Cognitive Impairment in Older Adults with Heart Failure: Prevalence, Documentation, and Impact on Outcomes

Abstract

Background Despite the fact that 80% of patients with heart failure are over age 65, recognition of cognitive impairment by physicians in this population has received relatively little attention. The purpose of our study was to evaluate physician documentation (as a measure of recognition) of cognitive impairment at time of discharge in a cohort of older adults hospitalized for heart failure. Methods We performed a prospective cohort study of older adults hospitalized with a primary diagnosis of heart failure. Cognitive status was evaluated with the Folstein Mini-Mental State Examination (MMSE) at the time of hospitalization. A score of 21–24 was used to indicate mild cognitive impairment, and a score of ≤20 to indicate moderate to severe impairment. To evaluate physician documentation of cognitive impairment, we used a standardized form with a targeted keyword strategy to review hospital discharge summaries. We calculated the proportion of patients with cognitive impairment documented as such by physicians, and compared characteristics between groups with and without documented cognitive impairment. We then analyzed the association of cognitive impairment, and documentation of cognitive impairment, with 6-month mortality or readmission using Cox proportional hazards regression. Results A total of 282 patients completed the cognitive assessment. Their mean age was 80 years of age, 18.8% were nonwhite, and 53.2% were female. Cognitive impairment was present in 132/282 patients (46.8% overall; 25.2% mild, 21.6% moderate-severe). Among those with cognitive impairment, 30/132 (22.7%) were documented as such by physicians. Compared with patients whose cognitive impairment was documented by physicians, those whose impairment was not documented were younger (81.3 years vs. 85.2 years, P<0.05) and had less severe impairment (median MMSE score 22.0 vs. 18.0, P<0.01). After multivariable adjustment, patients whose cognitive impairment was not documented were significantly more likely to experience 6-month mortality or hospital readmission than patients without cognitive impairment. Conclusions Cognitive impairment is common in older adults hospitalized for heart failure, yet frequently not documented by physicians. Implementation of strategies to improve recognition and documentation of cognitive impairment may improve the care of these patients, particularly at the time of hospital discharge.

Cognitive Decline in Heart Failure: More Attention is Needed

“…2,6,8,10,22,23 A twofold increase in 30-day death and readmissions, 8 almost fivefold rates of 1-year mortality, 23 as well as increase in hospitalisation and/or death within 5 years were demonstrated. 22 Such association with poor outcomes is observed even in cases of mild CI, 8 which frequently remains undiagnosed.…”

“…Reported prevalence [2][3][4][5][6][7][8] of cognitive dysfunction in the heart failure (HF) population parallels the severity of HF, being the highest in the acute decompensation settings (see Table 1). …”

“…Dodson et al found that patients with unrecognised cognitive decline exhibited a higher 6-month mortality and hospital readmissions. 6 Intact memory and executive function are necessary to recognise worsening symptoms, adhere to medication regimens and numerous lifestyle modifications, follow scheduled clinic visits, and comply with dietary recommendations. Even mild cognitive deficits may interfere with adherence to self-care practices.…”

Heart and Brain Interconnection – Clinical Implications of Changes in Brain Function During Heart Failure –

“…72 A prospective cohort study of older adults hospitalized with a primary diagnosis of HF showed that patients with moderate-severe cognitive impairment were significantly more likely to die or be readmitted to hospital at 6 months compared with patients with no impairment (adjusted HR, 1.60; 95% CI, 1.03-2.48; P=0.04). 73 The substudy of the Trial of Intensified vs. standard Medical therapy in Elderly patients with Congestive Heart Failure (TIME-CHF) also reported that severe cognitive impairment was related to higher mortality (HR 1.53, 95% CI 1.02-2.30, P=0.04). 74 …”

Management of Heart Failure in Patients Nearing the End of Life–There is So Much More To Do

“…42 Patients with decompensated HF can experience difficulty with short-term memory, working memory, executive control and processing speed. Executive dysfunction and memory problems interfere with self-care and problem-solving, though many patients seemingly converse normally despite moderate-tosevere impairment.…”