Cardiovascular Disease

1. Cognitive Impairment in
Patients Hospitalized For
Acute Coronary Syndromes
Jane S. Saczynski, PhD
David D. McManus, MD
Molly E. Waring, PhD
Milena D. Anatchkova, PhD
Jerry H. Gurwitz, MD
Catarina I. Kiefe, PhD MD
University of Massachusetts Medical School & Meyers
Primary Care Institute

2. 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

3. 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)

4. Knowledge of Cognitive Status
May Guide Discharge and
Transitional Care Planning

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

6. 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

7. 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

8. 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

9. In-Hospital Baseline Assessment
• Medication Adherence
– Morisky Scale
• Caregiving Support
– Assistance received
– Unmet need
• Demographics

10. 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

11. Prevalence of Cognitive Impairment
During Hospitalization for ACS
• TICS range: 19 – 40
– mean = 32.1; SD = 3.1
• 31% were cognitively impaired
– TICS <=30

12. Characteristics by Cognitive Impairment
Cognitive Impairment
Total No Yes
p-value†
Characteristic (N=1121) (n=778) (n=343)
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

13. Characteristics by Cognitive Impairment
Cognitive Impairment
Total No Yes
p-value†
Characteristic (N=1121) (n=778) (n=343)
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

14. 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)

15. 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

16. 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

17. Funding
• National Heart Lung and Blood Institute
(U01HL105268-01)
• National Institute on Aging (K01 AG33643)

18. TRACE-CORE Investigators
University 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).