Diagnostic Accuracy of Cognitive Screening Instruments in Heart Failure: A Systematic Review

Mapping research on cognitive impairment in heart failure patients: A bibliometric analysis from 2013 to 2022

Background

Cognitive impairment is a common concern among individuals with heart failure, and the intersection of these conditions poses significant challenges for scholarly investigation. This study aims to conduct a comprehensive bibliometric analysis to visually depict the current state and emerging trends regarding cognitive impairment among heart failure patients.

Methods

Articles focusing on cognitive impairment in heart failure patients published between 2013 and 2022 were retrieved from the Web of Science Core Collection on February 3, 2023. Analysis of publication trends was conducted using Microsoft Excel 2016. The bibliometric analysis，involving identification of the leading countries, institutions, and authors, as well as the analysis of keywords co-occurrence and burst-detection, was performed using CiteSpace and VOSviewer.

Results

A total of 260 original articles were included. The data showed a stable pattern of annual publications on cognitive impairment in heart failure patients over the last ten years. The United States stood out with 129 publications, Kent State University in the USA led in institutional output with 32 articles, and Gunstad John was identified as the most influential author with 32 articles and 572 citations. Analysis of keyword co-occurrence network revealed core research themes encompassing risk factors, interventions, assessment, and underlying mechanisms of cognitive impairment in heart failure patients.

Conclusions

This study presents the first bibliometric analysis of research on cognitive impairment in heart failure patients over the past decade, offering valuable insights for exploring future research frontiers in this domain. The findings provide researchers, clinicians, and policymakers with key information to advance understanding and interventions for cognitive impairment in heart failure patients.

Current Practices and Attitudes of Cardiac Nurses Regarding Cognitive Screening in Patients With Acute Coronary Syndrome

BACKGROUND

Cognitive impairment (CI) is common in patients with acute coronary syndrome (ACS) but is often undetected and may affect recovery and secondary prevention uptake. Nurses play a crucial role providing care for patients with ACS and promoting secondary prevention.

AIM

This study aimed to explore current nursing practices and barriers regarding CI screening in patients with ACS.

METHODS

Cardiac nurses were recruited from three metropolitan teaching hospitals and two professional associations in Australia and undertook a 38-question purpose-built survey.

RESULTS

A total of 95 nurses participated (mean age 38±13 years; 78% [n=74] female): 69 were registered nurses, and 48% had received CI training. Only 16% of nurses in our sample reported that they regularly screen for CI, and 23% reported that they never screen; however, 59% believed screening should be part of everyday practice. Nurses mostly screened when ward policy required admission/daily cognitive screening (34%) or when they suspected cognitive problems or decline (39%). Nurses in acute settings (vs non-acute) were nine times more likely to screen when adjusting for confounders. The typically used screening instruments assessed delirium/confusion and dementia but not milder CI. Common barriers to screening included communication difficulties, patients too unstable/unwell, time constraints requiring clinical care prioritisation, and being unaware of patients' normal cognition status.

CONCLUSIONS

Screening practices for CI in the context of ACS were found to be suboptimal, with only 16% of nurses in our sample reporting regularly screening. The most used methods focus on screening for delirium. Given current practice, many CI cases will be missed, especially mild CI, which will negatively affect secondary prevention efforts. Further research is required to identify appropriate methods to implement routine screening within the nursing clinical workflow and establish a suitable screening tool.

Cognitive Impairment in Heart Failure: A Heart Failure Society of America Scientific Statement

Cognitive impairment is common among adults with heart failure (HF), as both diseases are strongly related to advancing age and multimorbidity (including both cardiovascular and noncardiovascular conditions). Moreover, HF itself can contribute to alterations in the brain. Cognition is critical for a myriad of self-care activities that are necessary to manage HF, and it also has a major impact on prognosis; consequently, cognitive impairment has important implications for self-care, medication management, function and independence, and life expectancy. Attuned clinicians caring for patients with HF can identify clinical clues present at medical encounters that suggest cognitive impairment. When present, screening tests such as the Mini-Cog, and consideration of referral for comprehensive neurocognitive testing may be indicated. Management of cognitive impairment should focus on treatment of underlying causes of and contributors to cognitive impairment, medication management/optimization, and accommodation of deficiencies in self-care. Given its implications on care, it is important to integrate cognitive impairment into clinical decision making. Although gaps in knowledge and challenges to implementation exist, this scientific statement is intended to guide clinicians in caring for and meeting the needs of an increasingly complex and growing subpopulation of patients with HF.

Structural Relationships Between Cognitive Function, Depressive Symptoms, Self-Care Confidence, and Maintenance in Patients With Heart Failure

Introduction

In order to promote self-care maintenance behavior in patients with heart failure (HF), it is necessary to identify the direct and indirect effects of major latent variables.

Objective

This study aimed to identify structural relationships between different domains of cognitive function, depression and self-care confidence, and self-care maintenance.

Methods

This descriptive study involved a secondary analysis using data of 201 patients with HF from two observational studies in three hospitals in Korea. The structural equation model using AMOS version 24.0 was constructed to assess the relationships among the variables. The Seoul Neuropsychological Screening Battery was used to assess global cognition, immediate/delayed memory, and executive function, and the Self-Care of HF Index v.6.2. was used for self-care confidence and maintenance.

Results

Self-care maintenance was affected by memory function with a significant direct effect (β=.43, p = .006), as well as self-care confidence (β=.70, p < .001). Memory function and global function indirectly affected self-care maintenance through self-care confidence (β = -.37, p = .002; β = .14, p = .030). Depressive symptoms also had an indirect effect through self-care confidence on self-care maintenance (β = -.21, p = .005).

Conclusion

This study confirmed that it is important to increase self-care confidence through supportive care and to maintain memory function for maintaining self-care in the chronic course of HF patients. In particular, this study suggests that it is necessary to perform periodic memory check-ups for chronic HF patients on an outpatient basis, and counseling and education are needed to improve memory and increase confidence in self-care.

Evaluating the discriminatory power of the velocity field diagram and timed-up-and-go test in determining the fall status of community-dwelling older adults: a cross-sectional observational study

BACKGROUND

Systematic reviews demonstrated that gait variables are the most reliable predictors of future falls, yet are rarely included in fall screening tools. Thus, most tools have higher specificity than sensitivity, hence may be misleading/detrimental to care. Therefore, this study aimed to determine the validity, and reliability of the velocity field diagram (VFD -a gait analytical tool), and the Timed-up-and-go test (TUG)-commonly used in Nigeria as fall screening tools, compared to a gold standard (known fallers) among community-dwelling older adults.

METHOD

This is a cross-sectional observational study of 500 older adults (280 fallers and 220 non-fallers), recruited by convenience sampling technique at community health fora on fall prevention. Participants completed a 7-m distance with the number of steps and time it took determined and used to compute the stride length, stride frequency, and velocity, which regression lines formed the VFD. TUG test was simultaneously conducted to discriminate fallers from non-fallers. The cut-off points for falls were: TUG times ≥ 13.5 s; VFD's intersection point of the stride frequency, and velocity regression lines (E1) ≥ 3.5velots. The receiver operating characteristic (ROC) area under the curves (AUC) was used to explore the ability of the E1 ≥ 3.5velots to discriminate between fallers and non-fallers. The VFD's and TUG's sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were determined. Alpha was set at p < 0.05.

RESULTS

The VFD versus TUG sensitivity, specificity, PPV and NPV were 71%, 27%, 55%, and 42%, versus 39%, 59%, 55%, and 43%, respectively. The ROC's AUC were 0.74(95%CI:0.597,0.882, p = 0.001) for the VFD. The optimal categorizations for discrimination between fallers/non-fallers were ≥ 3.78 versus ≤ 3.78 for VFD (fallers versus non-fallers prevalence is 60.71% versus 95.45%, respectively), with a classification accuracy or prediction rate of 0.76 unlike TUG with AUC = 0.53 (95% CI:0.353,0.700, p = 0.762), and a classification accuracy of 0.68, and optimal characterization of ≥ 12.81 s versus ≤ 12.81 (fallers and non-fallers prevalence = 92.86% versus 36.36%, respectively).

CONCLUSION

The VFD demonstrated a fair discriminatory power and greater reliability in identifying fallers than the TUG, and therefore, could replace the TUG as a primary tool in screening those at risk of falls.

The Utility of Cognitive Screening in Asian Patients With Heart Failure: A Systematic Review

Background

The prevalence of undiagnosed cognitive impairment in patients with heart failure is alarmingly high in Asia. There is still no consensus on cognitive screening tools to detect cognitive impairment in the Asian heart failure population. The clinical implications based on our systematic review may help to improve cognitive screening practice for patients with heart failure in Asia.

Methods

This review is registered in the PROSPERO (CRD42021264288). Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach, we searched PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature, Scopus, the Web of Science, PsycINFO, the Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, and Wanfang Data in English and Chinese literatures concerning heart failure and cognitive impairment.

Results

The search yielded 21 eligible studies. Only in five studies, cognitive brief tests, including the Montreal Cognitive Assessment (MoCA), the Mini-Mental State Examination (MMSE), and the Mini-Cog, were used as cognitive screening tools for Asian patients with heart failure. In the rest 16 studies, brief cognitive tests were used as screening tools for global cognition. Only one study validated screening tests against a gold standard formal neuropsychological assessment test battery. Among these studies, patients with heart failure tended to perform worse than patients without heart failure. The presence of cognitive impairment in patients with heart failure is associated with poorer self-care, quality of life, and hospital readmission.

Conclusion

Brief cognitive tests have been used in Asian patients with heart failure and these tests are frequently used as a measure of global cognitive function for cognitive screening. However, validating brief cognitive tests against a gold standard formal neuropsychological assessment in Asian patients with heart failure is lacking. Future studies need to address methodological issues to validate cognitive screening measures in a larger population of Asian patients with heart failure.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/.

Cognitive Impairment in Heart Failure-A Review

Cognitive impairment (CI) is common in heart failure (HF). Patients with HF demonstrate reduced global cognition as well as deficits in multiple cognitive domains compared to controls. Degree of CI may be related to HF severity. HF has also been associated with an increased risk of dementia. Anatomical brain changes have been observed in patients with HF, including grey matter atrophy and increased white matter lesions. Patients with HF and CI have poorer functional independence and self-care, more frequent rehospitalisations as well as increased mortality. Pathophysiological pathways linking HF and CI have been proposed, including cerebral hypoperfusion and impaired cerebrovascular autoregulation, systemic inflammation, proteotoxicity and thromboembolic disease. However, these mechanisms are poorly understood. We conducted a search on MEDLINE, Embase and Scopus for original research exploring the connection between HF and CI. We then reviewed the relevant literature and discuss the associations between HF and CI, the patterns of brain injury in HF and their potential mechanisms, as well as the recognition and management of CI in patients with HF.

Cognitive Impairment in Acute Heart Failure: Narrative Review

Cognitive impairment (CI) represents a common but often veiled comorbidity in patients with acute heart failure (AHF) that deserves more clinical attention. In the AHF setting, it manifests as varying degrees of deficits in one or more cognitive domains across a wide spectrum ranging from mild CI to severe global neurocognitive disorder. On the basis of the significant negative implications of CI on quality of life and its overwhelming association with poor outcomes, there is a compelling need for establishment of detailed consensus guidelines on cognitive screening methods to be systematically implemented in the population of patients with heart failure (HF). Since limited attention has been drawn exclusively on the field of CI in AHF thus far, the present narrative review aims to shed further light on the topic. The underlying pathophysiological mechanisms of CI in AHF remain poorly understood and seem to be multifactorial. Different pathophysiological pathways may come into play, depending on the clinical phenotype of AHF. There is some evidence that cognitive decline closely follows the perturbations incurred across the long-term disease trajectory of HF, both along the time course of stable chronic HF as well as during episodes of HF exacerbation. CI in AHF remains a rather under recognized scientific field that poses many challenges, since there are still many unresolved issues regarding cognitive changes in patients hospitalized with AHF that need to be thoroughly addressed.

Heart and brain interactions in heart failure: Cognition, depression, anxiety, and related outcomes

BACKGROUND

Cognitive impairment, anxiety and depression are common in heart failure (HF) patients and its evolution is not fully understood.

OBJECTIVES

To assess the cognitive status of HF patients over time, its relation to anxiety and depression, and its prognostic impact.

METHODS

Prospective, longitudinal, single center study including patients enrolled in a structured program for follow-up after hospital admission for HF decompensation. Cognitive function, anxiety/depression state, HF-related quality of life (QoL) were assessed before discharge and during follow-up (between 6^th and 12^th month) using Montreal Cognitive Assessment (MoCA), Hospital Anxiety and Depression Scale (HADS) and Kansas City Cardiomyopathy Questionnaire, respectively. HF related outcomes were all cause readmissions, HF readmissions and the composite endpoint of all-cause readmissions or death.

RESULTS

43 patients included (67±11.3 years, 69% male); followed-up for 8.2±2.1 months. 25.6% had an abnormal MoCA score that remained stable during follow-up (22.6±4.2 vs. 22.2±5.5; p=NS). MoCA score <22 at discharge conferred a sixfold greater risk of HF readmission [HR=6.42 (1.26-32.61); p=0.025], also predicting all-cause readmissions [HR=4.00 (1.15-13.95); p=0.03] and death or all-cause readmissions [HR=4.63 (1.37-15.67); p=0.014]. Patients with higher MoCA score showed a greater ability to deal with their disease (p=0.038). At discharge, 14% and 18.6% had an abnormal HADS score for depression and anxiety, respectively, which remained stable during follow-up and was not related to MoCA.

CONCLUSIONS

Cognitive function, anxiety and depressive status remain stable in HF patients despite optimized HF therapy. Cognitive status shall be routinely screened to adopt attitudes that improve management as it has an impact on HF-related QoL and prognosis.

Heart and brain interactions in heart failure: Cognition, depression, anxiety, and related outcomes

BACKGROUND

Cognitive impairment, anxiety and depression are common in heart failure (HF) patients and its evolution is not fully understood.

OBJECTIVES

To assess the cognitive status of HF patients over time, its relation to anxiety and depression, and its prognostic impact.

METHODS

Prospective, longitudinal, single center study including patients enrolled in a structured program for follow-up after hospital admission for HF decompensation. Cognitive function, anxiety/depression state, HF-related quality of life (QoL) were assessed before discharge and during follow-up (between 6^th and 12^th month) using Montreal Cognitive Assessment (MoCA), Hospital Anxiety and Depression Scale (HADS) and Kansas City Cardiomyopathy Questionnaire, respectively. HF related outcomes were all cause readmissions, HF readmissions and the composite endpoint of all-cause readmissions or death.

RESULTS

43 patients included (67±11.3 years, 69% male); followed-up for 8.2±2.1 months. 25.6% had an abnormal MoCA score that remained stable during follow-up (22.6±4.2 vs. 22.2±5.5; p=NS). MoCA score <22 at discharge conferred a sixfold greater risk of HF readmission [HR=6.42 (1.26-32.61); p=0.025], also predicting all-cause readmissions [HR=4.00 (1.15-13.95); p=0.03] and death or all-cause readmissions [HR=4.63 (1.37-15.67); p=0.014]. Patients with higher MoCA score showed a greater ability to deal with their disease (p=0.038). At discharge, 14% and 18.6% had an abnormal HADS score for depression and anxiety, respectively, which remained stable during follow-up and was not related to MoCA.

CONCLUSIONS

Cognitive function, anxiety and depressive status remain stable in HF patients despite optimized HF therapy. Cognitive status shall be routinely screened to adopt attitudes that improve management as it has an impact on HF-related QoL and prognosis.

Cognitive impairment predicts mortality in outpatient veterans with heart failure

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.

Cognitive Assessment Test: Validation of a Short Cognitive Test for the Detection of Mild Cognitive Disorder

Introduction

Cognitive disorders are a clinical and research challenge; in particular, the mild cognitive disorder (MiCD) requires diagnostic suspicion and tools with adequate performance for its detection. The objective of this study was the validation of a short cognitive test (CATest) for the detection of MiCD in population of 50 years or more.

Methods

A diagnostic accuracy study was assembled and performed in a prospective cohort. A consecutive sample of 200 Colombian subjects who represented the whole spectrum of the condition of interest allowed us to reach the objective. Validity was determined by concurrent criteria. The cut points were determined by the ROC curves considering the best overall performance and accuracy of the test.

Results

CATest was validated to detection of MiCD at a cut-off point of 18. As a result, scores lower than 18 classified the participants as MiCD. At this cut-off point, CATest showed sensitivity of 84.3% (CI 76 to 90.16), specificity of 71.4% (CI 95% 61.8 to 79.43), positive predictive value of 75% ( 95% CI 66.79 to 82.42), and area under curve AUC 0.8518 (standard error SE 0.0265).

Discussion

CATest has an adequate performance as a short cognitive test for the detection of MiCD. Its performance is superior to MiniMental and similar to Montreal Cognitive test (MoCA) according to the data reported in the literature. The advantages over other tests are the evaluation of all cognitive domains, time of application, and easy interpretation of results. CATest is a free use alternative for MiCD detection.

Detecting and Managing Cognitive Impairment to Improve Engagement in Heart Failure Self-Care

PURPOSE OF THE REVIEW

The purpose of this review was to examine the recent literature on detecting cognitive impairment in patients with heart failure (HF) and the evidence indicating any ramifications of cognitive impairment on patient engagement in HF self-care.

RECENT FINDINGS

Mild cognitive impairment (MCI) is common in HF and impacts on patients' engagement in self-care, yet it is frequently not detected. The use of screening tools, even when brief, improves detection of MCI. However, the most sensitive, specific and feasible screening measure to use in practice is yet to be identified. A full neuropsychological assessment is required to determine a diagnosis of cognitive impairment and to identify the specific areas of cognitive deficit. In patients with HF, there appears to be differing clusters of cognitive deficits. Identification of these deficits may help inform the application of specific cognitive training strategies to ameliorating cognitive changes in HF patients and potentially enhance engagement in self-care. Screening for cognitive impairment is crucial in the management of HF patients to ensure that potential self-care deficits are prevented. The optimal screening tool is yet to be identified.

Self-care confidence may be more important than cognition to influence self-care behaviors in adults with heart failure: Testing a mediation model

BACKGROUND

Cognitive impairment can reduce the self-care abilities of heart failure patients. Theory and preliminary evidence suggest that self-care confidence may mediate the relationship between cognition and self-care, but further study is needed to validate this finding.

OBJECTIVES

The aim of this study was to test the mediating role of self-care confidence between specific cognitive domains and heart failure self-care.

DESIGN

Secondary analysis of data from a descriptive study.

SETTINGS

Three out-patient sites in Pennsylvania and Delaware, USA.

PARTICIPANTS

A sample of 280 adults with chronic heart failure, 62 years old on average and mostly male (64.3%).

METHODS

Data on heart failure self-care and self-care confidence were collected with the Self-Care of Heart Failure Index 6.2. Data on cognition were collected by trained research assistants using a neuropsychological test battery measuring simple and complex attention, processing speed, working memory, and short-term memory. Sociodemographic data were collected by self-report. Clinical information was abstracted from the medical record. Mediation analysis was performed with structural equation modeling and indirect effects were evaluated with bootstrapping.

RESULTS

Most participants had at least 1 impaired cognitive domain. In mediation models, self-care confidence consistently influenced self-care and totally mediated the relationship between simple attention and self-care and between working memory and self-care (comparative fit index range: .929-.968; root mean squared error of approximation range: .032-.052). Except for short-term memory, which had a direct effect on self-care maintenance, the other cognitive domains were unrelated to self-care.

CONCLUSIONS

Self-care confidence appears to be an important factor influencing heart failure self-care even in patients with impaired cognition. As few studies have successfully improved cognition, interventions addressing confidence should be considered as a way to improve self-care in this population.

Management of Cognitive Impairment in Heart Failure

OPINION STATEMENT

Cognitive impairment (CI) is an inclusive term to describe trouble with memory, learning, concentration, or decision-making. CI is highly prevalent in patients with heart failure (HF) and is known to be associated with a variety of poor outcomes. While published HF guidelines recommend screening for CI, they do not indicate how, due to a lack of consensus in the literature about which instrument to use. Our recommendation is to use the Mini-Cog for this purpose because of its brevity and utility in identifying patients with HF at high risk for hospitalization or mortality. At this time, there is minimal published clinical trial evidence about how to manage CI in patients with HF. Reasonable approaches to management may include following guideline-directed medical therapy for HF, treatment of hypertension and atrial fibrillation, management of depression, proactive diagnosis and treatment of sleep apnea, and encouragement of aerobic exercise and weight loss. Left ventricular assist device (LVAD) therapy in patients with Stage D HF may improve CI in the short term after implantation, though there is a risk of worsening CI in the intermediate and long term. Clinicians who care for patients with HF should routinely screen for CI and when identified should encourage interventions to support self-care, increase family involvement, and arrange for more frequent follow-up.