Cognitive Screening in Heart Failure

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Photo Credit: APA PsycNET

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

Frailty and Advanced Heart Failure

dodson%20headshotThis week we published a review in the Journal Current Cardiovascular Risk Reports  on the concept of frailty and advanced heart failure in older adults. As geriatricians have long known, frailty–defined as an increased vulnerability to physiologic stressors–is an incredibly common and often unrecognized syndrome in older patients. Cardiologists are increasingly recognizing that frailty predicts a broad range of outcomes, including mortality, in conditions such as heart failure, but also other situations such as acute myocardial infarction and transcatheter aortic valve replacement.

A few highlights from our paper:

– 80% of patients with heart failure are over age 65.

– As the heart failure population continues to age, the burden of frailty has increased.

– The estimated prevalence of frailty in advanced heart failure varies widely, with some estimates ranging up to 3 out of every 4 patients.

– It is challenging to determine causality between heart failure and frailty; they share common inflammatory pathways and one syndrome may mimic the other.

With our current technologies, one of the most pressing clinical questions is whether placement of a left ventricular assist device (LVAD) in advanced systolic heart failure can reverse the frailty phenotype, by correcting underlying physiologic derangements. Flint et al. have put forward the concept of “LVAD-responsive frailty” and “LVAD-independent frailty” – with an illustrative figure cited in our paper. Their concept emphasizes the considerable heterogeneity that exists within heart failure populations. We will need further studies to be able to predict where frailty may improve, in order to better counsel patients about their expected outcomes.

 

By: John Dodson