Editor's Note: Summary based on Agarwal KS, Kazim R, Xu J, Borson S, Taffet GE. Unrecognized cognitive impairment and its effect on heart failure readmissions of elderly adults. J Am Geriatr Soc 2016;64:2296-301.

Rationale for Study/Background: To determine whether 30-day readmissions were associated with presence of cognitive impairment (CI) more in elderly adults with heart failure (HF) than in those with other diagnoses and whether medical teams recognized CI.

Methods:

Design: One-year prospective cohort quality improvement program of cognitive screening and retrospective chart review of documentation and outcomes. CI testing with the Mini-Cog test was completed within 48 hours before planned discharge.

Inclusion Criteria: Individuals aged 70 and older who were discharged home from the unit between January 27 and December 18, 2014, were eligible for the project. Individuals with any primary diagnosis of HF, independent of etiology, were included in the HF group, as were those with preserved or reduced ejection fraction.

Exclusion Criteria: Individuals were ineligible if they were being evaluated for or given a cardiac transplant or ventricular assist device; had a primary oncology diagnosis; had end-stage renal disease undergoing dialysis; or were scheduled to be discharged to hospice, skilled nursing facility (SNF), long-term acute care hospital, or nursing home.

Primary outcome(s): Investigators reviewed the EMR for hospital readmissions within 30 days of discharge.

Statistical Analysis: Data were presented as means and standard deviations for continuous variables and numbers and percentages for categorical variables.

Results: Mini-Cog scores were less than 4 (indicating CI) in 157 encounters (82 [67.7%] with HF, 75 [62.5%] without). Mini-Cog scores were similar in rate and distribution between groups. Individuals with HF and CI had a significantly higher 30-day readmission rate than did the other groups (26.8% vs. 13.2%; P = .01; HF, no CI, 12.8%; no HF, no CI, 13.3%; CI, no HF, 13.3%). In individuals with HF and CI, those with documented caregiver education had lower readmission rates than those without (14.3% vs. 36.2%; P = .03). Fewer than 9% had documentation of CI in the medical record.

Conclusion: Cognitive impairment (CI), which is frequently undocumented, may indicate greater risk of readmission for individuals with HF than those without. Screening for CI, adapting discharge for it, and involving family and caregivers in discharge education may help reduce readmissions.

Limitations of study: These include inability to follow people for mortality after discharge, loss of 77 participants to the study because testing was missed or refused, and the retrospective collection of some data. In a prospective cohort study, it is difficult to sort out cause and effect.

Geriatric perspective for the cardiovascular clinician: Even though cognitive impairment (CI) is a marker of severity of illness, this study importantly documents that substantial CI often goes undetected in the chart, and clinicians who focus on the care of older persons note that such lack of documentation usually means lack of detection. Importantly, the study also documents that CI in HF patients is associated with higher readmissions. The authors correctly point out that better detection can lead to better discharge planning and post discharge management. It is likely that coordinated detection and management of such patients could help reduce repeat hospitalization.

Keywords: Aged, Caregivers, Cognition, Disease Management, Heart Failure, Heart Transplantation, Heart-Assist Devices, Renal Dialysis, Geriatrics

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