Richard Josephson

Cognitive impairment is independently associated with reduced instrumental activities of daily living in persons with heart failure

Background:Heart failure (HF) is a disabling disease that often affects instrumental activities of daily living (instrumental ADLs). Despite high rates of disability in this population, little is known about the effects of cognitive impairment on instrumental ADLs in this population. Objective:The current study examined whether cognitive functioning predicts instrumental ADL performance in persons with HF. Methods:Persons with HF (N = 122; 68.49 [SD, 9.43] years; 35.2% female) completed neuropsychological testing, fitness assessment, and self-reported instrumental and basic ADL function as part of a larger protocol. Neuropsychological tests included the Mini-Mental State Examination and Trail Making Tests A and B. The 2-minute step test estimated fitness. Instrumental and basic ADL function was based on self-report on the Lawton-Brody Activities of Daily Living Scale. Hierarchical regression analyses were used to determine the independent contribution of cognitive function to ADLs in HF. Results:Heart failure patients reported high rates of impairments in instrumental ADLs, but indicated requiring little or no assistance with basic ADLs. Cognitive function showed incremental predictive validity for driving (R2 change = .07, P = .03) and medication management (R2 change = .14, P < .001). In each case, poorer neuropsychological test performance was associated with poorer instrumental ADL function. Conclusion:In persons with HF, cognitive performance is an independent predictor of independence in driving and medication management. Strategies to maintain or improve cognitive functioning in HF may help patients remain functionally independent in their daily living.

Can serial exercise testing improve the prediction of coronary events in asymptomatic individuals

An abnormal ST segment response to treadmill exercise has a low predictive value for future coronary events (angina pectoris, nonfatal myocardial infarction, or cardiac death) in apparently healthy individuals. To determine whether the conversion from a normal to an abnormal ST segment response might identify individuals at high risk for a future coronary event, we analyzed the results of serial exercise tests performed at 2-4-year intervals in 726 male and female volunteers, aged 22-84 years (mean, 55.1 years), from the Baltimore Longitudinal Study of Aging (BLSA). All subjects were free of cardiovascular disease at entry by history, physical examination, and resting 12-lead electrocardiogram. Over a mean overall follow-up of 7.4 years, coronary events occurred in 34 of 178 (19.1%) of those with an abnormal ST response to exercise versus 30 of 548 (5.5%) in those with a normal response (p = 0.001). Angina pectoris was the most common presenting coronary event regardless of ST segment exercise response. Among individuals with an abnormal ST segment response, the incidence of events was virtually identical between those with an initially abnormal response (group 1) and those who converted from a normal to an abnormal response (group 2), 19.8% versus 18.5%. After adjustment for standard coronary risk factors by proportional hazards regression analysis, the risk of a coronary event relative to subjects with persistently normal ST segment responses (group 3) remained nearly identical in the two groups, 2.72 in group 1 (p less than 0.003) and 2.80 in group 2 (p less than 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebral Perfusion is Associated With White Matter Hyperintensities in Older Adults With Heart Failure

Cognitive impairment is common in heart failure (HF) and believed to be the result of cerebral hypoperfusion and subsequent brain changes including white matter hyperintensities (WMHs). The current study examined the association between cerebral blood flow and WMHs in patients with HF and the relationship between WMHs and cognitive impairment. Sixty-nine patients with HF completed the Mini-Mental State Examination (MMSE) and underwent echocardiography, transcranial Doppler sonography for cerebral blood flow velocity of the middle cerebral artery, and brain magnetic resonance imaging. Multivariable hierarchical regression analyses controlling for medical and demographic characteristics as well as intracranial volume showed reduced cerebral blood flow velocity of the middle cerebral artery was associated with greater WMHs (β=-0.34, P=.02). Follow-up regression analyses adjusting for the same medical and demographic factors in addition to cerebral perfusion also revealed marginal significance between increased WMHs and poorer performance on the MMSE (β=-0.26, P=.05). This study suggests that reduced cerebral perfusion is associated with greater WMHs in older adults with HF. These findings support the widely proposed mechanism of cognitive impairment in HF patients and prospective studies are needed to confirm these results.

Cognitive function and treatment adherence in older adults with heart failure.

Objective Treatment recommendation and guidelines for patients with heart failure (HF) can be complex, and past work has shown that patients with HF demonstrate low rates of adherence to recommended health behaviors. Although previous work has identified several medical, demographic, and psychosocial predictors of the capacity to adhere to treatment recommendations of persons with HF, little is known about the contribution of cognitive impairment to reported treatment adherence in this population. Methods A total of 149 persons with HF (mean [standard deviation] = 68.08 [10.74] years) completed a brief fitness assessment and neuropsychological testing. Treatment adherence was assessed using the Heart Failure Compliance Questionnaire, a brief measure that asks participants to report their adherence to a variety of recommended health behaviors (i.e., medication management, diet, and exercise, among others). Results The percentage of participants who reported poor overall adherence was 16.1%, with particularly high rates of nonadherence to dietary and exercise recommendations. Hierarchical regression analyses adjusting for possible confounds revealed that reduced performance on attention (&bgr; = .26, p = .01), executive function (&bgr; = .18, p = .04), and language (&bgr; = .22, p = .01) was associated with poorer overall adherence. Follow-up analyses showed that these cognitive domains were associated with behaviors such as keeping doctor appointments, medication management, and dietary recommendations (p < .05 for all). Conclusions The current findings demonstrate that cognitive function is an independent contributor to adherence in older adults with HF. Prospective studies that objectively measure treatment adherence are needed to clarify these findings and identify possible strategies to improve outcomes in this population. Trial Registration: clinicaltrials.gov Identifier: NCT00871897.

Randomized controlled trial of mindfulness-based stress reduction for prehypertension.

Objective Mindfulness-based stress reduction (MBSR) is an increasingly popular practice demonstrated to alleviate stress and treat certain health conditions. MBSR may reduce elevated blood pressure (BP). Treatment guidelines recommend life-style modifications for BP in the prehypertensive range (systolic BP [SBP] 120–139 mm Hg or diastolic BP [DBP] 80–89 mm Hg), followed by antihypertensives if BP reaches hypertensive levels. MBSR has not been thoroughly evaluated as a treatment of prehypertension. A randomized clinical trial of MBSR for high BP was conducted to determine whether BP reductions associated with MBSR exceed those observed for an active control condition consisting of progressive muscle relaxation (PMR) training. Methods Fifty-six men (43%) and women (57%) averaging (standard deviation) 50.3 (6.5) years of age (91% white) with unmedicated BP in the prehypertensive range were randomized to 8 weeks of MBSR or PMR delivered in a group format. Treatment sessions were administered by one treatment provider and lasted approximately 2.5 hours each week. Clinic BP was the primary outcome measure. Ambulatory BP was a secondary outcome measure. Results Analyses were based on intent to treat. Patients randomized to MBSR exhibited a 4.8-mm Hg reduction in clinic SBP, which was larger than the 0.7-mm Hg reduction observed for PMR (p = .016). Those randomized to MBSR exhibited a 1.9-mm Hg reduction in DBP compared with a 1.2-mm Hg increase for PMR (p = .008). MBSR did not result in larger decreases in ambulatory BP than in PMR. Conclusions MBSR resulted in a reduction in clinic SBP and DBP compared with PMR. Trial Registration ClinicalTrials.gov identifier: NCT00440596.

Improvements in Cognitive Function Following Cardiac Rehabilitation for Older Adults With Cardiovascular Disease

ABSTRACT Cognitive impairment is common in persons with cardiovascular disease (CVD). Cardiac rehabilitation (CR) improves many aspects of CVD linked to cognitive impairment. The current study explored whether CR may improve cognitive function. Potential mechanisms for cognitive changes were also examined through exploratory analyses, including changes in cardiovascular fitness and cerebral blood flow. Fifty-one older adults with CVD underwent neuropsychological assessment at baseline and discharge from a 12-week CR program. Cardiovascular fitness (i.e., metabolic equivalents [METs]) was estimated from a symptom-limited volitional stress test. Transcranial doppler quantified mean cerebral blood flow velocity and pulsatility indexes for the middle cerebral artery and anterior cerebral artery (ACA). Repeated measures ANOVA showed improvements in global cognition, attention-executive-psychomotor function, and memory. Exploratory analyses revealed improvement in METs and changes in ACA flow velocity, but only improvement in METs was related to improved verbal recall. CVD patients exhibited improvements in multiple cognitive domains following a 12-week CR program, suggesting that cognitive impairment is modifiable in this population. Although other studies are needed to elucidate underlying mechanisms, exploratory analyses suggest that cognitive improvements may be better explained by physiological processes other than improved cardiovascular fitness and cerebral blood flow.

Depression is associated with reduced physical activity in persons with heart failure.

OBJECTIVE Reduced physical activity is common in persons with heart failure (HF). However, studies of correlates and modifiers of physical activity in this population rarely employ objective measures. Motivational and mood related factors that may exacerbate inactivity in HF patients are also rarely investigated. In this study, we examined the relationship between physical activity as assessed by accelerometry, and depression in older adults with HF. METHODS At baseline, older adults with HF (N = 96; 69.81 ± 8.79) wore an accelerometer for seven days, and completed a brief fitness assessment, neuropsychological testing, and psychosocial measures including the Beck Depression Inventory-II (BDI-II). Medical and demographic history was obtained through record review and self-report. RESULTS Accelerometer measures showed that HF patients averaged 587 minutes of sedentary time and just 0.31 minutes of vigorous activity per day. Lower daily step count was associated with poorer quality of life and reduced cognitive function. A multiple linear regression adjusting for important demographic and medical variables found that greater number of depressive symptoms on the BDI-II independently predicted lower physical activity levels. CONCLUSION Consistent with past work, the current study found that low physical activity is common in older adults with HF. Depression is an independent predictor of physical activity in older adults with HF and reduced physical activity is associated with numerous adverse psychosocial outcomes. Future studies need to determine whether treatment of depression can boost physical activity and thus improve health outcomes in this population.

ACC/AHA/SCAI/AMA-Convened PCPI/NCQA 2013 performance measures for adults undergoing percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures, the Society for Cardiovascular Angiography and Interventions, the American Medical Association-Convened Physician Consortium for Performance Improvement, and the National Committee for Quality Assurance.

American College of Cardiology (ACC)/American Heart Association (AHA) performance measure sets can serve as vehicles to accelerate appropriate translation of scientific evidence into clinical practice. These documents are intended to provide practitioners and institutions that deliver cardiovascular

Obesity interacts with cerebral hypoperfusion to exacerbate cognitive impairment in older adults with heart failure.

Background: Cerebral hypoperfusion accompanies heart failure (HF) and is associated with reduced cognitive performance. Obesity is prevalent in persons with HF and is also a likely contributor to cognitive function, as it has been independently linked to cognitive impairment in healthy individuals. The current study examined the association between obesity and cognitive performance among older adults with HF and whether obesity interacts with cerebral hypoperfusion to exacerbate cognitive impairment. Methods: Patients with HF (n = 99, 67.46 ± 11.36 years of age) completed neuropsychological testing and impedance cardiography. Cerebral blood flow velocity (CBF-V) measured by transcranial Doppler sonography quantified cerebral perfusion and body mass index (BMI) operationalized obesity. Results: A hierarchical regression analysis showed that lower CBF-V was associated with reduced performance on tests of attention/executive function and memory. Elevated BMI was independently associated with reduced attention/executive function and language test performance. Notably, a significant interaction between CBF-V and BMI indicated that a combination of hypoperfusion and high BMI has an especially adverse influence on attention/executive function in HF patients. Conclusions: The current findings suggest that cerebral hypoperfusion and obesity interact to impair cognitive performance in persons with HF. These results may have important clinical implications, as HF patients who are at high risk for cerebral hypoperfusion may benefit from weight reduction.

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.