Congestive heart failure and cognitive impairment in an older population. Osservatorio Geriatrico Campano Study Group

Cognitive impairment is associated with BDNF-TrkB signaling mediating synaptic damage and reduction of amino acid neurotransmitters in heart failure

Heart failure (HF) is often accompanied by cognitive impairment (CI). Brain-derived neurotrophic factor (BDNF) deficiency is closely associated with CI. However, the role and mechanism of BDNF in HF with CI is still not fully understood. Here, the case-control study was designed including 25 HF without CI patients (HF-NCI) and 50 HF with CI patients (HF-CI) to investigate the predictive value of BDNF in HF-CI while animal and cell experiments were used for mechanism research. Results found that BDNF levels in serum neuronal-derived exosomes were downregulated in HF-CI patients. There was no significant difference in serum BDNF levels among the two groups. HF rats showed obvious impairment in learning and memory; also, they had reduced thickness and length of postsynaptic density (PSD) and increased synaptic cleft width. Expression of BDNF, TrkB, PSD95, and VGLUT1 was significantly decreased in HF rats brain. In addition, compared with sham rats, amino acids were significantly reduced with no changes in the acetylcholine and monoamine neurotransmitters. Further examination showed that the number of synaptic bifurcations and the expression of BDNF, TrkB, PSD95, and VGLUT1 were all decreased in the neurons that interfered with BDNF-siRNA compared with those in the negative control neurons. Together, our results demonstrated that neuronal-derived exosomal BDNF act as effective biomarkers for prediction of HF-CI. The decrease of BDNF in the brain triggers synaptic structural damage and a decline in amino acid neurotransmitters via the BDNF-TrkB-PSD95/VGLUT1 pathway. This discovery unveils a novel pathological mechanism underlying cognitive impairment following heart failure.

Septal E/e' Ratio Is Associated With Cerebral White Matter Hyperintensity Progression in Young-Old Hypertensive Patients

Background: The incidence of hypertension increases with age, as does that of brain abnormalities associated with cerebral pathologic and functional degeneration. Little is known about the relationship between hypertension-related cardiac changes and cerebral pathologic degeneration. We examined the relationship between left ventricular (LV) diastolic dysfunction and cerebral white matter hyperintensity (WMH) progression in young-old hypertensive patients. Methods and Results: This single-center prospective longitudinal observational study included 156 individuals aged 65-75 years with well-controlled hypertension, normal LV contraction, and no history of symptomatic heart failure. WMH was quantified on brain magnetic resonance imaging (MRI). The primary outcome was the rate of WMH volume progression between the baseline and follow-up MRI (∆WMH). Participants were classified into tertiles on the basis of ∆WMH (small, medium, and large ∆WMH). The mean (±SD) age at recruitment was 69.6±2.8 years, and the mean follow-up period was 4.6 years. The ratio of early diastolic mitral inflow velocity to early diastolic septal mitral annulus velocity (septal E/e') was significantly higher in the large ∆WMH group than in the small and medium ∆WMH groups. On multiple regression analysis, septal E/e' was significantly positively associated with square-root-transformed ∆WMH (β=0.457, P<0.001). Conclusions: Septal E/e' was significantly positively associated with the rate of progression of WMH volume, suggesting that LV diastolic dysfunction is associated with the progression of abnormal brain aging.

Profiles of cognitive impairment in chronic heart failure-A cluster analytic approach

Background

Cognitive impairment is a major comorbidity in patients with chronic heart failure (HF) with a wide range of phenotypes. In this study, we aimed to identify and compare different clusters of cognitive deficits.

Methods

The prospective cohort study "Cognition.Matters-HF" recruited 147 chronic HF patients (aged 64.5 ± 10.8 years; 16.2% female) of any etiology. All patients underwent extensive neuropsychological testing. We performed a hierarchical cluster analysis of the cognitive domains, such as intensity of attention, visual/verbal memory, and executive function. Generated clusters were compared exploratively with respect to the results of cardiological, neurological, and neuroradiological examinations without correction for multiple testing.

Results

Dendrogram and the scree plot suggested three distinct cognitive profiles: In the first cluster, 42 patients (28.6%) performed without any deficits in all domains. Exclusively, the intensity of attention deficits was seen in the second cluster, including 55 patients (37.4%). A third cluster with 50 patients (34.0%) was characterized by deficits in all cognitive domains. Age (p = 0.163) and typical clinical markers of chronic HF, such as ejection fraction (p = 0.222), 6-min walking test distance (p = 0.138), NT-proBNP (p = 0.364), and New York Heart Association class (p = 0.868) did not differ between clusters. However, we observed that women (p = 0.012) and patients with previous cardiac valve surgery (p = 0.005) prevailed in the "global deficits" cluster and the "no deficits" group had a lower prevalence of underlying arterial hypertension (p = 0.029). Total brain volume (p = 0.017) was smaller in the global deficit cluster, and serum levels of glial fibrillary acidic protein were increased (p = 0.048).

Conclusion

Apart from cognitively healthy and globally impaired HF patients, we identified a group with deficits only in the intensity of attention. Women and patients with previous cardiac valve surgery are at risk for global cognitive impairment when suffering HF and could benefit from special multimodal treatment addressing the psychosocial condition.

Prevalence and factors associated with cognitive impairment in Chinese heart failure patients: A pilot study

Background

The prevalence of Cognitive impairment (CI) is high in patients with heart failure (HF). It leads to poor prognosis, such as self-care, hospital readmission and increased mortality. However, such information among Chinese population is unclear.

Objective

The purpose of this study was to examine the prevalence of CI in Chinese patients with HF, and explore its correlation with biomarkers and clinical factors to better manage HF patients with CI.

Methods

This study is a cross-sectional study of 200 hospitalized HF patients in China. The cognitive function of HF patients was assessed by the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE).

Results

The majority are male (62.5%, n = 125), have primary school and below level of education (57.5%, n = 115), NYHA III and above (62%, n = 124). They have an average MoCA score of 15.10 ± 8.18, MMSE score of 19.55 ± 8.23. Age, NYHA class, and atrial fibrillation were independently associated with CI (p &lt; 0.05). There was a significant association between CI and the 4th quartile of TNT (p = 0.013), and the 3rd and 4th quartile of NT-proBNP (p = 0.015, p = 0.038).

Conclusions

The prevalence of undiagnosed CI in Chinese HF patients is high (81%). HF patients with high levels of TNT or NT-proBNP or both values may be at risk of developing CI. Therefore, we suggest that HF patients with older age, atrial fibrillation, NYHA class II and III, as well as elevated TNT or NT-proBNP or both values to be followed up with a formal evaluation for CI. Nurses need to provide targeted health education program for cognitively impaired HF population to improve their self-care ability and nursing outcome.

Prevalence and Incidence of Cognitive Impairment and Dementia in Heart Failure - A Systematic Review, Meta-Analysis and Meta-Regression

INTRODUCTION

The burden of cognitive impairment in HF patients is significant and leads to longer hospital stay, higher readmission rates, and increased mortality. This review seeks to synthesize the available studies to determine the prevalence and incidence of cognitive impairment and dementia in HF patients.

METHODS

PubMed, Embase, PsychoINFO and Cochrane databases were systematically searched from their inception through to 3 May 2021. Study and population characteristics, total patients with HF, prevalence of cognitive impairment and dementia in HF patients and cognitive assessment tool were abstracted by two reviewers.

RESULTS

In heart failure patients, overall prevalence for cognitive impairment and dementia was 41.42% (CI) and 19.79% (dementia) respectively. We performed a meta-regression analysis which demonstrated that the risk of cognitive impairment and dementia increased with age.

DISCUSSION

Further research should investigate whether HF accelerates the rate of cognitive decline and the progression of dementia.

Effect of Aging on Educational Differences in the Risk of Cognitive Impairment: A Gender-Specific Analysis Using Korean Longitudinal Study of Aging (2006–2016)

This study examined the effect of aging on gender-specific educational differences in the risk of cognitive impairment using a nationally representative sample of 4278 men and 5495 women aged 45 years and older from the dataset of the Korean Longitudinal Study of Aging. Sociodemographics, lifestyle, and medical conditions were included as covariates in the mixed logistic regression analysis models. The prevalence of cognitive impairment was higher in women than in men at baseline. The risk of cognitive impairment in each age group decreased with education in both men and women. The risk by educational rank was worse at lower levels and increased with age, more so for women than men. Aging appears to widen the impact of educational differences on the risk of cognitive impairment and is more unfavorable for women than for men. Public health policies regarding population aging need to consider this and identify the target population to reduce both the level of and the difference in the risk of cognitive impairment.

Cognitive impairment and its association with circulating biomarkers in patients with acute decompensated heart failure

BACKGROUND

Cognitive impairment (CI) is common in patients with heart failure (HF), but the association between CI and biomarkers related to HF or cognitive decline in patients with HF remains unclear.

METHODS

This prospective observational study investigated the incidence of CI, subsequent cognitive changes, and the association between CI and novel biomarkers in patients with left ventricular ejection fraction < 40% who were hospitalized for acute decompensated HF. Patients were evaluated for CI, depressive symptoms, and quality of life with the Mini-Mental State Examination (MMSE) and the Mini-Cog, Beck Depression Inventory (BDI)-II, and Kansas City Cardiomyopathy Questionnaire (KCCQ), respectively. The primary endpoint was a composite of all-cause mortality or hospitalization for HF at one year.

RESULTS

Among the 145 patients enrolled in this study, 54 had CI (37.2%) at baseline. The mean MMSE increased significantly at the 3-month and 1-year follow-up, accompanied by decreased BDI-II and increased KCCQ scores. The improvement in the MMSE scores mainly occurred in patients with CI. Among the biomarkers assayed, only growth/differentiation factor (GDF)-15 > 1621.1 pg/mL was significantly associated with CI (area under the curve = 0.64; P = 0.003). An increase in GDF-15 per 1000 units was associated with an increased risk of the primary endpoint (hazard ratio = 1.42; 95% confidence interval: 1.17-1.73; P < 0.001).

CONCLUSIONS

In patients with HF with CI, cognitive function, depression, and quality of life measures improved at the 3-month and 1-year follow-up. GDF-15 predicted CI with moderate discrimination capacity and was associated with worse HF outcomes.

Cognitive decline and risk of dementia in individuals with heart failure: A systematic review and meta-analysis

AIM

To determine the association between heart failure (HF) and cognitive change and dementia.

METHODS AND RESULTS

Systematic search of three electronic databases was performed and 29 eligible studies involving approximately 3 million participants were identified. Twelve studies examined dementia and 20 cognitive change, but only a subset of studies could be included in the meta-analysis. These findings indicated that HF was not significantly associated with dementia (n=8, hazard ratio [HR] 1.18, 95% confidence interval [CI] [0.93, 1.50]), but increased the risk of cognitive impairment (n=3, HR 1.80, 95%CI [1.14,2.86]) . Additionally, HF was associated with poorer mean cognitive performance in global cognition (Hedges' g -0.73, 95%CI [-1.12, -0.35]), memory (Hedges' g -0.57, 95%CI [-0.72, -0.42]), executive function (Hedges' g -0.58, 95%CI [-0.72, -0.43]), attention/speed (Hedges' g -0.50, 95%CI [-0.63, -0.37]) and language (Hedges' g -0.61, 95%CI [-1.05, -0.17]).

CONCLUSION

Patients with HF perform worse on all cognitive tests, and have an increased risk of cognitive impairment. These findings highlight the need for clinicians to consider cognition as part of routine care for patients with HF.

Cardiac electrical remodeling and neurodegenerative diseases association

Cardiac impairment contributes significantly to the mortality associated with several neurodegenerative diseases, such as Alzheimer's disease (AD), Parkinson's disease (PD), and Huntington's disease (HD), primarily recognized as brain pathologies. These diseases may be caused by aggregation of a misfolded protein, most often, in the brain, although new evidence also reveals peripheral abnormalities. After characterization of the cardiac involvement in neurodegenerative diseases, several studies concentrated on elucidating the cause of the impaired cardiac function. However, most of the current knowledge is focused on the mechanical aspects of the heart rather than the electrical disturbances. The main objective of this review is to summarize the most recent advances in the elucidation of cardiac electrical remodeling in the neurodegenerative environment. We aimed to determine a crosstalk between the heart and the brain in three neurodegenerative conditions: AD, PD, and HD. We found that the most studies demonstrated important alterations in the electrocardiogram (ECG) of patients with neurodegeneration and in animal models of the conditions. We also showed that little is described when considering excitability disruptions in cardiomyocytes, for example, action potential impairments. It is a matter of contention whether central nervous system abnormalities or the peripheral ones increase the risk of heart diseases in patients with neurodegenerative conditions. To determine this notion, there is a need for new heart studies focusing specifically on the cardiac electrophysiology (e.g., ECG and cardiomyocyte excitability). This review could serve as an important guide in designing novel accurate approaches targeting the heart in neuronal conditions.

Which Occupation is Highly Associated with Cognitive Impairment? A Gender-Specific Longitudinal Study of Paid and Unpaid Occupations in South Korea

Background: To examine the associations between paid and unpaid occupations and the risk of cognitive impairment with respect to gender in a middle-aged population using the dataset of a nationally representative longitudinal survey. Methods: Overall, 24,925 observations of 5865 participants aged 45–64 years were sampled from the seven waves of the Korean Longitudinal Study of Ageing (2006–2018). A dichotomous outcome variable was derived based on the Korean version of the Mini-Mental State Examination scores, and occupations were grouped into 12 categories, including three unpaid ones. Sociodemographics, lifestyle, and medical conditions were included as covariates in the mixed logistic regression models. Adjusted odds ratios and predicted probabilities of cognitive impairment were estimated. Results: In the longitudinal models with all-studied covariates, the risk of cognitive impairment was similar between genders but differed across occupation categories for each gender. Moreover, the association between occupation and cognitive impairment varied between genders. Regarding the predicted probability, in men, the retired category exhibited the highest risk of cognitive impairment. However, in women, the highest risk was related to the homemakers category, with the risk being more than five times higher than those in the professionals and related workers category. Conclusions: Public health policies to reduce the risk of cognitive impairment in the middle-aged population need to be designed and implemented with respect to both gender and occupation.

Cognitive impairment in patients with atrial fibrillation: Implications for outcome in a cohort study

BACKGROUND

The impact of cognitive status on outcomes of patients with atrial fibrillation (AF) is not well defined.

AIMS

To assess the prevalence of cognitive impairment in AF patients and evaluate its association with: i) all-cause mortality; ii) a composite endpoint of death, stroke/systemic embolism, hemorrhages, acute coronary syndrome, pulmonary embolism, new/worsening heart failure.

METHODS

In a cohort study, cognitive status was assessed at baseline by the Mini Mental State examination adjusted for age and education (aMMSE). aMMSE <24 was considered indicative of cognitive impairment.

RESULTS

The cohort included 437 patients (61.3% male, mean age 73.4 ± 11.7 years). Sixty-three patients (14.4%) had cognitive impairment at baseline aMMSE. Permanent AF (odds ratio [OR] 1.750; 95%CI 1.012-3.025; p = .045), haemoglobin levels (OR 0.827; 95%CI 0.707-0.967; p = .017) and previous treatment with antiplatelet drugs only, without oral anticoagulation, (OR 4.352; 95%CI 1.583-11.963; p = .004) were independently associated with cognitive impairment at baseline. After a median follow-up of 887 days (interquartile range 731-958) 30 patients died (7.1%), and 97 (22.9%) reached the composite endpoint. After adjustment for Elixhauser Comorbidy Measure, aMMSE <24 was significantly associated with all-cause mortality (hazard ratio [HR] 2.473, 95%CI 1.062-5.756, p = .036) and with the composite endpoint (HR 1.852, 95%CI 1.106-3.102, p = .019).

CONCLUSIONS

In patients with AF, cognitive impairment (aMMSE <24) is associated with worse outcomes, and the association of adverse outcomes with previous treatment with antiplatelet drugs only, without oral anticoagulation, highlights the potential role of appropriate antithrombotic treatment for improving patient prognosis.

Effect of Sacubitril-Valsartan in reducing depression in patients with advanced heart failure

BACKGROUND

Depression is highly prevalent in Heart Failure (HF). Treatment with sacubitril/valsartan improved quality of life and survival in HF patients. Aim of the study was to investigate prospectively the effect of sacubitril/valsartan on depression in advanced HF patients in waiting list for heart transplant (HT).

METHODS

37 consecutive patients with advanced HF in waiting list for HT were treated with sacubitril/valsartan. We analyzed data derived from the assessment performed the year before the beginning of sacubitril/valsartan, at study entry, and at one year of follow-up. Depression was assessed with Beck Depression Inventory II (BDI) scale. Cognitive function were assessed with Mini-Mental State Examination (MMSE). Functioning was evaluated measuring meters at 6 Minute Walking Test (6MWT) and maximum rate of oxygen consumption (VO₂ max).

RESULTS

At baseline, 64.9% of HF patients were in NYHA III and 35.1% NYHA IIIB, BDI was 15.2 ± 5.2 with 59.5% of patients with a score > 13. MMSE was 27.8 ± 2.6. After one year of follow-up NYHA class improved significantly, with 56.8% in NYHA II, 40.5% in NYHA III and 2.7% NYHA in IIIB (p < 0.001). VO₂ max and 6MWT increased. Notably, BDI was 9.5 ± 3.9 with 21.6% of patients with a score > 13. MMSE remain stable (28.2 ± 2.1) (p = 0.104). No statistical differences are observed between data collected in the evaluation 1-year before and soon before treatment with sacubitril/valsartan. Multivariate regression analysis demonstrate a relationship between reduction in BDI-II score and improvement in six-minute walking test independently by the effect of sex, age, selective serotonin reuptake inhibitors, VO₂ max, NT-proBNP, PAPs, NYHA class differences evaluated at follow-up versus baseline.

CONCLUSIONS

Our study showed a reduction in depressive symptomatology in heart transplant waiting list patients treated with sacubitril/valsartan. The improvement in depressive symptomatology was paralleled by 6MWT increase in the follow-up.

Predicting non-elective hospital readmission or death using a composite assessment of cognitive and physical frailty in elderly inpatients with cardiovascular disease

Background

We aimed to assess the utility of the combination of the mini-mental state examination (MMSE) + clock drawing test (CDT) and the Fried phenotype for predicting non-elective hospital readmission or death within 6 months in elderly inpatients with cardiovascular disease (CVD).

Methods

A single-center prospective cohort was conducted from September 2018 to February 2019. Inpatients ≥65 years old were recruited. Predictive validity was tested using a Cox proportional hazards regression model analysis, and the discriminative ability was evaluated by the receiver operating characteristic (ROC) curve.

Results

A total of 542 patients were included. Overall, 12% (64/542) screened positive for cognitive impairment, 16% (86/542) were physically frail and 8% (44/542) had cognitive impairment combined with physical frailty, showing an older age (P < 0.001) and a lower education level (P < 0.001) than physically frail patients. A total of 113 patients (20.9%) died or were readmitted at 6 months. Frail participants with a normal (hazard ratio [HR]: 1.73, 95% confidence interval [CI]: 1.06–2.82, P = 0.028) or impaired cognition (HR: 2.50, 95% CI: 1.27–4.91, P = 0.008) had a higher risk of non-elective hospital readmission or death than robust patients after adjusting for the age, sex, education level, marital status, the presence of diabetes mellitus, heart failure, and history of stroke. The area under the ROC curve (AUC) showed that the discriminative ability in relation to 6 months readmission and death for the MMSE + CDT + Fried phenotype was 0.65 (95% CI: 0.60–0.71), and the AUC for men was 0.71 (95% CI: 0.63–0.78), while that for women was 0.60 (95% CI: 0.51–0.69).

Conclusions

Accounting for cognitive impairment in the frailty phenotype may allow for the better prediction of non-elective hospital readmission or death in elderly inpatients with CVD in the short term.

Trial registration

ChiCTR1800017204; date of registration: 07/18/2018.

Hemodynamic Instability in Heart Failure Intensifies Age-Dependent Cognitive Decline

This review attempts to examine two key elements in the evolution of cognitive impairment in the elderly who develop heart failure. First, major left side heart parts can structurally and functionally deteriorate from aging wear and tear to provoke hemodynamic instability where heart failure worsens or is initiated; second, heart failure is a major inducer of cognitive impairment and Alzheimer's disease in the elderly. In heart failure, when the left ventricular myocardium of an elderly person does not properly contract, it cannot pump out adequate blood to the brain, raising the risk of cognitive impairment due to the intensification of chronic brain hypoperfusion. Chronic brain hypoperfusion originates from chronically reduced cardiac output which progresses as heart failure worsens. Other left ventricular heart parts, including atrium, valves, myocardium, and aorta can contribute to the physiological shortfall of cardiac output. It follows that hemodynamic instability and perfusion changes occurring from the aging heart's blood pumping deficiency will, in time, damage vulnerable brain cells linked to specific cognitive regulatory sites, diminishing neuronal energy metabolism to a level where progressive cognitive impairment is the outcome. Could cognitive impairment progress be reversed with a heart transplant? Evidence is presented detailing the errant hemodynamic pathways leading to cognitive impairment during aging as an offshoot of inefficient structural and functional heart parts and their contribution to heart failure.

Differential Risk of Cognitive Impairment across Paid and Unpaid Occupations in the Middle-Age Population: Evidence from the Korean Longitudinal Study of Aging, 2006-2016

To examine and quantify the risk of cognitive impairment across a variety of occupations including unpaid work in a middle-age population using the dataset of a nationally representative longitudinal survey. A total of 20,932 observations of 5865 subjects aged 45–64 were obtained from six waves of the Korean Longitudinal Study of Aging (2006–2016). A dichotomous outcome variable was constructed on the basis of the Korean Versions of the Mini-Mental State Examination scores, and occupations were grouped into 10 occupation categories, including unpaid housekeepers. Socio-demographics, lifestyle, and medical conditions were used as covariates in mixed logistic regression models. Adjusted odds ratios and predicted probabilities of cognitive impairment were computed and adjusted for a complex survey design. In longitudinal models with all studied covariates, the risk of cognitive impairment differed significantly across occupation categories, but the association of occupation with the risk of cognitive impairment was the same between genders. In terms of the predicted probability, the risk of cognitive impairment in the unpaid housekeepers’ category (11.2%, 95% confidence interval (CI): 10.4% to 11.9%) was the highest among occupation categories, being three times higher than in the professionals’ and related workers’ category (3.7%, 95% CI: 1.6% to 5.7%). Public policies based on studies of the risk of cognitive impairment across different occupations in the middle-age population should be designed so as to prevent cognitive impairment in the middle-age population as well as their older life stages, particularly targeting high-risk groups such as people engaged in unpaid domestic and care activities.

Improving Cerebrovascular Function to Increase Neuronal Recovery in Neurodegeneration Associated to Cardiovascular Disease

Mounting evidence indicates that the presence of cardiovascular disease (CVD) and risk factors elevates the incidence of cognitive impairment (CI) and dementia. CVD and associated decline in cardiovascular function can impair cerebral blood flow (CBF) regulation, leading to the disruption of oxygen and nutrient supply in the brain where limited intracellular energy storage capacity critically depends on CBF to sustain proper neuronal functioning. During hypertension and acute as well as chronic CVD, cerebral hypoperfusion and impaired cerebrovascular function are often associated with neurodegeneration and can lead to CI and dementia. Currently, all forms of neurodegeneration associated to CVD lack effective treatments, which highlights the need to better understand specific mechanisms linking cerebrovascular dysfunction and CBF deficits to neurodegeneration. In this review, we discuss vascular targets that have already shown attenuation of neurodegeneration or CI associated to hypertension, heart failure (HF) and stroke by improving cerebrovascular function or CBF deficits.

Association of cardiovascular structure and function with cerebrovascular changes and cognitive function in older patients with end-stage renal disease

The Dutch prospective multicenter cohort study COPE (Cognitive decline in Older Patients with End stage renal disease) aimed to investigate the association of cardiovascular structure and function with cerebrovascular changes and cognitive function in 85 older patients with chronic kidney disease stage 4 and 5, awaiting either dialysis or conservative care. MRI was performed measuring aortic stiffness (pulse wave velocity [PWV]) and cardiac systolic function (ejection fraction and cardiac index). Outcomes were MRI-derived cerebrovascular changes (microbleeds, lacunes and white matter hyperintensities) and cognitive function (memory, executive function and psychomotor speed). Mean age was 76 years and 66% were male. No statistically significant associations were observed between cardiovascular parameters and cerebrovascular changes. Cognitive function was worse in patients with high compared to low PWV in all three cognitive domains. Although there were clinically relevant associations of high PWV with poor cognition in all domains, after adjustment for age, sex and education only the Trail Making Test A remained statistically significant (p=0.030). In conclusion, this study suggests that a higher PWV might be associated with lower cognitive function, suggesting that arterial stiffness may be an underlying mechanism of development of cognitive impairment in older patients with ESRD. Larger studies should replicate and extend these findings.

Associations between heart failure and risk of dementia: A PRISMA-compliant meta-analysis

BACKGROUND

There are differences among the outcomes regarding cognitive impairment in heart failure (HF) because the evidence is fragmented and sample size is small. Therefore we aimed to systematically review and analyze the available evidence about the association between HF and dementia.

METHODS

In the present study, we searched for articles published until August 2019 in the following databases: PubMed, Web of Science, EMBASE, Medline and Google Scholar. The pooled multivariate odds ratio (OR) or relative risk (RR) and 95% confidence intervals (CI) were obtained by the use of STATA 12.0 software.

RESULTS

The meta-analysis showed a positive association between HF and risk of all-cause dementia (OR/RR = 1.28, 95% CI 1.15 to 1.43, I = 70.0%, P < 0.001). Additionally, the study showed no significant association between HF and risk of Alzheimer's disease (AD) (OR/RR = 1.38, 95% CI 0.90 to 2.13, I = 74.8%, P = 0.008).

CONCLUSION

In conclusion, HF was associated with an increased risk of developing dementia. In addition, large scale prospective studies are essential to explore the associations between HF and risk of AD.

Cognitive impairment in heart failure is associated with altered Wnt signaling in the hippocampus

Age represents the highest risk factor for death due to cardiovascular disease. Heart failure (HF) is the most common cardiovascular disease in elder population and it is associated with cognitive impairment (CI), diminishing learning and memory process affecting life quality and mortality in these patients. In HF, CI has been associated with inadequate O₂ supply to the brain; however, an important subset of HF patients displays CI with almost no alteration in cerebral blood flow. Importantly, nothing is known about the pathophysiological mechanisms underpinning CI in HF with no change in brain tissue perfusion. Here, we aimed to study memory performance and learning function in a rodent model of HF that shows no change in blood flow going to the brain. We found that HF rats presented learning impairments and memory loss. In addition, HF rats displayed a decreased level of Wnt/β-catenin signaling downstream elements in the hippocampus, one pathway implicated largely in aging diseases. Taken together, our results suggest that in HF rats CI is associated with dysfunction of the Wnt/β-catenin signaling pathway. The mechanisms involved in the alterations of Wnt/β-catenin signaling in HF and its contribution to the development/maintenance of CI deserves future investigations.

Neurocognitive Disorders in Heart Failure: Novel Pathophysiological Mechanisms Underpinning Memory Loss and Learning Impairment

Heart failure (HF) is a major public health issue affecting more than 26 million people worldwide. HF is the most common cardiovascular disease in elder population; and it is associated with neurocognitive function decline, which represent underlying brain pathology diminishing learning and memory faculties. Both HF and neurocognitive impairment are associated with recurrent hospitalization episodes and increased mortality rate in older people, but particularly when they occur simultaneously. Overall, the published studies seem to confirm that HF patients display functional impairments relating to attention, memory, concentration, learning, and executive functioning compared with age-matched controls. However, little is known about the molecular mechanisms underpinning neurocognitive decline in HF. The present review round step recent evidence related to the possible molecular mechanism involved in the establishment of neurocognitive disorders during HF. We will make a special focus on cerebral ischemia, neuroinflammation and oxidative stress, Wnt signaling, and mitochondrial DNA alterations as possible mechanisms associated with cognitive decline in HF. Also, we provide an integrative mechanism linking pathophysiological hallmarks of altered cardiorespiratory control and the development of cognitive dysfunction in HF patients. Graphical Abstract Main molecular mechanisms involved in the establishment of cognitive impairment during heart failure. Heart failure is characterized by chronic activation of brain areas responsible for increasing cardiac sympathetic load. In addition, HF patients also show neurocognitive impairment, suggesting that the overall mechanisms that underpin cardiac sympathoexcitation may be related to the development of cognitive disorders in HF. In low cardiac output, HF cerebral infarction due to cardiac mural emboli and cerebral ischemia due to chronic or intermittent cerebral hypoperfusion has been described as a major mechanism related to the development of CI. In addition, while acute norepinephrine (NE) release may be relevant to induce neural plasticity in the hippocampus, chronic or tonic release of NE may exert the opposite effects due to desensitization of the adrenergic signaling pathway due to receptor internalization. Enhanced chemoreflex drive is a major source of sympathoexcitation in HF, and this phenomenon elevates brain ROS levels and induces neuroinflammation through breathing instability. Importantly, both oxidative stress and neuroinflammation can induce mitochondrial dysfunction and vice versa. Then, this ROS inflammatory pathway may propagate within the brain and potentially contribute to the development of cognitive impairment in HF through the activation/inhibition of key molecular pathways involved in neurocognitive decline such as the Wnt signaling pathway.

Self-management of heart failure in dementia and cognitive impairment: a systematic review

BACKGROUND

The cornerstone of effective management in heart failure (HF) is the ability to self-care. Aims include i) To determine factors influencing self-care in HF patients with cognitive impairment (CI) and ii) to determine the influence of cognitive domains on self-care in patients with HF and CI.

METHODS

MEDLINE, CINAHL, EMBASE, EBSCOHost, PsychINFO, ProQuest Research Library, Health Technology Assessment Database, The Cochrane Library, Web of Science and Scopus databases were systematically searched. Original research describing the relationship between cognition and HF self-care in community-dwelling older persons with dementia/CI in English, published in a peer-reviewed journal from 1^stJanuary(2000)-22^ndMarch(2016) was identified. Study and population characteristics, data sources, self-care processes, methods of cognitive assessment, cognitive domains affected, study outcomes, impact of impairment, and other risk factors of self-care impairment were abstracted by two reviewers.

RESULTS

Of 10,688 studies identified, 14 met the inclusion criteria. Patients with HF and CI ranged from 14 to 73%. Where reported, self-care maintenance adequacy ranged from 50 to 61%; self-care management adequacy ranged from 14 to 36% and self-care confidence adequacy ranged from 0 to 44% on the Self-care of Heart Failure Index (SCHFI). All but one study predicted poor self-care ability according to poor outcome on cognitive testing. Additionally, specific cognitive domain deficits impaired self-care. Subjects with lower cognitive scores were less likely to seek assistance while subjects with depression had poor self-care abilities.

CONCLUSIONS

Clinicians must consider the type and severity of impairments in cognitive domains to tailor management. Awareness of depression, self-confidence and support access may modulate self-care ability.

Protective effect of physical activity on mortality in older adults with advanced chronic heart failure: A prospective observational study

Objectives

The objective of this study was to evaluate the effect on mortality of self-reported physical activity evaluated by the physical activity scale for the elderly (PASE) in elderly patients with advanced heart failure enrolled in a cardiac rehabilitation unit after heart failure decompensation (NYHA class IIIB).

Methods

The study prospectively enrolled 314 elderly patients (≥65 years) with heart failure in NYHA class IIIB (symptomatic with a recent history of dyspnoea at rest) consecutively admitted to cardiac rehabilitation between January 2010 and July 2011. Comprehensive geriatric assessment was performed. Physical activity was evaluated by PASE and stratified in tertiles (0–15, 16–75 and >75). Mortality was collected from September to October 2015 in 300 patients.

Results

The mean age was 74.5 ± 6.1 (range 65–89); 74.7% were men, 132 patients (44.0%) died during the follow-up (44.1 ± 20.7 months). Univariate analysis shows that physical activity level conducted before heart failure decompensation was inversely related to mortality (from 76.0% to 8.2%, P = 0.000). Multivariate analysis confirms that the PASE score predicts mortality independently of several demographic and clinical variables (hazard rate 0.987, 95% confidence interval (CI) 0.980–0.994, P = 0.000). Notably, when considering PASE 0–15 versus 16–75 score and PASE 0–15 versus > 75 score, the hazard rate is 4.06 (95% CI 1.67–9.84, P < 0.001) and 7.25 (95% CI 2.7–19.5, P < 0.001), respectively.

Conclusions

Physical activity level evaluated by the PASE score is inversely related to mortality in elderly patients with advanced heart failure confirming the reduction of mortality exerted by moderate physical activity in such patients.

Anticoagulant use in atrial fibrillation and risk of dementia: review of contemporary knowledge

INTRODUCTION

Atrial fibrillation (AF) is strongly associated with dementia, including idiopathic dementias such as Alzheimer's disease. The relative risk of dementia is highest in AF patients 70 years and younger, and the burden of exposure to arrhythmia appears to underlie part of the risk. Areas covered: Anticoagulation choices and approach influence dementia risk. In warfarin patients, inadequate time spent in therapeutic range is highly associated with the increased dementia risk long-term. This risk is further accentuated with frequent over anticoagulation in patients also receiving aspirin. Direct oral anticoagulant therapies in early observational studies show that there is potential for improving long-term risk of dementia when compared to warfarin, although prospective trials are needed. AF and dementia are end manifestations of systemic disease; a systemic approach is needed with early treatment of shared risk factors to prevent disease presentation altogether. Expert commentary: In this review, we will bring together available data with regards to the link between anticoagulant use for AF and dementia. Anticoagulation initiation timing, use, and efficacy remain critical risk factors for dementia in AF patients and consequently provide opportunities to decrease risk.

Association of Atrial Fibrillation With Cognitive Decline and Dementia Over 20 Years: The ARIC-NCS (Atherosclerosis Risk in Communities Neurocognitive Study)

BACKGROUND

Previous studies have reported that atrial fibrillation (AF) is associated with cognitive decline and dementia. These studies, however, had limited follow-up, were based mostly on white and highly selected populations, and did not account for attrition. We evaluated the association of incident AF with 20-year change in cognitive performance (accounting for attrition) and incident dementia in the ARIC (Atherosclerosis Risk in Communities) Study.

METHODS AND RESULTS

We analyzed data from 12 515 participants (mean age, 56.9 [SD, 5.7] years in 1990-1992; 56% women and 24% black) from 1990 to 1992 through 2011 to 2013. Incident AF was ascertained from study ECGs and hospital discharge codes. Cognitive tests were performed in 1990 to 1992, 1996 to 1998, and 2011 to 2013. Incident dementia was clinician adjudicated. We used generalized estimating equations and Cox proportional hazards models to assess the association of time-dependent AF with change in Z scores of cognitive tests and incident dementia, respectively. During 20 years, 2106 participants developed AF and 1157 participants developed dementia. After accounting for cardiovascular risk factors, including ischemic stroke, the average decline over 20 years in global cognitive Z score was 0.115 (95% confidence interval, 0.014-0.215) greater in participants with AF than in those without AF. Further adjustment for attrition by multiple imputation by chained equations strengthened the association. In addition, incident AF was associated with an increased risk of dementia (hazard ratio, 1.23; 95% confidence interval, 1.04-1.45), after adjusting for cardiovascular risk factors, including ischemic stroke.

CONCLUSIONS

AF is associated with greater cognitive decline and increased risk of dementia, independent of ischemic stroke. Because cognitive decline is a precursor to dementia, our findings prompt further investigation to identify specific treatments for AF that will delay the trajectory of cognitive decline and, thus, prevent dementia in patients with AF.

Medication use in a cohort of newly admitted nursing home residents (Ageing@NH) in relation to evolving physical and mental health

BACKGROUND

Medication use is high among nursing home (NH) residents, but there is a lack of longitudinal studies, determining medication use at admission and its evolution over time.

AIM

Describing the evolution of the medication use two years after entering a NH, compared to the baseline observations and exploring the relation to the physical and mental health.

METHODS

Data from the observational prospective Ageing@NH study, based on an inception cohort of newly admitted residents at NHs (65+) was used, selecting those consenting and with medication chart available. Information about socio-demographic, functional and mental characteristics, as well as medication use, was collected at baseline, year 1 and year 2.

RESULTS

Medication chart was available for n = 741 at baseline (mean age 83.8, 66% female), and for n = 342 residents in year 2. The mean number of total medications increased from 8.9 to 10.1 (p-value < 0.001). Polypharmacy was high, with an increase in extreme polypharmacy from 23% to 32%. The biggest increase was noted in the respiratory (from 17% to 27%) and alimentary medications (from 80% to 87%). Cardiovascular medication use in year 2, was lower in those with stable high dependency (77%) and those evolving from low to high dependency (79%), than those with stable low dependency (89%) (p < 0.025). For residents with or evolving to dementia symptoms, decline in most medication groups was observed, especially in pain and sleeping medications, while antipsychotics use increased.

CONCLUSION

Although medication use was high, signs of deprescribing were noted when the physical and mental health of the residents declined.

Impact of delirium on postoperative frailty and long term cardiovascular events after cardiac surgery

BACKGROUND

Postoperative delirium (POD) is a common and critical complication after cardiac surgery. However, the relationship between POD and postoperative physical frailty and the effect of both on long-term clinical outcomes have not been fully explored.

OBJECTIVE

We aimed to examine the associations among POD, postoperative frailty, and major adverse cardiac events (MACE).

DESIGN

This was a prospective cohort study.

METHODS

We studied 329 consecutive patients undergoing elective cardiac surgery. The intensive care delirium screening checklist was used to assess POD. Postoperative frailty was defined by handgrip strength and walking speed. Patients were subsequently followed-up to detect MACE.

RESULTS

POD was present in 13.2%, while the incidence of postoperative frailty was 27.0%. POD was independently associated with development of postoperative frailty (adjusted odds ratio = 2.98). During follow-up, MACE occurred in 14.1% of all participants. On multivariate Cox proportional hazard analysis, POD (adjusted hazard ratio (HR) = 3.36), postoperative frailty (HR = 2.21), postoperative complications (HR = 1.54), and left ventricular ejection fraction (HR = 0.95) were independently associated with increased risk of MACE.

LIMITATIONS

It is a single-center study with a risk of bias. We did not investigate follow up cognitive function.

CONCLUSIONS

POD was a predictor of postoperative frailty after cardiac surgery. Both postoperative frailty and POD were associated with the incidence of MACE, while POD was the stronger predictor of MACE. Thus, POD and frailty play critical roles in the risk stratification of patients undergoing cardiac surgery.

Burden of Psychosocial and Cognitive Impairment in Patients With Atrial Fibrillation

BACKGROUND

Impairments in psychosocial status and cognition relate to poor clinical outcomes in patients with atrial fibrillation (AF). However, how often these conditions co-occur and associations between burden of psychosocial and cognitive impairment and quality of life (QoL) have not been systematically examined in patients with AF.

METHODS

A total of 218 patients with symptomatic AF were enrolled in a prospective study of AF and psychosocial factors between May 2013 and October 2014 at the University of Massachusetts Medical Center. Cognitive function, depression, and anxiety were assessed at baseline and AF-specific QoL was assessed 6 months after enrollment using validated instruments. Demographic and clinical information were obtained from a structured interview and medical record review.

RESULTS

The mean age of the study participants was 63.5 ± 10.2 years, 35% were male, and 81% had paroxysmal AF. Prevalences of impairment in 1, 2, and 3 psychosocial/cognitive domains (eg, depression, anxiety, or cognition) were 75 (34.4%), 51 (23.4%), and 16 (7.3%), respectively. Patients with co-occurring psychosocial/cognitive impairments (eg, >1 domain) were older, more likely to smoke, had less education, and were more likely to have heart failure (all P < 0.05). Compared with participants with no psychosocial/cognitive impairments, AF-specific QoL at 6 months was significantly poorer among participants with baseline impairment in 2 (B = -13.6, 95% CI: -21.7 to -5.4) or 3 (B = -15.1, 95% CI: -28.0 to -2.2) psychosocial/cognitive domains.

CONCLUSION

Depression, anxiety, and impaired cognition were common in our cohort of patients with symptomatic AF and often co-occurred. Higher burden of psychosocial/cognitive impairment was associated with poorer AF-specific QoL.

Effects of a Sedentary Intervention on Cognitive Function

PURPOSE

To examine the effects of a free-living, sedentary-inducing intervention on cognitive function.

DESIGN

Randomized controlled, parallel group intervention.

SETTING

University campus.

PARTICIPANTS

Thirty-three young adults (n = 23 intervention; n = 10 control).

MEASURES

The intervention group was asked to eliminate all exercise and minimize steps to ≤5000 steps/day for 1 week, whereas the control group was asked to continue normal physical activity (PA) levels for 1 week. Both groups completed a series of 8 cognitive function assessments (assessing multiple parameters of cognition) preintervention and immediately postintervention. The intervention group was asked to resume normal PA levels for 1 week postintervention and completed the cognitive assessments for a third time at 2 weeks postintervention.

ANALYSIS

Split-plot repeated-measures analysis of variance.

RESULTS

The results of our statistical analyses showed that the group × time interaction effect was not significant ( P > .05) for any of the evaluated cognitive parameters.

CONCLUSION

These findings demonstrate the need for future experimental investigations of sedentary behavior to better understand its effects on cognitive function. However, although previous work has demonstrated favorable effects of acute and chronic PA on cognitive function, our findings suggest that a 1-week period of reduced PA does not detrimentally affect cognitive function, which may have encouraging implications for individuals going through a temporary relapse in PA.

Hyponatremia, Cognitive Function, and Mobility in an Outpatient Heart Failure Population

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.

Validity of self-reported hospital admissions in clinical trials depends on recall period length and individual characteristics

RATIONALE, AIMS AND OBJECTIVES

We investigated the validity of self-reported admission data compared to administrative records in a clinical trial.

METHOD

In the randomized KORINNA study (ISRCTN02893746), hospital admission data were collected in telephone interviews with 273 elderly patients quarterly over a 1-year period and thereafter annually over a 2-year period. Data were compared with administrative records and discharge letters. Mixed models were used to investigate if recall period and individual characteristics influence validity.

RESULTS

Specificity (>99%) and sensitivity (94%) of self-reported data did not differ for different recall periods (3 months vs. 12 months). The differences between self-reported and registered inpatient days were not statistically significant. Having regard to all the admissions within the time period of last interview and dropping out, the bias was up to 40% underestimation. The chance of disagreement was significantly smaller [odds ratio (OR) of misremember an admission = 0.596, P = 0.049, confidence interval (CI) = 0.355 to 1.00; OR of misremember length of stay = 0.521, P = 0.002, CI = 0.344 to 0.789] for 3-month periods, but this was primarily driven by number of admissions within the recall period. Individuals with better health and longer stays had a significantly smaller chance of disagreement.

CONCLUSIONS

The bias within one year was not influenced by applying various recall periods, although the probability of correctly self-reported single hospital admission was higher using a recall period of three months. It can be recommended that lengthened recall periods of 12 months are appropriate for gathering self-reported hospital admission data in elderly people with myocardial infarction.

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.

Health Status and Self-care Outcomes After an Education-Support Intervention for People With Chronic Heart Failure

BACKGROUND

The rising cost of hospitalizations for heart failure (HF) care mandates intervention models to address education for self-care success. The effectiveness of memory enhancement strategies to improve self-care and learning needs further examination.

OBJECTIVE

The objective of this study was to examine the effects of an education-support intervention delivered in the home setting, using strategies to improve health status and self-care in adults/older adults with class I to III HF. Our secondary purpose was to explore participants' subjective perceptions of the intervention.

METHODS

This study used a randomized, 2-group design. Fifty people were enrolled for 9 months and tested at 4 time points-baseline; after a 3-month education-support intervention; at 6 months, after 3 months of telephone/e-mail support; and 9 months, after a 3-month period of no contact. Advanced practice registered nurses delivered the intervention. Memory enhancement methods were built into the teaching materials and delivery of the intervention. We measured the intervention's effectiveness on health status outcomes (functional status, self-efficacy, quality of life, emotional state/depressive symptoms, and metamemory) and self-care outcomes (knowledge/knowledge retention, self-care ability). Subjects evaluated the usefulness of the intervention at the end of the study.

RESULTS

The mean age of the sample was 62.4 years, with a slight majority of female participants. Participants were well educated and had other concomitant diseases, including diabetes (48%) and an unexpected degree of obesity. The intervention group showed significant improvements in functional status, self-efficacy, and quality of life (Kansas City Cardiomyopathy Questionnaire); metamemory Change and Capacity subscales (Metamemory in Adulthood Questionnaire); self-care knowledge (HF Knowledge Test); and self-care (Self-care in Heart Failure Index). Participants in both groups improved in depressive scores (Geriatric Depression Scale).

CONCLUSIONS

An in-home intervention delivered by advanced practice registered nurses was successful in several health status and self-care outcomes, including functional status, self-efficacy, quality of life, metamemory, self-care status, and HF knowledge.

Burden of Comorbidities and Functional and Cognitive Impairments in Elderly Patients at the Initial Diagnosis of Heart Failure and Their Impact on Total Mortality: The Cardiovascular Health Study

OBJECTIVES

The purpose of this study was to determine the prevalence of clinically relevant comorbidities and measures of physical and cognitive impairment in elderly persons with incident heart failure (HF).

BACKGROUND

Comorbidities and functional and cognitive impairments are common in the elderly and often associated with greater mortality risk.

METHODS

We examined the prevalence of 9 comorbidities and 4 measures of functional and cognitive impairments in 558 participants from the Cardiovascular Health Study who developed incident HF between 1990 and 2002. Participants were followed prospectively until mid-2008 to determine their mortality risk.

RESULTS

Mean age of participants was 79.2 ± 6.3 years with 52% being men. Sixty percent of participants had ≥3 comorbidities, and only 2.5% had none. Twenty-two percent and 44% of participants had ≥1 activity of daily living (ADL) and ≥1 instrumental activity of daily living (IADL) impaired respectively. Seventeen percent of participants had cognitive impairment (modified mini-mental state exam score <80, scores range between 0 and 100). During follow up, 504 participants died, with 1-, 5-, and 10-year mortality rates of 19%, 56%, and 83%, respectively. In a multivariable-adjusted model, the following were significantly associated with greater total mortality risk: diabetes mellitus (hazard ratio [HR]: 1.64; 95% confidence interval [CI]: 1.33 to 2.03), chronic kidney disease (HR: 1.32; 95% CI: 1.07 to 1.62 for moderate disease; HR: 3.00; 95% CI: 1.82 to 4.95 for severe), cerebrovascular disease (HR: 1.53; 95% CI: 1.22 to 1.92), depression (HR: 1.44; 95% CI: 1.09 to 1.90), functional impairment (HR: 1.30; 95% CI: 1.04 to 1.63 for 1 IADL impaired; HR: 1.49; 95% CI: 1.07 to 2.04 for ≥2 IADL impaired), and cognitive impairment (HR: 1.33; 95% CI: 1.02 to 1.73). Other comorbidities (hypertension, coronary heart disease, peripheral arterial disease, atrial fibrillation, and obstructive airway disease) and measures of functional impairments (ADLs and 15-ft walk time) were not associated with mortality.

CONCLUSIONS

Elderly patients with incident HF have a high burden of comorbidities and functional and cognitive impairments. Some of these conditions are associated with greater mortality risk.

Cerebral impairment in heart failure

Patients with heart failure (HF) exhibit a wide range of symptoms, including dyspnea, sleep-disordered breathing, autonomic abnormalities, cognitive dysfunction, and neuropsychological disturbances. These symptoms, which affect quality of life and morbidity and mortality in the condition, are largely related to structural and functional changes in the brain. There are increasing reports of brain abnormalities in HF, but often the linkages between brain injury and common HF clinical symptomatology are not clearly described. In this review, we will discuss the current evidence of brain injury and the associated clinical symptoms in HF, focusing on those brain regions that are commonly damaged in the condition. We will also provide a brief exploration of some potential mechanisms for brain injury in HF.

Coronary heart disease risk factors and outcomes in the twenty-first century: findings from the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study

REasons for Geographic and Racial Differences in Stroke (REGARDS) is a longitudinal study supported by the National Institutes of Health to determine the disparities in stroke-related mortality across USA. REGARDS has published a body of work designed to understand the disparities in prevalence, awareness, treatment, and control of coronary heart disease (CHD) and its risk factors in a biracial national cohort. REGARDS has focused on racial and geographical disparities in the quality and access to health care, the influence of lack of medical insurance, and has attempted to contrast current guidelines in lipid lowering for secondary prevention in a nationwide cohort. It has described CHD risk from nontraditional risk factors such as chronic kidney disease, atrial fibrillation, and inflammation (i.e., high-sensitivity C-reactive protein) and has also assessed the role of depression, psychosocial, environmental, and lifestyle factors in CHD risk with emphasis on risk factor modification and ideal lifestyle factors. REGARDS has examined the utility of various methodologies, e.g., the process of medical record adjudication, proxy-based cause of death, and use of claim-based algorithms to determine CHD risk. Some valuable insight into less well-studied concepts such as the reliability of current troponin assays to identify "microsize infarcts," caregiving stress, and CHD, heart failure, and cognitive decline have also emerged. In this review, we discuss some of the most important findings from REGARDS in the context of the existing literature in an effort to identify gaps and directions for further research.

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 function in ambulatory patients with systolic heart failure: insights from the warfarin versus aspirin in reduced cardiac ejection fraction (WARCEF) trial

We sought to determine whether cognitive function in stable outpatients with heart failure (HF) is affected by HF severity. A retrospective, cross-sectional analysis was performed using data from 2, 043 outpatients with systolic HF and without prior stroke enrolled in the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) Trial. Multivariable regression analysis was used to assess the relationship between cognitive function measured using the Mini-Mental Status Exam (MMSE) and markers of HF severity (left ventricular ejection fraction [LVEF], New York Heart Association [NYHA] functional class, and 6-minute walk distance). The mean (SD) for the MMSE was 28.6 (2.0), with 64 (3.1%) of the 2,043 patients meeting the cut-off of MMSE <24 that indicates need for further evaluation of cognitive impairment. After adjustment for demographic and clinical covariates, 6-minute walk distance (β-coefficient 0.002, p<0.0001), but not LVEF or NYHA functional class, was independently associated with the MMSE as a continuous measure. Age, education, smoking status, body mass index, and hemoglobin level were also independently associated with the MMSE. In conclusion, six-minute walk distance, but not LVEF or NYHA functional class, was an important predictor of cognitive function in ambulatory patients with systolic heart failure.

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.

Treatment for chronic heart failure in the elderly: current practice and problems

Treatment for chronic heart failure (CHF) is strongly focused on evidence-based medicine. However, large trials are often far away from the "real world" of geriatric patients and their messages are poorly transferable to the clinical management of CHF elderly patients. Precipitating factors and especially non-cardiac comorbidity may decompensate CHF in the elderly. More importantly, drugs of first choice, such as angiotensin-converting enzyme inhibitors and β-blockers, are still underused and effective drugs on diastolic dysfunction are not available. Poor adherence to therapy, especially for cognitive and depression disorders, worsens the management. Electrical therapy is indicated, but attention to the older age groups with reduced life expectancy has to be paid. Physical exercise, stem cells, gene delivery, and new devices are encouraging, but definitive results are still not available. Palliative care plays a key role to the end-stage of the disease. Follow-up of CHF elderly patient is very important but tele-medicine is the future. Finally, self-care management, caregiver training, and multidimensional team represent the critical point of the treatment for CHF elderly patients.

Long-term mortality in frail elderly subjects with osteoarthritis

OBJECTIVE

Elderly subjects are characterized by a high prevalence of OA and clinical frailty. This study aimed to examine the predictive role of clinical frailty on long-term mortality in elderly subjects with and without OA.

METHODS

Mortality was evaluated after a 12-year follow-up in 698 subjects with and 590 subjects without OA recruited in 1992. Clinical frailty was assessed according to the Frailty Staging System and stratified in tertiles.

RESULTS

After a 12-year follow-up, mortality was 42.2% in subjects without and 55.8% in subjects with OA (P = 0.256). With increasing frailty, mortality increased by 30.5% (P for trend < 0.001) in subjects without and by 45.6% in subjects with OA (P for trend < 0.001). Multivariate analysis showed that frailty [hazard ratio (HR) = 1.49 for each unit of increase, 95% CI 1.32, 1.94, P < 0.001) but not OA (HR = 1.28, 95% CI 0.987, 1.39, P = 0.412) was predictive of long-term mortality. Moreover, when Cox regression analysis was performed, frailty enhanced the risk of long-term mortality for each unit of increase by 32% (HR = 1.32, 95% CI 1.06, 1.65, P = 0.03) in the absence of OA and by 98% in the presence (HR = 1.98, 95% CI 1.63, 2.95, P < 0.01) of OA.

CONCLUSION

Clinical frailty significantly predicts mortality in subjects without OA and even more in those with OA. Thus clinical frailty may be considered a new prognostic factor to identify subjects with OA at high risk of mortality.

The Mini-Mental State Exam (MMSE) is not sensitive to cognitive impairment in bariatric surgery candidates

BACKGROUND

Cognitive dysfunction is common among bariatric surgery candidates and associated with poorer weight loss outcomes. Identification of a brief screening measure to detect cognitive impairment in this population is needed, because comprehensive neuropsychological evaluations may not be available in all clinical settings.

METHODS

The present study examined the utility of the Mini-Mental State Examination (MMSE) for detecting cognitive impairment in 30 bariatric surgery candidates by comparing impairment on the MMSE (at varying cutoffs) to impairment on a comprehensive neuropsychological test battery.

RESULTS

Results indicated that the MMSE showed low sensitivity and specificity in identifying impairment, even at the more stringent MMSE cutoffs of 27 and 28.

CONCLUSION

These findings suggest that the MMSE is a poor screener for cognitive impairment in bariatric surgery candidates. Future research is needed to identify or develop cognitive screeners for use in this population.