| Abstract|| |
Background: Congestive cardiac failure (CCF) patients show several neuropsychological impairments and reduced quality of life and impairment of functioning.
Objective: The objective of this study was to recognize the deficits in cognition in CCF patients and comparing this cognitive function in the same number of healthy participants.
Materials and Methods: A case–control study design was adopted. The study was conducted in the cardiology department of a tertiary care hospital. Convenience sampling was done. Twenty-one participants with CCF (New York Cardiac Association – Class III severity) and 21 healthy participants participated in the study. Each participant in the control group was screened by the General Health Questionnaire-12-item version. We evaluated both groups for the various domains of their cognitive function using a comprehensive battery of neuropsychological tests. Student's t-test was used to analyze the difference between the means for the study variables.
Results: We observed that attention, executive function, working memory, psychomotor speed, and visuospatial ability were impaired in the patients with CCF compared to the controls. However, they did not differ significantly in language function.
Conclusions: Cognitive functioning is significantly impaired in CCF patients.
Keywords: Cardiac failure, cognitive deficits, neuropsychological testing
|How to cite this article:|
Ravindran OS, Vaishnaruby S, Karthik M S, Merciline AD. Impairment of cognitive functions in congestive cardiac failure patients. Indian J Psychiatry 2019;61:146-50
| Introduction|| |
Cardiac failure (CF) is a key public health condition which significantly impacts the sufferers regarding the quality of life (QoL) and cognition., CF affects around 2% of the populace in the United States and is among the most common disorders of the cardiovascular system, it is in the third place., The CF prevalence in India has been estimated to be 1.3–4.6 million, and 0.5–1.8 million is the yearly incidence. CF is associated with repeated in-patient admissions, decreased QoL, substantial morbidity, and more mortality.,
Impaired cognition led to poor outcome in CF patients. Dysfunctional cognition is seen in 15%–85% of patients with CF.,, In an earlier study by Trojano et al., over 500 CF hospital in-patients were tested with a battery of seven neuropsychological tests. Significantly, lower scores were seen in the case group compared with the control group on at least three or more neuropsychological tests. CF patients have frequently shown impaired attention, executive function, memory, and psychomotor speed., Several studies have found that impairment of cognition is linked to higher CF severity, greater CF duration, advanced age, and increased presence of comorbidity.,,, Patients' reasoning and decision-making capabilities may be compromised due to this, which may lead to poor self-care ability. In India, there is a dearth of studies in this regard. With this background, we undertook this study to identify the impairment in cognition in congestive CF (CCF) patients and to compare them with equal number of healthy participants.
| Materials and Methods|| |
A case–control study was done using a convenience sampling. Participants diagnosed with CCF (n = 21) were recruited from the Department of Cardiology attached to Cardiac Care Center at Sri Ramachandra Institute of Higher Education and Research in Chennai. We approached 30 stable outpatients with severe CF (New York Cardiac Association Class III) to take part in our study. Nine of them declined, stating that they were unwilling to take part in the study, and the case group finally consisted of 21 individuals with CCF. We did the study from February 2016 to April 2016. Inclusion criteria were age being 40–65 years, presence of CF (New York Heart Association [NYHA] Class III) for a minimum 6 months before the study commencement and a minimum educational qualification of 8th standard. Exclusion criteria were conditions whose role in causing impaired cognition is well established (e.g., current or past alcohol or other substance misuse, history of major mental or neurologic disease, kidney failure warranting dialysis, or terminal disease). We recruited healthy controls (n = 21), who were matched for age and sex, from among the families of CF patients and other volunteers. Among the control participants, there was no diagnosed heart disorder, history of cerebrovascular accident, and pulmonary or neurologic disease which may lead to brain dysfunction. Each participant in the control group was screened by the General Health Questionnaire-12-item version for the possible presence of psychological distress. Threshold marks of 2 and 3 were taken up to include and discard the controls from the study. We provided complete information to the participants in both groups and got their written consent at the commencement of our research. We obtained approval from the Institutional Ethics Committee of our institution.
The battery of neuropsychological assessments administered to the participants (both CF and controls) is sensitive to cardiovascular conditions. It took around 90 min to administer the battery to each participant. The validity and reliability of the battery are well established, and it has been shown to discriminate well the persons with normal cognition, mild cognitive impairment, and dementia. The battery included seven neuropsychological tests which measure six neuropsychological domains. Attention was assessed using the Digit-Span Subtest from the Wechsler Adult Intelligence Scale, 3rd edition. We assessed the executive function using the Trail Making Test (TMT)-B and the Stroop Color- Word Test Part III. Working memory was assessed using the Spatial Span Subtest from the Wechsler Memory Scale, 3rd edition. We assessed the psychomotor speed using the TMT-A. The Block Design Subtest from the WAIS-III was administered to assess visuospatial function. The information subtest from the Postgraduate Institute Battery of Brain Dysfunction was administered to assess language function. We administered the battery within one session, keeping in accordance with the prescribed standard method in the manual. The second author (SVR), with experience in neuropsychological testing, administered the assessment in a quiet room. The domains of cognition assessed, the neuropsychological assessments administered, and short explanations of the assessment tools are shown in [Table 1].
|Table 1: Domains of cognition, neuropsychological tests, and test description|
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Data were analyzed using the Statistical Package for Social Sciences for Windows, version 16 (SPSS Inc., Chicago, III, USA). Student's t-test was employed to calculate the difference between the means. Statistical significance was fixed at P < 0.05.
| Results|| |
[Table 2] shows the sociodemographic profile of the study participants.
Participants' age ranged between 40 and 65 years. Participants' mean age in both patient and control groups was 56.29 (standard deviation = 6.05) years. Most of the participants were males in both case and control groups (80.95%). There was an equal number of postgraduates and graduates in both patient and control groups (52.38%). Many patients were married (85.71%) and employed (80.95%). Regarding comorbidity, all the CF patients have hypertension (100%), followed by diabetes mellitus (81%) and obesity (19.04%).
[Table 3] shows the results of the neuropsychological assessment of both case and control groups. The two groups differed significantly in attention, executive function, working memory, psychomotor speed, and visuospatial ability. However, they did not differ significantly in language function.
|Table 3: Neuropsychological assessment results of case and control groups|
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| Discussion|| |
Cognitive dysfunctions in CF are associated with various parts of the brain. In this study, CF patients have shown poor performance in attention, executive function, working memory, psychomotor speed, and visuospatial ability, except language function in various neuropsychological measures. Regarding attention and psychomotor speed, they have obtained low marks on digit-span test (immediate verbal recall) and TMT-A (psychomotor speed), respectively, indicating that CF patients have impaired attention and psychomotor speed. The above results are comparable to the findings of Gorkin et al., who reported that participants with CCF have greater difficulty on digit-span and trail making-A tests. It can be explained that the CF patients' deficits in cognition may be due to influences such as anxiety, medical comorbidities, and concomitant drug use which is unrelated to CCF presence.
The study group has obtained low marks on TMT-Part B (executive function) and Stroop test (response inhibition) than the healthy participants indicating that they have deficits in executive functions. In persons with CF, frontal lobe impairment is common, which may lead to impaired executive function. This manifests as trouble in organizing thought, framing and accomplishing goals, and problem-solving skills., In the current study, CF patients have shown executive dysfunction which may lead to impairment of day-to-day functioning. The above finding is like the findings of other studies which reported that impaired cognition in persons with CF may lead to poor self-care and escalate the threat of mortality and inpatient admissions.
The results of the spatial span test have shown that CF patients have working memory difficulties. Effective working memory is essential for the integration of complex psychological activities such as planning, conceptual thinking, and ability to adapt. Prefrontal cortex participates in higher psychological functions. Dysfunctions in this region appear to be quite serious because it can have significant influence on ability to understand and follow medical recommendations.
Our finding of problems in recognizing the clinical manifestations leading to frequent inpatient admissions when the disease relapses are similar to the findings of other researchers.
The persons with CF in our study have shown deficits in attention, psychomotor speed, and executive functions. Impairments in these domains compromise the capability of persons with CF to adhere to complicated treatment regimens, salt-restricted diet, and for taking adequate care of themselves., Self-care is a dynamic process of decision-making directed toward the maintenance of health by being compliant to medicines and dietary advice, managing and recognizing symptoms, enactment of alterations in case of deteriorating, and evaluating right personal behaviors. Deciding on matters related to self-care is the function of the prefrontal, frontal, and temporal cortex that is often compromised in participants with CF. Our findings indicate that the participants with CF have shown difficulties in self-care. This is consistent with the findings of the past investigators.
The study group has obtained low marks on the block design test which measures the visuospatial ability. It agrees with the study done by Kindermann et al., among this population. Navigation and topographical orientation deficits and problems in dressing, recognition of known faces, or grasping things are common manifestations of visuospatial deficits. Areas of parietal lobes, occipital cortex, lateral prefrontal cortex, medial and inferior temporal cortex, basal ganglia, and white matter tracts are involved in visuospatial ability. In this study, patients with CF have shown difficulties in visuospatial ability which may contribute to decreases in self-care and less compliance to treatment and managing self-care, which agrees fine with earlier reported studies.
Language function was not significantly different between the two groups. It is possible that the measure used in this study to assess the language function was not challenging enough to detect the differences among cases and controls. The findings of the present research are consistent with earlier researches on cognitive performance of CF patients.
Several researchers have studied the relationship between CF severity and impairment of cognition., In the current study, individuals with CF (NYHA Class III) have shown deficits in various domains which are in line with other studies.
This is a pioneering research from this region of India to evaluate the cognition of CF patients. The results of this research have vital clinical implications. CF is a multifaceted illness to manage because it involves decision-making of high level and symptom cognizance. Within 30 days of discharge, one-fourth of the persons with CF are readmitted, because of reduced cognizance of poor symptom status. It is possible that increased rate of inpatient admission and trouble in the management of symptoms of CF are related to cognition deficits. The findings of this research powerfully support the utility of screening of cognition in clinical settings. Further research is required to find the cause of the impairment of cognition so that it can be prevented.
The sample size is small in this study comprised only stable outpatients with CF. Confounders could be concomitant medical illnesses which might impair cognition. CF patients commonly have comorbidities such as systemic hypertension and diabetes mellitus which are considered as risk factors. Several studies reported that hypertension could induce specific harmful effects in the frontal cortex, which is responsible for executive functions, while other studies found an association between impaired cognition and compromised glucose metabolism and Type II diabetes. CF patients have both hypertension and diabetes, and they have shown poor cognitive performance on various neuropsychological measures.
Future studies with large samples involving the comparison of the cognitive profile of individuals with diastolic and systolic dysfunction can be studied. Essentially, forthcoming research might be directed toward the determination of the biological processes involved in poor cognition in CF patients.
| Conclusions|| |
We found impairment of cognition in the domains of attention, executive functions, working memory, psychomotor speed, and visuospatial ability in patients with CCF.
The authors would like to acknowledge Dr. A.G. Tejus Murthy, Assistant Professor of Psychiatry, PIMS, Puducherry, for his valuable suggestions in manuscript preparation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Levy D, Kenchaiah S, Larson MG, Benjamin EJ, Kupka MJ, Ho KK, et al.
Long-term trends in the incidence of and survival with heart failure. N Engl J Med 2002;347:1397-402.
Pressler SJ, Subramanian U, Kareken D, Perkins SM, Gradus-Pizlo I, Sauvé MJ, et al.
Cognitive deficits and health-related quality of life in chronic heart failure. J Cardiovasc Nurs 2010;25:189-98.
Jessup M, Brozena S. Heart failure. N Engl J Med 2003;348:2007-18.
Kenchaiah S, Narula J, Vasan RS. Risk factors for heart failure. Med Clin North Am 2004;88:1145-72.
Huffman MD, Prabhakaran D. Heart failure: Epidemiology and prevention in India. Natl Med J India 2010;23:283-8.
Calvert MJ, Freemantle N, Cleland JG. The impact of chronic heart failure on health-related quality of life data acquired in the baseline phase of the CARE-HF study. Eur J Heart Fail 2005;7:243-51.
Giamouzis G, Kalogeropoulos A, Georgiopoulou V, Laskar S, Smith AL, Dunbar S, et al.
Hospitalization epidemic in patients with heart failure: Risk factors, risk prediction, knowledge gaps, and future directions. J Card Fail 2011;17:54-75.
Zuccalà G, Pedone C, Cesari M, Onder G, Pahor M, Marzetti E, et al.
The effects of cognitive impairment on mortality among hospitalized patients with heart failure. Am J Med 2003;115:97-103.
Almeida OP, Tamai S. Congestive heart failure and cognitive functioning amongst older adults. Arq Neuropsiquiatr 2001;59:324-9.
Festa JR, Jia X, Cheung K, Marchidann A, Schmidt M, Shapiro PA, et al.
Association of low ejection fraction with impaired verbal memory in older patients with heart failure. Arch Neurol 2011;68:1021-6.
Roman DD, Kubo SH, Ormaza S, Francis GS, Bank AJ, Shumway SJ, et al.
Memory improvement following cardiac transplantation. J Clin Exp Neuropsychol 1997;19:692-7.
Trojano L, Antonelli Incalzi R, Acanfora D, Picone C, Mecocci P, Rengo F, et al.
Cognitive impairment: A key feature of congestive heart failure in the elderly. J Neurol 2003;250:1456-63.
Vogels RL, Scheltens P, Schroeder-Tanka JM, Weinstein HC. Cognitive impairment in heart failure: A systematic review of the literature. Eur J Heart Fail 2007;9:440-9.
Vogels RL, Oosterman JM, van Harten B, Scheltens P, van der Flier WM, Schroeder-Tanka JM, et al.
Profile of cognitive impairment in chronic heart failure. J Am Geriatr Soc 2007;55:1764-70.
Bennett SJ, Sauvé MJ. Cognitive deficits in patients with heart failure: A review of the literature. J Cardiovasc Nurs 2003;18:219-42.
Pressler SJ. Cognitive functioning and chronic heart failure: A review of the literature (2002-july 2007). J Cardiovasc Nurs 2008;23:239-49.
Pressler SJ, Subramanian U, Kareken D, Perkins SM, Gradus-Pizlo I, Sauvé MJ, et al.
Cognitive deficits in chronic heart failure. Nurs Res 2010;59:127-39.
Pullicino PM, Wadley VG, McClure LA, Safford MM, Lazar RM, Klapholz M, et al.
Factors contributing to global cognitive impairment in heart failure: Results from a population-based cohort. J Card Fail 2008;14:290-5.
Cameron J, Worrall-Carter L, Page K, Riegel B, Lo SK, Stewart S, et al.
Does cognitive impairment predict poor self-care in patients with heart failure? Eur J Heart Fail 2010;12:508-15.
Goldberg D, Williams P. A User's Guide to the General Health Questionnaire. Berkshire, England: NFER-Nelson; 1991.
Hachinski V, Ladecola C, Petersen RC, Breteler MM, Nyenhuis DL, Black SE, et al.
National institute of neurological disorders and stroke-Canadian stroke network vascular cognitive impairment harmonization standards. Stroke 2006;37:2220-41.
Wechsler D. Wechsler adult intelligence scale. In: Administration and Scoring Manual. 3rd
ed. USA: The Psychological Corporation; 1997.
Reitan RM. Trail Making Test. Tucson, AZ: Reitan Neuropsychological Laboratory; 1992.
Golden CJ, Freshwater SM. Stroop color and word test. In: A Manual for Clinical and Experimental Uses. 2nd
ed. USA: Stoelting Co.; 1998.
Wechsler D. Wechsler memory scale. In: Administration and Scoring Manual. 3rd
ed. USA: The Psychological Corporation; 1997.
Pershad D, Verma SK. Handbook of Postgraduate Institute of Battery of Brain Dysfunction. India: National Psychological Corporation; 1980.
Gorkin L, Norvell NK, Rosen RC, Charles E, Shumaker SA, McIntyre KM, et al.
Assessment of quality of life as observed from the baseline data of the studies of left ventricular dysfunction (SOLVD) trial quality-of-life substudy. Am J Cardiol 1993;71:1069-73.
Goetz CG, editor. Textbook of Clinical Neurology. 2nd
ed. St. Louis: Elsevier Press; 2003. p. 546.
Román GC. Vascular dementia: Distinguishing characteristics, treatment, and prevention. J Am Geriatr Soc 2003;51:296-304.
McLennan SN, Pearson SA, Cameron J, Stewart S. Prognostic importance of cognitive impairment in chronic heart failure patients: Does specialist management make a difference? Eur J Heart Fail 2006;8:494-501.
Jablkowska K, Karbownik-Lewinska M, Nowakowska K, Junik R, Lewinski A, Borkowska A. Working memory and executive functions in hyperthyroid patients with Graves disease. Arch Psychiatry Psychother 2009;1:69-75.
Wolfe R, Worrall-Carter L, Foister K, Keks N, Howe V. Assessment of cognitive function in heart failure patients. Eur J Cardiovasc Nurs 2006;5:158-64.
Sauvé MJ, Lewis WR, Blankenbiller M, Rickabaugh B, Pressler SJ. Cognitive impairments in chronic heart failure: A case controlled study. J Card Fail 2009;15:1-10.
Dickson VV, Tkacs N, Riegel B. Cognitive influences on self-care decision making in persons with heart failure. Am Heart J 2007;154:424-31.
Kindermann I, Fischer D, Karbach J, Link A, Walenta K, Barth C, et al.
Cognitive function in patients with decompensated heart failure: The cognitive impairment in heart failure (CogImpair-HF) study. Eur J Heart Fail 2012;14:404-13.
Hjelm C, Dahl A, Broström A, Mårtensson J, Johansson B, Strömberg A, et al.
The influence of heart failure on longitudinal changes in cognition among individuals 80 years of age and older. J Clin Nurs 2012;21:994-1003.
Antonelli Incalzi R, Trojano L, Acanfora D, Crisci C, Tarantino F, Abete P, et al.
Verbal memory impairment in congestive heart failure. J Clin Exp Neuropsychol 2003;25:14-23.
Bennett SJ, Pressler ML, Hays L, Firestine LA, Huster GA. Psychosocial variables and hospitalization in persons with chronic heart failure. Prog Cardiovasc Nurs 1997;12:4-11.
Naylor MD, Stephens C, Bowles KH, Bixby MB. Cognitively impaired older adults: From hospital to home. Am J Nurs 2005;105:52-61.
Dickson VV, Deatrick JA, Riegel B. A typology of heart failure self-care management in non-elders. Eur J Cardiovasc Nurs 2008;7:171-81.
Pugh KG, Kiely DK, Milberg WP, Lipsitz LA. Selective impairment of frontal-executive cognitive function in African Americans with cardiovascular risk factors. J Am Geriatr Soc 2003;51:1439-44.
Awad N, Gagnon M, Messier C. The relationship between impaired glucose tolerance, type 2 diabetes and cognitive function. J Clin Exp Neuropsychol 2004;26:1044-80.
Dr. Ottilingam Somasundaram Ravindran
No. 30 (New No. 17), 23rd Cross Street, Besant Nagar, Chennai - 600 090, Tamil Nadu
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]