Diagnose, address cognitive impairment in heart failure patients, society says
A new scientific statement from the Heart Failure Society of America advises clinicians to be alert to clues such as difficulty with money or running out of medicine, among other recommendations.
Clinicians caring for patients with heart failure should screen for cognitive impairment, according to a scientific statement from the Heart Failure Society of America.
The statement, which was published March 12 in the Journal of Cardiac Failure, notes that the prevalence of cognitive impairment has been found to be as high as 78% in some subgroups of heart failure patients, with substantial effects on self-care, medication management, function and independence, health-related quality of life, and life expectancy. Patients with cognitive impairment may have difficulties with performing daily weight checks, reading food labels, and managing medications, according to the statement.
"Clinicians caring for patients with HF [heart failure] should be attuned to clinical clues present at medical encounters that suggest the presence of cognitive impairment," the statement said, such as difficulty with money, running out of medicine, or forgetting to shower or bathe. The statement listed several formal screening tools that can be used to assess cognition in patients with heart failure, including the Mini-Cog, the Mini Mental State Exam, and the Montreal Cognitive Assessment. Tools should be chosen based on available time and personnel, but clinicians should also be mindful of differences in the tests' diagnostic performance, the statement said. Clinicians may want to refer patients with suspected cognitive impairment to a specialist for further testing, according to the statement.
Underlying causes of cognitive impairment as well as comorbid conditions should be treated, the statement said. Examples include controlling hypertension, considering anticoagulation in patients with atrial fibrillation, and screening for and managing other potentially reversible causes of cognitive impairment, including mood disorders, obstructive sleep apnea, hypothyroidism, vitamin B12 deficiency, infection, and impaired hearing and vision, according to the statement.
Clinicians should carefully review all medications, reconsider risk-benefit ratios, and consider deprescribing where appropriate, the statement said. It noted that cholinesterase inhibitors are not recommended to treat cognitive impairment unrelated to Alzheimer's disease or Lewy bodies and that newly approved monoclonal antibodies should be used with caution and only in conjunction with shared decision making in patients with heart failure, since most are taking antiplatelets and anticoagulants.
Among other topics, the statement also addressed accommodation of deficiencies in self-care and integration of a cognitive impairment diagnosis into complex decision making, including advance care planning. The statement authors also called for further research. "Gaps related to understanding underlying pathophysiological mechanisms, optimal approaches to screening and reversing cognitive impairment are important areas of future work," they wrote. By addressing these gaps, the field has an opportunity to improve care for this vulnerable segment of the population, the authors added.