Cognitive Impairment In Heart Failure Research Articles

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

Cognitive impairment is prevalent in heart failure (HF) with severe consequences, including increased risk of mortality and reduced ability to self-manage HF symptoms. Identifying cognitive impairment through screening would assist clinicians in managing HF and comorbid cognitive impairment. However, the accuracy of cognitive screening instruments for HF has not been adequately determined. The aim of this study was to determine the diagnostic accuracy of cognitive screening instruments in screening for mild cognitive impairment (MCI) in HF patients. A systematic review of major electronic bibliographic databases was searched from January 1999 to June 2013. Inclusion criteria were as follows: primary studies examining cognitive impairment in HF, administration of a cognitive screening instrument and neuropsychological test battery, and cognitive impairment indicated by performance on neuropsychological tests 1.5 SDs less than that of normative data. Methodological rigor of included publications was evaluated using 2 bias risk instruments: QUality Assessment of Diagnostic Accuracy Studies and STAndards for the Reporting of Diagnostic accuracy studies. The precision, accuracy, and receiver operating characteristic curves of the Mini Mental State Examination were computed. From 593 citations identified, 8 publications met inclusion criteria. Risk of bias included selective HF patient samples, and no study examined the diagnostic test accuracy of the cognitive screening instruments. The Mini Mental State Examination had low sensitivity (26%) and high specificity (95%) with a score of 28 or less as the optimal threshold for MCI screening. Screening for cognitive impairment in HF is recommended; however, future studies need to establish the diagnostic accuracy of screening instruments of MCI in this population.

The association between atrial fibrillation and cognitive function in patients with heart failure.

Atrial fibrillation (AF) is associated with cognitive impairment in heart failure (HF). The purpose of this study was to examine whether AF independently predicted cognitive function in HF patients after controlling for more demographic, medical and psychological characteristics, and whether the timing of AF onset in relation to HF diagnosis independently contributed to cognitive function in HF patients with AF. A total of 188 hospitalized HF patients (62.8% male, age 66.3±10.6 years) completed cognitive function assessment with the Montreal Cognitive Assessment (MoCA). A history of AF, along with other medical characteristics, was ascertained through a review of participants' medical charts. The timing of AF onset in relation to HF diagnosis was categorized into AF occurring prior to HF diagnosis (i.e. prior AF) and AF developing after HF diagnosis (i.e. incident AF). Altogether 72 participants had a positive diagnostic history of AF. Specifically, 41 had prior AF, and 31 developed AF subsequently. In HF patients, AF was associated with poorer performance on cognitive function after controlling for more confounders (β=-0.112, ΔR2=0.010, p=0.046). Among HF patients with AF, incident AF independently predicted poorer cognitive function (β=-0.238, ΔR2=0.027, p=0.047). AF independently contributes to cognitive function in HF patients after adjusting for more confounding variables. The timing of AF onset in relation to HF diagnosis independently predicts cognitive function in HF patients with AF. Prospective studies are needed to elucidate possible mechanisms for the association between AF and cognitive function in HF populations.

Cognitive decline in heart failure.

Cognitive impairment (CI) is common in older adults with heart failure (HF). The prevalence of CI is higher among patients with HF than in those without. The spectrum of CI in HF is similar to that observed in the general population and may range from delirium to isolated memory or non-memory-related deficits to dementia. Both HF with reduced ejection fraction and HF with preserved ejection fraction have been associated with defects in different domains of cognition. Numerous risk factors have been shown to contribute to CI in HF. Additionally, various pathophysiological mechanisms related to HF can contribute to cognitive decline. These conditions are not routinely screened for in clinical practice settings with HF populations, and guidelines on optimal assessment strategies are lacking. Validated tools and criteria should be used to differentiate acute cognitive decline (delirium) from chronic cognitive decline such as mild cognitive impairment and dementia. CI in HF has been associated with higher rates of disability and impairment in self-care activities that may in turn increase healthcare cost, hospital readmission and mortality. Early detection of CI may improve clinical outcomes in older adults with HF. Appropriate HF management strategies may also help to reduce CI in patients with HF, and future research is needed to develop and test newer and more effective interventions to improve outcomes in patients with HF and CI.

Carotid Artery Vascular Mechanics Serve as Biomarkers of Cognitive Dysfunction in Aortic-Banded Miniature Swine That Can Be Treated With an Exercise Intervention.

BackgroundCognitive impairment in the setting of heart failure with preserved ejection fraction remains poorly understood. Using aortic‐banded miniature swine displaying pathological features of human heart failure with preserved ejection fraction, we tested the hypothesis that increased carotid artery stiffness and altered carotid blood flow control are associated with impaired memory independent of decreased cardiac output. Furthermore, we hypothesized that chronic exercise prevents carotid artery vascular restructuring and preserves normal blood flow control and cognition in heart failure with preserved ejection fraction.Methods and ResultsYucatan pigs aged 8 months were divided into 3 groups: control (n=7), aortic‐banded sedentary (n=7), and aortic‐banded exercise trained (n=7). At 6 months following aortic‐banded or control conditions, memory was evaluated using a spatial hole‐board task. Carotid artery vascular mechanics and blood flow were assessed at rest, and blood flow control was examined during transient vena cava occlusion. Independent of decreased cardiac output, the aortic‐banded group exhibited impaired memory that was associated with carotid artery vascular stiffening, elevated carotid artery vascular resistance, and exaggerated reductions in carotid artery blood flow during vena cava occlusion. Chronic exercise augmented memory scores, normalized blood flow control, and improved indices of carotid artery vascular stiffening. Indices of vascular stiffening were significantly correlated with average memory score.ConclusionsCarotid artery stiffness and altered vasomotor control correlate with impaired cognition independent of cardiac systolic dysfunction. Carotid artery vascular mechanics may serve as a biomarker for vascular cognitive impairment in heart failure with preserved ejection fraction. Chronic low‐intensity exercise reduces vascular stiffening and improves cognition, highlighting the utility of exercise therapy for treating vascular cognitive impairment in heart failure with preserved ejection fraction.

Relationships Among Cognitive Function and Cerebral Blood Flow, Oxidative Stress, and Inflammation in Older Heart Failure Patients

BackgroundThe mechanisms for cognitive impairment in heart failure (HF) are unclear. We investigated the relative contributions of cerebral blood flow velocity (BFV), oxidative stress, and inflammation to HF-associated cognitive impairment. Methods and ResultsThirty-six HF patients (≥60 years) and 40 healthy controls (68 ± 7 vs 67 ± 5 years, P > .05; 69% vs 50% male, P > .05) completed the Cognitive Drug Research computerized assessment battery and Stroop tasks. Common carotid (CCA) and middle cerebral arterial BFV were obtained by transcranial Doppler. Blood samples were collected for oxidant (diacron-reactive oxygen metabolites; F2-isoprostanes), antioxidant (coenzyme Q10; CoQ10), and inflammatory markers (high-sensitivity C-reactive protein). Compared with controls, patients exhibited impaired attention (Cognitive Drug Research's Power of Attention domain, congruent Stroop) and executive function (incongruent Stroop). Multiple regression modeling showed that CCA-BFV and CoQ10 but not group predicted performance on attention and executive function. Additionally, in HF patients, CCA-BFV and CoQ10 (β = −0.34 vs β = −0.35) were significant predictors of attention, and CCA-BFV (β = −0.34) was a predictor of executive function. ConclusionsPower of Attention and executive function is impaired in older HF patients, and reduced CCA-BFV and CoQ10 are associated with worse cognition. Interventions addressing these mechanisms may improve cognition in older HF patients.

Cognitive Impairment Among Elderly Patients With Chronic Heart Failure and Related Factors.

BackgroundPatients with heart failure (HF) older than 65 years have a two-fold increased risk of cognitive impairment than elders without HF. Identifying factors affecting cognitive impairment in HF may present targets for intervention.ObjectivesThe aim of the present study was to determine cognitive function and related factors among elderly patients with heart failure.Patients and MethodsIn this cross-sectional study, 184 elderly patients with heart failure were selected from four Mazandaran University of Medical Sciences teaching hospitals using convenience sampling. Data were collected from patients’ medical records and by interview, using the abbreviated mental test, geriatric depression scale, and Charlson comorbidity index.ResultsThere were significant relationships between cognitive status and living arrangement (P < 0.001), education (P < 0.001), hypertension (P = 0.039), anemia (P = 0.046), Charlson comorbidity index (P < 0.001) and geriatric depression scale (P < 0.001).ConclusionsScreening of cognitive impairment in elderly patients with heart failure seems necessary.

Evidence-Based Heart Failure Medications and Cognition.

The etiology of cognitive impairment in heart failure (HF) is controversial and likely multifactorial. Physicians may hesitate to prescribe evidence-based HF medication because of concerns related to potential negative changes in cognition among a population that is already frequently impaired. We conducted a study to determine if prescription of evidence-based HF medications (specifically, β-blockers, angiotensin-converting enzyme inhibitors, angiotensin-receptor blocking agents, diuretics, and aldosterone inhibitors) was associated with cognition in a large HF sample. A total of 612 patients completed baseline data collection for the Rural Education to Improve Outcomes in Heart Failure clinical trial, including information about medications. Global cognition was evaluated using the Mini-Cog. The sample mean (SD) age was 66 (13) years, 58% were men, and 89% were white. Global cognitive impairment was identified in 206 (34%) of the 612 patients. Prescription of evidence-based HF medications was not related to global cognitive impairment in this sample. This relationship was maintained even after adjusting for potential confounders (eg, age, education, and comorbid burden). Prescription of evidence-based HF medications is not related to low scores on a measure of global cognitive function in rural patients with HF.

Management of Cognitive Impairment in Heart Failure

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.

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

ObjectiveEvaluate capacity of the Automated Neuropsychological Assessment Metrics (ANAM) to detect cognitive impairment (CI) in heart failure (HF) patients. BackgroundCI 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. MethodsInvestigators administered the ANAM and MMSE to 57 HF patients, compared against a composite model of cognitive function. ResultsANAM 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. ConclusionsThe 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.

Atrial fibrillation may be a hidden factor for the development of cognitive impairment in patients with heart failure.

To the editor We read the article entitled ‘Cognitive impairment in heart failure patients’ by Leto, et al. [1] with great interest. In this review, they demonstrated pathophysiological determinants of cognitive impairment in heart failure (HF) population. HF prevalence is increasing in the general population throughout the world. As HF is a complex clinical entity, underlying mechanisms with HF and cognitive impairment are mixed and intertwined. HF is a well known risk factor for dementia and functional brain abnormalities. Co-morbidities such as hypertension and diabetes are main reasons for the association between HF and cognitive impairment as well as decreased cerebral perfusion due to systolic dysfunction. Medications in HF populations also play a role in development of cognitive impairment through side effects on cerebral perfusion. [2] In the present review, the authors pointed out important variables that can be related with HF and cognitive impairment such as left ventricular ejection fraction, systolic and diastolic blood pressure, NYHA functional class and B-type natriuretic peptide. However, atrial fibrillation (AF) which is a most prevalent arrhythmia in general population has also shown to be related to cognitive decline. [3] Furthermore, due to the silent attacks, undiagnosed episodes of paroxysmal AF have been frequently encountered in this subjects. The incidence of AF was increased in the elderly patients. The prevalence of AF was found to be 9% in individuals > 80 years of age and 0.1% in subjects < 55 years of age. [4] These data are derived from the trials in which the diagnosis was based on a 12-lead electrocardiogram obtained during an office visit. According to the duration of the episodes, AF is classified into 3 types: paroxysmal AF, persistent AF, and permanent AF. While the other types of AF can be easily diagnosed with routine 12-lead ECG, paroxysmal AF may be overlooked. In order to determine attacks of paroxysmal AF, ambulatory monitoring is required. Therefore, it is presumed that the real-world prevalence of AF is higher than those determined in the trials. The cognitive impairment due to AF in elderly patients is both related with micro-emboli and a decline in cerebral perfusion. It seems that AF may exacerbate HF and subsequent cerebral blood flow reduction. Independently from its type, AF increases the risk of thromboembolism five times. [4] CHADS-VASc scoring system has been using in patients with AF in order to quantify the risk for thromboembolism. According to this scoring system, existence of congestive heart failure, hypertension, age 65 to 74 years, age ≥ 75 years (doubled risk), diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism (doubled risk), vascular disease and female gender are risk factors for thromboembolic stroke in patients with AF. [5] It has been particularly indicated in this scoring system that the embolic risk of the elderly people with AF is as high as the patients with prior stroke. With the aging population in our modern world, it is obvious to be an incremental rise in the prevalence of AF. Furthermore, it is important to shed light on the relationship between cognitive impairment and AF as a main problem in patients with HF, so that preventative efforts will lead way to reduce the burden of cognitive impairment in HF patients. Therefore, in a review addressing cognitive impairment in HF population, we believe that discussing AF might be useful for researchers dealing with this group of patients.

‘Hearts and minds’: association, causation and implication of cognitive impairment in heart failure

The clinical syndrome of heart failure is one of the leading causes of hospitalisation and mortality in older adults. An association between cognitive impairment and heart failure is well described but our understanding of the relationship between the two conditions remains limited. In this review we provide a synthesis of available evidence, focussing on epidemiology, the potential pathogenesis, and treatment implications of cognitive decline in heart failure. Most evidence available relates to heart failure with reduced ejection fraction and the syndromes of chronic cognitive decline or dementia. These conditions are only part of a complex heart failure-cognition paradigm. Associations between cognition and heart failure with preserved ejection fraction and between acute delirium and heart failure also seem evident and where data are available we will discuss these syndromes. Many questions remain unanswered regarding heart failure and cognition. Much of the observational evidence on the association is confounded by study design, comorbidity and insensitive cognitive assessment tools. If a causal link exists, there are several potential pathophysiological explanations. Plausible underlying mechanisms relating to cerebral hypoperfusion or occult cerebrovascular disease have been described and it seems likely that these may coexist and exert synergistic effects. Despite the prevalence of the two conditions, when cognitive impairment coexists with heart failure there is no specific guidance on treatment. Institution of evidence-based heart failure therapies that reduce mortality and hospitalisations seems intuitive and there is no signal that these interventions have an adverse effect on cognition. However, cognitive impairment will present a further barrier to the often complex medication self-management that is required in contemporary heart failure treatment.

Effectiveness of the Brief Interview for Mental Status (BIMS) as a Screening Tool for Cognitive Impairment in the Geriatric Heart Failure Population

Cognitive impairment in patients with heart failure is highly prevalent and often under-recognized. As a result of impaired cognition, these patients, who are followed throughout the care continuum, often have difficulty complying with fluid and salt restrictions, medication regimens, and appointments. Noncompliance due to cognitive impairment may reduce patient quality of life and may increase the risk of hospital admissions and readmissions and the risk of mortality due to heart failure. The Brief Interview for Mental Status (BIMS) is used in skilled and long term care facilities to screen for cognitive impairment. There is no accepted brief screening tool for cognitive impairment in heart failure.

Cognitive impairment in heart failure: towards a consensus on screening

cognitive impairment was classified assevere if HF patients scored ≤7 on the Hodkinson AbbreviatedMentalTest.Thisscreeningquestionnairehasbeenusedingeneralageingpopulationstoscreenfordementia.Fromthe611 patientsenrolledinthestudy,56(9%)wereclassifiedwithseverecognitiveimpairment on the basis of the screening questionnaire, withno other neuropsychological assessment.

Cognitive impairment in heart failure: clinical and functional markers and vital status at 12 months follow-up

Cognitive impairment in heart failure: clinical and functional markers and vital status at 12 months follow-up

Cognitive performance in older adults with stable heart failure: Longitudinal evidence for stability and improvement

ABSTRACTCognitive impairment is prevalent in heart failure (HF), though substantial variability in the pattern of cognitive impairment is found across studies. To clarify the nature of cognitive impairment in HF, we examined longitudinal trajectories across multiple domains of cognition in HF patients using latent growth class modeling. 115 HF patients completed a neuropsychological battery at baseline, 3-months and 12-months. Participants also completed the Beck Depression Inventory-II (BDI-II). Latent class growth analyses revealed a three-class model for attention/executive function, four-class model for memory, and a three-class model for language. The slope for attention/executive function and language remained stable, while improvements were noted in memory performance. Education and BDI-II significantly predicted the intercept for attention/executive function and language abilities. The BDI-II also predicted baseline memory. The current findings suggest that multiple performance-based classes of neuropsychological test performance exist within cognitive domains, though case-controlled prospective studies with extended follow-ups are needed to fully elucidate changes and predictors of cognitive function in HF.

Obesity as a risk factor for poor neurocognitive outcomes in older adults with heart failure

Heart failure (HF) has reached epidemic proportions and is a significant contributor to poor outcomes. HF is an established risk factor for Alzheimer's disease, vascular dementia, and abnormalities on neuroimaging. Moreover, up to 80% of HF patients also exhibit milder impairments on cognitive tests assessing attention, executive function, memory, and language. The mechanisms of cognitive impairment in HF are not entirely clear and involve a combination of physiological processes that negatively impact the brain. Cerebral hypoperfusion and common comorbid conditions in HF are among the most commonly proposed contributors to poor neurocognitive outcomes in this population. Obesity is another likely risk factor for adverse brain changes and cognitive impairment in HF, as it is a known contributor to neurocognitive outcomes in healthy and patient samples. This paper reviews the literature on HF and cognitive function and introduces obesity as a significant risk factor for poor neurocognitive outcomes in this population.

Cognitive impairment in heart failure: results from the Trial of Intensified versus standard Medical therapy in Elderly patients with Congestive Heart Failure (TIME‐CHF) randomized trial

Up to 50% of patients with heart failure (HF) may suffer from severe cognitive impairment (SCI), but longitudinal studies are sparse, and effects of changes in HF severity on cognitive function are unknown. Therefore, we assessed the prevalence of SCI in HF patients, its relationship with HF severity, its effects on morbidity and mortality, and the relationship between changes in HF severity and cognitive function. We included 611 patients from the Trial of Intensified versus standard Medical therapy in Elderly patients with Congestive Heart Failure (TIME-CHF) and assessed cognitive function [Hodkinson Abbreviated Mental Test (AMT)] in relation to severity of HF (NYHA class, NT-proBNP) at baseline and 18 months (n = 382) and effects on hospitalization-free survival and mortality. SCI (i.e. AMT score ≤ 7) was present in 9.2% of patients at baseline, but only 20% of them had a diagnosis of dementia. Prevalence of SCI remained stable during follow-up. SCI was present at baseline more often in NYHA IV patients compared with NYHA II [odds ratio 2.94; 95% confidence interval (CI) 1.15-7.51, P = 0.025], but it was not related to NT-proBNP levels. SCI was related to higher mortality (hazard ratio 1.53, 95% CI 1.02-2.30, P = 0.04), but not hospitalization-free survival. Changes in HF severity were not significantly related to changes in cognitive function. SCI is a frequent, but often unrecognized finding in HF patients, but the influence of HF severity and its changes on cognitive function were less than hypothesized. Trial registration ISRCTN43596477.

Elevated Levels of Interleukin 6 and C‐Reactive Protein Associated With Cognitive Impairment in Heart Failure

There is abundant evidence on inflammatory mechanisms in heart failure (HF) that are used for prognostication of the disease; however, data are lacking regarding the association between elevated cytokines, C-reactive protein (CRP), and cognition in HF. A cross-sectional pilot study of 38 patients with HF, aged 62 years (standard deviation± 9 years), predominantly men (68%) and Caucasian (79%) were screened for cognitive function using the Montreal Cognitive Assessment (MoCA). The study aimed to examine cognitive scores on MoCA with cytokines, interleukin 6 [IL-6] and tumor necrosis factor α [TNF-α], and CRP as indicators of early cognitive changes in HF. The result showed no direct correlation between cardiac variables and the MoCA score. The MoCA score, however, was inversely associated with IL-6 (r=-0.53, P=.001) and CRP (r=-0.34, P=.04), with no association to TNF-α. Regression analysis on the MoCA score and log-transformed IL-6 accounted for an additional 11% variation and remained statistically significant (P=.008) after controlling for covariates of education, living arrangements, and loneliness. The large effect size (R(2) =0.87) found in this pilot study provides rationale for a larger exploratory study to examine associations between cognitive function, cytokines, and CRP levels and help design future intervention studies.

The independent association of hypertension with cognitive function among older adults with heart failure

ObjectiveHypertension is the most common comorbidity among heart failure (HF) patients and has been independently linked with cognitive impairment. Cognitive impairment is prevalent among HF patients, though the extent to which hypertension contributes to cognitive function in this population is unclear. Methods116 HF patients (31.0% women, 67.68±11.16years) completed neuropsychological testing and impedance cardiography. History of physician diagnosed hypertension, along with other medical characteristics, was ascertained through a review of participants' medical charts. Results69.8% of the HF patients had a diagnostic history of hypertension. After adjustment for demographic and medical characteristics (i.e., cardiac index, medication status, and resting blood pressure), hypertension was independently associated with attention/executive function/psychomotor speed (ΔF(1,103)=10.85, ΔR2=.07, p<.01) and motor functioning (ΔF(1,103)=4.46, ΔR2=.04, p<.05). HF patients with a diagnosed history of hypertension performed worse in these domains than those without such history. ConclusionThe current findings indicate that diagnostic history of hypertension is an important contributor to cognitive impairment in HF. Hypertension frequently precedes HF and future studies should examine whether sustained hypertension compromises cerebral autoregulatory mechanisms to produce brain damage and exacerbate cognitive impairment in this population.

Cognitive function in patients with decompensated heart failure: the Cognitive Impairment in Heart Failure (CogImpair‐HF) study

The objective of this study was to examine cognitive and psychological processes systematically in patients with decompensated chronic heart failure (CHF) and to document changes in cognitive function after compensation. Executive functions, episodic memory, and attention are impaired in patients with stable CHF, influencing health behaviour and disease management. Cognitive function and psychological co-morbidities are associated with hospitalization, disability, and mortality. Cognitive performance, self-perceived quality of life, and depression were compared in 20 patients with decompensated CHF [ejection fraction (EF) 27 ± 8%, N-terminal pro brain natriuretic peptide (NT-proBNP) 10 880 pg/mL, interquartile range (4495-13 683)] before and after compensation, 20 age- and gender-matched stable CHF patients [New York Heart Association (NYHA) III-IV, EF 32 ± 10%, NT-proBNP 1881 pg/mL (323-1502)], and 20 healthy controls (EF 70 ± 5%). Patients with decompensated CHF showed significantly poorer performance in terms of short-term memory, working memory, executive control, and processing speed (P < 0.05) compared with stable CHF patients. Compensation improved the cognitive performance of decompensated CHF patients up to the level of patients with stable CHF. Compared with healthy controls, both patient groups were affected with respect to episodic memory (P < 0.0001) and fluid intelligence (P < 0.01). Decompensated heart failure patients are highly impaired in cognitive functioning, which improves but does not normalize after compensation. Neuropsychological diagnostics delivers important details for daily life activities and might identify individuals deserving special care.