HFpEF patients. Conclusions Most heart failure patients (HFrEF and HFpEF) seen in an ambulatory setting had impairment of cognitive function and mobility, with a higher prevalence among those with hyponatremia. Screening can be done using tests that can be administered in a clinical setting.
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Affiliation(s)
- Monirah Albabtain
- Department of Pharmacy, Prince Sultan Military Medical City, Riyad, Saudi Arabia
| | | | - John M Nicklas
- Division of Cardiology, University of Michigan Health Systems, Ann Arbor, MI, USA
| | - Scott L Hummel
- Division of Cardiology, University of Michigan Health Systems, Ann Arbor, MI, USA
| | | | | | - Tami L Remington
- College of Pharmacy and Health System, University of Michigan, Ann Arbor, MI, USA
| | | | - Michael P Dorsch
- College of Pharmacy and Health System, University of Michigan, Ann Arbor, MI, USA
| | - Barry E Bleske
- College of Pharmacy, University of New Mexico, Albuquerque, NM, USA
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4
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Shakib S, Clark RA. Heart Failure Pharmacotherapy and Supports in the Elderly - A Short Review. Curr Cardiol Rev 2016; 12:180-5. [PMID: 27338867 PMCID: PMC5011195 DOI: 10.2174/1573403x12666160622102802] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 12/18/2015] [Accepted: 01/11/2016] [Indexed: 12/22/2022] Open
Abstract
Heart failure is predominantly a disease of the elderly with an increasing prevalence with increasing age. Increasing age is also associated with increased multi-morbidity such that elderly heart failure patients typically have five to six comorbidities in addition to heart failure. Elderly patients are also more likely to have heart failure with preserved ejection fraction (HFpEF), and there are fewer evidence-based treatments with proven efficacy in HFpEF. Hence the management of heart failure in these patients is largely about managing the symptoms of heart failure, along with the other cardiovascular and non-cardiovascular comorbidities. Any proposed treatments need to be considered for the potential for reduced benefit due to the competing risk of morbidity and mortality from the patient’s other conditions. In patients with heart failure, health related quality of life is impacted by both comorbidities and frailty, and frailty is associated with an increased risk of emergency department visits and hospitalisation. Frailty may also be associated with increased adverse reactions to medications. Although newer guidelines have more information on the management of these comorbidities there are still many areas of uncertainty and potential treatment conflicts. Further research is required on the interactions between different comorbidities, their treatments and heart failure and its management.
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Affiliation(s)
- Sepehr Shakib
- Department of Clinical Pharmacology, Mail Delivery Point 22, Royal Adelaide Hospital, North Terrace, ADELAIDE, South Australia, 5005.
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5
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González-Moneo MJ, Sánchez-Benavides G, Verdu-Rotellar JM, Cladellas M, Bruguera J, Quiñones-Ubeda S, Enjuanes C, Peña-Casanova J, Comín-Colet J. Ischemic aetiology, self-reported frailty, and gender with respect to cognitive impairment in chronic heart failure patients. BMC Cardiovasc Disord 2016; 16:163. [PMID: 27577747 PMCID: PMC5006572 DOI: 10.1186/s12872-016-0349-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 08/19/2016] [Indexed: 11/10/2022] Open
Abstract
Background Decisive information on the parameters involved in cognitive impairment in patients with chronic heart failure is as yet lacking. Our aim was to determine the functional and psychosocial variables related with cognitive impairment using the mini-mental-state examination (MMSE) with age-and education-corrected scores. Methods A cohort study of chronic heart failure patients included in an integrated multidisciplinary hospital/primary care program. The MMSE (corrected for age and education in the Spanish population) was administered at enrolment in the program. Analyses were performed in 525 patients. Demographic and clinical variables were collected. Comprehensive assessment included depression (Yesavage), family function (family APGAR), social network (Duke), dependence (Barthel Index), frailty (Barber), and comorbidities. Univariate and multivariate logistic regression were performed to determine the predictors of cognitive impairment. Results Cognitive impairment affected 145 patients (27.6 %). Explanatory factors were gender (OR: 2.77 (1.75–4.39) p < 0.001), ischemic etiology (OR: 1.99 (1.25–3.17) p = 0.004), frailty (OR: 1.58 (0.99 to 2.50, p =0.050), albumin > 3.5 (OR: 0.59 (0.35–0.99) p = 0.048), and beta-blocker treatment (OR: 0.36 (0.17 to 0.76, p = 0.007)). No association was found between cognitive impairment and social support or family function. Conclusion The observed prevalence of cognitive impairment using MMSE corrected scores was 27.6 %. A global approach in the management of these patients is needed, especially focusing on women and patients with frailty, low albumin levels, and ischemic aetiology heart failure.
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Affiliation(s)
- María J González-Moneo
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Grup de recerca biomedica en malalties del cor GREC (Heart Diseases Biomedical Research Group), IMIM (Hospital del Mar Medical Research Institute), 88, Doctor Aiguader, 08003, Barcelona, Spain.,San Martin Primary Care Center, Barcelona, Spain.,Jordi Gol University Institute for Research Primary Healthcare, Barcelona, Spain
| | - Gonzalo Sánchez-Benavides
- Neurofunctionality of Brain and Language Group, Neurosciences Research Programme, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - José M Verdu-Rotellar
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Grup de recerca biomedica en malalties del cor GREC (Heart Diseases Biomedical Research Group), IMIM (Hospital del Mar Medical Research Institute), 88, Doctor Aiguader, 08003, Barcelona, Spain.,San Martin Primary Care Center, Barcelona, Spain.,Jordi Gol University Institute for Research Primary Healthcare, Barcelona, Spain
| | - Mercé Cladellas
- Grup de recerca biomedica en malalties del cor GREC (Heart Diseases Biomedical Research Group), IMIM (Hospital del Mar Medical Research Institute), 88, Doctor Aiguader, 08003, Barcelona, Spain
| | - Jordi Bruguera
- Grup de recerca biomedica en malalties del cor GREC (Heart Diseases Biomedical Research Group), IMIM (Hospital del Mar Medical Research Institute), 88, Doctor Aiguader, 08003, Barcelona, Spain
| | - Sonia Quiñones-Ubeda
- Neurofunctionality of Brain and Language Group, Neurosciences Research Programme, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Cristina Enjuanes
- Grup de recerca biomedica en malalties del cor GREC (Heart Diseases Biomedical Research Group), IMIM (Hospital del Mar Medical Research Institute), 88, Doctor Aiguader, 08003, Barcelona, Spain
| | - Jordi Peña-Casanova
- Neurofunctionality of Brain and Language Group, Neurosciences Research Programme, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Josep Comín-Colet
- Grup de recerca biomedica en malalties del cor GREC (Heart Diseases Biomedical Research Group), IMIM (Hospital del Mar Medical Research Institute), 88, Doctor Aiguader, 08003, Barcelona, Spain.
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Yang H, Niu W, Zang X, Lin M, Zhao Y. The association between atrial fibrillation and cognitive function in patients with heart failure. Eur J Cardiovasc Nurs 2016; 16:104-112. [PMID: 27036954 DOI: 10.1177/1474515116641299] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is associated with cognitive impairment in heart failure (HF). AIMS The purpose of this study was to examine whether AF independently predicted cognitive function in HF patients after controlling for more demographic, medical and psychological characteristics, and whether the timing of AF onset in relation to HF diagnosis independently contributed to cognitive function in HF patients with AF. METHODS A total of 188 hospitalized HF patients (62.8% male, age 66.3±10.6 years) completed cognitive function assessment with the Montreal Cognitive Assessment (MoCA). A history of AF, along with other medical characteristics, was ascertained through a review of participants' medical charts. The timing of AF onset in relation to HF diagnosis was categorized into AF occurring prior to HF diagnosis (i.e. prior AF) and AF developing after HF diagnosis (i.e. incident AF). RESULTS Altogether 72 participants had a positive diagnostic history of AF. Specifically, 41 had prior AF, and 31 developed AF subsequently. In HF patients, AF was associated with poorer performance on cognitive function after controlling for more confounders (β=-0.112, ΔR2=0.010, p=0.046). Among HF patients with AF, incident AF independently predicted poorer cognitive function (β=-0.238, ΔR2=0.027, p=0.047). CONCLUSION AF independently contributes to cognitive function in HF patients after adjusting for more confounding variables. The timing of AF onset in relation to HF diagnosis independently predicts cognitive function in HF patients with AF. Prospective studies are needed to elucidate possible mechanisms for the association between AF and cognitive function in HF populations.
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Affiliation(s)
- Huifeng Yang
- 1 School of Nursing, Tianjin Medical University, China
| | - Weihua Niu
- 2 Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, China
| | - Xiaoying Zang
- 1 School of Nursing, Tianjin Medical University, China
| | - Mei Lin
- 3 Department of Nursing, General Hospital of Tianjin Medical University, China
| | - Yue Zhao
- 1 School of Nursing, Tianjin Medical University, China
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Wood NI, Sawiak SJ, Buonincontri G, Niu Y, Kane AD, Carpenter TA, Giussani DA, Morton AJ. Direct evidence of progressive cardiac dysfunction in a transgenic mouse model of Huntington's disease. J Huntingtons Dis 2016; 1:57-64. [PMID: 24339845 DOI: 10.3233/jhd-2012-120004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
HD is a progressive genetic neurological disorder, characterized by motor as well as cognitive impairments. The gene carrying the mutation causing Huntington's disease (HD) is not brain specific, and there is increasing evidence for peripheral, as well as brain pathology in this disorder. Here, we used in vivo and ex vivo techniques to assess the cardiac function of mice transgenic for the HD mutation. Using magnetic resonance imaging (MRI) of the beating heart, we show that abnormalities previously reported in end-stage mice are present by mid-stages of the disease. We also found abnormalities that have not been hitherto reported, including changes in cardiac efficiency and a mechanical distortion of the beating heart. Using the Langendorff preparation, we show reduced coronary blood flow, impaired myocardial contractility and reduced left ventricular developed pressure in HD mouse hearts. Together, our findings suggest that there is significant pathology of the HD mouse heart, even by mid stages of disease. Previous clinical research has demonstrated that the risk of cognitive symptoms increases markedly in patients with heart failure. R6/2 mice show significant progressive cognitive abnormalities, so we hypothesize that cardiac pathology in the R6/2 mouse may contribute, not only to their progressive decline and death, but also to their cognitive dysfunction. We suggest that closer attention should be paid to cardiovascular symptoms in HD patients.
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Affiliation(s)
- Nigel I Wood
- Department of Pharmacology, University of Cambridge, Tennis Court Road, Cambridge CB2 1PD, UNITED KINGDOM
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Cameron JD, Gallagher R, Pressler SJ, McLennan SN, Ski CF, Tofler G, Thompson DR. Sensitivity and Specificity of a Five-Minute Cognitive Screening Test in Patients With Heart Failure. J Card Fail 2016; 22:99-107. [DOI: 10.1016/j.cardfail.2015.08.343] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 08/25/2015] [Accepted: 08/28/2015] [Indexed: 11/16/2022]
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9
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Xie SS, Goldstein CM, Gathright EC, Gunstad J, Dolansky MA, Redle J, Hughes JW. Performance of the Automated Neuropsychological Assessment Metrics (ANAM) in detecting cognitive impairment in heart failure patients. Heart Lung 2015; 44:387-94. [PMID: 26354858 DOI: 10.1016/j.hrtlng.2015.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 06/21/2015] [Accepted: 07/06/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Evaluate capacity of the Automated Neuropsychological Assessment Metrics (ANAM) to detect cognitive impairment (CI) in heart failure (HF) patients. BACKGROUND CI is a key prognostic marker in HF. Though the most widely used cognitive screen in HF, the Mini-Mental State Examination (MMSE) is insufficiently sensitive. The ANAM has demonstrated sensitivity to cognitive domains affected by HF, but has not been assessed in this population. METHODS Investigators administered the ANAM and MMSE to 57 HF patients, compared against a composite model of cognitive function. RESULTS ANAM efficiency (p < .05) and accuracy scores (p < .001) successfully differentiated CI and non-CI. ANAM efficiency and accuracy scores classified 97.7% and 93.0% of non-CI patients, and 14.3% and 21.4% with CI, respectively. CONCLUSIONS The ANAM is more effective than the MMSE for detecting CI, but further research is needed to develop a more optimal cognitive screen for routine use in HF patients.
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Affiliation(s)
- Susan S Xie
- Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
| | - Carly M Goldstein
- Kent State University, Kent, OH 44242, USA; Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | | | | | - Mary A Dolansky
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH 44106, USA
| | | | - Joel W Hughes
- Kent State University, Kent, OH 44242, USA; Summa Health System, Akron, OH 44304, USA
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Management of chronic heart failure in the older population. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2015; 11:329-37. [PMID: 25593582 PMCID: PMC4292097 DOI: 10.11909/j.issn.1671-5411.2014.04.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Revised: 08/22/2014] [Accepted: 09/30/2014] [Indexed: 01/07/2023]
Abstract
Chronic heart failure (CHF) is the leading cause of hospitalization for those over the age of 65 and represents a significant clinical and economic burden. About half of hospital re-admissions are related to co-morbidities, polypharmacy and disabilities associated with CHF. Moreover, CHF also has an enormous cost in terms of poor prognosis with an average one year mortality of 33%–35%. While more than half of patients with CHF are over 75 years, most clinical trials have included younger patients with a mean age of 61 years. Inadequate data makes treatment decisions challenging for the providers. Older CHF patients are more often female, have less cardiovascular diseases and associated risk factors, but higher rates of non-cardiovascular conditions and diastolic dysfunction. The prevalence of CHF with reduced ejection fraction, ischemic heart disease, and its risk factors declines with age, whereas the prevalence of non-cardiac co-morbidities, such as chronic renal failure, dementia, anemia and malignancy increases with age. Diabetes and hypertension are among the strongest risk factors as predictors of CHF particularly among women with coronary heart disease. This review paper will focus on the specific consideration for CHF assessment in the older population. Management strategies will be reviewed, including non-pharmacologic, pharmacologic, quality care indicators, quality improvement in care transition and lastly, end-of-life issues. Palliative care should be an integral part of an interdisciplinary team approach for a comprehensive care plan over the whole disease trajectory. In addition, frailty contributes valuable prognostic insight incremental to existing risk models and assists clinicians in defining optimal care pathways for their patients.
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Lambrinou E, Protopapas A, Kalogirou F. Educational Challenges to the Health Care Professional in Heart Failure Care. Curr Heart Fail Rep 2014; 11:299-306. [DOI: 10.1007/s11897-014-0203-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Inglis SC, Conway A, Cleland JG, Clark RA. Is age a factor in the success or failure of remote monitoring in heart failure? Telemonitoring and structured telephone support in elderly heart failure patients. Eur J Cardiovasc Nurs 2014; 14:248-55. [PMID: 24681423 DOI: 10.1177/1474515114530611] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 03/14/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND There are few data regarding the effectiveness of remote monitoring for older people with heart failure. We conducted a post-hoc sub-analysis of a previously published large Cochrane systematic review and meta-analysis of relevant randomized controlled trials to determine whether structured telephone support and telemonitoring were effective in this population. METHODS A post hoc sub-analysis of a systematic review and meta-analysis that applied the Cochrane methodology was conducted. Meta-analyses of all-cause mortality, all-cause hospitalizations and heart failure-related hospitalizations were performed for studies where the mean or median age of participants was 70 or more years. RESULTS The mean or median age of participants was 70 or more years in eight of the 16 (n=2659/5613; 47%) structured telephone support studies and four of the 11 (n=894/2710; 33%) telemonitoring studies. Structured telephone support (RR 0.80; 95% CI=0.63-1.00) and telemonitoring (RR 0.56; 95% CI=0.41-0.76) interventions reduced mortality. Structured telephone support interventions reduced heart failure-related hospitalizations (RR 0.81; 95% CI=0.67-0.99). CONCLUSION Despite a systematic bias towards recruitment of individuals younger than the epidemiological average into the randomized controlled trials, older people with heart failure did benefit from structured telephone support and telemonitoring. These post-hoc sub-analysis results were similar to overall effects observed in the main meta-analysis. While further research is required to confirm these observational findings, the evidence at hand indicates that discrimination by age alone may be not be appropriate when inviting participation in a remote monitoring service for heart failure.
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Huijts M, van Oostenbrugge RJ, Duits A, Burkard T, Muzzarelli S, Maeder MT, Schindler R, Pfisterer ME, Brunner-La Rocca HP. Cognitive impairment in heart failure: results from the Trial of Intensified versus standard Medical therapy in Elderly patients with Congestive Heart Failure (TIME-CHF) randomized trial. Eur J Heart Fail 2014; 15:699-707. [DOI: 10.1093/eurjhf/hft020] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Marjolein Huijts
- Department of Neurology; Maastricht University Medical Centre (MUMC); Maastricht The Netherlands
- School for Mental Health and Neuroscience (MHeNS); Maastricht University; Maastricht The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM); Maastricht University; Maastricht The Netherlands
| | - Robert J. van Oostenbrugge
- Department of Neurology; Maastricht University Medical Centre (MUMC); Maastricht The Netherlands
- School for Mental Health and Neuroscience (MHeNS); Maastricht University; Maastricht The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM); Maastricht University; Maastricht The Netherlands
| | - Annelien Duits
- School for Mental Health and Neuroscience (MHeNS); Maastricht University; Maastricht The Netherlands
- Department of Psychiatry and Psychology, MUMC; Maastricht The Netherlands
| | - Thilo Burkard
- Department of Cardiology; University Hospital Basel; Basel Switzerland
| | - Stefano Muzzarelli
- Department of Cardiology; University Hospital Basel; Basel Switzerland
- Division of Cardiology; Fondazione Cardiocentro Ticino; Lugano Switzerland
| | - Micha T. Maeder
- Department of Cardiology; University Hospital Basel; Basel Switzerland
- Division of Cardiology; Kantonsspital St. Gallen; St. Gallen Switzerland
| | - Ruth Schindler
- Department of Cardiology; University Hospital Basel; Basel Switzerland
| | | | - Hans-Peter Brunner-La Rocca
- Cardiovascular Research Institute Maastricht (CARIM); Maastricht University; Maastricht The Netherlands
- Department of Cardiology; University Hospital Basel; Basel Switzerland
- Department of Cardiology, MUMC; Maastricht The Netherlands
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14
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Harkness K, Heckman GA, McKelvie RS. The older patient with heart failure: high risk for frailty and cognitive impairment. Expert Rev Cardiovasc Ther 2014; 10:779-95. [DOI: 10.1586/erc.12.49] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Hajduk AM, Lemon SC, McManus DD, Lessard DM, Gurwitz JH, Spencer FA, Goldberg RJ, Saczynski JS. Cognitive impairment and self-care in heart failure. Clin Epidemiol 2013; 5:407-16. [PMID: 24187511 PMCID: PMC3810196 DOI: 10.2147/clep.s44560] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Heart failure (HF) is a prevalent chronic disease in older adults that requires extensive self-care to prevent decompensation and hospitalization. Cognitive impairment may impact the ability to perform HF self-care activities. We examined the association between cognitive impairment and adherence to self-care in patients hospitalized for acute HF. Design Prospective cohort study. Setting and participants A total of 577 patients (mean age = 71 years, 44% female) hospitalized for HF at five medical centers in the United States and Canada. Measurements and methods Participants were interviewed for information on self-reported adherence to self-care using the European Heart Failure Self-care Behaviour Scale. We assessed cognitive impairment in three domains (memory, processing speed, and executive function) using standardized measures. Patients’ demographic and clinical characteristics were obtained through medical record review. Multivariable linear regression was used to examine the association between cognitive impairment and self-care practices adjusting for demographic and clinical factors. Results A total of 453 patients (79%) were impaired in at least one cognitive domain. Average adherence to self-care activities among patients with global cognitive impairment did not differ significantly from those without cognitive impairment (30.5 versus 29.6; 45-point scale). However, impaired memory was associated with lower self-care scores (P = 0.006) in multivariable models. Conclusion Cognitive impairment is highly prevalent among older patients hospitalized for HF. Memory impairment is associated with poorer adherence to self-care practices. Screening for memory impairment in patients with HF may help to identify patients at risk for poor self-care who may benefit from tailored disease management programs.
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Affiliation(s)
- Alexandra M Hajduk
- Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA ; Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA
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Gallagher R, Sullivan A, Burke R, Hales S, Gillies G, Cameron J, Saliba B, Tofler G. Mild Cognitive Impairment, Screening, and Patient Perceptions in Heart Failure Patients. J Card Fail 2013; 19:641-6. [DOI: 10.1016/j.cardfail.2013.08.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 07/25/2013] [Accepted: 08/02/2013] [Indexed: 10/26/2022]
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Cameron J, Ski CF, McLennan SN, Rendell PG, Whitbourn RJ, Thompson DR. Development of the Heart Failure Screening Tool (Heart-FaST) to measure barriers that impede engagement in self-care. Eur J Cardiovasc Nurs 2013; 13:408-17. [PMID: 23969781 DOI: 10.1177/1474515113502461] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Screening for self-care capacity is advocated before applying educational strategies. No screening tool has been specifically developed to assess barriers that impede engagement in self-care in people with heart failure. Earlier conceptual work (InCOGNITO) identified NYHA class, mild cognitive impairment and depressive symptoms as barriers that impede engagement in HF self-care. AIMS Study aims were: 1) to develop the Heart Failure Screening Tool (Heart-FaST) as a means of assessing three critical barriers to self-care; 2) to assess the content validity of the Heart-FaST; and 3) to test the feasibility of implementing the Heart-FaST in clinical practice. METHODS The Heart-FaST was developed from barriers identified in previous research (InCOGNITO) and from expert panel consensus. Content validity was assessed by examining the proportion of experts who scored each item as relevant. RESULTS The InCOGNITO study indicated that four cognitive tasks, seven emotional questions and NYHA functional class were significantly correlated with the self-care scales: maintenance, management and confidence. These factors were used to create the Heart-FaST items. Consensus on wording and items to be included in the Heart-FaST was reached after two rounds of panel discussion. All items had an item-level content validity index ≥ 0.78. High scores on each barrier (physical, cognitive and emotional functioning) suggest poor self-care and the need for more intensive disease management efforts. CONCLUSION The Heart-FaST measures three critical barriers that impede engagement in self-care. In clinical practice this tool may assist in individually tailoring educational and support strategies to promote effective heart failure self-care.
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Affiliation(s)
- Jan Cameron
- Cardiovascular Research Centre, Australian Catholic University, Melbourne, Australia
| | - Chantal F Ski
- Cardiovascular Research Centre, Australian Catholic University, Melbourne, Australia
| | - Skye N McLennan
- School of Psychology, Australian Catholic University, Melbourne, Australia
| | - Peter G Rendell
- School of Psychology, Australian Catholic University, Melbourne, Australia
| | - Robert J Whitbourn
- Cardiovascular Research Centre, Australian Catholic University, Melbourne, Australia
| | - David R Thompson
- Cardiovascular Research Centre, Australian Catholic University, Melbourne, Australia
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Dodson JA, Truong TTN, Towle VR, Kerins G, Chaudhry SI. Cognitive impairment in older adults with heart failure: prevalence, documentation, and impact on outcomes. Am J Med 2013; 126:120-6. [PMID: 23331439 PMCID: PMC3553506 DOI: 10.1016/j.amjmed.2012.05.029] [Citation(s) in RCA: 178] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 05/15/2012] [Accepted: 05/18/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND Despite the fact that 80% of patients with heart failure are aged more than 65 years, recognition of cognitive impairment by physicians in this population has received relatively little attention. The current study evaluated physician documentation (as a measure of recognition) of cognitive impairment at the time of discharge in a cohort of older adults hospitalized for heart failure. METHODS We performed a prospective cohort study of older adults hospitalized with a primary diagnosis of heart failure. Cognitive status was evaluated with the Folstein Mini-Mental State Examination at the time of hospitalization. A score of 21 to 24 was used to indicate mild cognitive impairment, and a score of ≤20 was used to indicate moderate to severe impairment. To evaluate physician documentation of cognitive impairment, we used a standardized form with a targeted keyword strategy to review hospital discharge summaries. We calculated the proportion of patients with cognitive impairment documented as such by physicians and compared characteristics between groups with and without documented cognitive impairment. We then analyzed the association of cognitive impairment and documentation of cognitive impairment with 6-month mortality or readmission using Cox proportional hazards regression. RESULTS A total of 282 patients completed the cognitive assessment. Their mean age was 80 years of age, 18.8% were nonwhite, and 53.2% were female. Cognitive impairment was present in 132 of 282 patients (46.8% overall; 25.2% mild, 21.6% moderate-severe). Among those with cognitive impairment, 30 of 132 (22.7%) were documented as such by physicians. Compared with patients whose cognitive impairment was documented by physicians, those whose impairment was not documented were younger (81.3 vs 85.2 years, P<.05) and had less severe impairment (median Mini-Mental State Examination score 22.0 vs 18.0, P<.01). After multivariable adjustment, patients whose cognitive impairment was not documented were significantly more likely to experience 6-month mortality or hospital readmission than patients without cognitive impairment. CONCLUSIONS Cognitive impairment is common in older adults hospitalized for heart failure, yet it is frequently not documented by physicians. Implementation of strategies to improve recognition and documentation of cognitive impairment may improve the care of these patients, particularly at the time of hospital discharge.
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Affiliation(s)
- John A. Dodson
- Section of Cardiology, Department of Internal Medicine Yale University School of Medicine, New Haven, CT
- Section of Geriatrics, Department of Internal Medicine Yale University School of Medicine, New Haven, CT
| | - Tuyet-Trinh N. Truong
- General Internal Medicine, Department of Internal Medicine Yale University School of Medicine, New Haven, CT
| | - Virginia R. Towle
- Section of Geriatrics, Department of Internal Medicine Yale University School of Medicine, New Haven, CT
| | - Gerard Kerins
- Section of Geriatrics, Department of Internal Medicine, Hospital of Saint Raphael, New Haven, CT
| | - Sarwat I. Chaudhry
- General Internal Medicine, Department of Internal Medicine Yale University School of Medicine, New Haven, CT
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Cameron J, Worrall-Carter L, Page K, Stewart S, Ski CF. Screening for mild cognitive impairment in patients with heart failure: Montreal cognitive assessment versus mini mental state exam. Eur J Cardiovasc Nurs 2012; 12:252-60. [PMID: 22514141 DOI: 10.1177/1474515111435606] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cognitive impairments occur frequently in patients with chronic heart failure (CHF), resulting in worse health outcomes than expected. These impairments can remain undetected unless specifically screened. There are limited sensitive screening measures available in nursing practice to identify mild cognitive impairment (MCI). AIM To compare the Montreal Cognitive Assessment (MoCA) with the Mini Mental State Exam (MMSE) in screening for MCI in CHF patients. METHODS The MMSE and MoCA were administered to 93 hospitalized CHF patients (70±11 years), without a history of neurocognitive problems. Patients with low MoCA scores (<26) were compared to those with low MMSE scores (<27). Two different parameters were examined between the MoCA and the MMSE: level of MCI agreement (Kappa coefficient) and task errors on assessed cognitive domains (χ2 test). RESULTS Statistically more patients had low MoCA scores compared with low MMSE scores (66 vs. 30, p=0.02). The MoCA classified 38 (41%) patients as cognitively impaired that were not classified by the MMSE. A significantly low level of agreement was found (κ=0.25, p=0.001) between the MMSE and MoCA in identifying patients with scores suggestive of MCI. More task errors were observed on the MoCA cognitive domains compared with the MMSE cognitive domains. In 68% of patients with low cognitive scores, visuospatial task errors were observed on tasks from the MoCA compared with 22% on a similar task of the MMSE. CONCLUSION The MoCA, a screening tool for MCI, identified subtle but potentially clinically relevant cognitive dysfunctions with greater frequency than MMSE.
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Affiliation(s)
- Jan Cameron
- Cardiovascular Research Centre, Australian Catholic University, Melbourne, Australia.
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Bauer LC, Johnson JK, Pozehl BJ. Cognition in heart failure: an overview of the concepts and their measures. ACTA ACUST UNITED AC 2012; 23:577-85. [PMID: 22023229 DOI: 10.1111/j.1745-7599.2011.00668.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE To review cognitive impairment and explore current measurement concerns faced by nurse practitioners caring for individuals with heart failure. DATA SOURCES Review of peer-reviewed research articles published on the topic. CONCLUSIONS Cognitive impairment is prevalent among individuals with heart failure. Impairment frequently involves one or more domains, including attention, memory, and executive function. No gold standard screening measure was identified from the reviewed literature. IMPLICATIONS FOR PRACTICE It is imperative that clinicians are aware of cognitive impairment and its implications for their patients with heart failure. Cognitive impairment likely contributes to multiple clinical implications, including a decreased ability to attend to and comprehend patient education materials and an inability to appropriately assess and self-manage symptoms.
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Affiliation(s)
- Lisa C Bauer
- Department of Physiological Nursing, University of California, San Francisco, California 94143, USA.
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