Cognitive impairment might not the first thing we think about when treating patients with congestive heart failure and anemia. But you may be surprised to find out- these disease processes can often be causes of memory loss and cognitive impairment. Therefore, it’s essential that we fully learn how these patients can be affected as a whole, so we can provide them with the most well rounded and effective plan of care possible!
Correlation between Congestive heart failure and Anemia:
Anemia is present in approximately one third of patients with congestive heart failure. There are multiple factors that can contribute to these conditions co-existing, and it’s hard to say in general terms if one is causative of the other. Firstly, they do have several risk factors in common, such as chronic kidney disease, Diabetes Mellitus, inflammation, advanced age and exposure to toxins such as chemotherapy.
It appears that in some cases, congestive heart failure can lead to anemia and in others the opposite is true. There are many complex mechanisms that go into the domino effect of each of these scenarios, but in simplified terms… if a person has congestive heart failure that leads to things like renal dysfunction, inflammation, nutritional deficiencies, or blood loss or if they are on a medication such as an ACE inhibitor or beta blocker… these things can then lead to anemia. On the flip side, if a person has anemia (due to any number of reasons) – this would cause the need for an increase in their cardiac output in order to get the needed amount of oxygenated blood to all the tissues and organs that need it. This, in turn, can overwork the heart and lead to congestive heart failure.
The combination of anemia, chronic kidney disease and iron deficiency in patients with congestive heart failure occurs often, and is associated with progression of these disease process, cognitive impairment, and poor prognosis. So, although you could surmise for each specific case you encounter that one diagnosis may have led to the other, it is still unclear whether anemia leads to advanced congestive heart failure and worse outcome or if anemia is merely a sign of more advanced disease. But the bottom line is, they coexist often and have effects that we don’t always think about.
Prevalence of cognitive impairment in those with heart failure
Causes of memory loss and cognitive impairment have also been clearly associated with congestive heart failure. One study identified patients with heart failure who had anemia as having a greater than four times more risk of cognitive impairment compared to the heart failure patients who did not have anemia. And if you remember… one third of patients with heart failure also have anemia. This is a huge number of patients that are at risk for having cognitive impairment that very well may slip through the cracks without receiving cognitive assessment or intervention. Patients with heart failure usually have so many medical care needs, that cognitive impairment may (unfortunately) be the last thing the team is worrying about. But it should be one of the first things on the list! If physicians and other clinicians are trying to implement new treatments, new medications, new lifestyle changes, etc. the patient with cognitive impairment will not be taking all the instructions in as well as they may appear to be. And in order to more effectively address all these other aspects of care, we must evaluate for and intervene when cognitive impairment may affect carryover of education on the disease process and treatment.
Screen and Identify early
Two different screening processes would be useful to initiate with all patients with congestive heart failure.
- Since anemia is quite prevalent in those with heart failure, we would want to identify if it is present or not in order for the anemia itself to be treated (and also to give us insight into what we may find during our cognitive assessment). Simple blood work would be able to identify if these patients are also experiencing anemia and therefore be at a higher risk for cognitive impairment. After discussion with the care team, this could be something that would be incorporated into a clinical pathway and could be included in a physician order set for congestive heart failure right off the bat!
- As mentioned before, a Speech Language Pathologist referral is not something you would think of first when caring for people with heart failure, but given what we now know about the correlation between heart failure, anemia and cognitive impairment, it would be worth discussing with the team how to make it standard to screen cognitive function in these patients. This may not need to be initiated by the Speech therapist themselves but could be a step in the process of the multidisciplinary evaluations that occur in the early stages of forming the care plan. The physical or occupational therapist could include in their assessment any number of standardized cognitive assessments in order to more accurately refer these patients to the Speech therapist so a more comprehensive cognitive assessment can take place when needed. These assessments could include the Brief Cognitive Assessment Tool – short form (BCAT – SF), the Saint Louis University Mental Status exam (SLUMS), or the Mini-mental State Exam (MMSE). Any of these options (and others not listed) will provide a quick and easy way to identify, objectively, if cognitive impairment is present and if further assessment is needed. Caution should be used when simply relying on observation of functional activity and conversation with the patient to use as your screening process, as patients often learn how to compensate for deficits and can “cover up” the severity of the impairment. They may seem ok and be able to carry on simple conversation and routine daily tasks without difficulty. Using an objective measure is always the way to go – so talk to your team and figure out which one would be the best fit for your needs!
Find a few of the suggested outcome measures here.
Circle back to function
Functionally speaking we will already be looking at certain things during our regular assessments, such as their ability to complete activities of daily living and perform their basic care needs, manage their medications and any other tasks that they would normally complete. These tasks may warrant “the usual” intervention by the therapy team but may also warrant support and education to the caregivers as these patients may require more support from a cognitive standpoint than they did previously.
During bathing and dressing tasks, depending on the severity of cognitive impairment, the person may have difficulty with sequencing the steps involved, they may be forgetful and perseverate on one aspect of the task, they may not have the ability to initiate basic hygiene needs, or be able to recognize if things have been completed thoroughly. This would be a great opportunity for the Speech Language Pathologist to coordinate with the Occupational therapist in order to institute the appropriate strategies and increase carryover of skills from one session to the next.
The same types of principals would apply to instrumental activities of daily living, but especially with medication management. Mishandling of medications or non-compliance with medication recommendations is one of the leading causes of rehospitalization and patients with heart failure often have new medications they are dealing with or have frequent adjustment of the medication they are currently on. Combine that with untreated cognitive impairment and you have a rehospitalization waiting to happen! It is important to provide strategies to these patients for them to not only take the right pill at the right time but also to teach them what the pills look like out of the bottle! Their pill box is bound to spill at some point… so putting together a visual aid so they can identify their pills and reorganize them accurately, will be a very useful thing for them to have.
There are countless examples of how cognitive impairment can affect a person’s daily life, but getting the caregiver involved is key. The patient with congestive heart failure may have been a person that previously was able to complete everything on their own and is currently pretty good at compensating for the cognitive impairments they have. This would be a patient that the family will most likely not identify as someone needing help. It will be our job to advocate for the patient and really educate them and their caregivers on everything that may have changed and what they may now need assistance with. This could range from setting up the pill box once per week, to helping them get dressed and undressed in the morning and evening, to staying with them overnight. It will all depend on their individual need. The American Heart Association has really great resources for patients, caregivers, and clinicians. You can find them here.
With all the things these patients are going through, the first step in providing the best care possible is making sure to identify where the impairments lie. Now that we know how highly correlated cognitive impairment is with congestive heart failure and anemia… we can’t unknow it! We must act. Talk to your team and make a plan. These are simple (but important) steps we can all take to improve our skill and improve the care we provide!
To learn more about the (not so obvious) aspects of heart failure, check out our short (but information packed!) webinar – Update Your Care Plan: Heart Failure.
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