Emily C. Gathright

The MoCA and MMSE as screeners for cognitive impairment in a heart failure population: A study with comprehensive neuropsychological testing

OBJECTIVE To examine the ability of the Mini Mental Status Examination (MMSE) and Montreal Cognitive Assessment (MoCA) to detect cognitive impairment in persons with heart failure (HF). BACKGROUND Although the MMSE and MoCA are commonly used screeners in HF, no research team has validated their performance against neuropsychological testing. METHODS Participants were 106 patients with HF (49.1% male, 68.13 ± 9.82 years) who completed the MoCA, MMSE, and a full neuropsychological battery. Sensitivity and specificity were examined. Discriminant function analyses tested whether the screeners correctly detected cognitive impairment. RESULTS A MoCA score <25 and MMSE score of <28 yielded optimal sensitivity/specificity (.64/.66 and .70/.66, respectively). The MoCA correctly classified 65% of patients, Wilks lambda = .91, χ(2)(1) = 9.89, p < .01, and the MMSE correctly classified 68%, Wilks lambda = .87, χ(2)(1) = 14.26, p < .001. CONCLUSIONS In HF, both the MoCA and MMSE are useful in identifying the majority of patients with and without cognitive impairment. Both tests misclassified approximately one-third of patients, so continued monitoring and evaluation of patients is needed in conjunction with screening.

Randomized Controlled Feasibility Trial of Two Telemedicine Medication Reminder Systems for Older Adults with Heart Failure

We conducted a feasibility study of a telehealth intervention (an electronic pill box) and an m-health intervention (an app on a smartphone) for improving medication adherence in older adults with heart failure. A secondary aim was to compare patient acceptance of the devices. The participants were 60 adults with HF (65% male). Their average age was 69 years and 83% were Caucasian. Patients were randomized using a 2 × 2 design to one of four groups: pillbox silent, pillbox reminding, smartphone silent, smartphone reminding. We examined adherence to 4 medications over 28 days. The overall adherence rate was 78% (SD 35). People with the telehealth device adhered 80% of the time and people with the smartphone adhered 76% of the time. Those who received reminders adhered 79% of the time, and those with passive medication reminder devices adhered 78% of the time, i.e. reminding did not improve adherence. Patients preferred the m-health approach. Future interventions may need to address other contributors to poor adherence such as motivation.

Adherence to Antidepressant Medications: A Randomized Controlled Trial of Medication Reminding in College Students

Abstract Objectives: To determine if medication reminding via smartphone app increases adherence to antidepressant medications in college students. Participants: College students (N = 57) enrolled at a state-funded institution who had a current prescription for an antidepressant and regularly used a smartphone device. Methods: Participants were randomized to either a reminder group or a control group. Both groups were asked to complete a survey and undergo a manual pill count at the beginning of the study and 30 days later. Results: There was a strong trend suggesting that the use of a medication reminder app was beneficial for adherence to antidepressant medication regimens. Factors influencing medication adherence in college students included health beliefs, use of illicit drugs, and type of professional care received. Conclusions: Use of a medication reminder may increase adherence to antidepressant medications in college students.

Depression increases the risk of mortality in patients with heart failure: A meta-analysis

BACKGROUND Depression is a risk factor for mortality in cardiovascular diseases. Prior studies confirm that depression predicts adverse outcomes in patients with heart failure (HF). However, data were inconclusive regarding the effect of depression on mortality. This meta-analysis examines the relationship between depression and mortality in HF. METHODS Prospective studies of depression and mortality in HF published between 1999 and April 2016 were located using PubMed, PsychINFO, and MEDLINE. Comprehensive Meta-Analysis software was used to compute an aggregated effect size estimates of hazard ratios and to conduct subgroup analyses. RESULTS Eighteen studies met inclusion criteria. For 8 aggregated univariate and 14 multivariate estimates, depressive symptoms were related to all-cause mortality. A pooled HR of 3 multivariate analyses indicated that depressive symptoms were not linked to cardiovascular mortality. In subgroup analyses, depression predicted all-cause mortality in samples with a mean age >65. The impact of depression on all-cause mortality also differed by follow-up duration, with samples with shorter follow-up durations demonstrating a larger effect. CONCLUSIONS In HF, depression is related to increased all-cause mortality risk, with stronger effects in samples with shorter follow-up and in older adults. In older adults, depression may serve as a marker of more severe HF. However, this possibility is difficult to examine given inconsistent adjustment for HF severity. Additional studies may assist in determining the relationship between depression and cardiovascular mortality, as the low number of studies examining cardiovascular mortality may have precluded detection of an effect.

Effects of exercise on c-reactive protein in healthy patients and in patients with heart disease: A meta-analysis.

Decreases in circulating hsCRP have been associated with increased physical activity and exercise training, although the ability of exercise interventions to reduce hsCRP and which individuals benefit the most remains unclear. This meta-analysis evaluates the ability of exercise to reduce hsCRP levels in healthy individuals and in individuals with heart disease. A systematic review and meta-analysis was conducted that included exercise interventions trials from 1995 to 2012. Forty-three studies were included in the final analysis for a total of 3575 participants. Exercise interventions significantly reduced hsCRP (standardized mean difference -0.53 mg/L; 95% CI, -0.74 to -0.33). Results of sub-analysis revealed no significant difference in reductions in hsCRP between healthy adults and those with heart disease (p = .20). Heterogeneity between studies could not be attributed to age, gender, intervention length, intervention type, or inclusion of diet modification. Exercise interventions reduced hsCRP levels in adults irrespective of the presence of heart disease.​.

Cognitive Function Does Not Impact Self-reported Health-Related Quality of Life in Heart Failure Patients

Background:Adults with heart failure (HF) often demonstrate impairment across multiple domains of cognitive functioning and report poor health-related quality of life (HRQoL). Previous researchers have found that cognitive deficits were generally not associated with HRQoL in a carefully evaluated sample. The exception was memory, which was only weakly associated with HRQoL. However, cognitive deficits interfere with self-care and disease self-management, which could be expected to affect HRQoL. Objective:We sought to verify this counterintuitive finding in a large well-characterized sample of HF patients using a well-validated neuropsychological battery. Methods:Participants were 302 adults (63% male) predominately white (72.5%) HF patients (68.7 ± 9.6 years) recruited from 2 medical centers. Self-reported HRQoL was assessed using the Kansas City Cardiomyopathy Questionnaire. Participants completed a neuropsychological battery examining attention, executive function, memory, and visuospatial functioning. Hierarchical multiple linear regression was used for analyses. Results:Mild global cognitive impairment was observed in 29.5% of the sample (Modified Mini-Mental State [3MS] Examination score <90). Controlling for gender, depression, HF severity, premorbid IQ, comorbidities, and education, only executive function predicted HRQoL, &bgr; = .17, P < .05. However, executive function accounted for only 0.6% of the variance in HRQoL. Conclusion:Cognitive function generally did not predict HRQoL in HF patients. The correlates of HRQoL in HF do not appear to include mild cognitive impairment. Other factors may play a bigger role such as disease severity, age, and depressive symptoms. Future studies should investigate modifiable determinants of HRQoL in HF patients, toward the goal of finding interventions that preserve HRQoL during this chronic illness.

Health Literacy and Global Cognitive Function Predict E-Mail but Not Internet Use in Heart Failure Patients

Background. The internet offers a potential for improving patient knowledge, and e-mail may be used in patient communication with providers. However, barriers to internet and e-mail use, such as low health literacy and cognitive impairment, may prevent patients from using technological resources. Purpose. We investigated whether health literacy, heart failure knowledge, and cognitive function were related to internet and e-mail use in older adults with heart failure (HF). Methods. Older adults (N = 119) with heart failure (69.84 ± 9.09 years) completed measures of health literacy, heart failure knowledge, cognitive functioning, and internet use in a cross-sectional study. Results. Internet and e-mail use were reported in 78.2% and 71.4% of this sample of patients with HF, respectively. Controlling for age and education, logistic regression analyses indicated that higher health literacy predicted e-mail (P < .05) but not internet use. Global cognitive function predicted e-mail (P < .05) but not internet use. Only 45% used the Internet to obtain information on HF and internet use was not associated with greater HF knowledge. Conclusions. The majority of HF patients use the internet and e-mail, but poor health literacy and cognitive impairment may prevent some patients from accessing these resources. Future studies that examine specific internet and email interventions to increase HF knowledge are needed.

Relationship between depression and medication adherence in cardiovascular disease: the perfect challenge for the integrated care team

Many individuals with cardiovascular disease (CVD) experience depression that is associated with poor health outcomes, which may be because of medication nonadherence. Several factors influence medication adherence and likely influence the relationship between depression and medication adherence in CVD patients. This comprehensive study reviews the existing literature on depression and medication adherence in CVD patients, addresses the methods of and problems with measuring medication adherence, and explains why the integrated care team is uniquely situated to improve the outcomes in depressed CVD patients. This paper also explores how the team can collaboratively target depressive symptoms and medication-taking behavior in routine clinical care. Finally, it suggests the limitations to the integrated care approach, identifies targets for future research, and discusses the implications for CVD patients and their families.

Influence of Depression on Utilization of Cardiac Rehabilitation Postmyocardial Infarction: A STUDY OF 158 991 MEDICARE BENEFICIARIES

PURPOSE: On the basis of several small studies, depression is often considered a barrier to cardiac rehabilitation (CR) enrollment and program completion. The purpose of this research was to examine the association between depression diagnosis and participation in CR in a large sample of Medicare beneficiaries with recent myocardial infarction (MI). METHODS: This was a retrospective study of Medicare beneficiaries with an MI during 2008 (N = 158 991). CR enrollment was determined by the Carrier and Outpatient files using the Healthcare Common Procedure Coding System #93797 or #93798. Depression diagnosis was obtained from the International Classification of Diseases, Ninth Revision (ICD-9) codes in the Medicare Provider Analysis and Review (MEDPAR), Outpatient and Carrier Files. The association between depression diagnosis and CR attendance was evaluated using multivariable logistic regression. RESULTS: Overall, 14% (n = 22 735) of the study population attended CR within 1 year of MI diagnosis. Twenty-eight percent (n = 43 827) had a diagnosis of depression, with 96% of cases documented before enrollment in CR. Twenty-eight percent with a diagnosis of depression compared with 9% without depression attended CR. In adjusted analysis, patients with depression were 3.9 (99% CI, 3.7-4.2) times more likely to attend CR compared with those without depression. Program completion (≥25 sessions) was more common in those with depression (56%) than in those without (35%) (P < .001). CONCLUSIONS: Diagnosis of depression in Medicare beneficiaries was strongly associated with attending CR and attending more sessions of CR compared with those without depression. Depression is not a barrier to CR participation after MI in Medicare beneficiaries.

The impact of medication nonadherence on the relationship between mortality risk and depression in heart failure

Objective: Heart failure affects more than 5 million U.S. adults, and approximately 20% of individuals with heart failure experience depressive symptoms. Depression is detrimental to prognosis in heart failure, conferring approximately a 2-fold increase in mortality risk. Medication nonadherence may help explain this relationship because depressed patients are less likely to adhere to the medication regimen. Method: Depression, electronically monitored medication adherence, and mortality were measured in a sample of 308 patients with heart failure participating in a study of self-management behavior. Cardiovascular and all-cause mortality data were obtained from the Centers for Disease Control and Prevention’s National Death Index (median 2.9-year follow-up). Cox proportional hazards regression was used to assess the relationship between depression and mortality, with and without adjustment for age, gender, disease severity, and medication nonadherence. Results: In adjusted analyses, depression was associated with an increased all-cause mortality risk (hazard ratio 1.87; 95% confidence interval 1.04–3.37). Depression was not related to cardiovascular mortality, potentially because of a low number of cardiac-related deaths. When medication nonadherence was added to the model, nonadherence (hazard ratio 1.01; 95% confidence interval 1.004–1.02), but not depression, predicted all-cause mortality risk. Conclusions: Depressive symptoms confer increased all-cause mortality risk in heart failure, and medication nonadherence contributes to this relationship. Depression and nonadherence represent potentially modifiable risk factors for poor prognosis. Future research is needed to understand whether interventions that concomitantly target these factors can improve outcomes.