The clinical implications of cognitive impairment in elderly patients with chronic heart failure

Is it time for Heart-Brain clinics? A clinical survey and proposition to improve current care for cognitive problems in heart failure

BACKGROUND

Cognitive impairment is highly prevalent among patients with heart failure (HF). International guidelines on the management of HF recommend screening for cognitive impairment and tailored care for patients with cognitive impairment. However, practical guidance is lacking. In this study, we explore cardiologists' perspective on screening and care for cognitive impairment in patients with HF. We give an example of a multidisciplinary Heart-Brain care pathway that facilitates screening for cognitive impairment in patients with HF.

METHODS

We distributed an online survey to cardiologists from the Dutch working groups on Geriatric Cardiology and Heart Failure. It covered questions about current clinical practice, impact of cognitive impairment on clinical decision-making, and their knowledge and skills to recognize cognitive impairment.

RESULTS

Thirty-six out of 55 invited cardiologists responded. Only 3% performed structured cognitive screening, while 83% stated that not enough attention is paid to cognitive impairment. More than half of the cardiologists desired more training in recognizing cognitive impairment and three-quarters indicated that knowing about cognitive impairment would change their treatment plan. Eighty percent agreed that systematic cognitive screening would benefit their patients and 74% wished to implement a Heart-Brain clinic. Time and expertise were addressed as the major barriers to screening for cognitive impairment.

CONCLUSION

Although cardiologists are aware of the clinical relevance of screening for cognitive impairment in cardiology patients, such clinical conduct is not yet commonly practiced due to lack of time and expertise. The Heart-Brain care pathway could facilitate this screening, thus improving personalized care in cardiology.

Glutathione Peroxidase Activity Is Altered in Vascular Cognitive Impairment-No Dementia and Is a Potential Marker for Verbal Memory Performance

Background:

Coronary artery disease (CAD) increases risk for vascular cognitive impairment-no dementia (VCIND), a precursor to dementia, potentially through persistent oxidative stress.

Objective:

This study assessed peripheral glutathione peroxidase activity (GPX), which is protective against oxidative stress, in VCIND versus cognitively normal CAD controls (CN). GPX activity was also evaluated as a biomarker of cognition, particularly verbal memory.

Methods:

120 CAD patients with VCIND (1SD below norms on executive function or verbal memory (VM)) or without (CN) participated in exercise rehabilitation for 24 weeks. Neurocognitive and cardiopulmonary fitness (VO_2peak) assessments and plasma were collected at baseline and 24-weeks.

Results:

GPX was higher in VCIND compared to CN (F_1,119 = 3.996, p = 0.048). Higher GPX was associated with poorer baseline VM (β= –0.182, p = 0.048), and longitudinally with VM decline controlling for sex, body mass index, VO_2peak, and education (b[SE] = –0.02[0.01], p = 0.004). Only CN participants showed improved VM performance with increased fitness (b[SE] = 1.30[0.15], p < 0.005).

Conclusion:

GPX was elevated in VCIND consistent with a compensatory response to persistent oxidative stress. Increased GPX predicted poorer cognitive outcomes (verbal memory) in VCIND patients despite improved fitness.

Cognitive Function in Cardiac Patients: Exploring the Occupational Therapy Role in Lifestyle Medicine

Patients with cardiac dysfunction are at increased risk of mild cognitive impairment, which can affect their ability to successfully engage in daily activities important for home and community safety and in maintaining health and well-being. This risk increases in accordance with the number of cardiac conditions and cardiovascular risk factors or comorbidities. Occupational therapy has a role in chronic disease management in assessing and improving functional abilities affected by physical, emotional, and cognitive domains. With a holistic and client-centered approach, occupational therapy can complement lifestyle medicine principles through promotion and enablement of engagement in purposeful activity and self-management practices. It is suggested that the clinical management of patients with cardiac dysfunction expands beyond the traditional physical aspects of care to encompass cognitive considerations and incorporate occupational therapy in practice.

An Investigation of Emotion Recognition and Theory of Mind in People with Chronic Heart Failure

Objectives

Cognitive deficits are common in patients with chronic heart failure (CHF), but no study has investigated whether these deficits extend to social cognition. The present study provided the first empirical assessment of emotion recognition and theory of mind (ToM) in patients with CHF. In addition, it assessed whether each of these social cognitive constructs was associated with more general cognitive impairment.

Methods

A group comparison design was used, with 31 CHF patients compared to 38 demographically matched controls. The Ekman Faces test was used to assess emotion recognition, and the Mind in the Eyes test to measure ToM. Measures assessing global cognition, executive functions, and verbal memory were also administered.

Results

There were no differences between groups on emotion recognition or ToM. The CHF group’s performance was poorer on some executive measures, but memory was relatively preserved. In the CHF group, both emotion recognition performance and ToM ability correlated moderately with global cognition (r = .38, p = .034; r = .49, p = .005, respectively), but not with executive function or verbal memory.

Conclusion

CHF patients with lower cognitive ability were more likely to have difficulty recognizing emotions and inferring the mental states of others. Clinical implications of these findings are discussed.

Performance of the Automated Neuropsychological Assessment Metrics (ANAM) in detecting cognitive impairment in heart failure patients

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.

Cognitive impairment in heart failure patients

Cognitive damage in heart failure (HF) involves different domains thus interfering with the ability for single patient to self-care and to cope with treatment regimens, modifying symptoms and health behaviours. Many cerebral and functional changes were detected in brain imaging, involving areas of both grey and white matter deputed to cognition. Although various instruments are available to explore cognition, no consensus was obtained on better tools to be used in HF population. Reduction in cerebral blood flow, decreased cardiac output, alterations of cerebrovascular reactivity and modification of blood pressure levels are the main features involved in the etiopathogenetic mechanisms of cognitive deficit. Several cardiac variables, laboratory parameters, demographic and clinical elements were studied for their possible relation with cognition and should be properly evaluated to define patients at increased risk of impairment. The present review gathers available data pointing out assured information and discussing possible areas of research development.

Cognitive impairment and cardiovascular diseases in the elderly. A heart-brain continuum hypothesis

The aging population is increasing and, therefore, a higher prevalence of cardiac disease is emerging; including hypertension, coronary artery disease, atrial fibrillation and chronic heart failure. Large cohort studies have revealed a relationship among increased risk for cognitive impairment and dementia in cardiovascular diseases probably due to embolic stroke or chronic cerebral hypoperfusion. Thus, the aim of the present review is to overview the studies that investigate the presence and/or the development of cognitive impairments and dementia in patients with varied types of cardiovascular disease. Finally, a continuum among hypertension, coronary artery disease, atrial fibrillation and chronic heart failure with to the development of cognitive impairment and progression to dementia has been hypothesized.

The journey of the frail older adult with heart failure: implications for management and health care systems

The heart failure epidemic predominantly affects older people, particularly those with concurrent co-morbid conditions and geriatric syndromes. Mortality and heath service utilization associated with heart failure are significant, and extend beyond the costs associated with acute care utilization. Over time, older people with heart failure experience a journey characterized by gradual functional decline, accelerated by unpredictable disease exacerbations, requiring greater support to remain in the community, and often ultimately leading to institutionalization. In this narrative review, we posit that the rate of functional decline and associated health care resource utilization can be attenuated by optimizing the management of heart failure and associated co-morbidities. However, to realize this objective, the manner in which care is delivered to frail older people with heart failure must be restructured, from the bedside to the level of the health care system, in order to optimally anticipate, diagnose and manage co-morbidities.

Medication management of chronic heart failure in older adults

Heart failure (HF) is a common problem in older adults. Individuals aged 65 years or older are at a higher risk for developing HF, especially diastolic HF or HF with preserved ejection fraction (HFpEF). HF can be seen in up to 20 % of adults aged 85 years or older. In contrast to middle-aged (40-64 years) HF patients, multiple cardiac, non-cardiac and geriatric syndrome co-morbidities are seen in elderly HF patients. Additionally, age-related changes in pharmacokinetics and pharmacodynamics influence medication therapy. Hence, the management of older patients with HF is challenging and treatment should be modified in the light of the above-mentioned conditions. This article discusses the current evidence for medication management in both systolic HF or HF with reduced ejection fraction (HFrEF) and HFpEF, noting, however, the limited data for HFpEF and HFrEF in those 80 years of age or older. The objective of this article is to discuss evidence-based and outcomes-driven pharmacologic management strategies for chronic HF in the older adults for whom functional and other patient-centered outcomes might be more than or as important as clinical outcomes. Optimal management would be expected to help to reduce illness burden, reduce mortality and hospitalizations, and improve function and quality of life.

Effects of Cognitive Speed of Processing Training Among Older Adults With Heart Failure

OBJECTIVE

Cognitive deficits pose serious problems for older adults with heart failure (HF). Cognitive speed of processing training improves cognition among older adults but has not been examined among older adults with HF.

METHOD

Data from the ACTIVE study were used to examine the effects of cognitive speed of processing training on cognitive and functional performance among older adults with HF.

RESULTS

Of the 54 participants included in the analyses, 23 who were randomized to cognitive training performed significantly better on a composite of everyday speed of processing from pre- to post-training compared with 31 participants who were randomized to the control group, F(1, 51) = 28.67, p ≤ .001, [Formula: see text] = .360.

DISCUSSION

Results indicate that speed of processing training may improve everyday cognitive performance among older adults with HF. Future studies should investigate the longitudinal effects of cognitive training with HF patients.

Cognitive impairment in older adults with heart failure: prevalence, documentation, and impact on outcomes

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.

Chronic Ischemic Heart Disease Affects Health Related Quality of Life

Background

Chronic diseases endanger not only physical health but also psychological and social health of patient. Thus, evaluation of such patients for psychological treatment decisions is very important.

Method

This is a descriptive study that was performed with 50 chronic patients (ischemic heart disease) selected from Valiasr and Mousavi at cardiac wards in Zanjan Province. They were given three types of questionnaire: demographic, WHOQOL, and Zung depression and anxiety index. The information was statically analyzed by frequency chart, central indexes, dispersion, Chi-Square and t tests, Pearson’s correlation index (P < 0.05).

Results

The average of quality of life in all patients were calculated as was respectively 12.19, 11.98, 12.08, and 12.4 in physical, psychological, social and environmental domains respectively, 68 percent of total number of the patients had various degrees of anxiety and 78 percent of them had various degrees of depression. There was a significant relationship between the life quality average in all domains and anxiety intensity and depression intensity (P < 0.05) and there was a significant relationship between life quality average in all domains and income (P < 0.05).

Conclusion

As the level of depression and anxiety goes up, quality of life decreases pointing out that they have a reverse relationship. Depression and anxiety are one of the most significant factors of quality of life among other variables. Regarding specific conditions of the treatment, it is necessary to pay special attention to psychological aspects.

Geriatric conditions in heart failure

As the U.S. population ages, the prevalence of geriatric conditions in patients with heart failure is increasing, although they currently fall outside the traditional heart failure disease model. In this review, we describe the co-occurrence of four common geriatric conditions (cognitive impairment, frailty, falls, and incontinence) in older adults with heart failure, their mechanisms of interaction, and their association with outcomes. We propose a new paradigm to meet the needs of the aging heart failure population that includes comprehensive assessment of geriatric conditions and tailoring of therapy and surveillance accordingly. Coordination among relevant disciplines such as cardiology and geriatrics may facilitate this transition. Further research is needed in order to understand how to optimize care for patients with specific impairments in order to improve outcomes.

Cognitive impairment in heart failure

Cognitive impairment (CI) is increasingly recognized as a common adverse consequence of heart failure (HF). Although the exact mechanisms remain unclear, microembolism, chronic or intermittent cerebral hypoperfusion, and/or impaired cerebral vessel reactivity that lead to cerebral hypoxia and ischemic brain damage seem to underlie the development of CI in HF. Cognitive decline in HF is characterized by deficits in one or more cognition domains, including attention, memory, executive function, and psychomotor speed. These deficits may affect patients' decision-making capacity and interfere with their ability to comply with treatment requirements, recognize and self-manage disease worsening symptoms. CI may have fluctuations in severity over time, improve with effective HF treatment or progress to dementia. CI is independently associated with disability, mortality, and decreased quality of life of HF patients. It is essential therefore for health professionals in their routine evaluations of HF patients to become familiar with assessment of cognitive performance using standardized screening instruments. Future studies should focus on elucidating the mechanisms that underlie CI in HF and establishing preventive strategies and treatment approaches.

Measurement of cognitive function in chronic heart failure: a feasibility study

Assessment of cognition is critical to providing optimal care to individuals with heart failure. Traditional neuropsychological batteries are time consuming. This pilot study obtained feasibility data for a brief neuropsychological battery. Mean administration time was 40 ± 7.5 minutes, averting subject fatigue, and the battery was sensitive to cognitive impairments.

Automated weight monitoring in chronic heart failure: the excluded majority

We interviewed nurses and patients with heart failure who were participating in a research trial of home telemonitoring in which weight data were monitored automatically by a call centre. A total of 35 interviews were conducted and the transcripts were analysed thematically. The results indicated that nurses disagreed about the role of weight monitoring and the practicalities of telemonitoring in their daily practice, indicating that the process was idiosyncratic to each user. The lack of personal feedback and nursing contact discouraged patients from weight monitoring, suggesting that a feedback mechanism may have to be adapted to suit patients. There were other factors which created barriers to acceptance by patients and staff. Home telemonitoring for heart failure cannot be evaluated effectively using the standard approach commonly employed. New studies are required.

Association of diagnosis of ischaemic heart disease, diabetes mellitus and heart failure with cognitive function in the elderly population

OBJECTIVE

The aim of this study was to describe the association between ischaemic heart disease (IHD), diabetes mellitus (DM) and heart failure (HF) and the prevalence of cognitive impairment.

METHODS

In a cross-sectional, community-based study in Karlskrona, Sweden, 1402 participants of the Swedish National Study on Ageing and Care (60-96 y) underwent a medical examination and psychological testing including the Mini Mental State Examination (MMSE). Of these, 58% stated that they were treated for hypertension, IHD, DM or HF, or had ECG abnormalities (positive screen).

RESULTS

The prevalence of cognitive impairment (MMSE score < 24) in patients treated for IHD, DM or HF was 28.5% compared to 16.1% in the population with a negative screen without cardiovascular disease or DM. After stratification by age, the difference was seen to be due to a higher prevalence of cognitive impairment in the age group 70-79 y, where 68.8% of the cognitively impaired came from the group treated for IHD, DM or HF. The odds ratio for cognitive impairment in this age group was 4.4 (95% CI 1.7-11.4), when compared to those with a negative screen as baseline.

CONCLUSION

This study has shown that the patient group treated for IHD, DM or HF has a higher prevalence of cognitive impairment and a higher risk of developing early cognitive impairment between the ages of 70 and 79 y. Although this study has not provided conclusive evidence that cardiovascular disease and DM are associated with the early development of cognitive impairment, it provides incentive for further studies.

Características clínicas e psicossociais do paciente com insuficiência cardíaca que interna por descompensação clínica

Este estudo teve como objetivo identificar perfil sociodemográfico e clínico, história de hospitalizações por Insuficiência Cardíaca (IC) e seguimento (consultas regulares, tratamento medicamentoso, fatores facilitadores e dificultadores do seguimento) do paciente internado por quadro de descompensação clínica. Foram entrevistados 61 pacientes com idade média de 58,1 (± 15,9) anos, 3,5 (± 4,4) anos de estudo e renda individual de 1,3 (± 2,4) salários-mínimos. A maioria dos sujeitos se encontrava em classe funcional III ou IV da New York Heart Association, tendo como causa mais freqüente de hospitalização, os sinais/sintomas da forma congestiva da IC. 75,4% dos sujeitos relataram acompanhamento clínico, porém de periodicidade irregular. Constatou-se utilização de terapêutica medicamentosa em proporção inferior à recomendada pela literatura. Os achados devem auxiliar a identificação dos pacientes com maior risco de descompensação da IC e assim, desenhar e implementar intervenções específicas visando a redução das re-hospitalizações por IC.

The prevalence and impact of anergia (lack of energy) in subjects with heart failure and its associations with actigraphy

BACKGROUND

Anergia (lack of energy) is a newly delineated, criterion-based geriatric syndrome. Because heart failure (HF) is a common chronic condition among older adults and a because a cardinal symptom of HF is reduced energy, we characterized the degree of anergia in subjects with HF and evaluated its relevance to disease severity, functional performance, and quality of life.

METHODS AND RESULTS

Prospective 3-month cohort study among a convenience sample of 61 subjects (61 +/- 15 years, 48% women, ejection fraction 41 +/- 16%) with New York Heart Association (NYHA) Class I-III HF were studied. The criterion for anergia was based on the major criterion "sits around for lack of energy" and any 2 of 6 minor criteria. Principal measures in addition to demographic and clinical characteristics included functional performance (NYHA class, 6-minute walk, cardiopulmonary exercise testing), plasma B-type natriuretic peptide, and quality of life (SF-12 and Minnesota Living with Heart Failure Questionnaire). To evaluate the relevance of anergia to daily function, each subject wore an Actigraph, a watch-like wrist device that continuously and automatically monitors patient activity levels and energy expenditure, for 3 months. Anergia was prevalent in 39% of this population. Anergia was associated with decrements in functional capacity (higher NYHA Class and lower 6-minute walk distance) as well as reduction in quality of life, but was not associated with ejection fraction. Actigraphy data demonstrated that HF subjects with anergia spent significantly less time performing moderate physical activity and the peak activity counts per day were significantly lower than HF subjects without anergia. Additionally, the amplitude of circadian rhythm was lower, suggesting altered sleep and activity patterns in HF subjects with anergia compared with those without anergia. Over the 3 months of follow-up, there was a significant association between anergia and intercurrent hospitalization.

CONCLUSIONS

Anergia is significantly associated with several of the cardinal domains of HF. Its presence is associated with demonstrable differences in both physical activity and circadian rhythm as measured by actigraphy and an increased risk of hospitalizations. Accordingly, anergia may be a target for intervention among HF subjects.

Patient education in heart failure

The preparation of chronically ill patients for self-care has traditionally rested on the assumption that patients require certain knowledge and skills. A review of the literature on the subject of patient education in heart failure suggests that although teaching patients about the care of a chronic condition is necessary, it may be more effective if supplemented by continuing reinforcement, symptom monitoring, and behavioral reinforcement by an interdisciplinary team. Nurses have an opportunity and a responsibility to dissect and test the teaching-learning process in heart failure. Evidence that builds on what is already known about patient education will allow nurses to construct protocols that can be adopted as standards of practice and included in electronic health records.

Unraveling the mechanisms for heart failure patients' beliefs about compliance

BACKGROUND

Compliance with medication, diet, and monitoring symptoms is a problem in heart failure (HF) patients. Noncompliance can lead to worsening symptoms and is associated with personal beliefs about compliance. To intervene effectively, knowledge of factors related to patients' beliefs about compliance is needed.

OBJECTIVES

The aims of this study are to: (1) gain insight into patients' beliefs about compliance; (2) examine the association of demographic variables and depressive symptoms to beliefs; (3) assess compliance with medication, diet, and daily weighing; and (4) examine the association of compliance to patients' beliefs.

METHODS

Nine hundred fifty-four HF patients completed questionnaires on beliefs about medication and diet; 297 patients also completed a questionnaire on beliefs about symptom monitoring. Most important barriers and benefits were assessed as well as differences in beliefs between subgroups and the association between compliance and beliefs.

RESULTS

The most important barriers were diuresis during the night (57%), the taste of food (51%), and limited ability to go out (33%). A barrier related to failure to weigh daily was forgetfulness (26%). Patients with depressive symptoms and patients with a low level of HF knowledge experienced more barriers to compliance with the HF regimen. Self-reported compliance with medication was almost 99%, compliance with diet 77%, and with daily weighing 33%.

CONCLUSIONS AND IMPLICATIONS

In order to improve compliance, it is important that interventions should be directed to those patients who experience more barriers to compliance, such as patients with depressive symptoms and patients with a low level of knowledge on the HF regimen. Improvement of knowledge, therefore, will remain an important issue in HF management programs.

Symptoms of dysautonomia, sleep disturbance, and abnormal cognition in pediatric heart failure

Sleep disorders, autonomic dysfunction, and abnormal cognition are important comorbidities in adult patients with heart failure and are associated with disease progression, morbidity, and mortality. The clinical incidence of these conditions is unknown in children with heart failure. We sought to determine the incidence of symptoms that may be attributable to autonomic dysfunction among children with dilated cardiomyopathy and heart failure. We performed a retrospective chart review of patients with dilated cardiomyopathy seen at our institution between 1999 and 2005. We reviewed charts for symptoms of dysautonomia, sleep problems, or abnormal cognition. From the records of 204 pediatric patients, we identified 69 patients aged 7-18 years with severe dilated cardiomyopathy. Of these, 55 (80%) had symptoms attributable to dysautonomia, 20 (29%) had evidence of sleep disturbance, and 3 (4%) had abnormal cognition. Dysautonomia and sleep disturbances are prevalent in children with heart failure, congruent with studies of adult patients. Based on our data, it is not possible to draw conclusions about any cognitive deficits in this population. Because relatively few subjects' charts explored symptoms of sleep disturbance, we speculate that sleep symptoms may be underappreciated.

Cognitive impairment in heart failure: a systematic review of the literature

BACKGROUND

Heart failure (HF) and cognitive impairment are common medical conditions that are becoming increasingly prevalent in the aging Western population. They are associated with frequent hospitalisation and increased mortality, particularly when they occur simultaneously. Evidence from a number of studies suggests that HF is independently associated with impairment in various cognitive domains.

AIMS

This systematic literature review evaluates the relation between cognitive deterioration and heart failure.

METHODS

We searched electronic databases from 1966 to May 2006 for studies that investigated cognitive function in HF patients. Twenty-two controlled studies that met the inclusion criteria were selected for analysis. Study characteristics and data on global cognitive performance, memory scores, psychomotor speed and depression scores were extracted and analysed using the Cochrane Review Manager software.

RESULTS

Pooled analysis shows diminished neuropsychological performance in HF patients, as compared to control subjects. In a pooled sample of 2937 heart-failure patients and 14,848 control subjects, the odds ratio for cognitive impairment was 1.62 (95% confidence interval:1.48-1.79, p<0.0001) among subjects with HF.

CONCLUSION

This review confirms the relationship between HF and cognitive impairment, but it also stresses the need for additional systematic neuropsychological data and adequate neuro-imaging from representative populations of HF patients.

Congestive heart failure and Alzheimer's disease

The increase in average life expectancy is resulting in an increasing prevalence of major invalidating illnesses, such as cardiovascular disease and dementia. Congestive heart failure (CHF) is a chronic, progressive disease representing the advanced stage of cardiac illnesses. Cognitive impairment is known to be a frequent feature of CHF patients. The epidemiologic pictures of mild cognitive impairment (MCI), Alzheimer's disease (AD) and CHF are predicted to worsen with the demographic expansion of the elderly population. Nevertheless, there has been little structured research on cognitive impairment in patients with CHF. This is unfortunate not only because CHF is the leading cause of hospitalization in the elderly and a leading cause of disability and death, but also for important clinical and socioeconomic implications including those related to comorbidity in advanced age and the need to early detect factors which may precipitate the conversion of MCI to AD. In this review, several aspects of the role of CHF in cognitive impairment are evaluated. Owing to the lack of studies focusing on CHF in AD, the pathophysiology of cardiac failure in cognitive impairment is addressed in light of possible preventive strategies against the onset of AD. These include prevention of oxygen radical and peroxynitrite production, supplementation of nitric oxide (NO) donors, as well as the achievement of an adequate antioxidant supply, better if obtained with a targeted and individualized nutritional approach. A systematic neuropsychologic testing of older patients with heart failure is to identify those with early cognitive impairment and promptly establish traditional therapies such as angiotensin converting enzyme (ACE) inhibitors, digoxin or beta-blockers. The neuropsychologic assessment in CHF patients is also fundamental to disclose conditions potentially favoring the onset of cognitive impairment such as depression. Finally, management schemes should include exercise training programs as well as patient and caregiver education.

Cognitive impairment in heart failure

Heart failure is reaching epidemic proportions in the United States, causing a constellation of disabling symptoms. Cognitive impairment in people with heart failure may be more common than previously known with multiple etiologies from both the disease process and the treatment. Exemplars from a research study are used to illustrate the perspective of heart failure patients. Given the critical importance of memory deficits on patient education, potential nursing interventions to address the issue of cognitive impairment are described.

Concordance between elderly patients' understanding of and their primary healthcare physician's diagnosis of heart failure

OBJECTIVE

The objective was to study primary healthcare patients' understanding of their diagnosis of heart failure (HF), using patients treated for diabetes mellitus (DM) as a comparative group.

DESIGN

A cross-sectional community based study.

SETTING

Karlskrona community situated on the Swedish south-east coast with 60,600 inhabitants.

SUBJECTS

A total of 1402 subjects, aged 60-96 years in 10 age cohorts, selected randomly from the national population registry participating in the Swedish National study on Ageing and Care - Blekinge.

MAIN OUTCOME MEASURES

Understanding of diagnosis of HF or DM in primary healthcare. Prevalence of cognitive impairment.

RESULTS

In all, 39.8% of patients with a diagnosis of HF treated in primary healthcare and 97.1% of patients with DM had an understanding of their respective diagnosis. Cognitive impairment was significantly more prevalent in the groups of patients treated for HF (OR 1.9, 95% CI 1.2 to 3.0) and DM (OR 1.8, 95% CI 1.1 to 3.1), when compared with those not treated for either HF or DM. The odds ratio for understanding of diagnosis was 0.013 (95% CI 0.003 to 0.052, p < 0.001) in patients treated for HF, compared with patients treated for DM, when adjusted for the subject's age, sex, and cognitive function.

CONCLUSION

In this study it was shown that patients' understanding of their diagnosis was highly dependent on diagnosis, independently of age, sex, or cognitive function. The results suggest that there is room for improvement of care in primary healthcare, to increase HF patients' understanding of their diagnosis.

Prognostic importance of cognitive impairment in chronic heart failure patients: does specialist management make a difference?

BACKGROUND

Cognitive impairment is common among chronic heart failure (CHF) patients.

AIMS

To determine the prognostic significance of cognitive impairment in patients participating in a randomized study of a CHF management program (CHF-MP).

METHODS

CHF patients were randomized to a CHF-MP (n=100) or usual care (n=100). Baseline cognition was assessed using the Mini Mental Status Examination (MMSE). Five-year all-cause mortality, and combined death-or-readmission, were compared on the basis of the presence (MMSE 19-26) or absence (MMSE >26) of cognitive impairment.

RESULTS

27 patients (13.5%) had cognitive impairment and, on an adjusted basis, were more likely to die (96.3% versus 68.2%. RR 2.19, 95% CI 1.41 to 3.39: P<0.001) and/or experience an unplanned hospitalization (100% versus 94%. RR 1.44, 95% CI 1.06 to 1.95: P=0.019). Cognitively impaired patients had a similar (non-significant) adjusted risk of death-or-readmission in both the CHF-MP (RR 1.40, 95% CI 0.63 to 3.11: P=0.403) and in usual care (RR 1.38, 95% CI 0.75 to 2.53: P=0.305). In the usual care cohort, cognitive impairment was associated with a greater (non-significant), adjusted risk of death (RR 1.61, 95% CI 1.10 to 4.92: P=0.122). In the CHF-MP, adjusted risk of death was significantly higher for cognitively impaired patients (RR 2.33, 95% CI 1.10 to 4.92: P=0.027).

CONCLUSION

These data suggest that "mild" cognitive impairment is of prognostic importance in CHF: even when a CHF-MP has been applied.

Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006: diagnosis and management

Heart failure remains a common diagnosis, especially in older individuals. It continues to be associated with significant morbidity and mortality, but major advances in both diagnosis and management have occurred and will continue to improve symptoms and other outcomes in patients. The Canadian Cardiovascular Society published its first consensus conference recommendations on the diagnosis and management of heart failure in 1994, followed by two brief updates, and reconvened this consensus conference to provide a comprehensive review of current knowledge and management strategies. New clinical trial evidence and meta-analyses were critically reviewed by a multidisciplinary primary panel who developed both recommendations and practical tips, which were reviewed by a secondary panel. The resulting document is intended to provide practical advice for specialists, family physicians, nurses, pharmacists and others who are involved in the care of heart failure patients. Management of heart failure begins with an accurate diagnosis, and requires rational combination drug therapy, individualization of care for each patient (based on their symptoms, clinical presentation and disease severity), appropriate mechanical interventions including revascularization and devices, collaborative efforts among health care professionals, and education and cooperation of the patient and their immediate caregivers. The goal is to translate best evidence-based therapies into clinical practice with a measureable impact on the health of heart failure patients in Canada.

Assessment of cognitive function in heart failure patients

BACKGROUND

Research on the cognitive capacity of heart failure patients is limited, with a paucity of benchmark information available for this population. It is highly likely that cognitive deficits affect patients' understanding of disease and treatment requirements, as well as limiting their functional capacity and ability to implement treatment plans, and undertake self-care.

AIMS

The purpose of this study was to establish a comprehensive neurocognitive profile of the heart failure patient through systematic neurocognitive assessment and to determine whether an association existed between severity of heart failure and cognitive abilities.

METHODS

Thirty-eight patients were recruited from the heart failure patient databases of two metropolitan hospitals in Melbourne, Australia. Participants were individually assessed using four standardised, internationally recognised neuropsychological tests that examined current and premorbid intelligence, memory and executive functioning.

RESULTS

Although there was no significant decline from premorbid general intellectual function, other specific areas of deficit, including impaired memory and executive functioning, were identified. There were no significant correlations between heart failure severity and the neurocognitive measures used.

CONCLUSION

The results support the need to recognise cognitive impairment in people with heart failure and to develop an abbreviated method of assessing cognitive function that can be easily implemented in the clinical setting. Identifying cognitive deficits in this population will be useful in guiding the content and nature of treatment plans to maximise adherence and minimise worsening of heart failure symptoms.

Qualitative analysis of the male experience of heart failure

OBJECTIVE

The purpose of this study was to gain insight from the patient's perspective into how it is to live with moderate chronic heart failure (HF).

METHODS

Twenty men with moderate chronic HF in New York Heart Association classes II to III, aged 43 to 73 years, were interviewed with open-ended questions. The interviews were analyzed using qualitative inductive content analysis as a method.

RESULTS

Both the consequences of the illness and how the patients adjusted to them were described in the narratives. The consequences were physical, emotional, cognitive, social, and vocational and included thoughts about death. Adjusting to the illness involved changing one's lifestyle, being aware of one's physical ability and disability, developing psychologic strategies, and adjusting to medication.

CONCLUSIONS

The findings of this study demonstrate a wider range of disabilities as a consequence of moderate chronic HF and show several more ways of adjusting to the illness than previously reported in men.

Older patients with chronic heart failure within Swedish community health care: a record review of nursing assessments and interventions

BACKGROUND

Older patients with chronic heart failure constitute a large group within community home care that is at high risk for re-hospitalization. However, hospital readmission can be prevented if early signs of deterioration are recognized and proper interventions applied.

AIMS AND OBJECTIVES

The aim of the study was to audit nursing care for older chronic heart failure patients within the Swedish community health care system.

DESIGN

The study adopted a retrospective descriptive design.

METHODS

In a Swedish urban municipality nursing documentation from 161 records on patients diagnosed with chronic heart failure was collected retrospectively from community nursing home care units. Patient records were reviewed for characteristics of nursing care and assessed for comprehensiveness in recording.

RESULTS

The main results showed that medical care of patients with chronic heart failure was poorly recorded, making it possible only to follow fragments of the care process. The nursing notes showed poor adherence to current clinical guidelines. Only 12% of the records contained notes on patients' body weight and only 4% noted patients' knowledge about chronic heart failure. When interventions did occur, they largely consisted of drug administration.

CONCLUSIONS

The findings revealed flaws in the recording of specific assessment and interventions as well as poor adherence to current international clinical guidelines.

RELEVANCE TO CLINICAL PRACTICE

Supportive guidelines available at the point of care are needed to enhance proper community-based home health care for older patients with chronic heart failure.

Cognitive deficits in patients with heart failure: a review of the literature

PURPOSE

Chronic heart failure (HF) and cognitive impairments (CI) are common problems in the elderly. Both are associated with increased mortality and disability, decreased quality of life, and increased health care costs. While these conditions may occur by chance in the same individual, there is increasing evidence that HF is independently associated with CI. The purpose of this article is to review and critique the literature addressing the prevalence, type, and severity of CI in HF patients, the clinical factors associated with CI, and the potential pathophysiology underlying the development of CI, and to recommend priority areas for future research.

RESULTS

Memory and attention deficits are the most frequently occurring CI in this patient population, followed by slowed motor response times and difficulties in problem solving. Prevalence rates range from 30% to 80% depending upon the age of the patients and the characteristics of the sample being studied. Most patients have mild impairments, although as many as one fourth may have moderate to severe CI. The relationship between left ventricular ejection fraction and cognition is inconsistent and may be nonlinear. The pathophysiology underlying the development of CI in HF patients may be related to both cerebral infarction and cerebral hypoperfusion either alone or in combination.

CONCLUSIONS

The current literature is limited by studies with sometimes small or nonrepresentative samples, few matched control studies, and lack of longitudinal data that could indicate the conditions that favor the development of CI over time. Future research needs to focus on (1) determining the types, frequency, and severity of impairments in cognitive functioning among a representative sample of HF patients, (2) explicating the pathological mechanisms and the clinical factors that underlie the development of cognitive deficits, and (3) identifying the ways CI influences quality of life. Interventions can then be developed to prevent or delay the occurrence of CI or to minimize their effect on patient self-management and quality of life.

Heart failure management in the elderly postoperative patient

As the population ages, the elderly will account for a significant portion of surgical cases. These patients have age-related cardiovascular changes and can suffer from multiple chronic disease conditions. Congestive heart failure is a chronic condition that afflicts nearly five million Americans. It is the most common diagnosis among patients 65 years or older, with 8% to 10% of senior citizens having this chronic disease. A comprehensive understanding of the pathophysiology, assessment, and management strategies of congestive heart failure will give the orthopaedic nurse the knowledge needed to help minimize the morbidity and mortality associated with this disease.

Fatigued elderly patients with chronic heart failure: do patient reports and nurse recordings correspond?

PURPOSE

To compare descriptions of fatigue from interviews with elderly people with chronic congestive heart failure (CHF) and data recorded by nurses at an outpatient heart failure clinic.

METHODS

Patients (N = 158) were screened for moderate to severe CHF and interviewed using a revised form of the Fatigue Interview Schedule (FIS). Seventy-nine of these patients were offered visits at a nurse-monitored heart failure clinic. Nursing documentation of fatigue in patient records (n = 56) at the heart failure clinic was compared to the patient interviews.

FINDINGS

Results indicated poor concordance between patients' descriptions and record content concerning fatigue. Decreased libido was linked to fatigue according to the patients but not to the nurses' notes. Cognitive characteristics of fatigue were rarely recorded, but were more frequent in patient interviews.

CONCLUSIONS

Nurses must recognize characteristics and factors related to fatigue in patients and develop strategies to help patients cope with their restricted ability in daily life.

PRACTICE IMPLICATIONS

Using the words and expressions of the patients and the diagnostic characteristics of fatigue in record-keeping can support the nurses understanding of patients living with CHF.