Congestive heart failure and cognitive functioning amongst older adults

Cognitive Impairment in Heart Failure: A Heart Failure Society of America Scientific Statement

Cognitive impairment is common among adults with heart failure (HF), as both diseases are strongly related to advancing age and multimorbidity (including both cardiovascular and noncardiovascular conditions). Moreover, HF itself can contribute to alterations in the brain. Cognition is critical for a myriad of self-care activities that are necessary to manage HF, and it also has a major impact on prognosis; consequently, cognitive impairment has important implications for self-care, medication management, function and independence, and life expectancy. Attuned clinicians caring for patients with HF can identify clinical clues present at medical encounters that suggest cognitive impairment. When present, screening tests such as the Mini-Cog, and consideration of referral for comprehensive neurocognitive testing may be indicated. Management of cognitive impairment should focus on treatment of underlying causes of and contributors to cognitive impairment, medication management/optimization, and accommodation of deficiencies in self-care. Given its implications on care, it is important to integrate cognitive impairment into clinical decision making. Although gaps in knowledge and challenges to implementation exist, this scientific statement is intended to guide clinicians in caring for and meeting the needs of an increasingly complex and growing subpopulation of patients with HF.

The Efficiency of Attentional Networks in Takostubo Syndrome: A Study With the Attentional Network Task for Interaction

INTRODUCTION

The role of cardiovascular risk factors in the occurrence and progression of cognitive impairment is relevant in aging studies. In this condition, attention is one of the processes less studied, but preliminary evidence suggests an association between cardiometabolic alterations and attentional decline. Attention is not a unitary process but a set of independent systems (Alerting, Orienting, Executive), which can interact in certain conditions to ensure maximum behavioral efficiency.

METHODS

We investigated attentive networks and their interactions in patients with Takostubo syndrome (TTS). In all, 20 participants with TTS and 20 individuals without cardiovascular pathologies performed an Attention-Network Task for Interaction, which assesses attentional networks and their interactions.

RESULTS

Patients with TTS showed an atypical orienting effect when compared to the control group. Moreover, only the control group exhibited an interaction between orienting and alerting.

CONCLUSION

These findings establish the relevance of brain-heart interaction in identifying attentional impairment as a prodrome of progressively severe cognitive impairment in TTS.

Cognitive Impairment in Acute Heart Failure: Narrative Review

Cognitive impairment (CI) represents a common but often veiled comorbidity in patients with acute heart failure (AHF) that deserves more clinical attention. In the AHF setting, it manifests as varying degrees of deficits in one or more cognitive domains across a wide spectrum ranging from mild CI to severe global neurocognitive disorder. On the basis of the significant negative implications of CI on quality of life and its overwhelming association with poor outcomes, there is a compelling need for establishment of detailed consensus guidelines on cognitive screening methods to be systematically implemented in the population of patients with heart failure (HF). Since limited attention has been drawn exclusively on the field of CI in AHF thus far, the present narrative review aims to shed further light on the topic. The underlying pathophysiological mechanisms of CI in AHF remain poorly understood and seem to be multifactorial. Different pathophysiological pathways may come into play, depending on the clinical phenotype of AHF. There is some evidence that cognitive decline closely follows the perturbations incurred across the long-term disease trajectory of HF, both along the time course of stable chronic HF as well as during episodes of HF exacerbation. CI in AHF remains a rather under recognized scientific field that poses many challenges, since there are still many unresolved issues regarding cognitive changes in patients hospitalized with AHF that need to be thoroughly addressed.

Cognitive impairment and depression after acute myocardial infarction: associations with ejection fraction and demographic characteristics

Cognitive impairment and depression are often associated with acute myocardial infarction, however, the risk factors for their occurrence after myocardial infarction are still unclear. To determine the effect of reduced ejection fraction and demographic characteristics on the occurrence of cognitive impairment and depression after myocardial infarction. In the prospective study, the final sample consisted of 82 patients. Based on the value of the ejection fraction, the patients were divided into those with a value of < 40% and those having a value of ≥ 40%. Demographic data (age, gender, education), and data on comorbidities, were collected from the patients' medical history. The instruments of studies were: Mini-mental test and Beck depression inventory. The occurrence of cognitive impairment and depression was not, to a significant degree, associated with the level of ejection fraction. In contrast, demographics have shown positive predictive effects. Among demographic characteristics, the age of the patient proved to be a significant predictor for the occurrence of cognitive impairment (p = 0.004). The probability of cognitive impairment increases 1.16 times for each year of life. Significant depression predictor was female gender (p = 0.014). The probability of depression was 3.5 times greater for female gender. Cognitive impairment after acute myocardial infarction is more common in older patients, and depression in more common in women.

Neuropsychological Assessment and Screening in Heart Failure: a Meta-Analysis and Systematic Review

A variety of neuropsychological changes secondary to heart failure have been documented in the literature. However, what remains unclear are which neuropsychological abilities are the most impacted by heart failure and what tests have the sensitivity to measure that impact. Eight databases were searched for articles that examined the neuropsychological functioning of patients with heart failure. Some of the inclusion criteria were articles had to have a heart failure group with a demographically comparable control group and standardized neuropsychological testing. Exclusion criteria included articles with a heart failure group with any other type of major organ failure, or comparisons that were between different classes of heart failure rather than between a heart failure and non-heart failure group. A total of 33 articles met the inclusion criteria (total heart failure sample n = 8900) and provided effect size data for 20 neuropsychological domains. All observed domain-level differences between heart failure and non-heart failure groups were statistically significant, except for simple motor functioning and confrontation naming. The greatest differences in performance were in executive functioning, global cognition, complex psychomotor speed, and verbal memory. The highest effect sizes came from Trail-Making Test-Part B, CAMCOG, Symbol Digit Modality Test, and California Verbal Learning Test. The neuropsychological patterns of heart failure suggested diffuse cognitive involvement, with higher-level processes being most affected. It is important to track neurocognition in this clinical population since neuropsychological impairment is prevalent, and screening measures appear to be reliable. Such screening and further assessment would inform future medical treatment and may improve patient care management.

Return on Investment and Value Research in Neuropsychology: A Call to Arms†

There is substantial empirical evidence to support the clinical value of neuropsychological evaluation and the incremental value of neuropsychological assessment, suggesting such evaluation is beneficial in the prediction and management of clinical outcomes. However, in the cost-conscious and evolving era of healthcare reform, neuropsychologists must also establish the economic value, or return on investment, of their services. There is already a modest body of literature that demonstrates the economic benefits of neuropsychological evaluation, which is reviewed in the current paper. Neuropsychologists will need to be able to communicate, and develop evidence of, economic value of their services; thus, this paper also discusses common concepts, terms, and models used in healthcare valuation studies. Finally, neuropsychologists are urged to incorporate these financial concepts in their clinical practice and research.

Hemodynamic Instability in Heart Failure Intensifies Age-Dependent Cognitive Decline

This review attempts to examine two key elements in the evolution of cognitive impairment in the elderly who develop heart failure. First, major left side heart parts can structurally and functionally deteriorate from aging wear and tear to provoke hemodynamic instability where heart failure worsens or is initiated; second, heart failure is a major inducer of cognitive impairment and Alzheimer's disease in the elderly. In heart failure, when the left ventricular myocardium of an elderly person does not properly contract, it cannot pump out adequate blood to the brain, raising the risk of cognitive impairment due to the intensification of chronic brain hypoperfusion. Chronic brain hypoperfusion originates from chronically reduced cardiac output which progresses as heart failure worsens. Other left ventricular heart parts, including atrium, valves, myocardium, and aorta can contribute to the physiological shortfall of cardiac output. It follows that hemodynamic instability and perfusion changes occurring from the aging heart's blood pumping deficiency will, in time, damage vulnerable brain cells linked to specific cognitive regulatory sites, diminishing neuronal energy metabolism to a level where progressive cognitive impairment is the outcome. Could cognitive impairment progress be reversed with a heart transplant? Evidence is presented detailing the errant hemodynamic pathways leading to cognitive impairment during aging as an offshoot of inefficient structural and functional heart parts and their contribution to heart failure.

Associations of decision making abilities with blood pressure values in older adults

OBJECTIVES

Decision making, key to successful aging, has implications for financial success, physical health, and well being. While poor decision making has been linked with increased risk of mortality, age-related cognitive decline, and dementia, less is known regarding its associations with chronic disease indicators. We investigated the associations of decision making with blood pressure (BP) values [i.e., SBP, mean arterial pressure (MAP), and pulse pressure (PP), separately] in a community-based cohort study of aging.

METHODS

Participants were 908 nondemented older adults (age ∼81 years; 75% women) from the Rush Memory and Aging Project. Decision making was measured using questions designed to simulate materials used in financial and healthcare settings in the real world and yielded a total score and domain-specific health and financial decision making scores. Two seated and one standing BP measurement were taken with all three contributing to average SBP, MAP that is, [SBP + (2 × DBP)]/3, and PP, that is, SBP - DBP. Participants were queried about hypertension status and antihypertension medications were visually inspected and coded. Participants also underwent medical history and cognitive assessments.

RESULTS

In separate multivariable linear regression models, total decision making scores were inversely associated with SBP, MAP, and PP after adjusting for age, sex, education, antihypertension medication use, diabetes, and cumulative cardiovascular disease burden (P values = 0.03). Decision making remained associated with these BP values after additional adjustment for global cognition.

CONCLUSION

Poorer decision making is associated with higher BP values in nondemented older adults.

Impairment of cognitive functions in congestive cardiac failure patients

BACKGROUND

Congestive cardiac failure (CCF) patients show several neuropsychological impairments and reduced quality of life and impairment of functioning.

OBJECTIVE

The objective of this study was to recognize the deficits in cognition in CCF patients and comparing this cognitive function in the same number of healthy participants.

MATERIALS AND METHODS

A case-control study design was adopted. The study was conducted in the cardiology department of a tertiary care hospital. Convenience sampling was done. Twenty-one participants with CCF (New York Cardiac Association - Class III severity) and 21 healthy participants participated in the study. Each participant in the control group was screened by the General Health Questionnaire-12-item version. We evaluated both groups for the various domains of their cognitive function using a comprehensive battery of neuropsychological tests. Student's t-test was used to analyze the difference between the means for the study variables.

RESULTS

We observed that attention, executive function, working memory, psychomotor speed, and visuospatial ability were impaired in the patients with CCF compared to the controls. However, they did not differ significantly in language function.

CONCLUSIONS

Cognitive functioning is significantly impaired in CCF patients.

Subclinical Compromise in Cardiac Strain Relates to Lower Cognitive Performances in Older Adults

BACKGROUND

Global longitudinal strain (GLS), reflecting total shortening of the myocardium during the cardiac cycle, has emerged as a more precise myocardial function measure than left ventricular ejection fraction (LVEF). Longitudinal strain may be selectively affected in subclinical heart disease, even in the presence of normal LVEF. This study examines subclinical cardiac dysfunction, assessed by GLS and LVEF, and cognition among older adults.

METHODS AND RESULTS

Vanderbilt Memory and Aging Project participants who were free of clinical dementia, stroke, and heart failure (n=318, 73±7 years, 58% male) completed neuropsychological assessment and cardiac magnetic resonance to quantify GLS and LVEF. Linear regression models related GLS and LVEF to neuropsychological performances, adjusting for age, sex, race/ethnicity, education, Framingham Stroke Risk Profile, cognitive diagnosis, and APOE*ε4 status. Models were repeated with a cardiac×cognitive diagnosis interaction term. Compromised GLS (reflected by higher values) related to worse naming (β=-0.07, P=0.04), visuospatial immediate recall (β=-0.83, P=0.03), visuospatial delayed recall (β=-0.22, P=0.03), and verbal delayed recall (β=-0.11, P=0.007). LVEF did not relate to worse performance on any measure (P>0.18). No diagnostic interactions were observed.

CONCLUSIONS

Our study results are among the first to suggest that compromised GLS relates to worse episodic memory and language performance among older adults who are free of clinical dementia, stroke, and heart failure. Subclinical cardiac dysfunction may correlate with cognitive health in late life, even when LVEF remains normal. The results add to growing evidence that GLS may be a more sensitive and preferred method for quantifying subclinical changes in cardiac function.

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

OBJECTIVE

Evaluate capacity of the Automated Neuropsychological Assessment Metrics (ANAM) to detect cognitive impairment (CI) in heart failure (HF) patients.

BACKGROUND

CI 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.

METHODS

Investigators administered the ANAM and MMSE to 57 HF patients, compared against a composite model of cognitive function.

RESULTS

ANAM 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.

CONCLUSIONS

The 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.

Cardiorespiratory fitness modifies the relationship between myocardial function and cerebral blood flow in older adults

A growing body of evidence indicates that cardiorespiratory fitness attenuates some age-related cerebral declines. However, little is known about the role that myocardial function plays in this relationship. Brain regions with high resting metabolic rates, such as the default mode network (DMN), may be especially vulnerable to age-related declines in myocardial functions affecting cerebral blood flow (CBF). This study explored the relationship between a measure of myocardial mechanics, global longitudinal strain (GLS), and CBF to the DMN. In addition, we explored how cardiorespiratory affects this relationship. Participants were 30 older adults between the ages of 59 and 69 (mean age=63.73years, SD=2.8). Results indicated that superior cardiorespiratory fitness and myocardial mechanics were positively associated with DMN CBF. Moreover, results of a mediation analysis revealed that the relationship between GLS and DMN CBF was accounted for by individual differences in fitness. Findings suggest that benefits of healthy heart function to brain function are modified by fitness.

Cognitive impairment and cardiovascular diseases in the elderly. A heart-brain continuum hypothesis

The aging population is increasing and, therefore, a higher prevalence of cardiac disease is emerging; including hypertension, coronary artery disease, atrial fibrillation and chronic heart failure. Large cohort studies have revealed a relationship among increased risk for cognitive impairment and dementia in cardiovascular diseases probably due to embolic stroke or chronic cerebral hypoperfusion. Thus, the aim of the present review is to overview the studies that investigate the presence and/or the development of cognitive impairments and dementia in patients with varied types of cardiovascular disease. Finally, a continuum among hypertension, coronary artery disease, atrial fibrillation and chronic heart failure with to the development of cognitive impairment and progression to dementia has been hypothesized.

The link between cardiovascular risk, Alzheimer's disease, and mild cognitive impairment: support from recent functional neuroimaging studies

OBJECTIVE

To review functional neuroimaging studies about the relationship between cardiovascular risk factors (CVRFs), Alzheimer's disease (AD), and mild cognitive impairment (MCI).

METHODS

We performed a comprehensive literature search to identify articles in the neuroimaging field addressing CVRF in AD and MCI. We included studies that used positron emission tomography (PET), single photon emission computerized tomography (SPECT), or functional magnetic resonance imaging (fMRI).

RESULTS

CVRFs have been considered risk factors for cognitive decline, MCI, and AD. Patterns of AD-like changes in brain function have been found in association with several CVRFs (both regarding individual risk factors and also composite CVRF measures). In vivo assessment of AD-related pathology with amyloid imaging techniques provided further evidence linking CVRFs and AD, but there is still limited information resulting from this new technology.

CONCLUSION

There is a large body of evidence from functional neuroimaging studies supporting the hypothesis that CVRFs may play a causal role in the pathophysiology of AD. A major limitation of most studies is their cross-sectional design; future longitudinal studies using multiple imaging modalities are expected to better document changes in CVRF-related brain function patterns and provide a clearer picture of the complex relationship between aging, CVRFs, and AD.

Impact of diabetes on cognitive impairment and disability in elderly hospitalized patients with heart failure

AIM

Heart failure (HF) and diabetes mellitus (DM) are each associated with cognitive impairment and disability. The aim of the present study was to evaluate the impact of DM on cognitive impairment and functional status in elderly hospitalized patients affected by HF.

METHODS

A total of 79 elderly hospitalized patients with HF were enrolled in the present study. They underwent physical and instrumental examination, and geriatric multidimensional assessment including Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS), activities of daily living (ADL) and instrumental activities of daily living (IADL). Differences between groups were established by t-test, Spearman's correlation coefficient was searched to examine the relation between variables. All results were considered significant if P was <0.05.

RESULTS

HF and DM coexisted in 43 patients (54.4% of cases); when they occurred together patients showed, compared with non diabetic patients, a greater clinical severity of HF (44.2% were in New York Heart Association class IV vs 16.7%, P = 0.017), a lower MMSE score (20.4 ± 3.6 vs 23 ± 3.8, P = 0.004), and a lower number of preserved functions in ADL (3 ± 1.6 vs 4 ± 1.8, P = 0.008) and in IADL (3.2 ± 1.7 vs 4.6 ± 2.3, P = 0.003). The correlation between DM and cognitive impairment, and disability was confirmed by multivariate and univariate analysis.

CONCLUSIONS

We confirm that DM is frequent in elderly hospitalized patients with HF, and we report that it has a negative impact on cognitive functions and functional status, worsening cognitive impairment, and disability observed in these patients. Comprehensive geriatric assessment is necessary for older adults with HF, especially when DM coexists.

Neuropsychological patterns differ by type of left ventricle dysfunction in heart failure

Cognitive impairment is common among individuals with heart failure. The purpose of this study was to compare cognitive profiles of individuals with systolic and diastolic dysfunction. Eighty individuals with heart failure completed the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Mini-Mental State Examination, Trail Making Test, and letter fluency. Approximately 25% of individuals with systolic dysfunction were impaired on the RBANS Total Scale score, compared with only 3% in the diastolic group. Additionally, individuals with systolic dysfunction scored lower than those with diastolic dysfunction on tests of immediate and delayed memory. The groups did not differ on tests of visuospatial skills, but there were mixed results on the RBANS Attention and Language subtests. Overall, the results of this study suggest that individuals with different types of cardiac dysfunction (systolic and diastolic dysfunction) demonstrate differential patterns of performance on neuropsychological tests. These findings have important clinical implications.

Phenotypic profiling of cognitive impairment risk among patients with heart failure: a literature review of the usefulness of cardiac-related variables

BACKGROUND

Mild cognitive impairment among patients with heart failure can be subtle. Heart failure-related variables such as ejection fraction, low systolic blood pressure and functional status are reportedly associated with cognitive impairment among heart failure patients. The purpose of this literature review was to examine the value of cardiac variables commonly assessed during heart failure-related hospitalizations for a phenotypic profile of the risk of cognitive impairment.

METHOD

A literature review of primary research studies was conducted. Electronic databases (PubMed and CINAHL) were searched using the keywords heart failure, blood pressure, ejection fraction, functional status, and B-type natriuretic peptide (BNP) in combination with the terms cognition, cognitive function, cognitive dysfunction, and cognitive impairment.

RESULTS

Thirty-seven studies met the inclusion criteria. Evidence supports the potential utility of lower ejection fraction, lower blood pressure and functional status and elevated B-type natriuretic peptide as a phenotypic profile for an increased risk of cognitive impairment.

IMPLICATIONS

If the risk for cognitive impairment is suspected, specific evaluations of cognition can be performed. For community-dwelling heart failure patients with mild cognitive impairment, more intense interventions to support self-care, increased family involvement and more frequent follow up may be necessary.

Cognitive impairment affects physical recovery of patients with heart failure undergoing intensive cardiac rehabilitation

Purpose. To determine whether the presence of cognitive impairment (CI) affects physical recovery of patients with chronic heart failure (CHF) undergoing a cardiac rehabilitation program (CRP). Methods. We enrolled 80 CHF patients (M/F = 53/27). CI was evaluated by means of the Mini-Mental State Examination (MMSE), exercise tolerance was evaluated by six-minute walking test (6 mwt). All patients underwent a 6-week CRP program at 50-70% of maximal V(O2). Patients were divided into two groups according to their MMSE (group 1: 16-23; group 2: 24-30). Results. MMSE resulted directly related to ejection fraction (r = 0.42; P = 0.03), and it was inversely related to creatinine (r = -0.36; P = 0.04). At 6 week group 1 had a lower increase in distance walked at 6 MWT than group 2 (P = 0.008). At multivariate logistic regression MMSE 16-23 predicted a reduced exercise recovery in the overall population (OR = 1.84; 95% CI = 1.50-2.18) and in women (OR = 1.42; 95% CI = 1.22-1.75), while it was not predicted in males. Conclusions. CI is a marker of advanced CHF and is an independent predictor of lower exercise recovery after CRP.

Association of N-terminal pro-brain natriuretic peptide with cognitive function and depression in elderly people with type 2 diabetes

BACKGROUND

Type 2 diabetes mellitus is associated with risk of congestive heart failure (CHF), cognitive dysfunction and depression. CHF itself is linked both to poor cognition and depression. The ventricular N-terminal pro-brain natriuretic peptide (NT-proBNP) is a marker of CHF, suggesting potential as a marker for cognitive impairment and/or depression. This was tested in the Edinburgh Type 2 Diabetes Study (ET2DS).

METHODOLOGY AND PRINCIPAL FINDINGS

Cross-sectional analysis of 1066 men and women aged 60-75 with type 2 diabetes. Results from seven neuropsychological tests were combined in a standardised general cognitive ability factor, 'g'. A vocabulary-based test estimated pre-morbid cognitive ability. The Hospital Anxiety and Depression Scale (HADS) assessed possible depression. After adjustment for age and sex, raised plasma NT-proBNP was weakly associated with lower 'g' and higher depression scores (ß -0.09, 95% CI -0.13 to -0.03, p = 0.004 and ß 0.08, 95% CI 0.04 to 0.12, p<0.001, respectively). Comparing extreme quintiles of NT-proBNP, subjects in the highest quintile were more likely to have reduced cognitive ability (within the lowest tertile of 'g') and 'possible' depression (HADS depression ≥8) (OR 1.80; 95% CI: 1.20, 2.70; p = 0.005 and OR 2.18; 95% CI: 1.28, 3.71; p = 0.004, respectively). Associations persisted when pre-morbid ability was adjusted for, but as expected were no longer statistically significant following the adjustment for diabetes-related and vascular co-variates (β -0.02, 95% CI -0.07 to 0.03, p>0.05 for 'g'; β 0.03, 95% CI -0.02 to 0.07, p>0.05 for depression scores).

CONCLUSION

Raised plasma NT-proBNP was weakly but statistically significantly associated with poorer cognitive function and depression. The prospective phases of the ET2DS will help determine whether or not NT-proBNP can be considered a risk marker for subsequent cognitive impairment and incident depression and whether it provides additional information over and above traditional risk factors for these conditions.

Patterns of Change in Cognitive Function over Six Months in Adults with Chronic Heart Failure

Few investigators have studied cognition over time in adults with heart failure (HF). A battery of neuropsychological tests was administered to 279 adults with chronic systolic or diastolic HF at baseline, three and six months. Growth mixture modeling (GMM) was used to model the measure anticipated to be most sensitive, the digit symbol substitution task (DSST). We describe how and why the DSST patterns change over time. Other measures of cognition were examined to identify consistency with the DSST patterns. The sample was predominantly male (63.2%), Caucasian (62.7%), mean age 62 years. The best fit GMM revealed two trajectories of DSST scores: Average processing speed group (40.5%) and Below Average processing speed (59.9%). Neither group changed significantly over the six month study. Other measures of cognition were consistent with the DSST patterns. Factors significantly associated with increased odds of being in the Below Average processing speed group included older age, male gender, Non-Caucasian race, less education, higher ejection fraction, high comorbid burden, excessive daytime sleepiness, and higher BMI. As some of the factors related to cognitive impairment are modifiable, research is needed to identify interventions to preserve and improve cognition in these patients.

Effect of cardiac function on cognition and brain structural changes in dementia

Background and Purpose

Cardiovascular risk factors are considered to also be risk factors for dementia. Recent studies have shown that the prevalence of cognitive dysfunction is high in patients with cardiac diseases. However, few studies have investigated the influence of cardiac function on cognition and brain structural changes in dementia. The aims of this study were to determine the relationship between cardiac and cognitive function, and to characterize any structural changes in the brain that could be caused by cardiac function in patients with dementia.

Methods

Dementia patients (n=93) were recruited prospectively with checking for the presence of vascular risk factors such as hypertension. Cognitive function was measured by the Mini-Mental State Examination, modified Mini-Mental State test, and Korean version of the Dementia Rating Scale. Brain magnetic resonance imaging was conducted to evaluate the cerebral white-matter changes (WMC), ventricular dilation, and cortical and hippocampal atrophy. Cardiac function was evaluated using two-dimensional echocardiography. We divided the patients into two groups according to the presence (+) or absence (-) of WMC.

Results

In the entire cohort, the size of the left atrium (LA) was positively correlated with the degree of WMC, irrespective of age (p<0.05). The LA was larger in the WMC (+) group (n=42) than in the WMC (-) group. General cognitive function was significantly lower in the WMC (+) group than in the WMC (-) group. Subjects with an enlarged LA tended to exhibit lower cognitive function and more-severe cerebral WMC.

Conclusions

Cardiac dysfunction represented by LA enlargement could be related to cognitive decline and WMC of the brain resulting from impairment of the cerebral hemodynamic process in dementia.

Cognitive impairment in heart failure

Cognitive impairment (CI) is increasingly recognized as a common adverse consequence of heart failure (HF). Although the exact mechanisms remain unclear, microembolism, chronic or intermittent cerebral hypoperfusion, and/or impaired cerebral vessel reactivity that lead to cerebral hypoxia and ischemic brain damage seem to underlie the development of CI in HF. Cognitive decline in HF is characterized by deficits in one or more cognition domains, including attention, memory, executive function, and psychomotor speed. These deficits may affect patients' decision-making capacity and interfere with their ability to comply with treatment requirements, recognize and self-manage disease worsening symptoms. CI may have fluctuations in severity over time, improve with effective HF treatment or progress to dementia. CI is independently associated with disability, mortality, and decreased quality of life of HF patients. It is essential therefore for health professionals in their routine evaluations of HF patients to become familiar with assessment of cognitive performance using standardized screening instruments. Future studies should focus on elucidating the mechanisms that underlie CI in HF and establishing preventive strategies and treatment approaches.

Proximal cerebral arteries develop myogenic responsiveness in heart failure via tumor necrosis factor-α-dependent activation of sphingosine-1-phosphate signaling

BACKGROUND

Heart failure is associated with neurological deficits, including cognitive dysfunction. However, the molecular mechanisms underlying reduced cerebral blood flow in the early stages of heart failure, particularly when blood pressure is minimally affected, are not known.

METHODS AND RESULTS

Using a myocardial infarction model in mice, we demonstrate a tumor necrosis factor-α (TNFα)-dependent enhancement of posterior cerebral artery tone that reduces cerebral blood flow before any overt changes in brain structure and function. TNFα expression is increased in mouse posterior cerebral artery smooth muscle cells at 6 weeks after myocardial infarction. Coordinately, isolated posterior cerebral arteries display augmented myogenic tone, which can be fully reversed in vitro by the competitive TNFα antagonist etanercept. TNFα mediates its effect via a sphingosine-1-phosphate (S1P)-dependent mechanism, requiring sphingosine kinase 1 and the S1P(2) receptor. In vivo, sphingosine kinase 1 deletion prevents and etanercept (2-week treatment initiated 6 weeks after myocardial infarction) reverses the reduction of cerebral blood flow, without improving cardiac function.

CONCLUSIONS

Cerebral artery vasoconstriction and decreased cerebral blood flow occur early in an animal model of heart failure; these perturbations are reversed by interrupting TNFα/S1P signaling. This signaling pathway may represent a potential therapeutic target to improve cognitive function in heart failure.

Cognition in heart failure: an overview of the concepts and their measures

PURPOSE

To review cognitive impairment and explore current measurement concerns faced by nurse practitioners caring for individuals with heart failure.

DATA SOURCES

Review of peer-reviewed research articles published on the topic.

CONCLUSIONS

Cognitive impairment is prevalent among individuals with heart failure. Impairment frequently involves one or more domains, including attention, memory, and executive function. No gold standard screening measure was identified from the reviewed literature.

IMPLICATIONS FOR PRACTICE

It is imperative that clinicians are aware of cognitive impairment and its implications for their patients with heart failure. Cognitive impairment likely contributes to multiple clinical implications, including a decreased ability to attend to and comprehend patient education materials and an inability to appropriately assess and self-manage symptoms.

Two-year course of cognitive function and mood in adults with congestive heart failure and coronary artery disease: the Heart-Mind Study

BACKGROUND

Congestive heart failure (CHF) has been associated with impaired cognitive function, but it is unclear if these changes are specific to CHF and if they get worse with time. We designed this study to determine if adults with CHF show evidence of cognitive decline compared with adults with and without coronary artery disease (CAD).

METHODS

A longitudinal study was carried out of 77 adults with CHF (ejection fraction, EF < 0.4), 73 adults with a clinical history of CAD and EF > 0.6, and 81 controls with no history of CAD. The Cambridge Cognitive Examination of the Elderly (CAMCOG) was the primary outcome measure. Secondary measures included the California Verbal Learning Test (CVLT), digit coding and copying, Hospital Anxiety and Depression Scale (HADS), and the short form health survey (SF36). Endpoints were collected at baseline and after 12 and 24 months.

RESULTS

The adjusted CAMCOG scores of CHF participants declined 0.9 points over two years (p = 0.022) compared with controls without CAD. There were no differences between the groups on other cognitive measures. Participants with CHF and with CAD experienced similar changes in cognitive function over two years. Left ventricular EF and six-minute walk test results could not explain the observed associations.

CONCLUSIONS

The changes in cognitive function and mood associated with CHF over two years are subtle and not specific to CHF.

Measurement of cognitive function in chronic heart failure: a feasibility study

Assessment of cognition is critical to providing optimal care to individuals with heart failure. Traditional neuropsychological batteries are time consuming. This pilot study obtained feasibility data for a brief neuropsychological battery. Mean administration time was 40 ± 7.5 minutes, averting subject fatigue, and the battery was sensitive to cognitive impairments.

Screening for cognitive deficits using the Montreal cognitive assessment tool in outpatients ≥65 years of age with heart failure

There is strong evidence to suggest that heart failure (HF) is an independent risk factor for cognitive impairment (CI). The combination of CI and HF is associated with increased mortality, repeat hospitalization, and poor quality of life. The purpose of this pilot study was to determine the presence of CI in older patients with HF using the Montreal Cognitive Assessment (MoCA), a brief screening instrument for CI. We conducted a cross-sectional descriptive study using the MoCA in outpatients with HF who were ≥ 65 years of age. Forty-four patients (mean ± SD 76 ± 6.6 years of age) completed the MoCA. More than 70% of patients scored below the MoCA cutoff score of 26, suggesting the presence of CI. However, 91% of patients with New York Heart Association classes III to IV versus 52% of patients with classes I to II had a MoCA score < 26 (p = 0.004). Patients with a recent hospital admission were more likely to have a MoCA score < 26 versus patients without a recent hospital admission (89% vs 62%, respectively, p < 0.045). Cognitive domain subscores showing significant differences (p <0.01) were short-term memory, visuospatial function, executive function, and language. In conclusion, this study sample represented a group of older patients with HF and no suspected or documented CI, but screening with the MoCA detected CI in >70% of the sample. The presence of CI was significantly more common in patients with advanced HF symptoms or a recent hospitalization. Future studies need to determine if the MoCA can identify the presence of CI that is predictive of adverse clinical outcomes in the HF population.

Relationship of reduced cerebral blood flow and heart failure severity in elderly males

INTRODUCTION

Brain detrimental effects are under-recognised complication of chronic heart failure (CHF). One of the major causes may be cerebral hypoperfusion. This study was designed to investigate the relationship between cerebral blood flow (CBF) and severity of CHF as well as to evaluate its determinants among different parameters of cardiac dysfunction.

METHODS

Seventy-one CHF males with NYHA class II and III and 20 control subjects age ≥ 55 years were recruited. CBF was evaluated by colour duplex sonography of extracranial arteries. Echocardiography, 6-min walk test, quality of life and endothelial function were also assessed. Serum NT-pro-BNP and adipokines levels (adiponectin and leptin) were measured.

RESULTS

CBF was significantly reduced in elderly patients with CHF compared to healthy controls (677 +/- 170 vs 783 +/- 128 ml/min, p=0.011). Reduced CBF was associated with reduced left ventricular ejection fraction (LVEF) (r=0.271, p=0.022), lower 6-min walk distance (r=0.339, p=0.004), deteriorated quality of life (r= -0.327, p=0.005), increased serum adiponectin (r= -0.359, p=0.002), and NT-pro-BNP levels (r= -0.375, p=0.001). In multivariate regression analysis, LVEF and adiponectin were independently associated with reduced CBF in CHF patients (R(2)=0.289).

CONCLUSION

CBF was reduced in elderly males with mild-to-moderate CHF, and was associated with factors that represent the severity of CHF including high serum adiponectin and NT-pro-BNP levels, decreased LVEF, impaired physical performance, and deteriorated quality of life.

Cardiac output as a potential risk factor for abnormal brain aging

Heart failure has served as a clinically useful model for understanding how cardiac dysfunction is associated with neuroanatomic and neuropsychological changes in aging adults, theoretically because systemic hypoperfusion disrupts cerebral perfusion, contributing to clinical brain injury. This review summarizes more recent data suggesting that subtle cardiac dysfunction or low normal levels of cardiac function, as quantified by cardiac output, are related to cognitive and neuroimaging markers of abnormal brain aging in the absence of heart failure or severe cardiomyopathy. Additional work is required, but such associations suggest that reduced cardiac output may be a risk factor for Alzheimer's disease (AD) and abnormal brain aging through the propagation or exacerbation of neurovascular processes, microembolism due to thrombosis, and AD neuropathological processes. Such mechanistic pathways are discussed in the context of a theoretical model that posits a direct pathway of injury between cardiac output and abnormal brain aging (i.e., reduced systemic blood flow disrupts cerebral blood flow homeostasis), contributing to clinical brain injury, independent of shared risk factors for both cardiac dysfunction and abnormal brain aging.

Longitudinal trajectories of cognitive decline among older adults with cardiovascular disease

BACKGROUND

The long-term course of cognitive impairments secondary to cardiovascular disease (CVD) is unclear. In this study, we prospectively investigated the temporal pattern, rate and hierarchy of cognitive decline attributable to CVD--a risk factor for the development of vascular cognitive impairment (VCI)--and examined the influence of cardiac surgery and heart failure on cognitive decline.

METHODS

A total of 172 older adults with CVD were administered a comprehensive battery of neuropsychological tests at study entry, and at 12 and 36 months thereafter. Random coefficient regressions were used to investigate the temporal course, rate and hierarchy of cognitive decline, as well as to examine the effect of heart failure (reported by 21% of the sample) and cardiac surgery (reported by 44% of the sample) on trajectories of cognitive change.

RESULTS

The course of decline in cognition was linear for language and attention-executive function-psychomotor speed, and curvilinear for visuospatial abilities, memory and overall cognition. The decline in attention-executive function-psychomotor speed was smaller than the decline in other domains. The greatest decline occurred in visuospatial abilities. The rate of decline in cognition was not altered by a history of heart failure. Patients who had undergone cardiac surgery exhibited slower deceleration in their rates of decline in overall cognition. At baseline, patients with a history of heart failure had comparatively poorer attention-executive function-psychomotor speed, overall cognition and, to a lesser extent, visuospatial scores.

CONCLUSION

There is measurable decline in neurocognitive function among patients with CVD. This decline is linear in some cognitive domains and curvilinear in others and is not attributable to the normal aging process. Cardiac surgery, but not heart failure, significantly affects the trajectory of cognitive decline. Because most vascular risk factors are modifiable, preventive measures such as lifestyle changes may be useful in retarding cognitive decline among patients with CVD, thus preventing the onset of VCI.

Relationship between cognitive function and 6-minute walking test in older outpatients with chronic heart failure

BACKGROUND AND AIMS

Cognitive decline and heart failure frequently coexist in the elderly. Although an epidemiologic association may partially explain this finding, cerebral hypoperfusion and cardioembolism have been advocated as pathophysiological links. The aim of the present study was to evaluate the relationship between mild cognitive decline and exercise capacity in older outpatients with chronic heart failure (CHF).

METHODS

We studied 80 elderly outpatients with stable CHF, mainly of ischemic etiology, assessing total exercise capacity with the 6-minute walking test (6MWT) and global cognitive function with the Mini Mental State Examination (MMSE). CHF severity, emotional status, comorbidity, disability and disease-specific quality of life were also determined at the time of enrollment.

RESULTS

A positive association was observed between the distance walked at 6MWT and MMSE score, even after adjusting for demographic parameters, indexes of CHF severity, comorbidities, level of disability, and quality of life.

CONCLUSIONS

An easy and reliable measure of cardiovascular global performance is independently associated with cognitive function in older outpatients affected by CHF. In the context of global aging, this observation emphasizes the importance of a comprehensive assessment, encompassing a standard, brief and reliable cognitive evaluation, in elderly CHF outpatients.

Memory dysfunction, psychomotor slowing, and decreased executive function predict mortality in patients with heart failure and low ejection fraction

BACKGROUND

The purpose of this study was to evaluate whether dysfunction of specific cognitive abilities is a predictor of impending mortality in adults with systolic heart failure (HF).

METHODS

A total of 166 stable outpatients with HF completed cognitive function evaluation in language, working memory, memory, visuospatial ability, psychomotor speed, and executive function using a neuropsychological test battery. Demographic and clinical variables, comorbidity, depressive symptoms, and health-related quality of life were also measured. Patients were followed for 12 months to determine all-cause mortality.

RESULTS

There were 145 survivors and 21 deaths. In logistic regression analyses, significant predictors of mortality were lower left ventricular ejection fraction (LVEF) and poorer scores on measures of global congnitive function Mini-Mental State Examination [MMSE], working memory, memory, psychomotor speed, and executive function. Memory loss was the most predictive cognitive function variable (overall chi(2) = 17.97, df = 2, P < .001; Nagelkerke R(2) = 0.20). Gender was a significant covariate in 2 models, with men more likely to die. Age, comorbidity, depressive symptoms, and health-related quality of life were not significant predictors. In further analyses, significant predictors of mortality were lower systolic blood pressure and poorer global cognitive function, working memory, memory, psychomotor speed, and executive function, with memory being the most predictive.

CONCLUSIONS

As hypothesized, lower LVEF and memory dysfunction predicted mortality. Poorer global cognitive score as determined by the MMSE, working memory, psychomotor speed, and executive function were also significant predictors. LVEF or systolic blood pressure had similar predictive values. Interventions are urgently needed to prevent and manage memory loss in HF.

Cognitive dysfunctions in intensive cardiac care unit

BACKGROUND

Cognitive impairment is gaining recognition as sequelae of heart failure and the ICCU environment adds to their worsening symptoms.

OBJECTIVES

To determine cognitive dysfunctions in patients with heart disease admitted in intensive cardiac care unit (ICCU) and to compare it with patients admitted in general medical wards with heart disease.

MATERIALS AND METHODS

A total of 30 patients admitted to ICCU with heart disease were taken for the study and compared to patients with heart disease admitted in general medicine wards (except ICCU). The tools used were SMMSE (Standardized Mini Mental State Examination) and BCRS (Brief Cognitive Rating Scale). Statistical tests used were Student 't' test and Chi-Square test.

RESULTS

This study showed cognitive dysfunctions in the domains of orientation, attention and constructional ability as measured by SMMSE and cognitive dysfunction in the domain of concentration as measured by BCRS. Overall cognitive dysfunctions were present in the total score of both SMMSE and BCRS scale, which was statistically very highly significant.

CONCLUSION

The results showed that the patients in ICCU had cognitive dysfunctions in the domains of orientation, attention, constructional ability and concentration. Overall cognitive dysfunctions were found in the total scores of SMMSE and BCRS, thus signifying a global cognitive deficit.

Carotid artery ultrasound and echocardiography testing to lower the prevalence of Alzheimer's disease

The use of two clinic office techniques, carotid artery ultrasound and echocardiography (CAUSE), to detect deficient brain blood flow delivery in the healthy, cognitively normal, older individual is proposed. Evidence indicates that persistent heart-to-brain blood flow deficit involving low cardiac output or low ejection fraction and carotid artery narrowing can promote cognitive impairment and that such impairment may lead to Alzheimer's disease (AD) or vascular dementia (VaD). A number of independent epidemiologic studies reported cardiovascular and cerebrovascular disease to be risk factors to AD and VaD. The clinical rationale for CAUSE is to detect and prevent progression of cognitive dysfunction in elderly persons and is based on the general understanding that mild cognitive impairment is a preclinical threshold to AD or VaD with high conversion rates to either dementia. The use of CAUSE is anticipated to prevent or attenuate, by appropriate clinical management, mild cognitive impairment arising from persistent brain hypoperfusion, a condition implicated in the promotion of cognitive impairment in the elderly and a common preclinical feature seen in AD and VaD. As detection of lowered cerebral perfusion from cardiac and carotid artery pathology is achieved using these cost-effective, noninvasive, and relatively accurate ultrasound procedures, a significant reduction in the number of new AD and VaD cases would be anticipated after appropriate patient treatment. In this context, a brief summary is presented outlining recent medical and surgical treatments that may improve cerebral blood flow insufficiency. The merit of CAUSE in screening and treating mentally healthy elderly persons who are identified as being at risk of cognitive decline is that it could blunt the soaring socioeconomic impact that will hammer the health care system of many nations by the mounting dementia prevalence rate expected in the next 25 years. A 5- year delay in the onset of AD could reduce the prevalence of AD by 50%. We are making preparations to test the merit of CAUSE in a clinical study of a cognitively healthy elderly population.

A health-related quality of life questionnaire in symptomatic patients with heart failure: validity and reliability of a Japanese version of the MRF28

BACKGROUND

Major characteristics of symptomatic patients with heart failure are exercise intolerance, poor prognosis, and poor quality of life (QOL). However, most QOL questionnaires are applicable for patients with mild to moderate heart failure, and are not sufficiently sensitive to discriminate between patients with NYHA classes III and IV. Therefore, it is necessary to prepare a questionnaire focused on patients with severe heart failure.

OBJECTIVES

We developed a Japanese version of the Maugeri Foundation Respiratory Failure (MRF28) questionnaire and assessed validity and reliability of MRF28 in heart failure patients.

METHODS

The MRF28 questionnaire was evaluated in 124 patients with heart failure (NYHA classes: I, 24; II, 31; III, 52; IV, 17). Reliability was evaluated by internal consistency and test-retest reliability. Validity was determined by correlation with World Health Organization Quality of Life (WHOQOL) questionnaire and physiological parameters.

RESULTS

The MRF28 showed high internal consistency and reproducibility. The total score and subscores were all increased with the progress of heart failure. The total score could differentiate patients among NYHA II, III, and IV, but could not between NYHA I and II. However, all subscores and total score changed consistently with changes in symptoms of heart failure.

CONCLUSION

MRF28 is a valid and reliable disease-specific questionnaire for assessing QOL in symptomatic patients with heart failure. Thus, this questionnaire may be useful for a QOL evaluation of patients with moderate to severe heart failure.

Profile of Cognitive Impairment in Chronic Heart Failure

OBJECTIVES

To determine the frequency and pattern of cognitive dysfunction in outpatients with chronic congestive heart failure (CHF) and to identify the corresponding demographic and clinical correlates.

DESIGN

Case-control study.

SETTING

Outpatient clinic in a community hospital.

PARTICIPANTS

Sixty-two outpatients with CHF, 53 controls diagnosed with cardiovascular disease uncomplicated by CHF (cardiac controls), and 42 healthy controls were investigated.

MEASUREMENTS

Neuropsychological assessment included tests of mental speed, executive function, memory, language, and visuospatial function. Composite z-scores for five cognitive domains and mean z-score for overall cognitive performance were computed. The cutoff score to indicate cognitive impairment was defined as the overall healthy participants' cognitive z-score minus 2 standard deviations. Independent demographic and clinical predictors of cognitive impairment were identified using linear regression analysis.

RESULTS

Patients with CHF showed a pattern of general cognitive impairment, including impairment of executive function, memory, language, mental speed, and attention. Twenty-five percent (P=.04) of patients with CHF were classified as cognitively impaired, compared with 15% of the cardiac controls and 4% of the healthy controls. Independent predictors of cognitive impairment in patients with CHF were estimated intelligence, New York Heart Association class, and presence of the apolipoprotein (Apo)E epsilon4 allele.

CONCLUSION

Cognitive dysfunction is relatively common in patients with CHF, with deficits being most prominent in the domains of executive function, memory, language, and mental speed. Disease severity and ApoE genotype are likely to be important determinants for cognitive impairment in patients with chronic CHF.

Correlation between Cognitive Impairment and Prognostic Parameters in Patients with Congestive Heart Failure

BACKGROUND

Cognitive impairment has been observed in patients with congestive heart failure (CHF). We analyzed in-hospital CHF patients with neuropsychological tests attempting to correlate the results with prognostic parameters.

METHODS

All subjects underwent a mini-mental state examination (MMSE), memory and learning tests (Corsi Block-tapping test, Verbal Span test, Prose Memory test, Visual Search), anxiety and depression scale test. New York Hospital Association (NYHA) class, brain natriuretic peptide (BNP) and left ventricular ejection fraction (LVEF) were evaluated.

RESULTS

Sixty patients (mean age 65.5 years) were analyzed. NYHA class was 2.9 +/- 0.9, LVEF was 32.9 +/- 13.7%, BNP plasma level 683.3 +/- 864.3 pg/mL. In 23.3% of cases a pathological MMSE score emerged; memory and learning test results were abnormal in 3.4-37%. A positive correlation between MMSE and age (r = 0.18, p = 0.01), BNP (r = 0.25, p = 0.02) was observed but not between MMSE and years of education, NYHA class and LVEF. The Corsi Block-tapping test was related to educational duration (r = 0.12, p = 0.02) with a positive trend for BNP (r = 0.2, p = 0.07). The Prose Memory test and Visual Search were influenced by the patients' educational level (r = 0.36, p = 0.0001; r = 0.27, p = 0.0001).

CONCLUSIONS

CHF patients manifest an impairment of MMSE and memory and learning test performance. In our population MMSE correlates to plasma BNP and advanced age.

Effects of Antidepressant Treatment on Cognitive Performance in Elderly Subjects With Heart Failure and Comorbid Major Depression: An Exploratory Study

Cognitive deficits are common in association with heart failure (HF), and it is possible that their severity is magnified by the concomitant presence of major depressive disorder (MDD). Using the Cambridge Mental Disorders of the Elderly Examination battery, the authors compared the cognitive performance of MDD-HF subjects (N=20), nondepressed HF subjects (N=23), and healthy control subjects (N=18). Scores were lower in both HF groups relative to control subjects. In the MDD-HF group, there were significant cognitive improvements after antidepressant treatment. Cognitive impairment is, therefore, significant in HF subjects with or without comorbid MDD, and it is important to recognize and treat MDD symptoms associated with HF.

Cognitive impairment in heart failure: a systematic review of the literature

BACKGROUND

Heart failure (HF) and cognitive impairment are common medical conditions that are becoming increasingly prevalent in the aging Western population. They are associated with frequent hospitalisation and increased mortality, particularly when they occur simultaneously. Evidence from a number of studies suggests that HF is independently associated with impairment in various cognitive domains.

AIMS

This systematic literature review evaluates the relation between cognitive deterioration and heart failure.

METHODS

We searched electronic databases from 1966 to May 2006 for studies that investigated cognitive function in HF patients. Twenty-two controlled studies that met the inclusion criteria were selected for analysis. Study characteristics and data on global cognitive performance, memory scores, psychomotor speed and depression scores were extracted and analysed using the Cochrane Review Manager software.

RESULTS

Pooled analysis shows diminished neuropsychological performance in HF patients, as compared to control subjects. In a pooled sample of 2937 heart-failure patients and 14,848 control subjects, the odds ratio for cognitive impairment was 1.62 (95% confidence interval:1.48-1.79, p<0.0001) among subjects with HF.

CONCLUSION

This review confirms the relationship between HF and cognitive impairment, but it also stresses the need for additional systematic neuropsychological data and adequate neuro-imaging from representative populations of HF patients.

Congestive heart failure and Alzheimer's disease

The increase in average life expectancy is resulting in an increasing prevalence of major invalidating illnesses, such as cardiovascular disease and dementia. Congestive heart failure (CHF) is a chronic, progressive disease representing the advanced stage of cardiac illnesses. Cognitive impairment is known to be a frequent feature of CHF patients. The epidemiologic pictures of mild cognitive impairment (MCI), Alzheimer's disease (AD) and CHF are predicted to worsen with the demographic expansion of the elderly population. Nevertheless, there has been little structured research on cognitive impairment in patients with CHF. This is unfortunate not only because CHF is the leading cause of hospitalization in the elderly and a leading cause of disability and death, but also for important clinical and socioeconomic implications including those related to comorbidity in advanced age and the need to early detect factors which may precipitate the conversion of MCI to AD. In this review, several aspects of the role of CHF in cognitive impairment are evaluated. Owing to the lack of studies focusing on CHF in AD, the pathophysiology of cardiac failure in cognitive impairment is addressed in light of possible preventive strategies against the onset of AD. These include prevention of oxygen radical and peroxynitrite production, supplementation of nitric oxide (NO) donors, as well as the achievement of an adequate antioxidant supply, better if obtained with a targeted and individualized nutritional approach. A systematic neuropsychologic testing of older patients with heart failure is to identify those with early cognitive impairment and promptly establish traditional therapies such as angiotensin converting enzyme (ACE) inhibitors, digoxin or beta-blockers. The neuropsychologic assessment in CHF patients is also fundamental to disclose conditions potentially favoring the onset of cognitive impairment such as depression. Finally, management schemes should include exercise training programs as well as patient and caregiver education.

Cognitive dysfunction in congestive heart failure: transcranial Doppler evidence of microembolic etiology

Cognitive symptoms are common in patients with congestive heart failure (CHF) and are usually attributed to low cerebral blood flow. In the present study, we aimed to evaluate global cognitive function (Mini Mental State Exam MMSE) in relation to both cardiac function (evaluated by echocardiogram) and cerebrovascular hemodynamics (evaluated by transcranial Doppler TCD) in CHF patients. In 83 patients studied, no correlation was found between echocardiographic parameters and MMSE scores. In contrast, a significant correlation was found between right middle cerebral artery (RMCA) mean flow velocity and MMSE score (r=0.231 p=0.039), as well as between RMCA pulsatility index and MMSE score (r s= -0.292 p=0.015). After excluding patients with a previous history of stroke, only RMCA pulsatility index correlated with MMSE score (r s=-0,314 p=0,007). The relationship between high cerebrovascular resistance and worse cognitive scores suggest that microembolism may be responsible for a significant proportion of cognitive symptoms in CHF patients.

Cognitive, emotional, and quality of life outcomes in patients with pulmonary arterial hypertension

Background

The effects of pulmonary arterial hypertension on cardiovascular and physical function are well documented. Limited information exists regarding the effects of pulmonary arterial hypertension on cognitive function despite patient reports of problems with memory and attention. Our primary purpose was to determine if a prospectively identified cohort of pulmonary arterial hypertension patients had cognitive sequelae. Our secondary purpose was to determine the relationships between cognitive sequelae and neuropsychological test scores with depression, anxiety, and quality of life.

Methods

Forty-six adults with pulmonary arterial hypertension underwent assessment of cognitive function, depression, anxiety, and quality of life using standardized neuropsychological tests and questionnaires. The patients' scores were compared to normal population data. Medical, affective, neuropsychological, and quality of life data for patients with and without cognitive sequelae were compared using analysis of variance, Chi-square, or Fisher exact tests for categorical data. Correlations assessed relationships between neuropsychological test scores, depression, anxiety, quality of life, and medical data.

Results

Cognitive sequelae occurred in 58% (27/46) of the pulmonary arterial hypertension patients. Patients with cognitive sequelae had worse verbal learning, delayed verbal memory, executive function, and fine motor scores compared to patients without cognitive sequelae. Twenty-six percent of patients had moderate to severe depression and 19% had moderate to severe anxiety. Depression, anxiety and quality of life were not different for patients with or without cognitive sequelae. Our patients had decreased quality of life, which was associated with worse working memory.

Conclusion

Patients with pulmonary arterial hypertension have cognitive impairments, depression, anxiety, and decreased quality of life. Depression, anxiety, and quality of life were similar for patients with cognitive sequelae compared to those without cognitive sequelae. Decreased quality of life was associated with worse verbal and working memory. Clinicians should be aware of adverse brain related outcomes in PAH patients. Attention to proximal determinants and possible interventions to prevent or reduce cognitive and emotional morbidity and decreased quality of life are warranted and should be an emphasis in outcomes research.

A conceptual model of cognitive deficits in chronic heart failure

PURPOSE

To describe a conceptual model to guide studies of cognitive deficits among patients with heart failure.

ORGANIZING FRAMEWORK

The conceptual framework of cognitive deficits in chronic heart failure is based on theoretical and empirical literature about (a) the pathophysiology of heart failure, (b) the pathophysiology of cognitive deficits, and (c) health-related quality of life. Other variables that may cause or contribute to cognitive deficits include age, the relative contributions of multiple comorbid conditions, hypertension, and depressive symptoms. Covariates that might influence cognitive deficits (medications, gender, and education) are also included in the model. The most prominent cognitive deficits are believed to occur in domains of attention, working memory, memory, learning, executive function, and psychomotor speed. The main outcome variable is health-related quality of life, which is believed to be influenced by circulatory insufficiency and cognitive deficits.

CONCLUSIONS

The conceptual model described in this paper is a framework for testing cognitive deficits that occur in heart failure. After validation through empirical testing, the model may be useful in developing interventions for patients with heart failure whose care is complicated by cognitive deficits.

Assessment of cognitive function in heart failure patients

BACKGROUND

Research on the cognitive capacity of heart failure patients is limited, with a paucity of benchmark information available for this population. It is highly likely that cognitive deficits affect patients' understanding of disease and treatment requirements, as well as limiting their functional capacity and ability to implement treatment plans, and undertake self-care.

AIMS

The purpose of this study was to establish a comprehensive neurocognitive profile of the heart failure patient through systematic neurocognitive assessment and to determine whether an association existed between severity of heart failure and cognitive abilities.

METHODS

Thirty-eight patients were recruited from the heart failure patient databases of two metropolitan hospitals in Melbourne, Australia. Participants were individually assessed using four standardised, internationally recognised neuropsychological tests that examined current and premorbid intelligence, memory and executive functioning.

RESULTS

Although there was no significant decline from premorbid general intellectual function, other specific areas of deficit, including impaired memory and executive functioning, were identified. There were no significant correlations between heart failure severity and the neurocognitive measures used.

CONCLUSION

The results support the need to recognise cognitive impairment in people with heart failure and to develop an abbreviated method of assessing cognitive function that can be easily implemented in the clinical setting. Identifying cognitive deficits in this population will be useful in guiding the content and nature of treatment plans to maximise adherence and minimise worsening of heart failure symptoms.

A nurse-based management program in heart failure patients affects females and persons with cognitive dysfunction most

It is important that congestive heart failure (CHF) patients know how to monitor and manage disease-associated signs and symptoms. CHF patients were randomised to follow-up at a nurse-based outpatient clinic (intervention group (IG); n = 103), or to follow-up in primary healthcare (control group (CG); n = 105). Patient knowledge of CHF and self-care were assessed by a questionnaire and cognitive function by a Mini Mental State Examination (MMSE) at baseline and at six months. Men knew more about CHF as compared to females at baseline (p < 0.01). However, females in the IG increased their knowledge of self-care between baseline and six months as compared to CG females (p < 0.05). Patients with cognitive dysfunction (MMSE < 24) presented lower scores on knowledge as compared to those with a MMSE of >24 at baseline (p < 0.01). These differences disappeared after the intervention. Thus, females seemed to gain more than men from a nurse-based management program and patients with in-hospital signs of cognitive dysfunction should be encouraged to participate.