Query: "Cognitive impairment and readmission in heart failure patients

title: Decreasing Heart Failure Readmission's among Elderly Patients with Cognitive Impairment by Engaging Family
abstract: Higher 30 day readmission rates have been documented in older patients with cognitive impairment (CI) and heart failure (HF)  To determine whether readmission rates are related primarily to HF severity or may be modified by inclusion of caregivers in nursing discharge education.  Prospective QI program of cognitive testing and inclusion of caregivers in discharge education. Retrospective chart review for outcomes.  Academic tertiary care hospital, two cardiovascular units with enhanced discharge education program.  232 patients age greater than 70 with diagnosis of HF screened for CI with documentation whether education included caregivers. Individuals with ventricular assist devices, transplant, or hospice excluded.  Patients were screened for CI using Mini Cog, if score  No differences in measures of HF severity between those with normal and abnormal Mini Cog  Patients age greater than 70 with HF and CI had two fold reduction in 30 day readmission rates when caregivers were involved in discharge education. No differences in HF severity were found in this group of HF patients with normal vs abnormal screens for CI using Mini Cog. Identification of CI and targeted caregiver engagement appear to be critical in reduction of readmission rates for older HF patients.

title: Cognitive impairment in patients hospitalized for congestive heart failure: data from the RICA Registry
abstract: The objective of this study is to determine the prevalence of cognitive impairment (CogI) in patients hospitalized for congestive heart failure, and the influence of CogI on mortality and hospital readmission. This is a multicenter cohort study of patients hospitalized for congestive heart failure enrolled in the RICA registry. The patients were divided into 3 groups according to their Short Portable Mental Status Questionnaire score: 0 3 errors (no CogI or mild CogI) 4 7 (moderate CogI) and 8 10 (severe CogI) A total of 3845 patients with a mean (SD) age of 79 (8.6) years were included; 2038 (53% were women. A total of 550 (14% patients had moderate CogI and 76 (2% had severe CogI. Factors independently associated with severe CogI were age (OR 1.09, 95% CI 1.05 1.14 p 0.001) male sex (OR 0.57, 95% CI 0.34 0.95, p 0.031) heart rate (OR 1.01, 95% CI 1.00 1.02, p 0.004) Charlson index (OR 1.16, 95% CI 1.06 1.27, p 0.002) and history of stroke (OR 2.67, 95% CI 1.60 4.44, p 0.001) Severe CogI was associated with higher mortality after one year (HR 3.05, 95% CI 2.25 4.14, p 0.001) The composite variable of death/hospital readmission was higher in patients with CogI (log rank p 0.001) Patients with heart failure and severe CogI are older and have a higher comorbidity burden, lower survival, and a higher rate of death or readmission at 1 year, compared to patients with no CogI.

title: Decreasing Heart Failure Readmissions Among Older Patients With Cognitive Impairment by Engaging Caregivers
abstract: Cognitive impairment is common in older patients with heart failure (HF) leading to higher 30 day readmission rates than those without cognitive impairment.  The aim of this study was to determine whether increased readmissions in older adults with cognitive impairment are related to HF severity and whether readmissions can be modified by caregiver inclusion in nursing discharge education.  This study used prospective quality improvement program of cognitive testing and inclusion of caregivers in discharge education with chart review. Two hundred thirty two patients older than 70 years admitted with HF were screened for cognitive impairment using the Mini Cog; if score was less than 4, nurses were asked to include caregivers in education on 2 cardiovascular units with an enhanced discharge program. Individuals with ventricular assist device, transplant, or hospice were excluded. Measurements include Mini Cog score, 30 day readmissions, readmission risk score, ejection fraction, brain natriuretic peptide, and medical comorbidities.  Risk Scores for HF did not correlate with Mini Cog scores, but admission brain natriuretic peptide levels were less abnormal in those with better Mini Cog scores. Only for patients with cognitive impairment, involving caregivers in discharge teaching given by registered and advanced practice nurses was associated with decreased 30 day readmissions from 35% to 16% (P .01) Readmission rates without/with cognitive impairment were 14.1% and 23.8% respectively (P .09) Abnormal Mini Cog screen was associated with a significantly increased risk of 30 day readmission (odds ratio, 2.23; 95% confidence interval, 1.06 4.68; P .03) whereas nurse documentation of education with family was associated with a significantly decreased risk of 30 day readmission (odds ratio, 0.46; 95% confidence interval, 0.24 0.90; P .02)  Involving caregivers in discharge education significantly reduced 30 day readmission rates for patients with HF and cognitive impairment. The Readmission Risk Score was similar between patients older than 70 years with and without cognitive impairment. We have hypothesis generating evidence that identification of cognitive impairment and targeted caregiver engagement by nurses may be critical in the reduction of readmission rates for older patients with HF.

title: COGNITIVE IMPAIRMENT IS VERY COMMON AMONG PATIENTS WITH HEART FAILURE REGARDLESS OF EJECTION FRACTION
abstract: Cognitive impairment (CI) is a common co morbiditiy associated with increased readmission rate and mortality in patients with heart failure (HF) However, the prevalence, characteristics and manifestations of CI may be different among patients with HF classified by left ventricular ejection fraction

title: Detecting cognitive impairment in hospitalised patients with acute heart failure: using a sensitive tool does matter.
abstract: It is associated with prolonged hospital stay and increased morbidity and mortality. Heart failure (HF) is also a major health problem in the elderly population and is one of the main reasons for hospital admission worldwide. Much evidence shows that, compared with other chronic diseases, cognitive impairment is more common in patients with HF. Delirium is a common cause of cognitive impairment in these patients, and has prognostic value for HF outcomes and deterioration of cognitive function.2 Previous research has found a positive relationship between delirium and increased risk of readmission as well as prolonged hospital stay among elderly patients with HF.3 Therefore, developing a specific screening tool for early identification of hospitalised patients at risk for cognitive impairment, and prompt management of delirium, may improve HF outcomes and quality of care. Screening for cognitive impairment is recommended as a routine clinical assessment for patients with HF worldwide.4 However, no consensus has been achieved on the optimal screening tool for detecting cognitive impairment in hospitalised patients with HF. Currently, a number of screening tools are available for detecting delirium in the general population of older adults,5 such as the Mini Mental State Examination (MMSE) Montreal Cognitive Assessment, and Mini Cog. However, a more specific tool is needed for elderly patients with HF. The cognitive status of elderly patients with HF is affected by low cerebral perfusion status, which is a common condition in the pathophysiology of HF. The MMSE was originally designed for dementia screening, but most elderly patients with HF have mild cognitive impairment. In this regard, previous research showed that the MMSE is a suitable screening tool for detecting moderate to severe cognitive impairment; however, its sensitivity in detecting mild cognitive impairment is questionable.6 In addition, Montreal Cognitive Assessment can detect an unrecognised cognitive impairment in a group of stable community dwelling patients with HF6; however, it has low specificity in ruling out mild cognitive impairment, owing to cut offs that are inappropriate for elderly patients with HF. The Hong Kong Med J 2019;25:81 2 http:/doi.org/10.12809/hkmj187772

title: Cognitive Impairment was Associated with Readmission in Elderly Patients with Heart Failure

title: Mild cognitive impairment predicts death and readmission within 30days of discharge for heart failure.
abstract: Cognitive impairment is highly prevalent in heart failure (HF) and may be associated with short term readmission. This study investigated the role of cognition, incremental to other clinical and non clinical factors, independent of depression and anxiety, in predicting 30 day readmission or death in HF.  This study followed 565 patients from an Australia wide HF longitudinal study. Cognitive function (MoCA score) together with standard clinical and non clinical factors, mental health and 2D echocardiograms were collected before hospital discharge. The study outcomes were death and readmission within 30days of discharge. Logistic regression, Harrell's C statistic, integrated discrimination improvement (IDI) and net reclassification index were used for analysis.  Among 565 patients, 255 (45% had at least mild cognitive impairment (MoCA<=22) Death (n=43, 8% and readmission (n=122, 21% within 30days of discharge were more likely to occur among patients with mild cognitive impairment (OR=2.00, p=0.001) MoCA score was also negatively associated with 30 day readmission or death (OR=0.91, p<0.001) independent of other risk factors. Adding MoCA score to an existing prediction model of 30 day readmission significantly improved discrimination (C statistic=0.715 vs. 0.617, IDI estimate 0.077, p<0.001) From prediction models developed from our study, adding MoCA score (C statistic=0.83) provided incremental value to that of standard clinical and non clinical factors (C statistic=0.76) and echocardiogram parameters (C statistic=0.81) in predicting 30 day readmission or death. Reclassification analysis suggests that addition of MoCA score improved classification for a net of 12% of patients with 30 day readmission or death and of 6% of patients without (p=0.002)  Mild cognitive impairment predicts short term outcomes in HF, independent of clinical and non clinical factors.

title: Heart Failure and Cognitive Impairment: Clinical Relevance and Therapeutic Considerations
abstract: Heart failure (HF) is a devastating condition characterized by poor quality of life, numerous complications, high rate of readmission and increased mortality. HF is the most common cause of hospitalization in the United States especially among people over the age of 64 years. The number of people grappling with the ill effects of HF is on the rise as the number of people living to an old age is also on the increase. Several factors have been attributed to these high readmission and mortality rates among which are; poor adherence with therapy, inability to keep up with clinic appointments and even failure to recognize early symptoms of HF deterioration which may be a result of cognitive impairment. Therefore, this review seeks to compile the most recent information about the links between HF and dementia or cognitive impairment. We also assessed the prognostic consequences of cognitive impairment complicating HF, therapeutic strategies among patients with HF and focus on future areas of research that would reduce the prevalence of cognitive impairment, reduce its severity and also ameliorate the effect of cognitive impairment coexisting with HF.

title: Defining the Relationship between Heart Failure (HF) and Cognitive Impairment (CI) A Quality Improvement Initiative
abstract: Higher 30 day readmission rates have been documented in older patients with heart failure (HF) and cognitive impairment (CI) A quality initiate at our hospital reviewed the CI among different age groups with heart failure, ranging from 50 >80 years of age.  To determine prevalence of CI in younger hospitalized HF patients in comparison to older, and if early readmission's are associated with CI in younger HF patients.  Prospective QI program of cognitive testing and inclusion of caregivers in discharge education. Retrospective chart review for outcomes.  Academic tertiary care hospital, two cardiovascular units with enhanced discharge program.  CI was common but much less prevalent in the patients  Screening for CI seems to be a useful part of CHF management only in those over 70 yrs of age where CI is common and results in frequent readmission's. For those under 50, CI is infrequent. For the middle age group, CI is fairly common, but is not associated with readmission's so the impetus for screening is reduced. We assumed that CI would impair HF management resulting in increased readmission's for all patients. Our data suggest targeting these efforts to the older HF patients.

title: Predictors of Heart Failure Self care in Patients Who Screened Positive for Mild Cognitive Impairment
abstract: Heart failure (HF) is associated with cognitive impairment, which could negatively affect a patient's abilities to carry out self care, potentially resulting in higher hospital readmission rates. Factors associated with self care in patients experiencing mild cognitive impairment (MCI) are not known. This descriptive correlation study aimed to assess levels of HF self care and knowledge and to determine the predictors of self care in HF patients who screen positive for MCI. The Montreal Cognitive Assessment was used to screen for MCI. In 125 patients with MCI hospitalized with HF, self care (Self care of Heart Failure Index) and HF knowledge (Dutch Heart Failure Knowledge Scale) were assessed. We used multiple regression analysis to test a model of variables hypothesized to predict self care maintenance, management, and confidence. Mean (SD) HF knowledge scores (11.24 [1.84] were above the level considered to be adequate (defined as >10) Mean (SD) scores for self care maintenance (63.57 [19.12] management (68.35 [20.24] and confidence (64.99  were consistent with inadequate self care (defined as scores <70) In multivariate analysis, HF knowledge, race, greater disease severity, and social support explained 22% of the variance in self care maintenance (P .001) age, education level, and greater disease severity explained 19% of the variance in self care management (P .001) and younger age and higher social support explained 20% of the variance in self care confidence scores (P .001) Blacks, on average, scored significantly lower in self care maintenance (P .03) In this sample, patients who screened positive for MCI, on average, had adequate HF knowledge yet inadequate self care scores. These models show the influence of modifiable and nonmodifiable predictors for patients who screened positive for MCI across the domains of self care. Health professionals should consider screening for MCI and identifying interventions that address HF knowledge and social support. Further research is needed to explain the racial differences in self care.