Cognitive Status and Initiation of Lifestyle Changes Following Acute Coronary Heart Syndrome: A Dissertation

Background: Cognitive impairment is prevalent in survivors of acute coronary syndrome (ACS) and increases risk for poor outcomes. Lifestyle changes are recommended to patients after ACS to reduce their risk for recurrent events, but cognitively impaired patients may encounter difficulties initiating these changes. This dissertation had three aims: (1) to examine cognitive status as a predictor of lifestyle changes after ACS, (2) to examine whether caregiver support moderates the association of cognitive status and initiation of lifestyle changes, and (3) to assess the reliability of self-reported lifestyle changes in cognitively impaired patients through comparison of their reports of lifestyle change with those from their caregivers. Methods: For aims 1 and 2, Poisson regression with robust error variance was used to examine the association of cognitive status and caregiver support with patient-reported initiation of five lifestyle changes (improving diet, increasing exercise, quitting smoking, reducing stress, and attending cardiac rehabilitation) in 881 patients from TRACE-CORE, a prospective longitudinal observational study of outcomes in ACS. For aim 3, pilot data from 78 patient-caregiver dyads from TRACE-CARE, an ancillary substudy, were used to examine whether patient-caregiver congruence on reports of lifestyle changes varied according to patients’ cognitive function. Results: Patient-reported rates of lifestyle change did not vary according to cognitive status, except for participation in cardiac rehabilitation. Caregiver support improved patient-reported rates of lifestyle change among cognitively intact patients but not cognitively impaired patients. Patients’ cognitive function was positively associated with patient-caregiver congruence on reports of initiation of lifestyle changes and patients with decreased cognitive function tended to over-report initiation of lifestyle changes compared to reports by their caregivers. Conclusion: Although cognitive status was not associated with initiation of most lifestyle changes and the influence of caregiver support on initiation of lifestyle changes was only beneficial to cognitively intact patients in this cohort of ACS patients, these null findings may be explained by the questionable validity of self-report in cognitively impaired patients. This dissertation yields new knowledge about secondary prevention in ACS patients and provides insight into the challenges of conducting patient-reported outcomes research in cognitively compromised populations

Cognitive Status, Initiation of Lifestyle Changes and Medication Adherence after Acute Coronary Syndrome: TRACE-CORE (Transitions, Risks, and Actions in Coronary Events- Center for Outcomes Research and Education)

Background: Lifestyle changes and medication adherence are often recommended to patients after acute coronary syndrome (ACS) as secondary prevention strategies. However, the impact of cognitive impairment (CI) on these secondary prevention strategies following ACS has not been examined. Methods: Cognitive status of 1374 patients with ACS from six hospitals in Massachusetts and Georgia enrolled in the ongoing TRACE-CORE (Transitions, Risks, and Actions in Coronary Events- Center for Outcomes Research and Education) study was assessed during hospitalization using the 41-point Telephone Interview for Cognitive Status (TICS). Information on recommendation and initiation of changes to diet, exercise, tobacco and alcohol use, stress, and cardiac rehabilitation attendance was collected through self-report one month after discharge. Medication adherence was assessed using the 8-item Morisky Scale. Among patients who reported receiving a recommendation for a lifestyle change, we modeled associations between CI and initiation of lifestyle changes and medication adherence, adjusting for demographics via logistic regression. Results: Mean age of participants was 63.0±11.1 years, 67% were male and 79% white; 526 (38.3%) screened positive for CI (TICS score ≤30) during hospitalization. Screening positive for CI was associated with being older, male, non-white, and less educated. Patients with CI more frequently received a recommendation to reduce alcohol use (25% vs. 16% of drinkers, p=.003) but were referred less often to a cardiac rehabilitation program (45% vs. 61%, p=.01). Among patients referred to cardiac rehabilitation (n=743), those with CI at baseline were less likely to report rehabilitation attendance at 1-month (OR= 0.70, 95%CI 0.50-0.97) compared to patients with normal cognitive function. Initiation of other lifestyle changes and medication adherence did not differ by cognitive status. Conclusions: CI is common among patients hospitalized for ACS and is associated with recommendation and initiation of certain lifestyle changes, making it an important factor to consider during the peri-discharge period

Cognitive impairment and self-care in heart failure

BACKGROUND: Heart failure (HF) is a prevalent chronic disease in older adults that requires extensive self-care to prevent decompensation and hospitalization. Cognitive impairment may impact the ability to perform HF self-care activities. We examined the association between cognitive impairment and adherence to self-care in patients hospitalized for acute HF. DESIGN: Prospective cohort study. SETTING AND PARTICIPANTS: A total of 577 patients (mean age = 71 years, 44% female) hospitalized for HF at five medical centers in the United States and Canada. MEASUREMENTS AND METHODS: Participants were interviewed for information on self-reported adherence to self-care using the European Heart Failure Self-care Behaviour Scale. We assessed cognitive impairment in three domains (memory, processing speed, and executive function) using standardized measures. Patients\u27 demographic and clinical characteristics were obtained through medical record review. Multivariable linear regression was used to examine the association between cognitive impairment and self-care practices adjusting for demographic and clinical factors. RESULTS: A total of 453 patients (79%) were impaired in at least one cognitive domain. Average adherence to self-care activities among patients with global cognitive impairment did not differ significantly from those without cognitive impairment (30.5 versus 29.6; 45-point scale). However, impaired memory was associated with lower self-care scores (P = 0.006) in multivariable models. CONCLUSION: Cognitive impairment is highly prevalent among older patients hospitalized for HF. Memory impairment is associated with poorer adherence to self-care practices. Screening for memory impairment in patients with HF may help to identify patients at risk for poor self-care who may benefit from tailored disease management programs

Burden of Psychosocial and Cognitive Impairment in Patients With Atrial Fibrillation

BACKGROUND: Impairments in psychosocial status and cognition relate to poor clinical outcomes in patients with atrial fibrillation (AF). However, how often these conditions co-occur and associations between burden of psychosocial and cognitive impairment and quality of life (QoL) have not been systematically examined in patients with AF. METHODS: A total of 218 patients with symptomatic AF were enrolled in a prospective study of AF and psychosocial factors between May 2013 and October 2014 at the University of Massachusetts Medical Center. Cognitive function, depression, and anxiety were assessed at baseline and AF-specific QoL was assessed 6 months after enrollment using validated instruments. Demographic and clinical information were obtained from a structured interview and medical record review. RESULTS: The mean age of the study participants was 63.5 +/- 10.2 years, 35% were male, and 81% had paroxysmal AF. Prevalences of impairment in 1, 2, and 3 psychosocial/cognitive domains (eg, depression, anxiety, or cognition) were 75 (34.4%), 51 (23.4%), and 16 (7.3%), respectively. Patients with co-occurring psychosocial/cognitive impairments (eg, \u3e 1 domain) were older, more likely to smoke, had less education, and were more likely to have heart failure (all P \u3c 0.05). Compared with participants with no psychosocial/cognitive impairments, AF-specific QoL at 6 months was significantly poorer among participants with baseline impairment in 2 (B = -13.6, 95% CI: -21.7 to -5.4) or 3 (B = -15.1, 95% CI: -28.0 to -2.2) psychosocial/cognitive domains. CONCLUSION: Depression, anxiety, and impaired cognition were common in our cohort of patients with symptomatic AF and often co-occurred. Higher burden of psychosocial/cognitive impairment was associated with poorer AF-specific QoL