The population of older adults seen in cardiovascular (CV) practices with multiple chronic conditions and accompanying cognitive dysfunction is growing. The 2018 World Alzheimer Report noted the incidence of dementia increasing every 3 seconds with a threefold change in prevalence between 2018 (50 million) and 2050 (152 million). Furthermore, in the United States there is a transition between mild neurocognitive disorder (also known as mild cognitive impairment [MCI]) to major neurocognitive impairment (dementia) every 68 seconds. Many of these individuals will have CV disease and seek care in CV practices. Therefore, it is important for the CV team to recognize the spectrum of cognitive changes from age-related cognitive decline to MCI and to dementia.

Coronary artery disease and cerebrovascular disease share some of the same CV risk factors that cause cognitive decline. A well-studied example is that of hypertension. Studies have shown that higher blood pressure is associated with a decline in cognitive performance, which may be due to a wide range of pathophysiological factors including white matter lesions, lacunar infarcts, altered cerebral blood flow regulation, cerebral hemorrhages, and reduced cerebral volume.¹ Metabolic syndrome and its components, waist circumference and fasting glucose, are also associated with cognitive impairment.² Insulin resistance is associated with smaller hippocampal volume and worse performance in the learning and memory domains of cognition.³ Insulin resistance and abnormal adipose deposition cause vascular endothelial damage, resulting in reduced cerebrovascular blood flow.⁴ Diabetes mellitus is also associated with smaller brain volume and attention and memory deficits.⁵ Large epidemiological studies have shown a higher prevalence of cognitive impairment in patients with atrial fibrillation and heart failure.^6,7 In addition to the above-mentioned pathophysiological mechanisms, reduced cardiac output, cerebral hypoperfusion, and systemic inflammation are plausible underlying mechanisms. Hence, CV practices will see a large population of older adult patients affected by cognitive decline.

Although formal testing is frequently needed to diagnose cognitive impairment, there are simple questions that can be asked on interviewing patients to assess whether cognitive decline is present and if there is a need for further testing. These include:

• Do you have difficulty learning and retaining new information and/or handling complex tasks (e.g., managing finances, driving)?
• Have others told you that you tend to repeat questions or tell the same stories multiple times?
• Do you have trouble remembering recent conversations, events, or appointments?
• Do you frequently misplace objects?
• Do you have difficulty with abstract thinking (e.g., solving complex puzzles or problems)?
• Do you have difficulty following a complex train of thought or performing tasks that require many steps, such as balancing a checkbook or cooking a meal (i.e., executive function)?

The CV team should know a patient's functional status. Asking about ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) can help determine functional status. ADLs include bathing, dressing, grooming, eating, toileting, walking, and transferring. IADLs include managing finances, managing transportation, shopping, meal preparation, house cleaning, home maintenance, managing communication, and managing medications. Insight into these responses will inform clinicians about a patient's ability to adhere to the treatment plan. The Functional Activities Questionnaire (FAQ) has been validated as a single tool to aid in the diagnosis of the degree of cognitive dysfunction. A score of ≥9 is considered significant and could be considered towards a diagnosis of dementia with accompanying cognitive domain assessment tools such as the Montreal Cognitive Assessment (MoCA) or the Saint Louis University Mental Status (SLUMS).

Aside from interviewing, tools such as the Eight-item Informant Interview to Differentiate Aging and Dementia (AD8®) questionnaire and the Mini-Cog© assessment can be used by the CV team for initial assessment of cognitive dysfunction. The AD8 questionnaire can be administered by medical assistants or as a questionnaire to be filled out by family with patient while in the waiting room. Many times, mild cognitive impairment is present, but cannot be identified on interviewing. In these situations, objective testing is revealing. If objective testing in the CV practice is abnormal, patients should be referred to geriatrics (older adults), psychiatry (comorbid psychiatric conditions), neurology (especially with atypical symptoms and neurological signs), or a memory clinic based on local practices and availability.

Cognitive decline is associated with frailty development,⁸ CV disease (CVD) development,^9,10 and poor outcomes. Memory, attention, and executive functioning are all necessary to adhere to medical recommendations and care for oneself.¹¹ Impairment in one or more of these domains can result in decreased adherence to medications, follow-up with providers, and care for oneself, which may explain its association with development and progression of CVD, rehospitalization, and mortality.¹² A gauge of cognitive function and functional status is important to determine whether a patient can independently access care, remember appointments, transport oneself to appointments, and take medications. If impairments are noted, then involving the appropriate specialists and linking patients to resources may improve medical adherence and CV outcomes.

References

1. Forte G, Casagrande M. Effects of blood pressure on cognitive performance in aging: a systematic review. Brain Sci 2020;10:919.
2. Lai MMY, Ames DJ, Cox KL, et al. Association between cognitive function and clustered cardiovascular risk of metabolic syndrome in older adults at risk of cognitive decline. J Nutr Health Aging 2020;24:300-4.
3. Rasgon NL, Kenna HA, Wroolie TE, et al. Insulin resistance and hippocampal volume in women at risk for Alzheimer's disease. Neurobiol Aging 2011;32:1942-8.
4. Arshad NA, Lin TS, Yahaya MF. Metabolic syndrome and its effect on the brain: possible mechanism. CNS Neurol Disord Drug Targets 2018;17:595-603.
5. Christman AL, Vannorsdall TD, Pearlson GD, Hill-Briggs F, Schretlen DJ. Cranial volume, mild cognitive deficits, and functional limitations associated with diabetes in a community sample. Arch Clin Neuropsychol 2010;25:49-59.
6. Kalantarian S, Stern TA, Mansour M, Ruskin JN. Cognitive impairment associated with atrial fibrillation: a meta-analysis. Ann Intern Med 2013;158:338-46.
7. Cannon JA, Moffitt P, Perez-Moreno AC, et al. Cognitive impairment and heart failure: systematic review and meta-analysis. J Card Fail 2017;23:464-75.
8. Atkinson HH, Rosano C, Simonsick EM, et al. Cognitive function, gait speed decline, and comorbidities: the health, aging and body composition study. J Gerontol A Biol Sci Med Sci 2007;62:844-50.
9. Santos CY, Snyder PJ, Wu WC, Zhang M, Echeverria A, Alber J. Pathophysiologic relationship between Alzheimer's disease, cerebrovascular disease, and cardiovascular risk: a review and synthesis. Alzheimers Dement (Amst) 2017;7:69-87.
10. Lopez OL, Jagust WJ, DeKosky ST, et al. Prevalence and classification of mild cognitive impairment in the Cardiovascular Health Study Cognition Study: part 1. Arch Neurol 2003;60:1385-9.
11. Faulkner KM, Uchmanowicz I, Lisiak M, Cichoń E, Cyrkot T, Szczepanowski R. Cognition and frailty in patients with heart failure: a systematic review of the association between frailty and cognitive impairment. Front Psychiatry 2021;12:713386.
12. Kewcharoen J, Prasitlumkum N, Kanitsoraphan C, et al. Cognitive impairment associated with increased mortality rate in patients with heart failure: a systematic review and meta-analysis. J Saudi Heart Assoc 2019;31:170-78.

Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Sleep Apnea

Keywords: Aged, Activities of Daily Living, Executive Function, Coronary Artery Disease, Metabolic Syndrome, Waist Circumference, Stroke, Lacunar, Frailty, Patient Readmission, Follow-Up Studies, Mental Status and Dementia Tests, Cerebrovascular Disorders, Aging, Dementia, Neurology, Insulins, Geriatrics

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