The Prevalence of Cognitive Impairment among African-American Patients with Congestive Heart Failure

Abimbola Akomolafe, MD, MPH, MSc; Alexander Quarshie, MD, MS; Patricia Jackson, RN; Jerome Thomas, MD; Orlando Deffer, MD; Adefisayo Oduwole, MD; Anekwe Onwuanyi, MD; Rigobert Lapu-Bula, MD, PhD; Gregory Strayhorn, MD, PhD; Elizabeth Ofili, MD, MPH; and Robert Mayberry, MPH, PhD Atlanta, Georgia
Financial support: This project was supported in part by grant number P01 HS10875 from the Agency for Healthcare Research and Quality for the Program for Healthcare Effectiveness Research and grant numbers P20RR 11 104, (CRC) 5P20RR1 104-09 and (CCRE) U54RR14758-05 for the MSM Clinical Research Center from the National Institutes of Health, National Center for Research Resources (NCRR).
This cross-seclional study sought to determine the prevalence of cognitive impairment among African-American patients with congestive heart failure (CHF). We studied 100 AfrcanAmerican CHF patients (aged 55-87 years) in New York Heart Association classes II-IV, who are enrolled in an ongoing, randomized, controlled tral, evaluating the effectiveness of a telemonitoring intervention to improve access to ambulatory care for heart failure patients. These CHF patients were recruited from an inner-city practice, rural physician practices and an urban physician practice in Atlanta. The Mini-Mental Status Examination (MMSE) was used to measure cognifion. Cognitive impairment was defined as a MMSE score of less than 24. The crude prevalence of cognitive impairment was 10%o in this population of African Americans with CHF. The results of multivariate logistic regression analysis indicated an increase in odds of cognitive impairment with increasing age [odds ratio (OR) = 1.10 and 95% confidence interval, 1.00-1.20; p=0.042]. There was no significant relationship between cognitive impairment and gender, education status, depression and severity of CHF. This study indicates that cognitive impairment is relatively prevalent among African Americans with CHF, but lower than previously reported among Caucasians with CHF. Key words: cognitive impairment a African Amercans U congestive * heart failure
2005. From the Department of Medicine, Clinical Research Center and Department of Family Medicine, Morehouse School of Medicine, Atlanta, GA. Send correspondence and reprnt requests for J Natl Med Assoc. 2005;97:689-694 to: Abimbola Akomolafe, MD, MPH, MSc, Department of Medicine, Section of Geri atrics, Morehouse School of Medicine, 720 Westview Ddve SW, Atlanta, GA 30310; phone: (404) 756-1330; fax: (404) 756-1328; e-mail: akomola@msm.edu

INTRODUCTION
Congestive heart failure (CHF) is a major public health problem affecting over 4.7 million Americans and 15 million people worldwide.' More than 550,000 new cases occur annually in the United States.'-3 Approximately 1.5-2% of the population has CHF, and the prevalence increases to 6-10% in patients 65 years and over.4-6 CHF is a major cause of morbidity and mortality among older people in Western countries.7 It is the leading indication for hospital admission in adults older than age 65.8 Among factors related to rehospitalization are nonadherence to medication and advice on lifestyle modifications, as well as failure to seek medical attention when the condition deteriorates.9-'l Despite advances in pharmacological treatment, the prognosis of older patients hospitalized for heart failure is poor, with one-month posthospitalization mortality exceeding 25% and one-year mortality greater than 50% in persons age 85 years and above.'2"'3 Although normal aging is not necessarily associated with diminished cognitive function, up to 17% of those aged 65 years and older do experience at least mild-to-moderate decreases in cognitive function, especially those related to memory, which are not related to dementia of either the vascular or Alzheimer's type.'4"5 Cognitive impairment is rapidly becoming a public health problem, and it shows a strong association with dependency,'6 morbidity'7 and mortality.'8 Decrease in cognitive function has been reported in patients with a variety of cardiovascular conditions.'9'20 There is increasing evidence that CHF is independently associated with cognitive impairment.2'-23 "Cardiogenic" or "circulatory" dementia24'25 has been proposed to explain cognitive impairment in these patients. CHF and cognitive impairment are both associated with increased mortality,26 disability,27 decreased quality of life28 and spousal and caregiver distress.29
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Our search of the medical literature highlighted the paucity of data on the prevalence of cognitive impairment among CHF patients, especially in the AfricanAmerican population.30 The above-referenced study indicated that African Americans were found to go home much sicker, more dependent and more cognitively impaired than their white counterparts. Because CHF disproportionately affects African Americans and the incidence and prevalence ofthis disease is higher in this population of patients than other racial groups,31 the high prevalence of cognitive impairment among this group of patients could have clinical and public health implications. Therefore, the present study sought to assess the prevalence of cognitive impairment among African-American patients with CHF.

METHODS
This cross-sectional sample was drawn from patients who were consecutively recruited for an ongoing, single-blinded, randomized, controlled trial evaluating the effectiveness of a telemonitoring, patient-oriented intervention to improve access to ambulatory care for heart failure patients. Eligible study subjects were African-American CHF patients, 55 years of age and older in New York Heart Associa-

tion (NYHA) classes II-IV, attending the inner-city practice (Grady Hospital and ambulatory clinic); rural counties surrounding Columbus, GA; and urban practice in metropolitan Atlanta. Patients were included if they had a primary diagnosis of heart failure (International Classification of Disease-9 code 428.0), NYHA severity index II and greater and were at high risk for readmission as measured by one of the following: a) patients who are within two weeks of a hospital discharge for heart failure and who had at least one heart failure hospitalization in the preceding six months; b) at least two emergency room visits over two months for heart failure exacerbation; and c) excessive office visits for heart failure exacerbation as documented by the primary physician (at least two such visits over two months were required for study entry). Patients with a confirmed diagnosis of CHF were excluded from this study for the following reasons: 1) hemodynamic instability, or need for inpatient or intensive-care unit monitoring; 2) uncooperative or combative patient; 3) patient in long-term facility; 4) advanced dementia or psychiatric illness; 5) refusal to participate by the patient or physician; and 6) inability to obtain informed consent. The diagnosis of CHF was confirmed when at least one of the fol-

Table 1. Characteristics of the Study Population (n=100) and Association with Cognitive Impairment All Subjects P Value Characteristic Cognitive Impairment n (%) Yes (n=10) No (n=90) Age n (%) n (%) 2 (20.00) <64 years 39 (39.00) 37 (41.11) 65-74 years 39 3 (30.00) (39.00) 36 (40.00) >75 years 22 (22.00) 5 (50.00) 17 (18.89) 0.074

Gender Females Males

64 36

(64.00) (36.00) (76.00) (23.00) (28.00) (26.00) (30.00) (16.00)

4 (40.00) 6 (60.00)

60 (66.67) 30 (33.33) 69 (76.67) 21 (23.33)

27 24 28 11

0.096

GDS

Normal
Depression Education <8th grade 9th-i 1 th grade 12th grade Some college
NYHA

76 23

8 (80.00) 2 (20.00)
1 2 2 5

0.812

28 26 30 16
62 37
44 56

(10.00) (20.00) (20.00) (50.00)

(30.00) (26.67) (31.11) (12.22)

0.038

Class II Class III-IV

(62.00) (37.00) (44.00) (56.00)

6 (60.00) 4 (40.00)
7 (70.00) 3 (30.00)

56 (62.92) 33 (37.08)
55 (55.00) 35 (35.00)

0.856

Ejection Fraction
>40 <40
0.988

GDS: Geriatric Depression Scale; NYHA: New York Heart Association; cognitive impairment based on Mini-Mental Status Exam Score (MMSE): a score <23 is defined as cognitive impairment, and a score of .24 and greater indicates no cognitive impairment.

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lowing were present: a) clinical signs and symptoms of heart failure responsive to diuretic therapy; b) radiologic evidence of pulmonary congestion; and c) documented left ventricular systolic or diastolic dysfunction. The study was approved by the human subjects protection/institutional review board. The 100 cases and controls that are currently enrolled in the primary study are included in this analysis.

Demographic Variables
Age was categorized in three levels (<64 years; 65 years and <74 years; and >75years) and also used as a continuous variable in the analysis. Depression was defined based on the Geriatric Depression Scale (GDS). Depression is present if the GDS score is .5 and absent if the score is <5. Gender was also used as a binary variable (male/female). Education was categorized into <8th-grade level, ninth-I Ith grade, 12th grade and some college. NYHA functional class was defined categorically (NYHA class II/III-IV).

Measure of Cognitive Impairment

The Mini-Mental Status Examination (MMSE) was used to measure cognitive status among recruited

patients. This scale consists of 30 items with a maximum score of 30. A total score of 23 or less has been accepted as indicating the presence of cognitive impairment.32 The MMSE is a face-to-face test that can be administered in 5-10 minutes. The questionnaire is the most widely used instrument to screen for cognitive impairment.32 Several studies have validated this scale in various ethnic groups, including African Americans. The internal consistency, reliability and sensitivity studies indicate that this instrument fulfilled its original goal of providing a brief screening test that quantitatively assesses the severity of cognitive impairment and documents cognitive changes occurring over time.32 The MMSE is affected by age, cultural background and education.32 In a clinical setting, the MMSE is not recommended unless the person has at least an eighth-grade education and is fluent in English. cognitive impairment in this study was defined according to the accepted definition. Those patients with a score of 23 or less were defined as having cognitive impairment and those patients with a score of 24 and above were defined as not cognitively impaired. A single, trained personnel member administered this instrument.

Table 2. Prevalence of Cognitive Impairment by Selected Characteristics P Value Percent Cognitive Selected Characteristics Impairment Age 5.13 <64 years 7.69 65-74 years 22.73 0.074 >75 years Gender Females Males Education <8th grade 9th-11 th grade 12th grade Some college
6.25 16.67

Assessment of Depression
Participants were screened for depression using the GDS, a measure of depressive symptoms over the past week. The GDS is a widely used questionnaire consisting of 15 true and false items (10 indicating the presence of depression when answered positively and five indicating depression when answered negatively), none of which have a specifically somatic content. A score of5 or greater is suggestive of depression. GDS has been validated among numerous ethnic groups in the United States.33 A face-to-face interview was conducted by the trained nurse coordinator who administered the MMSE.

0.096

3.57 7.69 6.67 31.25

8.70 10.39

0.038

Depression Yes No
NYHA Class 11 Class III-IV

0.812

9.68 10.81 12.90 13.04

0.856

Ejection Fraction
<40% >40%
0.988

Assessment of CHF Severity

The NYHA functional class was used to assess the severity of CHF symptoms. This classification has
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GDS: Geriatric Depression Scale; NYHA: New York Heart Association; cognitive impairment based on Mini-Mental Status Exam Score (MMSE): a score <23 is defined as cognitive impairment, and a score of .24 and greater indicates no cognitive impairment.

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Table 1 shows the characteristics of the study patients by cognitive impairment status. There were 36 men and 64 women (mean age 67.5 9.01 years). The mean GDS score was 2.67 3.19. The crude prevalence of cognitive impairment (MMSE<24) Statistical Analysis was 10% and the age-adjusted prevalence was The prevalence ofcognitive impairment was deter- 12.5%. Thirty-nine of the study subjects were <64 mined among this group of African-American years of age; 39 were between ages 65 and 74 years; patients with CHE The cognitive impairment preva- and 22 were .75 years. Twenty-eight had an educalence was also determined by selected characteristics. tion level <8th grade; 26 had a level between ninth Continuous variables in these analyses were and 11th grade; 30 completed high school; and 16 expressed as mean and standard deviation, while cate- had some college. Sixty-two subjects had NYHA gorical variables were expressed as percentages.42 We class II, while 37 had NYHA class III-IV, and data calculated the age-adjusted prevalence using the Cau- from one subject were missing. Fifty-six had an EF casian study population as our reference group.2' The of <40 and 44 had an EF >40. The mean and SD unpaired t-test was used to assess the relationship were 33 16.56 and 34 + 23.29, respectively. between the continuous variables and cognitive Patients with cognitive impairment were older than impairment status, while the Chi-squared test was their counterparts without cognitive impairment (77.0 + used to compare categorical variables and cognitive 8.01 vs. 66.9 + 8.9, p=0.04). There were no statistically impairment status.42 Finally, multiple logistic regres- significant differences between both groups of patients sion was used to assess the association between cog- with and without cognitive impairment by selected varinitive impairment and age, educational level, gender, ables (Table 1), except for education (Table 2). The depression, NYHA class and the EF42 Age was evalu- prevalence of cognitive impairment increased with ated in multiple logistic regression as a continuous increasing levels of education (p=O.038). In the multivariate logistic regression analysis, age and categorical variable. Stata 8.0 statistical package as a continuous variable was significantly related to was used for statistical analysis.42 the prevalence of cognitive impairment. The odds of cogTable 3 Association of Cognitive Impairment with Age, Gender, nitive impairment increase Education, Depression and NYHA Class 1.10 times with each one-year OR P Value Characteristics 95% Confidence Interval increase in age (OR=1.10, 95% confidence interval Age 1.0-1.20, p=0.042).
<64 years 65-74 years >75 years 1.00 0.99 6.00

been used for several years to determine the severity of CHE34'35 Ejection fraction (EF) was also used as an objective measure to assess the severity of CHF, and it is directly related to prognosis. The EF was categorized as <40% and >40%.

RESULTS

0.13-7.50 0.85-43.58

0.0421

DISCUSSION
The results of the present study indicated that cognitive impairment is relatively prevalent (10%) in African-American patients with CHF, and this prevalence increases with age. The prevalence of cognitive impairment among CHF patients has been assessed in several case-controlled studies.'921,36-39 In these studies almost exclusively among white men and women, the prevalence of cognitive impairment among patients with CHF varied widely between 13% and 54%. When we calculated an ageadjusted rate between the Caucasian group (as standard) and our population of CHF
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Gender Females Males

Depression No Yes

1.00 5.47

0.88-34.05

0.068

1.00 0.78

0.11-5.40

0.803

Education >8th grade 9th-1 1 th grade 12th grade Some college

1.00 2.02 1.79 8.93

1.00 4.22

0.15-7.11 0.14-22.54 0.80-98.89

0.074

NYHA2 Class II
Class 111-IV

0.66-26.93

0.127

P-value for age as a continuous variable in the model; 2 NYHA = New York Heart Association

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patients, the age-adjusted prevalence was 12.5%. However, no study has specifically assessed the prevalence of cognitive impairment among African-American patients with CHE Previous studies have indicated a relationship between cognitive impairment and age,40 gender, education and depression.4' It is also well-established that age is a risk factor for cognitive impairment.40 Our results are in line with these previous observations. Zuccala et al.22 indicated in their study that the extent of cognitive impairment correlated with the degree of left ventricular dysfunction. However, the results of the present study failed to demonstrate a relationship between cognitive impairment and gender, depression and severity of CHF, possibly because of a small sample size. Another potential explanation for this discrepancy is that while patients in our study were recruited from a selective group of patients in an ongoing, single-blinded, randomized, controlled trial evaluating the effectiveness of a telemonitoring, patient-oriented intervention to improve access to ambulatory heart failure patients, our study participants were much younger in age, had higher education than those in previous studies and they may not be representative of the general population of CHF patients. Despite these limitations, this study provides the first indication for the relatively high prevalence of cognitive impairment among African-American patients with CHE cognitive impairment has an important impact on a population of patients with CHF, since it has been shown to be associated with a significant risk of dementia, associated with disability,27 dependence,'6 morbidity'7 and mortality.'8 Cognitive impairment is rapidly becoming a public health problem with the aging of the population. cognitive impairment may also play a role in medication compliance, which may lead to frequent hospitalization and high mortality among CHF patients.'2"3 This study indicates that cognitive impairment is prevalent among patients with CHF and should be assessed by clinicians and other healthcare workers managing these patients. Further studies are needed to evaluate the relationship between cognitive impairment and hospital readmission rates. Previous studies have shown that CHF is the leading indication for hospital admission in adults older than age 65. Among factors related to rehospitalization are nonadherence to medication and advice on lifestyle modifications, as well as failure to seek medical attention when the condition deteriorates.9-" Future studies may clarify the role of cognitive impairment to CHF readmissions in African-American patients, who are at higher risk for readmissions. Healthcare professionals managing these patients would have to assess their patients for cognitive impairment and prescribe appropriate management.

ACKNOWLEDGEMENTS
We are grateful to Rena Staton of the Master of Clinical Research Program for her assistance in the manuscript preparation. We are also grateful to Dr. Oduwole, at Grady Memorial Hospital; Metropolitan Atlanta Cardiology group (Drs. Paul Douglas and Calvin McClarin); and Dr. Alonzo Jones in Columbus, GA for permitting us to include their patients in this study.
1. Amercan Heart Association. Heart and stroke facts: 1996 statistical supplement. Dallas: American Heart Association; 1996:15. 2. American College of Cardiology/American Heart Association Committee on Evaluation and Management of Heart Failure. Guidelines for the evaluation and management of heart failure. J Am Coll Cardiol. 1995; 26:1376-1398. 3. Eriksson H. Heart failure: a growing public health problem. J Intern Med.

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34. New York Heart Association Criteria Committee. Diseases of the Heart and Blood Vessels: Nomenclature and c(iteria for diagnosis. 6th ed. Boston, MA: Little, Brown; 1964. 35. ACC/AHA Guidelines for the evaluation and management of Chronic Heart Failure in the Adult: Executive Summary. J Am Coll Cardiol. 2001;38:2101-2113. 36. Gorkin L, Norvell NK, Rosen RC, et al for the SOLVD Investigators. 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;71:1069-1073. 37. Acanfora D, Trojano L, lannuzzi GL, et al. CHF Italian study investigators. The brain in congestive heart failure. Arch Gerontol Geriafr. 1996;23:247-256. 38. Almedia OP, Tamai S. Congestive heart failure and cognitive function amongst the older adults. Arq Neuropsiquiatr. 2001;59(2-B):324-329. 39. Ekman 1, Fagerberg B, Skoog 1. The clinical implications of cognitive impairment in eldery patients with chronic heart failure. J Cardiovasc Nurs.
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2001;57:1655-1662. 41. Arias-Merino ED, Orozco-Mares 1, Garabito-Espara LC, et al. Correlates of cognitive impairment in elderly residents of long term care institutions in the metropolitan area of Guadalajara, Mexico. J Nutr, Health & Aging. 2003;7:97-101. 42. Pagano M, Gauvreau K. Principles of Biostatistics 2000, California: Duxbury. U

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