Geriatrics and Gerontology special section
Clinical research study
Cognitive Impairment in Older Adults with Heart Failure: Prevalence, Documentation, and Impact on Outcomes

https://doi.org/10.1016/j.amjmed.2012.05.029Get rights and content

Abstract

Background

Despite the fact that 80% of patients with heart failure are aged more than 65 years, recognition of cognitive impairment by physicians in this population has received relatively little attention. The current study evaluated physician documentation (as a measure of recognition) of cognitive impairment at the time of discharge in a cohort of older adults hospitalized for heart failure.

Methods

We performed a prospective cohort study of older adults hospitalized with a primary diagnosis of heart failure. Cognitive status was evaluated with the Folstein Mini-Mental State Examination at the time of hospitalization. A score of 21 to 24 was used to indicate mild cognitive impairment, and a score of  20 was used to indicate moderate to severe impairment. To evaluate physician documentation of cognitive impairment, we used a standardized form with a targeted keyword strategy to review hospital discharge summaries. We calculated the proportion of patients with cognitive impairment documented as such by physicians and compared characteristics between groups with and without documented cognitive impairment. We then analyzed the association of cognitive impairment and documentation of cognitive impairment with 6-month mortality or readmission using Cox proportional hazards regression.

Results

A total of 282 patients completed the cognitive assessment. Their mean age was 80 years of age, 18.8% were nonwhite, and 53.2% were female. Cognitive impairment was present in 132 of 282 patients (46.8% overall; 25.2% mild, 21.6% moderate-severe). Among those with cognitive impairment, 30 of 132 (22.7%) were documented as such by physicians. Compared with patients whose cognitive impairment was documented by physicians, those whose impairment was not documented were younger (81.3 vs 85.2 years, P < .05) and had less severe impairment (median Mini-Mental State Examination score 22.0 vs 18.0, P < .01). After multivariable adjustment, patients whose cognitive impairment was not documented were significantly more likely to experience 6-month mortality or hospital readmission than patients without cognitive impairment.

Conclusions

Cognitive impairment is common in older adults hospitalized for heart failure, yet it is frequently not documented by physicians. Implementation of strategies to improve recognition and documentation of cognitive impairment may improve the care of these patients, particularly at the time of hospital discharge.

Section snippets

Study Design and Participants

We performed a prospective cohort study of older adults hospitalized for heart failure at 2 Connecticut Hospitals (Yale-New Haven Hospital and Hospital of Saint Raphael). Participants were enrolled in the Comorbidity in Older Patients with heart failure (COPing with Heart Failure) study, which recruited patients aged 65 years or more who were hospitalized for heart failure between October 31, 2008, and December 22, 2010. The objective of the COPing with Heart Failure study was to assess the

Study Sample

Of the 437 patients approached for enrollment, 48 were excluded because of dependency in activities of daily living, 3 were excluded because of delirium, and 104 declined participation, leaving a total of 282 (64.5%) who consented to participation in the study. There were no significant differences between patients who consented versus those who did not consent (mean age 80.0 vs 80.4 years, P = .87; female 53.2% vs 50.3%, P = .56; nonwhite 18.8% vs 16.4%, P = .62). The baseline clinical

Discussion

In our study of older adults hospitalized for heart failure, we found that cognitive impairment was common (present in 47% of the study sample) and yet documented in only a minority of patients. As expected, documentation improved as the severity of cognitive impairment increased, but even among patients with moderate-severe impairment it was documented in less than half of the patients. Although prior studies have demonstrated that cognitive impairment is present in a significant subset of

Conclusions

Cognitive impairment is present in a substantial number of older patients hospitalized for heart failure, yet it is infrequently documented by physicians at the time of hospital discharge. The presence of cognitive impairment and lack of documentation are associated with increased 6-month mortality or readmission. Future studies are needed to determine whether efforts to improve recognition and documentation at the time of inpatient hospitalization may inform individually tailored heart failure

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  • Cited by (0)

    Michael W. Rich, MD, Section Editor

    Funding: Dr Dodson is supported by a training grant in Geriatric Clinical Epidemiology from the National Institutes of Health (NIH)/National Institute on Aging (T32 AG019134) and a Clinical Research Loan Repayment award from the NIH/National Heart, Lung, and Blood Institute. Dr Chaudhry is supported by a Beeson Career Development Award from the NIH/National Institute on Aging (K23 AG030986).

    Conflict of Interest: None.

    Authorship: All authors had access to the data and played a role in writing this manuscript.

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