Cognitive Impairment in Patients Hospitalized For

Acute Coronary SyndromesJane S. Saczynski, PhDDavid D. McManus, MDMolly E. Waring, PhD

Milena D. Anatchkova, PhDJerry H. Gurwitz, MD

Catarina I. Kiefe, PhD MD

University of Massachusetts Medical School & Meyers Primary Care Institute

Cognitive Impairment is Common During Hospitalization

• Up to 40% of hospitalized patients are cognitive impaired

• Cognitive impairment is associated with lack of lack of functional recovery, readmission, institutionalization and mortality

• Chronic under-documentation in medical records

Cognitive Impairment Has Not Been Studied in ACS

• Most studies in the hospital setting focused on – Elderly patients– Surgical populations – Other conditions (e.g., heart failure)

Knowledge of Cognitive Status May Guide Discharge and Transitional Care Planning

Current Study Aim

To examine the prevalence of, and factors associated with, cognitive impairment among patients hospitalized for ACS.

TRACE-CORE• Transitions, Risks, and Actions in Coronary Events:

Centers for Outcomes Research and Education• Funded by NHLBI as a Center for Cardiovascular

Outcomes Research• Currently enrolling 2500 patients with ACS from 7

hospitals in 3 states• Will follow for 18 months through 1 in-hospital in-

person and 5 post-discharge telephone interviews with medical record abstractions through 24 months

In-Hospital Baseline Assessment

• 60-minute standardized interview

• Cognitive status - Telephone Interview for Cognitive Status (TICS)– Brief assessment of global cognitive function– Domains: orientation, memory, attention– 8-minute administration– Range 0-41; impairment : ≤30

In-Hospital Baseline Assessment• Psychosocial factors

– Depression – Patient Health Questionnaire (PHQ9) (>4 = high depressive symptoms)

– Anxiety – GAD-7 (>4 = high anxiety)– Stress – Perceived Stress Scale (PSS4)

• Quality of Life – SF-36– Seattle Angina Questionnaire (SAQ)– Disease Impact Scale

In-Hospital Baseline Assessment

• Medication Adherence– Morisky Scale

• Caregiving Support– Assistance received– Unmet need

• Demographics

Statistical Analyses

• Chi-square or t-tests used to compare baseline characteristics by cognitive impairment

• Logistic regression– Variables significant in bivariate analyses

included in multivariate model

Prevalence of Cognitive Impairment During Hospitalization for ACS

• TICS range: 19 – 40 – mean = 32.1; SD = 3.1

• 31% were cognitively impaired – TICS <=30

Characteristics by Cognitive Impairment

Cognitive Impairment

CharacteristicTotal

(N=1121)No

(n=778)Yes

(n=343)p-value†

Age, years, M (SD) 62 (11) 61 (11) 64 (11) 0.004

Sex, female, % 34 33 37 0.13

Education, % Less than high school 19 14 30

High school 28 28 29

College or more 53 58 41 <0.001

Non-white, % 24 21 29 0.003

Depression, % (PHQ-9) 49 45 56 0.001

Anxiety, % (GAD-7) 50 45 58 <0.001

Stress, PSS (0-20), M(SD) 4.8 (3.5) 4.6 (3.4) 5.3 (3.6) 0.002

Characteristics by Cognitive Impairment

Cognitive Impairment

CharacteristicTotal

(N=1121)No

(n=778)Yes

(n=343)p-value†

SF-36 (t-scores) Mental Subscale, M(SD) 47 (13) 48 (12) 44 (14) <0.001

Physical Subscale, M(SD) 41 (11) 61 (11) 64 (11) 0.005

Medication Adherence, Morisky 0.28

Low 42 41 46

Moderate 37 37 36

High 21 22 18

Caregiving Support, % 13 12 17 0.02

TICS Total Score, (0-41) 32.1 (3.1) 33.6 (2.1) 28.5 (1.7) <0.001

Factors Associated with Cognitive Impairment

Characteristic Odds Ratio (95% CI)

Age 1.02 (1.01, 1.03)

Education, > HS 0.6 (0.5, 0.8)

Race, White 0.7 (0.5, 0.9)

Anxiety 1.4 (1.0, 2.0)

Depression 0.9 (0.7, 1.4)

Stress 1.0 (0.9, 1.1)

Caregiving Support 1.3 (0.9, 1.0)

SF-36 Mental Domain 0.99 (0.9, 1.0)

SF-36 Physical Domain 0.97 (0.96, 0.99)

Key Findings

• Cognitive impairment is highly prevalent during hospitalization for ACS

• Patient demographic (older age, lower education, non-white race), psychosocial (high anxiety), and quality of life factors are independently associated with presence of cognitive impairment

Implications / Next Steps

• Need for increased attention to cognitive status in ACS

• Screening for cognitive impairment during hospitalization – Tailored transitional care– Closer post-discharge monitoring

• Post-discharge persistence of impairment

Funding

• National Heart Lung and Blood Institute (U01HL105268-01)

• National Institute on Aging (K01 AG33643)

TRACE-CORE InvestigatorsUniversity of Massachusetts Medical School:

Catarina I. Kiefe PhD MD (PI), Jeroan J. Allison MD MScEpi, Milena D. Anatchkova PhD, Frederick Anderson PhD, Arlene S. Ash PhD, Bruce Barton PhD MS MA, Robert J. Goldberg PhD, Joel M. Gore MD, Jerry H. Gurwitz MD, J. Lee Hargraves PhD, David D. McManus MD, Sharina D. Person PhD, Jane S. Saczynski,PhD, John E. Ware Jr., PhD, Molly E. Waring PhD, and Zi Zhang MD MPH

Mercer University School of Medicine: David C. Parish, MD (site PI) and Randolph S. Devereaux, PhD MSPH

Kaiser Permanente Georgia and the Rollins School of Public Health at Emory University:

Douglas W. Roblin, PhD (site PI)

University of Arizona College of Medicine: Joseph S. Alpert MD (site PI) and Sasanka N. Jayasuriya MD (site co-PI).