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LESSON
Heart Failure and Cognitive Impairment
Description/Etiology
Heart failure (HF) is a progressive clinical syndrome in which the heart fails to pump a
sufficient supply of blood to the body due to a functional or structural disorder. HF is the
endpoint of several types of cardiovascular disease. Although it can be treated with drugs or
heart transplantation, HF is often fatal (for more information, see Quick Lesson About …
Heart Failure: an Overview ).
Cognitive impairment is commonly reported in patients with severe HF; all patients with HF
should be screened for cognitive decline. The exact etiology of cognitive impairment in HF
is unclear; factors that might contribute to cognitive impairment in patients with HF include
cerebral ischemia resulting from decreased cerebral perfusion, cerebral infarction resulting
from emboli migration to the brain, and impaired cerebrovascular reactivity.
Patients with cognitive impairment might be unable to understand or comply with
the prescribed HF treatment regimen or to recognize worsening symptoms. Cognitive
impairment in patients with HF is associated with decreased quality of life (QOL), increased
utilization of healthcare resources related to HF, and increased mortality; the degree of
impairment is associated with the severity of HF manifestations. Treatment of HF, which
is aimed at improving cardiac output and cerebral perfusion and regulating heart rate and
blood pressure, can partially reverse HF-related cognitive deficits. Cognitive impairments
related to HF can also be moderated by diet; a diet containing a variety of fruits, vegetables,
lean meats, fish, low-fat dairy products, and whole grains might slow or cease cognitive
decline.
Facts and Figures
ICD-10
I50.0
Author
Debra Balderrama, RN, MSCIS
Glendale Adventist Medical Center,
Glendale, CA
Reviewers
Mary Woten, RN, BSN
Cinahl Information Systems, Glendale, CA
Tanja Schub, BS
Cinahl Information Systems, Glendale, CA
Nurse Excellence Practice Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
HF affects about 5.1 million individuals in the United States, with more than 650,000 new
patients diagnosed each year. Cognitive deficits affect 28–58% of patients with HF. HF is
associated with a 2–4-fold increased risk for developing cognitive impairment.
Risk Factors
Comorbid diseases or conditions often contribute to cognitive decline in older patients with
HF. The degree or rate of cognitive decline is directly related to decreases in left ventricular
ejection fraction, cardiac output, and systolic function. Other factors that increase the
risk for cognitive impairment in HF include depression, sleep-disordered breathing (i.e.,
obstructive sleep apnea), and anemia.
Signs and Symptoms/Clinical Presentation
Signs and symptoms of HF include tachycardia, pulmonary congestion,
hepatosplenomegaly, water weight gain, extreme fatigue, peripheral edema, decreased
urination, poor peripheral circulation, pallor, and exercise intolerance. Cognitive deficits
manifest as difficulty with complex reasoning, memory lapses, poor concentration skills,
forgetfulness, slowed reaction time, and confusion.
January 6, 2017
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2017, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
Assessment
› Patient History
• Ask patient and/or family about past and current signs of cognitive impairment (e.g., personality changes, memory
difficulties, judgment abnormalities, and difficulties performing activities of daily living [ADLs])
› Physical Findings of Particular Interest
• Patient might have pulmonary congestion, tachycardia, peripheral edema, and/or pallor
› Laboratory Tests
• B-type natriuretic peptide (BNP) elevation indicates LV dysfunction (normal value ≤ 100 pg/mL)
• Serum electrolyte panel might show electrolyte imbalance, which can result from the use of some medications (e.g.,
diuretics) used to treat HF
• CBC might reveal anemia
› Other Diagnostic Tests/Studies
• Echocardiography with Doppler flow studies can show abnormalities in cardiac structure and heart function
• EKG can identify arrhythmias
• Chest X-ray might show ventricular enlargement
• Cardiac catheterization can identify abnormalities
• An assessment tool for cognitive impairment (Global Deterioration Rating Scale, Mini-Mental State Exam, Geriatric
Depression Scale, Draw-A-Clock Test) can be used to evaluate for impaired cognition (for more information, see Nursing
Practice & Skill ... Depression Assessment in Older Adults: Using the Geriatric Depression Scale )
Treatment Goals
› Promote Optimum Physiologic and Cognitive Function
• Monitor vital signs, assess all physiologic systems (especially neurologic and cardiac), and review lab/diagnostic study
results; immediately report abnormalities to the treating clinician provide prescribed treatment
• Assess fall risk due to confusion and other HF-associated manifestations; maintain patient safety (e.g., airway,
circulation, and prevention of injury) (for more information, see Evidence-Based Care Sheet: Falls, Accidental: Risk
Assessment )
• Administer prescribed medications to treat HF; monitor the effectiveness of treatment and for adverse effects
–Diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), beta blockers,
digitalis, direct vasodilating drugs, calcium channel blockers, and/or anticoagulants can be prescribed (for more
information, see the series of Quick Lesson papers on medications administered to treat HF). Monitor for potential
adverse effects, including but not limited to the following:
- Potassium loss, fatigue, weakness, numbness, tingling, cramping, vomiting, and constipation from diuretics
- Dry cough, increased potassium, low blood pressure, dizziness, headache, and drowsiness from ACE inhibitors
- Headache, cough, fever, dizziness, diarrhea, and sore throat from ARBs
- Cold extremities, fatigue, and nightmares from beta blockers
- Anxiety, blurred vision, confusion, dizziness, headache, anorexia, hallucinations, nausea, and vomiting from digitalis
- Fatigue, flushing, edema, and heartburn from calcium channel blockers
- Bleeding from anticoagulants
• Request clinician referral, if appropriate, to a mental health clinician specializing in the treatment of cognitive impairment
associated with HF
–Administer psychotropic or other medications, as ordered, for treatment of cognitive impairment; monitor for potential
side effects prior to administration
–Educate patient/family about the risks and benefits of psychotropic medications
› Provide Emotional Support and Educate
• Assess patient/family anxiety level and ability to cope with a life-altering disease and disturbances in cognition; provide
emotional support, educate, and encourage discussion about HF pathophysiology, its common association with cognitive
impairment, potential complications, risk factors, treatment risks and benefits, coping with a life-threatening condition, and
individualized prognosis
• Individualize the education based on patient assessment; encourage questions and allow extra time for discussion because
patients with cognitive impairment often forget questions they intended to ask during visits by the treating clinician
• Request referral to a social worker for identification of local resources for in-home care, educational programs on HF and
cognitive impairment, and memory training programs
Food for Thought
› Healthcare providers often focus on physical manifestations and life-threatening symptoms of HF and can overlook
cognitive dysfunction
› Cognitive decline is more pronounced in younger persons with HF, particularly those awaiting heart transplantation
› In a study of 18 patients with HF, researchers found that cognitive dysfunction predicted impaired performance (e.g., more
collisions and missed stop signs) in a simulated driving scenario (Alosco et al., 2015)
› In a study of 136 older adults with HF, researchers in Japan reported that the presence of cognitive impairment was
associated with a 7.6-foldincreased risk of hospital readmission or death due to HF (Saito et al., 2015)
Red Flags
› Treatment regimens and behavior modification associated with lifestyle changes for patients with HF are very complex and
can be challenging for the cognitively impaired
› Patients with cognitive impairment might not be competent to understand and provide informed consent for procedures or
treatments
What Do I Need to Tell the Patient/Patient’s Family?
› Remind the patient and caregivers that medication management and compliance is key to prevent HF readmission in patients
with impaired cognitive status
› Educate patient and caregivers about continued care in the home, including medication schedules, dietary constraints, and
exercise; provide written materials, if available, and confirm that the caregiver can monitor the patient’s daily weight, heart
rate, and blood pressure
› Emphasize the importance of continued medical surveillance and seeking immediate medical attention if adverse drug effects
develop or for new or worsening signs and symptoms
› Encourage caregivers to become educated in strategies for providing mental stimulation, such as memory training programs
References
1. Alosco, M. L., Penn, M. S., Spritznagel, M. B., Cleveland, M. J., Ott, B. R., & Gunstad, J. (2015). Reduced physical fitness in patients with heart failure as a possible risk factor
for impaired driving performance. American Journal of Occupational Therapy, 69(2), 1-8. doi:10.5014/ajot.2015.013573
2. Alosco, M. L., Spitznagel, M. B., Raz, N., Cohen, R., Sweet, L. H., Colbert, L. H., ... Gunstad, J. (2013). Dietary habits moderate the association between heart failure and
cognitive impairment. Journal of Nutrition in Gerontology & Geriatrics, 32(2), 106-121. doi:10.1080/21551197.2013.781408
3. Bauer, L. C., Johnson, J. K., & Pozehl, B. J. (2011). Cognition in heart failure: An overview of the concepts and their measures. Journal of the American Academy of Nurse
Practitioners, 23(11), 577-585. doi:10.1111/j.1745-7599.2011.00668.x
4. Beer, C., Ebenezer, E., Fenner, S., Lautenschlager, N. T., Arnolda, L., Flicker, L., & Almeida, O. P. (2009). Contributors to cognitive impairment in congestive heart failure: A
pilot case-control study. Internal Medicine Journal, 39(9), 600-605. doi:10.1111/j.1445-5994.2008.01790.x
5. Davis, K. K., & Allen, J. K. (2013). Identifying cognitive impairment in heart failure: A review of screening measures. Heart & Lung: The Journal of Critical Care, 42(2), 92-97.
doi:10.1016/j.hrtlng.2012.11.003
6. Ganga, H. V., & Kokkirala, A. R. (2017). Heart failure. In F. F. Ferri (Ed.), 2017 Ferri's clinical advisor: 5 books in 1 (pp. 542-549). Philadelphia, PA: Elsevier.
7. Saito, H., Matsue, Y., Endo, Y., Hasegawa, Y., Negishi, Y., Soeda, M., ... Hasimoto, Y. (2015). Cognitive impairment is an independent predictor for prognosis in Japanese
heart failure patient in elderly. European Journal of Heart Failure Abstracts Supplement, 17(Suppl 1), 226.
8. Sauvé, M. J., Lewis, W. R., Blankenbiller, M., Rickabaugh, B., & Pressler, S. J. (2009). Cognitive impairments in chronic heart failure: A case controlled study. Journal of
Cardiac Failure, 15(1), 1-10. doi:10.1016/j.cardfail.2008.08.007
9. Stanek, K. M., Gunstad, J., Paul, R. H., Poppas, A., Jefferson, A. L., Sweet, L. H., & Cohen, R. A. (2009). Longitudinal cognitive performance in older adults with cardiovascular
disease: Evidence for improvement in heart failure. Journal of Cardiovascular Nursing, 24(3), 192-197. doi:10.1097/JCN.0b013e31819b54de
10. Taylor, J. (2015). Cognitive impairment predicts worse outcome in heart failure. European Heart Journal, 36(30), 1945.
11. Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Jr, Drazner, M. H., ... Wilkoff, B. L. (2013). 2013 ACCF/AHA guideline for the management of heart failure:
A report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. Circulation, 128(16), e240-327. doi:10.1161/
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