The effect of pacemaker mode on cognitive function

Neurologic complications of brady-arrhythmias

Brady-arrhythmias are responsible for both overt as well as subtle neurologic signs and symptoms, from the seemingly benign and nonspecific symptoms associated with presyncope, to sudden focal neurologic deficits. A brief background on nodal and infra-nodal brady-arrhythmias is provided, followed by extensive discussion regarding neurologic complications of brady-arrhythmias. The multiple mechanisms of and associations between Brady-arrhythmias and transient ischemic attacks and ischemic stroke are discussed. Controversial associations between brady-arrhythmias and neurologic disease are discussed as well, such as potential roles of brady-arrhythmias in cognitive impairment and sequelae of chronotropic incompetence; and the contribution of brady-arrhythmias to syncope and associated injuries to the nervous system. The chapter is written to stand on its own, with guidance toward other pertinent sections of this text where appropriate for further reading.

Extreme pacemaker reel syndrome in an elderly patient with cognitive impairment

Twiddler's syndrome is a rare cause of pacemaker failure, where patient manipulation of the pulse generator results in lead dislodgement or retraction. Variations in manifestation have been identified including reel syndrome, where rotation occurs around the transverse axis resulting in coiling of the leads, and ratchet syndrome where arm movement results in lead displacement. Device manipulation leading to device failure has been documented in up to 1.7% of implants, particularly in patients with large pockets or mental disorders. Such complications have serious consequences, particularly in pacing-dependent patients where loss of capture may result in asystole. This article reviews the case of an 84-year-old patient presenting at 8-month pacemaker follow-up in complete heart block with no evidence of pacemaker function.

"I'm Not Sure We Had A Choice": Decision Quality and The Use of Cardiac Implantable Electronic Devices In Older Adults With Cognitive Impairment

Background

The decision to implant a cardiac device in a person with Alzheimer’s disease or related dementia requires considering the possible trade-offs of quality of life (QOL) and quantity of life. This study measured the decision-making experience of patients with and without cognitive impairment (CI) who received a cardiac device and their family members who were involved in the decision.

Methods and Results

Semi-structured interviews and questionnaires were administered with 15 patient-family member dyads. Interviews revealed few conversations between physicians, patients and family members about the patient’s cognitive status or about the benefits, risks, and long-term implications of the device for someone with CI. Participants largely stated that the decision to get the device was based on the patient’s functional status at the time of the implant, and not on expectations about future functioning. Patients with CI had more regret, measured with the Decision Regret Scale (DRS), (p=0.037) and family members of patients without CI reported more decisional conflict, measured with the Decisional Conflict Scale (p=0.057).

Conclusions

Although CI impacts life expectancy and QOL, cognitive status was largely not discussed prior to device implant. Few differences were found between the experiences of dyads that included patients with or without CI.

The COGNITION study rationale and design: influence of closed loop stimulation on cognitive performance in pacemaker patients

BACKGROUND

Several studies showed the beneficial effect of pacemaker implantation on cognitive performance in patients with bradycardia. But it has never been investigated if patients with chronotropic incompetence may improve their cognitive performance if treated by a rate-adaptive system reacting to mental stress in comparison to the most frequently used accelerometer-driven pacing.

METHODS

The randomized, single-blind, multicenter COGNITION study evaluates if closed loop stimulation (CLS) offers incremental benefit in the speed of cognitive performance and the overall well-being of elderly patients with bradycardia compared with accelerometer-based pacing. Four hundred chronotropically incompetent patients older than 55 years will be randomized 3-6 weeks after implantation to CLS or accelerometer sensor. Follow-up visits are performed after 12 and 24 months. The speed of cognitive performance, which is the underlying function influencing all other aspects of cognitive performance, will be assessed by the number connection test, a standardized psychometric test for the elderly. Secondary endpoints include patient self-assessment of different aspects of health (by visual analogue scales), quality of life (by SF-8 health survey), the incidence of atrial fibrillation (episodes lasting for longer than 24 hours), and the frequency of serious adverse events.

CONCLUSION

In the ongoing COGNITION study, we aim at long-term comparison of two rate-adaptive systems, focusing on the cognitive performance of the patients, which was neglected in the past evaluation of pacemaker sensors.