Joseph D. Redle

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.

Greater body mass index is associated with poorer cognitive functioning in male heart failure patients.

BACKGROUND Heart failure (HF) and obesity are associated with cognitive impairment. However, few studies have investigated the relationship between adiposity and cognitive functioning in HF for each sex, despite observed sex differences in HF prognosis. We tested the hypothesis that greater body mass index (BMI) would be associated with poorer cognitive functioning, especially in men, in sex-stratified analyses. METHODS AND RESULTS Participants were 231 HF patients (34% female, 24% nonwhite, average age 68.7 ± 7.3 years). Height and weight were used to compute BMI. A neuropsychology battery tested global cognitive function, memory, attention, and executive function. Composites were created using averages of age-adjusted scaled scores. Regressions adjusting for demographic and medical factors were conducted. The sample was predominantly overweight/obese (76.2%). For men, greater BMI predicted poorer attention (ΔR(2) = 0.03; β = -0.18; P = .01) and executive function (ΔR(2) = 0.02; β = -0.13; P = .04); these effects were largely driven by men with severe obesity (BMI ≥40 kg/m(2)). BMI did not predict memory (P = .69) or global cognitive functioning (P = .08). In women, greater BMI was not associated with any cognitive variable (all P ≥ .09). DISCUSSION Higher BMI was associated with poorer attention and executive function in male HF patients, especially those with severe obesity. These patients may therefore have more difficulties with the HF treatment regimen and may have poorer outcomes.

Cognitive Function in Heart Failure Is Associated With Nonsomatic Symptoms of Depression But Not Somatic Symptoms.

Background:Patients with heart failure (HF) have high rates of cognitive impairment and depressive symptoms. Depressive symptoms have been associated with greater cognitive impairments in HF; however, it is not known whether particular clusters of depressive symptoms are more detrimental to cognition than others. Objective:The aim of this study was to identify whether somatic and/or nonsomatic depressive symptom clusters were associated with cognitive function in persons with HF. Methods:Participants were 326 HF patients (40.5% women, 26.7% non-white race-ethnicity, aged 68.6 ± 9.7 years). Depressive symptoms were measured using a depression questionnaire commonly used in medical populations: the Patient Health Questionnaire-9. Somatic and nonsomatic subscale scores were created using previous factor analytic results. A neuropsychological battery tested attention, executive function, and memory. Composites were created using averages of age-adjusted scaled scores. Regressions adjusting for demographic and clinical factors were conducted. Results:Regressions revealed that Patient Health Questionnaire-9 total was associated with attention (&bgr; = −.14, P = .008) and executive function (&bgr; = −.17, P = .001). When analyzed separately, the nonsomatic subscale, but not the somatic symptoms subscale (P values ≥ .092), was associated with attention scores (&bgr; = −.15, P = .004) and memory (&bgr; = −.11, P = .044). Both nonsomatic (&bgr; = −.18, P < .001) and somatic (&bgr; = −.11, P = .048) symptoms were related to executive function. When included together, only the nonsomatic symptom cluster was associated with attention (&bgr; = −.15, P = .020) and executive function (&bgr; = −.19, P = .003). Conclusions:Greater overall depressive symptom severity was associated with poorer performance on multiple cognitive domains, an effect driven primarily by the nonsomatic symptoms of depression. Clinical Implications:These findings suggest that screening explicitly for nonsomatic depressive symptoms may be warranted and that the mechanisms underlying the depression-cognitive function relationship in HF are not solely related to sleep or appetite disturbance. Thus, interventions that target patients’ somatic symptoms only (eg, poor appetite or fatigue) may not yield maximum cognitive benefit compared with a comprehensive treatment that targets depressed mood, anhedonia, and other nonsomatic symptoms.

Association Between Poorer Cognitive Function and Reduced Objectively Monitored Medication Adherence in Patients With Heart Failure.

Background—Subclinical cognitive impairment is prevalent in heart failure (HF); however, its role in important clinical outcomes, such as HF treatment adherence, is unclear. Given the complex polypharmacy in HF treatment, cognitive deficits may be important in predicting medication management. Thus, the objective of the current study was to examine the impact of cognitive function on medication adherence among community-dwelling patients with HF using objective assessments. Methods and Results—A prospective observational cohort design of 309 community-dwelling patients with HF (59.7% male, 68.7±9.7 years) and no history of dementia or neurological disease. Cognition was assessed using a neuropsychological battery at baseline. Medication adherence was objectively measured for 21 days using an electronic pillbox. Regression analyses tested whether attention, executive function, or memory predicted 21-day medication adherence. In unadjusted analyses, lower scores on all 3 cognitive domains predicted poorer medication adherence (&bgr;=0.52–85; P=0.001–0.009). After adjusting for demographic, clinical, and psychosocial variables, memory continued to predict medication adherence (&bgr;=0.51; P=0.008), whereas executive function (&bgr;=0.24; P=0.075) and attention were no longer a predictor (&bgr;=0.34; P=0.131). Conclusions—Poorer cognitive function, especially in regard to memory, predicted reduced medication adherence among patients with HF and no history of dementia. This effect remained after adjustment for factors known to predict adherence, such as depressed mood, social support, and disease severity level. Future studies should examine the link from cognitive impairment and medication nonadherence to clinical outcomes (eg, hospitalization and mortality). Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01461629.

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.

What is your patient's cognitive profile? Three distinct subgroups of cognitive function in persons with heart failure

PURPOSE The aim of this study was to determine whether patients with heart failure (HF) have distinct profiles of cognitive impairment. BACKGROUND Cognitive impairment is common in HF. Recent work found three cognitive profiles in HF patients-(1) intact, (2) impaired, and (3) memory-impaired. We examined the reproducibility of these profiles and clarified mechanisms. METHODS HF patients (68.6 ± 9.7 years; N=329) completed neuropsychological testing. Composite scores were created for cognitive domains and used to identify clusters via agglomerative-hierarchical cluster analysis. RESULTS A 3-cluster solution emerged. Cluster 1 (n=109) had intact cognition. Cluster 2 (n=123) was impaired across all domains. Cluster 3 (n=97) had impaired memory only. Clusters differed in age, race, education, SES, IQ, BMI, and diabetes (ps ≤ .026) but not in mood, anxiety, cardiovascular, or pulmonary disease (ps ≥ .118). CONCLUSIONS We replicated three distinct patterns of cognitive function in persons with HF. These profiles may help providers offer tailored care to patients with different cognitive and clinical needs.

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.

The association between cognitive function and objective adherence to dietary sodium guidelines in patients with heart failure

Background Although cognitive impairment is common in heart failure (HF) patients, its effects on sodium adherence recommendations are unknown. Purpose Our aim is to examine if cognitive function is associated with patient sodium adherence. Methods Sodium collection/excretion and cognitive function were assessed for 339 HF patients over a 5–8-week period. Neuropsychological testing was performed at baseline (Visit 1), whereas two 24-hour urine samples were collected within 7 weeks postbaseline. The ability to collect two 24-hour urine samples and the estimation of sodium excretion levels from these samples were used to estimate sodium adherence recommendations. Results Nearly half (47%) of the study participants (n=159) were unable to give two valid 24-hour urine samples. Participants who were unable to adhere to two valid 24-hour urine samples had significantly poorer attention and global cognition tests (P<0.044), with a trend for poorer executive function (P=0.064). Among those with valid samples, urine sodium level was not associated with global cognitive function, attention, executive function, or memory after adjusting for covariates. Female sex was associated with lower sodium excretion (all P<0.01); individuals with knowledge of sodium guidelines had less intake of sodium, resulting in excretion of less sodium (all P≤0.03). Conversely, higher socioeconomic status (SES) and body mass index (BMI) were associated with greater sodium (all P≤0.02 and P≤0.01). Conclusion Adherence to urine sodium collection was poor, especially among those with poorer cognitive function. Sodium consumption exceeded recommended amounts and was unrelated to cognitive function. Interventions for improving sodium adherence should focus on at-risk groups (high SES and BMI) and at improving knowledge of recommended salt intake.

Cognitive Function Predicts Risk for Clinically Significant Weight Gain in Adults With Heart Failure

Background: Few investigators have examined whether cognitive deficits predict poorer self-care of weight management recommendations and weight gain in adults with heart failure. Objective: The purposes of this study were (1) to examine whether cognition is associated with adherence to daily weighing and weight gain incidence and (2) to explore self-reported symptom perception and management when a weight increase occurs. Methods: In this observational study, participants completed neuropsychological testing, were given an electronic scale, and were instructed to record their weight for 21 days. Data for 301 participants were collected at baseline and 3 weeks after weight monitoring. Results: At baseline, only 35% of the enrolled respondents knew when to call their physician for increased weight gain, and 37% of the analyzed sample (n = 110/301) experienced a clinically significant weight gain. Regressions tested whether baseline attention, executive function, or memory predicted adherence to daily weighing and the likelihood of weight gain incidence. In unadjusted and adjusted covariate analyses, none of the cognitive domains predicted adherence to daily weighing (P ≥ .375); however, all 3 cognitive domains predicted an increased risk of a clinically significant weight gain (P ⩽ .05). Importantly, 65% of participants with a weight gain did not identify this symptom on self-report questions. Conclusions: Although cognitive deficits are not associated with adherence to daily weighing, adults with cognitive deficits may be at an increased risk for experiencing a clinically significant weight gain, and most do not perceive symptoms. Clinical Implications: Adults with heart failure require more than directions on self-care related to weight monitoring.