Cognition, Physical Function, and Quality of Life in Older Patients With Acute Decompensated Heart Failure

https://doi.org/10.1016/j.cardfail.2020.09.007Get rights and content

Highlights

  • In older hospitalized patients with acute decompensated heart failure, cognitive dysfunction is prevalent.

  • Cognitive dysfunction is associated with severe physical function deficits.

  • Concomitant impairment can jeopardize heart failure management strategies and patient safety.

  • Screening may decrease adverse events by identifying those who need tailored care.

Abstract

Background

Older adults with acute decompensated heart failure have persistently poor clinical outcomes. Cognitive impairment (CI) may be a contributing factor. However, the prevalence of CI and the relationship of cognition with other patient-centered factors such a physical function and quality of life (QOL) that also may contribute to poor outcomes are incompletely understood.

Methods and Results

Older (≥60 years) hospitalized patients with acute decompensated heart failure were assessed for cognition (Montreal Cognitive Assessment [MoCA]), physical function (Short Physical Performance Battery [SPPB], 6-minute walk distance [6MWD]), and QOL (Kansas City Cardiomyopathy Questionnaire, Short Form-12). Among patients (N = 198, 72.1 ± 7.6 years), 78% screened positive for CI (MoCA of <26) despite rare medical record documentation (2%). Participants also had severely diminished physical function (SPPB 6.0 ± 2.5 units, 6MWD 186 ± 100 m) and QOL (scores of <50). MoCA positively related to SPPB (ß = 0.47, P < .001), 6MWD ß = 0.01, P = .006) and inversely related to Kansas City Cardiomyopathy Questionnaire Overall Score (ß = –0.05, P < .002) and Short Form-12 Physical Component Score (ß = –0.09, P = .006). MoCA was a small but significant predictor of the results on the SPPB, 6MWD, and Kansas City Cardiomyopathy Questionnaire.

Conclusions

Among older hospitalized patients with acute decompensated heart failure, CI is highly prevalent, is underrecognized clinically, and is associated with severe physical dysfunction and poor QOL. Formal screening may reduce adverse events by identifying patients who may require more tailored care.

Section snippets

Study Design and Participants

This study is a cross-sectional analysis of the baseline assessment of the first 202 consecutively enrolled participants in the ongoing, National Institutes of Aging–sponsored, multicenter physical intervention trial, REHAB-HF, 198 of whom underwent cognitive screening. The design of REHAB-HF, including eligibility criteria and ADHF diagnosis confirmation, have been previously described.13,14 Briefly, patients were ≥60 years old and hospitalized for ≥24 hours for ADHF (regardless of ejection

Participant Characteristics

A total of 198 consecutively enrolled patients with cognitive data were included in this analysis. Patients averaged 72.1 ± 7.6 years of age, were mildly obese (BMI 33.2 kg/m2), and represented nearly equal proportions of males and females (46% vs. 54%) and whites and non-whites (52% vs. 48%). The majority (81%) had ≥12 years of formal education and 33% lived alone (Table 1).

Comorbidity burden was high with the majority of patients having hypertension (92%) and diabetes mellitus (55%). Also,

Discussion

This study systematically assessed cognitive dysfunction and examined its relationships with multiple measures of other important patient outcomes, including physical function and QOL, across multiple academic and community sites in an older, diverse ADHF population. We found that (1) CI was highly prevalent, (2) CI involved predominantly visuospatial, executive function, and recall domains, and (3) CI was associated with severe physical dysfunction and poor QOL. Each of these impairments is

Conclusions

Although the overwhelming majority of older hospitalized patients with ADHF had MoCA scores suggestive of CI, it was nearly always unrecognized clinically. Moreover, CI was global, affecting most domains of cognitive function, and was associated with severe impairments in physical function and QOL. Concomitant cognitive and physical impairment implies coordinated, systemic dysfunction, which has high potential to jeopardize patient HF self-management, safety, and functional independence. These

Declaration of Competing Interest

Dr. Kitzman is a consultant for AstraZeneca, Abbvie, GlaxoSmithKline, Merck, Corvia Medical, Bayer, CinRx, Boehringer-Ingleheim, and St. Luke's Medical Center in Kansas City, Kansas; received grant support from Novartis, AstraZeneca, Bayer, and St. Luke's Medical Center in Kansas City, Kansas; and owns stock in Gilead Sciences. Dr. Mentz receives research support from the National Institutes of Health (U01HL125511-01A1 and R01AG045551-01A1), Akros, Amgen, AstraZeneca, Bayer, GlaxoSmithKline,

Financial Disclosures

Supported in part by the following research grant awards from the National Institutes of Health: R01AG045551 and R01AG18915. Also supported in part by the Kermit Glenn Phillips II Chair in Cardiovascular Medicine at Wake Forest School of Medicine (DWK); the Claude D. Pepper Older Americans Independence Center (OAIC) NIH Grants P30AG021332 (DWK) and P30AG028716 (AMP); the Wake Forest Clinical and Translational Science Award, NIH Grant UL1TR001420, and the OAIC National Coordinating Center

Sponsor's Role

None.

References (46)

  • ML Alosco et al.

    Decreased physical activity predicts cognitive dysfunction and reduced cerebral blood flow in heart failure

    J Neurol Sci

    (2014)
  • T Siachos et al.

    Silent strokes in patients with heart failure

    J Card Fail

    (2005)
  • A Frey et al.

    Cognitive deficits and related brain lesions in patients with chronic heart failure

    JACC Heart Fail

    (2018)
  • KM Flint et al.

    Cardiac Rehabilitation in older adults with heart failure: fitting a square peg in a round hole

    Clin Geriatr Med

    (2019)
  • D Tanne et al.

    Cognitive functions in severe congestive heart failure before and after an exercise training program

    Int J Cardiol

    (2005)
  • C Groot et al.

    The effect of physical activity on cognitive function in patients with dementia: a meta-analysis of randomized control trials

    Ageing Res Rev

    (2016)
  • SA Clouston et al.

    The dynamic relationship between physical function and cognition in longitudinal aging cohorts

    Epidemiol Rev

    (2013)
  • M Stijntjes et al.

    Temporal relationship between cognitive and physical performance in middle-aged to oldest old people

    J Gerontol A Biol Sci Med Sci

    (2017)
  • HM Krumholz et al.

    Mortality, hospitalizations, and expenditures for the Medicare population aged 65 years or older, 1999-2013

    JAMA

    (2015)
  • K Dharmarajan et al.

    Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia

    JAMA

    (2013)
  • J Lovell et al.

    Self-management of heart failure in dementia and cognitive impairment: a systematic review

    BMC Cardiovasc Disord

    (2019)
  • QL Huynh et al.

    Cognitive domains and postdischarge outcomes in hospitalized patients with heart failure

    Circ Heart Fail

    (2019)
  • WD Reeves GR et al.

    A novel rehabilitation intervention for older patients with acute decompensated heart failure: The REHAB-HF Pilot Study

    JACC Heart Fail

    (2017)
  • Cited by (20)

    • Geriatric Domains in Patients with Heart Failure with Preserved Ejection Fraction

      2022, Cardiology Clinics
      Citation Excerpt :

      Finally, it may be reasonable to consider deprescribing commonly used agents with limited benefit—for example, beta-blockers are commonly used in HFpEF (86% prevalence in a recent randomized controlled trial),33 but they have limited data supporting benefits specifically for HFpEF,34,35 and some emerging data indicating potential for harm.36 The reported prevalence of cognitive impairment among patients with HF ranges from 22% to 78%.37,38 These differences reflect variations in the populations studied and diagnostic tools used across studies.

    View all citing articles on Scopus
    View full text