Cognitive impairment, which includes deficits in memory, language, concentration, and reasoning, is common and often unrecognized in older patients. As a trainee, one of my first projects was to work on a study that performed cognitive assessments in a series of 282 patients age >65 hospitalized for heart failure. We found that cognitive impairment was common – present to some degree in nearly half of patients – and documented by physicians in fewer than one-quarter of cases. Further, we found that cognitive impairment was associated with mortality or hospital readmission within 6 months – and that patients with impairment that was not documented by physicians constituted the highest risk group. Our findings mirrored previous studies (examples here and here) documenting the common co-occurrence of cognitive impairment with heart failure.
Translating findings like this into actionable clinical practice can be challenging, but some centers are starting to routinely incorporate cognitive screening into care. Cleveland Clinic, for example, has published findings from screening using the Mini-Cog (a simple test that involves 3-item recall and a clock drawing task) and found that an abnormal test result (indicating cognitive impairment) was the strongest predictor of readmission among 55 candidate variables. They subsequently published a protocol for training nurses to use the Mini-Cog in practice in order to facilitate implementation among clinical staff unfamiliar with the instrument.
When cognitive impairment is discovered, there’s no easy solution to management – but several strategies make intuitive sense. Involving family members more closely in caregiving — to remind patients of their appointments and to assist with medication management — may help to avoid problems related to nonadherence (for example, hospitalization for decompensated heart failure). In my own practice, I try to simplify medication regimens whenever possible in patients who are cognitively impaired, with the goal of improving adherence and avoiding adverse medication-related events. Finally, since cognitive impairment has many causes, referral to a memory center can help to establish a formal diagnosis and set expectations in terms of what to anticipate in the coming years.
By: John Dodson, MD, MPH