My name is Iran Gorodetsky. I am a heart failure cardiologist at University Hospitals in Cleveland, Ohio, and a professor of medicine at Case Western Reserve University School of Medicine. And it is my great pleasure to open up this HFSA Heart Failure Seminar titled Focus on Cognitive Impairment in Heart Failure. With me today are my colleagues, friends, and co-authors on this HFSA Cognitive Impairment Statement, including Dr. Parag Goyal from Weill Cornell Medicine, Dr. Rob DiDomenico from the University of Illinois, and Dr. Connie White-Williams from the University of Alabama at Birmingham. Here are our learning objectives for this evening, including explaining the impact of cognitive impairment on patients with heart failure, discussing the importance of addressing cognitive impairment in heart failure care, applying key recommendations from the HFSA Scientific Statement on Cognitive Impairment that we co-authored, and facilitating interdisciplinary collaboration in addressing cognitive impairment in heart failure. Our agenda tonight is going to be twofold. First, we're going to start off by describing what we feel are the top takeaways from the Cognitive Impairment in Heart Failure Statement that was published in the Journal of Cardiac Failure in March. And then we're going to transition to a panel discussion Q&A related to questions you guys may have, as well as some other questions that we thought would be relevant. Just by means of a reminder, you will be able to claim continuing education credit for this seminar. So watch out for your email. You'll get an email from HFSA that you should respond to to fill out a survey and then get credit. So without further ado, I will kick it off. This is the title of our statement, Cognitive Impairment in Heart Failure, published in the Journal of Cardiac Failure in March of 2024. I'm very fortunate to work with this outstanding group of co-authors, some of which are our co-panelists here in the seminar tonight. Cognition is derived from the Latin root cognisere, which means to know. It refers to the mental process of acquiring knowledge and understanding it. Abnormalities in cognition range from the expected decline in cognition of normal aging to pathological declines that can vary from mild to severe, whereby mild cognitive impairment may not affect the day-to-day life to severe cognitive impairment, which is dementia, which really leads to disability. Heart failure is linked with abnormalities in multiple organ systems that go beyond the cardiovascular system. The brain is often negatively impacted in adults with heart failure. Advanced age, multimorbidity, shared risk factors, and the pathophysiological mechanisms of heart failure all contribute to alterations in the brain, which can lead to cognitive impairment. The reported prevalence of cognitive impairment among patients with heart failure ranges from 22% to 78%. This wide range reflects differences in the definitions and severities of cognitive impairment, the diagnostic tools used to identify impairment, and the population studied. In a study of nearly 200 older adults hospitalized with worsening heart failure, a standardized assessment of cognition, called the MOCA, revealed that over 70% met the criteria for mild cognitive impairment, or MCI, while only 2% were actually detected clinically by clinicians like us. Also, the prevalence of cognitive impairment tends to be higher among hospitalized patients compared to those who are ambulatory due to multiple reasons, such as the acuity of illness and the hospitalization itself. So as Dr. Gorodetsky outlined, multiple factors that contribute to cognitive impairment in heart failure. So first is heart failure itself, which can lead to a number of brain alterations that contribute to cognitive impairment. So heart failure itself can lead to cerebral hypoperfusion, low dysregulation, and inflammatory processes with cytokine release. As a consequence of these, structural changes, such as disruption of tight junctions and white matter changes can occur. Moreover, related oxidative damage and local cerebral cytokine production can lead to amyloid deposition. As we know, patients with heart failure often also have a bunch of cardiovascular comorbid conditions like coronary artery disease and atrial fibrillation. In terms of coronary artery disease, if you've got atherosclerosis of your coronary arteries, there's a pretty good chance you have atherosclerosis of arteries surrounding your brain. But these cerebrovascular changes can further be exacerbated by traditional cardiovascular risk factors like diabetes, hyperlipidemia, suboptimal lifestyle behaviors like smoking and sedentary lifestyles. Atrial fibrillation also contributes and is interesting because it doesn't just contribute via stroke events, but it actually appears to contribute to cognitive impairment even in the absence of overt strokes. Purported mechanisms include hippocampal and global atrophy, chronic hypoperfusion, and also cumulative injury due to microemboli. And then beyond heart failure, beyond cardiovascular comorbid conditions, we know that patients often have a host of non-cardiovascular comorbid conditions, many of which can also contribute to cognitive impairment. These most notably include diabetes, chronic kidney disease, sleep disorders, and mood disorders, all of which have been shown to be associated with worse cognition. The last point I'll make is the potential etiologic contribution of polypharmacy. Polypharmacy is the condition of taking many medications. Polypharmacy is nearly universal in older adults with heart failure due to comorbidity burden. So while one could argue, well, polypharmacy is just a marker for the risk factor of having multiple chronic conditions, I'd also like to point out that polypharmacy itself can contribute to cognitive impairment through adverse drug events, as well as through drug-drug and drug-disease interactions that are often overlooked, especially when medication lists are really long with prescriptions from multiple physicians. So moving on to point number three, the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5, identifies six key domains of cognitive function. They include what is shown in the slide here, learning and memory, language, executive function, complex attention, perceptual motor function, and social cognition. In patients with heart failure, learning and memory is most commonly impacted, followed by executive function and complex attention. Learning and memory refer to the ability to record information and retrieve it at a later time. Executive function refers to cognitive processes that control behavior, including reasoning, problem-solving, and planning. Complex attention refers to the ability to concentrate selectively on descriptive information and discrete aspects of information while ignoring others. So keep all of these things in mind and think about the patients that you take care of who have heart failure, and you recognize that they need all of these domains in order to take care of themselves appropriately. For patients with heart failure when multiple cognitive domains are impacted simultaneously, it's incredibly difficult to perform key functions, including self-care, medication management, identification of red flags, and living independently. So let's talk a little bit more detail of how cognitive impairment affects these key activities of heart failure management. So self-care is defined as the process of maintaining health through health-promoting and preventative strategies. Self-care is of course a hallmark of heart failure treatment, but it's not easy. And actually it requires relatively intact cognition. This is because self-care activities are actually fairly complex. For patients who engage in self-care, they need all the domains that Dr. Gorodetsky just outlined, learning and memory, executive function, complex attention, perceptual motor function, language, and social cognition. So for example, to follow dietary restrictions, you need to remember the restriction. You need to have the knowledge of which agents have high sodium and then regulate your own behavior. To track symptoms or weight changes, again, you need to remember this advice from the physician, perceive whether you have symptoms that could reflect worsening heart failure, and then have sufficient executive function to do something about it, like call your clinician or adjust your diuretics. When any of these aspects of cognition is impaired, patients may struggle with self-care, which of course puts patients at risk for worsening symptoms and hospitalizations. You also need relatively intact cognition to manage medications. As mentioned earlier, patients with heart failure take a lot of medications. When cognitive impairment is present, patients may have difficulties with reading or understanding prescription labels, opening safety caps, and or filling their weekly pillboxes. This complexity is further compounded by medications that require multiple doses in a day or doses every other day, the need to cut pills in half, special rules about dosing, like requirements to take with meals, and dosing adjustments based on clinical status, such as weight-based diuretic dosing. Once again, I think it's fairly evident that when cognitive impairment is present, patients are at risk for bad things happening. In this case, it could lead to any number of medication challenges, including taking the wrong dose or not taking the medication at all. As cognitive impairment becomes more severe, it becomes increasingly associated with loss of function and independence. The perfect storm can occur when heart failure exacerbations, with heart failure exacerbations, when cardiac disease can further exacerbate cognitive impairment and patients' ability to live independently significantly degrades. Patients may lose their ability to carry out independent activities of daily living, including managing medications, managing communication, and shopping and meal preparation. It's not surprising that a proportion of this population will experience an accelerated need for long-term care. Cognitive impairment is also associated with a reduced life expectancy among adults with heart failure. It's frequently difficult to discern whether cognitive impairment is the primary driver or tracks with other important markers of risk, such as multimorbidity and frailty. Regardless, recognizing this association is important because it impacts the risk-benefit ratio of many therapeutic interventions. Without incorporating cognitive impairment, there's a risk for suboptimal decisions leading sometimes to futile therapeutic interventions and or interventions whose risk outweighs potential benefits. So there are some clinical clues that could indicate cognitive impairment. And in fact, a lot of these clues will become readily apparent in a routine health encounter. Some of these are listed here. In the interest of time, I'll just jump to the medication management one, which I think is perhaps the most common situation that we come across as heart failure clinicians. And as outlined here, if you're taking care of a patient who frequently forgets to take their medications or are frequently running out of their medications, I would try to explore that a little bit further. It's easy to call this non-adherence, but in many cases, it may not actually reflect an unwillingness to take medication or a lack of motivation. Rather, this non-adherence, not taking the medicine could actually reflect a deeper issue like cognitive impairment, which as we've been stressing here is really a critical issue that we have to pick up when it's present. Although there's no consensus about which formal screening tools should be used to assess cognition in patients with heart failure, several do exist and can be incorporated into routine practice. All of these tools have their strengths and weaknesses, which we describe in greater detail in our paper and it's beyond the scope of this seminar. But I do want to briefly share with you one of these tools called the MINICOG, which is an ultra short and validated test for screening cognitive impairment and can be deployed in less than three minutes in your clinical practice. So the MINICOG involves three steps. You ask the patient to memorize three words. The three words that the original authors developed in the MINICOG were these, banana, sunrise and chair. You then ask the patient to draw a clock. For example, you say in this circle, draw the numbers of the face of the clock and have the hands pointing at 20 minutes after eight. Here's an example of a clock drawn by a patient with heart failure. And you can see that it looks good. All the numbers are in approximately the right place. They're in order and the hands of the clock are pointing to 20 minutes after eight. Then step three, you ask the patient to recall the three words. The patient should not be prepared. You shouldn't tell them that they, you're gonna ask them the words again. So in some ways it's a surprise. In this case, our patient remembered two out of the three words. So how do we score this? The patient gets two out of two points for drawing the clock correctly. And then two out of three points for recalling these words. That's a total score of four. A score of three to five suggests that cognitive impairment and absent, such as in this patient, a score of zero to two suggests that cognitive impairment is present. Here are three clocks drawn by patients with heart failure. Look at the first clock. It looks at first glance okay, but when you ask the patient to draw 20 minutes after eight, the hands of the clock are not pointing in the right direction. In this case, the patient would get a zero out of two. This clock here shows the numbers are drawn in a completely different direction. The hands are not pointing at anything particularly correct. And then the patient seems to give up and draws the number 20. And then finally look at this clock, which looks completely chaotic. The patient draws the numbers outside of the circle and clearly this is wrong. So the point is, is that clock drawing makes cognitive impairment visible. And this is why we felt that the MINICOG could and should be used in clinical practice for non-experts like us who are cardiac experts, but not necessarily experts in neurology or the brain, but the tool is so simple and so quick to use and it really does give a lot of value. As clinicians, we can adopt strategies to help manage patients with cognitive impairment. And as we stated earlier, heart failure itself contributes to cognitive impairment. So an important goal would be to optimize guideline-directed medical therapy. In addition, treating those comorbid conditions such as hypertension, diabetes, kidney disease, depression and anxiety could help prevent or at least attenuate a decline in cognitive impairment. As you know, and we've talked about earlier, medication regimens for heart failure patients are complex. And with the addition of cognitive impairment, it is imperative that clinicians perform medication reconciliation and attempt to simplify these medication regimens. Thought should be given to de-prescribe medications if indicated. While further research is needed, early evidence has shown that exercise may improve cognition. And when we talk about self-care, an important strategy to help patients with their care at home is to activate the patient's social circle. We need to engage family, friends and other caregivers to help with various self-care activities, including mobility. Specific strategies to help manage cognitive impairment would be to include using education materials at appropriate reading levels and to use teach-back education to check for understanding. For medications, you may fill pillboxes to help patients manage their medications at home or utilize medication blister packs organized by day and time. It might also be helpful to help patients develop a reminder system. Again, having a caregiver available for medication support would be ideal. Again, clinicians could leverage remote monitoring and telehealth if indicated, and provide support using home health services, patient navigators and use a team-based approach. So shared decision-making and advanced care planning are also really important for managing cognitive impairment. Effective communication really is key to facilitate decision-making and implementing optimal management strategies for patients with heart failure and cognitive impairment. So in that effective communication, it's first important for clinicians to explicitly share the diagnosis of cognitive impairment its implications for care, the resulting uncertainties related to prognosis, not only with the patient, but also their care partners, if available. In addition, it may be helpful for clinicians to provide information about follow-up assessments that are necessary to determine the cause and the treatment plan for managing both heart failure and the cognitive impairment. When necessary, the need for referrals to other specialties may be a good idea. Referrals to other specialties may be needed and merits explanation. Incorporating the family members, caregivers in those discussions can be helpful given the importance of their support from a psychological and emotional standpoint, but also from a logistical and financial standpoint. Creating care plans that are evidence-based and patient-centered can seem difficult. It can even seem contradictory as guidelines stacking in older patients with multiple chronic conditions can lead to things like polypharmacy, accumulating side effects while health status wanes and life expectancy shortens. So to address this, really decisions should align with patient's values, goals, and preferences and should incorporate multiple domains of health, which you'll hear about in a few minutes. Treatment plans should subsequently reflect the greatest, as you already heard, the greatest expected benefit to harm ratio. Relatedly, advanced care planning is really important, especially in patients with heart failure and cognitive impairment, because both heart failure and cognitive impairment are life-limiting conditions that can negatively impact decision-making capacity over time. The whole purpose of advanced care planning is to promote and sustain value-concordant care over the course of a disease. Key elements of advanced care planning include understanding and sharing of values, goals, and preferences regarding future potential medical care decisions, choosing and preparing a trusted person to make medical decisions, and documenting these wishes so they can be enacted when future medical decisions need to be made. Given the high number of medical options and the day-to-day management involvement in heart failure care, loss of decision-making capacity can really pose a serious problem for adults with heart failure. So anticipatory planning related to decisions about deprescribing, avoidance of certain care, deactivation of defibrillator function, and pursuit of a palliative approach is thus critical for adults with heart failure and cognitive impairment. There are a host of resources that can actually guide this, and we do provide some of these in the scientific statement. Clinicians should be on high alert for coexisting deficits when cognitive impairment is present, and using a multi-domain model may help us with this. Pre-existing models of care, such as the previously published domain management approach, can assist clinicians with developing patient- centered care plans. The domain management approach provides a framework that outlines the importance of multiple domains of health that are necessary to provide optimal care to patients with heart failure. The domains, as seen on this slide, include medical domain, mind and emotion, physical functioning, and social environment. This model alerts clinicians to assess for multiple comorbidities, malnutrition, frailty, depression, social isolation, and several others. Given their prevalence in the setting of cognitive impairment, their synergistic effects on prognosis, and the subsequent complexity of decision-making, applying this domain management approach may especially be important when cognitive impairment is present. To effectively integrate these domains, patients with heart failure and cognitive impairment often benefit from a team-based approach. Team members may include medical specialists, such as physicians, advanced practice providers, nursing, pharmacy, social work, and others. And depending on your health care setting, not all of these team members are available, which can create individualized challenges. But ultimately, teams will need to work together with the patient and their social circle and their caregivers to provide the best care possible for the patient. So I'm going to wrap it up before we move to the Q&A session. Here are our 10 takeaway home messages from our scientific statement. First, cognitive impairment is common in adults with heart failure. Advanced age, common comorbid conditions, shared risk factors, and mechanisms of heart failure all contribute to alterations of the brain and cognitive impairment. Cognitive impairment often involves deficits in multiple domains, including learning and memory, executive function, complex attention, perceptual motor function, language, and social cognition. Multiple domains of cognition are required for patients to engage in activities that are necessary to manage heart failure, including self-care and medication adherence. When cognitive impairment is present, patients often struggle with these fundamental activities of heart failure management. Cognitive impairment negatively impacts function and life expectancy and complicates clinical decision-making. Clinical clues that may indicate underlying cognitive impairment include difficulty with activities of daily living, difficulty with devices, financial management, and challenges, difficulty with numbers and dates, medication management issues, and safety challenges. There are multiple cognitive impairment screening tools that are reasonable options for clinical practice, depending on the resources and personnel you have available. These include, as shown in the seminar today, the Mini-COG, but there are other tools, like the Mini-Mental State Exam, the Montreal Cognitive Assessment, or the MOCA, and the St. Louis University Mental Status Exam, or SLUMS. Management of cognitive impairment, if present, should include engagement and accommodations to account for challenges in self-care and medication management. Shared decision-making and advanced care planning are especially important when cognitive impairment is present, since heart failure and cognitive impairment are considered two incurable conditions. And finally, decision-making when cognitive impairment is complex and requires a multidisciplinary, multi-domain approach. So, I'll just, we'll just end here with our central illustration from our statement, which is really meant to convey the concept of that heart failure management is fundamentally altered when cognitive impairment is present. So, the message here really is, we need to look at the patient, we need to manage the patient through the lens of cognitive impairment. So, we really hope our listeners will check out the scientific statement, take a closer look at this central illustration. It's a really beautiful and informative central illustration, and we just want to thank the Journal of Cardiac Failure for publishing it, and their illustrator for assembling this for us. All right. Now, Rob, I'm going to, I'm going to turn it over to you. That was the more formal part. You know, everybody listened very patiently and quietly, but let's, let's have some fun. So, let's, I'll turn it over to you, Rob, with the Q&A. Absolutely. Thank you. Thanks to all of you for nicely and succinctly summarizing our statement. You know, we, if we think sort of to the beginning and from a pathophysiologic point of view, there's a question from the audience I think is really good in that, you know, the question is, do we expect differences in cognitive impairment and pathophysiology between HFRAF and HFPAF? Yes, I can, I can take that. You know, I think it would be easy to just say, oh, well, we're going to see more cognitive impairment in HFPAF because patients with HFPAF are older. And so that's what we're going to see cognitive impairment. And I think certainly age is a major risk factor and age predisposes the brain to various alterations. But I think what matters more is the fact that the heart failure syndrome itself not necessarily based on whether it's reduced DF, preserved DF, valvular disease, ischemic, non-ischemic, heart failure itself through elevated feeling pressures, congestion, low output, inflammatory processes, some of the mechanisms outlined earlier, but then it's also the presence of these cardiovascular conditions, which are contributing the non-cardiovascular conditions that are contributing. So I think it's less about HFPAF versus HFRAF. And I would say it's less about age even, and it's more about the constellation of these conditions that are all contributing to heart failure. So please, for those who are patients with heart failure who are a little bit younger, don't think that they can have cognitive impairment. And so I would argue the tools as outlined by Dr. Gordesky, such as the mini-cog and others, are broadly relevant for our patients. So actually, I have a follow-up to that. Your kind of your last statement about age. So we know, obviously, that age is a risk factor, but my question is, you know, getting at your latter kind of point, how often have you observed or suspected younger patients with heart failure who may have cognitive impairment, given the constellation of comorbidities and all the other factors at play? I'm just curious what your collective experience has been. Is that me? Dr. Gordesky, you want to take it? Yeah, I think it's a tough one. For sure, it's not just about age. We definitely see younger patients who have cognitive impairment. I do have to say that it seems like the younger patients with cognitive impairment maybe are sicker, both medically sicker and maybe are on more medications, just because, as we heard in the last half an hour, a lot of times cognitive impairment is not caused by one thing. It's multifactorial. So if you take age, which is a very clearly recognized driver of cognitive impairment, if you take age and then you layer on all the other stuff on it, it's just going to be more common. But certainly, younger patients can have cognitive impairment. And a lot of the times, because they're younger, we assume that they don't, and that can become dangerous. I'll add to that. Yeah, please do. Please do. And really in the setting of making decisions for advanced therapies. And so there are a lot of programs that are routinely incorporating some means of cognitive assessments. And I've been surprised by how prevalent these cognitive impairments have been. And then there's a conversation trying to figure out, well, is this reversible from treating their heart failure? So you give this person a transplant, you implant Nelvad, and you improve their heart failure. Are you going to reverse this aspect of fogginess, cognitive impairment, confusion, or are there intrinsic brain processes that are not going to get better? We don't have a great way of figuring that out. It's a major challenge. I'd be interested to hear what the experience has been in Cleveland as it relates to having these conversations. But it's tough. And I don't think we know the answer. So this is really an important area for future research of really trying to figure out how do we really incorporate cognitive impairment into these complex decision-making. It needs to be there. It's an important piece because having cognitive impairment is linked to worse outcomes. But if we could figure out what's reversible, well, we could tailor these decisions and provide better patient-centered care. I don't know. Dr. Gorodetsky, you lead a program. I'd be very interested to hear what you think. Well, in our program over the last few years, we've incorporated a John Affilalo's tool that looks at frailty. And it's kind of a global assessment of frailty that involves not only just physical testing, but also testing of people's brain through a very simple screening tool. We've also much more liberally have asked our occupational therapists on the inpatient setting to do the MOCA. And it's something that we use and we present to our advanced heart failure therapeutics committee when we try to make decisions about LVAD and transplant. And I think it's very eye-opening because you get a sense of patients' abilities to do things that function. And also you get a sense of their prognosis. One thing that I would caution people about is if you introduce a tool to assess for cognition, you can't shoot patients down in the committee just because they have cognitive impairment. Because remember the very first point that we made, 78% of people will have cognitive impairment. In fact, it's the norm for patients with heart failure. And we have a ton of data spanning multiple decades that advanced therapies like heart transplantation or LVAD will actually lead to improved cognition after those therapies are implemented. So I think it's important to look for, but it's a puzzle piece and a wider puzzle. Yeah. I'm glad you mentioned the frailty component because that was a question that we had from the audience is how effectively do you incorporate frailty assessment into your heart failure practices? So I think that's helpful. You touched on the mini cog and incorporating the frailty tool and other things like that. One of the questions I guess I have is practically speaking in these busy clinics that we're all sort of part of, how do you really implement that into your flow to get the information that you need? Is this something that's embedded maybe in your EMR? Is it something that the MAs assist with? How do you practically do this and fit it into your busy clinic schedules? Connie, do you want to address this first? I can just say that it's not easy. And it all depends on what your available team is with your clinic. And many times it is just you as the provider and the patient. So you don't have perhaps the RN or the social worker or someone else with you. So it really is going to be very individualized in what you can do in your very specific clinic setting. So I have a different approach. And I try to make it easy. So here's my perspective. Whenever I see a new patient in clinic, I try to do a very brief test of cognition, the mini cog, as part of my physical exam. So you know how it is. The first time you see a patient in clinic, your physical exam is a little bit more detailed. You take more time. You go a little bit slower. I don't have it embedded in the EMR to listen to the heart or to the lungs. It's just something that I do as part of the physical exam. And once you take that frame of mind that checking for cognition is a part of the physical exam, it's a vital sign. It's a physical finding. And once you do it, the first time you do it, like anything else, it's a little bit clunky and you're not used to it. But once you do three or four or five mini cogs, it's a little bit easier. It's actually very simple. It becomes a part of your workflow and it's extremely eye-opening. I'll tell you, for those of us who love to auscultate, it's probably even more important than auscultating. I mean, when you discover that somebody has cognitive impairment that you didn't recognize, the way you talk to them and their family totally changes. The way you educate them, the type of advice that you give, what you expect of them changes. And also on the other hand, sometimes you discover people that for sure you thought had cognitive impairment and you were going to take a different route and you discover, wait a second, even though this person is behaving a little bit weird, well, once you test them, their executive function and their memory are intact. And maybe then you have a completely different conversation that's more serious that you weren't expecting to have. So that would be my advice to our audience, which is consider just incorporating it into routine care. I would say for new patients. I think that for established patients, doing the same test over and over again probably degrades the efficacy of the test and you probably don't have time, but that's my spin on it. But there's value probably in longitudinal assessments. And I'll sort of, I'll share something that I think encompasses the points made by Dr. White-Williams and Dr. Gorodetsky, which is that there's a lot of variability and there's variability in how much healthcare systems payers are investing in this. The reality I think is heart failure patients are complicated. And man, if we don't spend a lot of time with them and embrace that complexity, nobody wins. The outcomes are not going to be good for the program. The patient's not going to be happy. And as professionals caring for these patients, we're not going to be happy. We're not spending the right time with these patients. So I think that this applies to cognitive impairment, frailty. It applies to lots of stuff that I think the heart failure clinicians are trying to do. And I think broadly, we need to move in the direction where we embrace that complexity and say, look, we've got to spend more time with these patients. And we need healthcare systems to invest in that, to allow the clinicians to spend the time that is necessary. Because I don't, I think all of us would agree, like that is necessary to provide the best possible care to these patients. And I think it'll translate to better outcomes. So as these patients get increasingly complex, I really, really hope healthcare systems and payers will pay attention to this. Excellent. Thank you. Dr. White-Williams, you talked a lot about the self-care options and the importance of it. And I'm curious, what are some of the common deficiencies you've observed in self-care among the heart failure patients with cognitive impairment? And more importantly, what's the approach to accommodating these deficiencies, particularly for those that may not have that social support structure in place? I think for us in our clinic, and we're taking care of underserved patients, the number one deficiency that we see is almost every hospital admission and discharge summary has patient didn't take medicine, forgot to take medicine, couldn't remember which medicines were important, didn't know which ones to buy because I only had money to buy one. So it really is exactly like we said, it's about spending time with patients. And we spend a lot of time on medication education, giving them tools, matching up what that pill looks like and what it's for and when you should take it and what happens if you don't take it. So we give them medication action sheets so that they can see what they should and should not. And then we are very fortunate, we have a nurse in our clinic who actually does, probably fills about 40 pill boxes a week for many patients. And I'm telling you, it's the lifeline. We'll fill them up for a month so we can see them every month they come back, but they have their medicine and they know to take it morning, noon, dinner and at night, and it makes a difference. And so that's just a huge social determinant that we can take care of in our clinic. And we feel that it works. Now, we need to study that, but our patients are at least coming back with empty pillboxes, so they are taking their meds. Thanks. You know, and you opened the door. I've resisted the urge to talk about polypharmacy and medications, you know, for the first couple of minutes of the panel here. But, you know, there's a comment in the, or comment slash question in the discussion. And I think there, you know, given the focus and the importance of polypharmacy, I think we need to really talk about that. So the point is well-made that, you know, guideline-directed medical therapy really mandates polypharmacy. When you think about heart failure in addition to all the other comorbidities. And so, you know, the question essentially is, how do you balance a reduction in hospitalization and morbidity from, you know, GDMT versus the potential contributions that polypharmacy may have to cognitive impairment? You know, is it realistic to say we're gonna, you know, deprescribe in this sort of scenario? So Dr. DiDomenico, you are moderating. However, you have expertise in this area. You are a co-author. I promise I will add commentary, but I would love to hear what you think. Is that allowed? Absolutely. That's why I resisted the urge. I didn't want this to be about me. I, you know, I do appreciate what Connie had said about, you know, the pillboxes in the, basically the support staff for the team, right? Whether that be an NP, a PA, a PharmD. The medication management is incredibly important. You know, we have a medication therapy management clinic here at UIC that does similar things to what you had described, you know, at your institution. And having experienced this recently with my father, simple pillbox, you know, reconciliation is important. You know, he was getting 17 medications from the VA on a routine basis and didn't, just figured they're sending them, so I must take them, right? And so there's that disconnect. So I really feel strongly about engaging, you know, your NPs, your PharmDs, and other support staff to help with some of these aspects. The other important thing that I think we often forget, especially in this era of EHRs and electronic prescribing, is, you know, when you send that prescription to the pharmacy electronically, that's a given, right? But when you discontinue that, it doesn't go away unless you actively, you know, cancel that order. And so in a lot of these programs where there's automatic refills and these folks that are already sort of confused and have some impaired cognition, I do worry that that contributes to their issues with polypharmacy. Even though we may have had the best intent, the fact that some of those programs are continually, you know, refilling and the patients may not have the, you know, the cognitive ability to discern, it really adds up to causing a lot of problems with regard to the polypharmacy. I'll stop there. I'm interested in your collective opinions as well. I agree with all of that. What I'll add to that is, and we've done a series of papers looking at not just the number of medications, but what are the medications? And so I'm not sure we're necessarily saying we're deprescribing guideline-directed medical therapy. There may be a role for that in the palliative sending, end-of-life setting, but short of that, there may very well be opportunities for deprescribing other agents that no longer have an indication that have just been on forever and ever. We shared some data that a significant proportion of patients after a heart failure hospitalization are still taking a medication that exacerbates heart failure. So there's plenty of opportunity. I think the field has been focused, appropriately so, on uptight treating GDMT, but it'd be great to concurrently also look at the rest of the agents and get rid of the stuff that patients just don't need. I'll share my own pet peeve, which is supplemental potassium, when these patients are not on an MRA. I mean, man, what an easy opportunity. You're, in fact, probably lowering burden because if you've ever asked patients how they feel about their potassium supplements, those giant horse pills, they hate it. You get to replace it with a tiny 25-milligram spironolactone, and it helps with diuresis, it drives up your potassium, and it's part of the guideline-directed medical therapy for heart failure regardless of ejection fraction. So I think, to answer the question, I think it's very challenging, but there are very practical opportunities to optimize GDMT while also mitigating the risks of elevated number of meds, i.e. polypharmacy. How do you handle the potential turf battles of getting rid of maybe non-cardiac meds that, as you say, and we all agree, like there's many that probably had no business being there for an extended period of time. So how do you do that delicate balance between your colleagues and other specialties or primary care? So Dr. White-Williams, you had talked about the importance of multidisciplinary care. I think that fits here, right? What do you think? Absolutely. Now, for us, our multidisciplinary care, we're fortunate, as I said, we have an NP-run clinic. So our NP is there. We have nurses, we have social work, we have a pharmacist, we have pharmacy students, which we absolutely love, and they do our pillboxes too. And then we have a public health patient coordinator who really manages all of our PAPs and our specialty DOH pharmacy for free medications. So I know that we are unique, but we're also just amazingly blessed because we're able to spend time with a population who used the emergency room for their primary care and heart failure care. And by spending that extra time, and our clinic visits aren't 15 minutes, they're usually about an hour and a half to two hours, and that's subsequent ones. So we're spending time to make sure that they understand what their heart failure regimen is, then we're keeping them out of the hospital and out of the EDs. And then if we need other subspecialties, we have to work with our specialties like the sleep clinic or EP because most of our patients don't have insurance, but we work with them and get our patients in to get those comorbidities looked at also. Thank you. We have a question in the chat that I think is also very relevant in terms of trying to discern between cognitive impairment and other things. So the question is, how do we evaluate cognitive impairment versus poor health literacy? And I would add to that, maybe even depression and anxiety, which sometimes cloud the picture. So how do we accommodate or adjust for that overlap perhaps in these patients with low health literacy? I bet you that the person who asked this question works like me and maybe all of us in an academic medical center that's urban. Come visit me in East Cleveland, where patients can have chaotic lives, where health literacy is low, where patients are sick and the burden of disease is high and not very well controlled. And then they show up to your clinic for 20 minutes the day after you listened to the HFSA cognitive impairment seminar and you're like, this is a joke. How can I handle this? So whoever asked that question, you have my sympathies and I share with a struggle. I don't have perfect answers. I would say that if you have never tried to test for cognition, you should try. And I'm very passionate about the Minicog having done research on it and I use it in my clinical practice. Drawing a clock is pretty universal. I mean, our kids are probably not gonna know how to draw clocks with hands and numbers. It's all gonna be digital, but for most of the people that we currently see, they should know how to draw the numbers of the face of the clock and the hands of the clock. If they draw something that looks like a melting Salvador Dali clock, you've got a problem. It's not health literacy. It's something with cognition. But as I started off by saying, the edges of all of this are very blurry and they can overlap and be very confusing. So I do share with that frustration. Yeah, you know, and actually, sorry, go ahead, Parag. You go first. I was just gonna say, I like the comment that this individual posted at the end. And it basically points to the fact that we often label these patients as being non-adherent when it's probably not their fault because of the poor cognition and maybe the low health literacy and mental health issues perhaps on top of that. So I think it's a very salient point. Sorry, Parag, go ahead. No, I was just gonna add, I agree with everything stated so far. It's a very insightful comment because health literacy education level has been shown to impact the diagnostic performance of some cognitive tests. And so as Dr. Gorodetsky outlined, there's some blurring and then Dr. Domenico, you outlined, well, we need to make sure that we characterize patients in the right way because these deficits are different and they have implications on the decisions that we're making. And so it brings me back to a comment I made earlier is we need more time with these patients. We need more sophistication and tools. We need better research so that we can incorporate processes that can disentangle some of this. The social determinants of health and the impact on how cognitive impairment might present, how it might be evaluated, how it might be managed. I mean, that's another really important and sticky area. So yeah, I would say more research and changes to our delivery model are really gonna be necessary so we understand what we're dealing with and can subsequently tailor and address, again, for the better of our patients. Thanks for the really insightful question. Yeah, and just like there's cognitive assessment, of course, there's health literacy assessments. And yet that's another instrument that you could add to your practice. We use the brief index, it's four questions and it gives us a mild, moderate, high, and it's very helpful with our patients, especially when we're trying to decide our reading materials or not. And then of course, depression and anxiety. So multiple instruments for that. And many of those are in our electronic health records. We use PHQ-9 and GAD-7 for that. And one of the problems is they're all present. So what do you do then? And so then that begs the question of, again, coming back to healthcare delivery and thinking about what to invest in. We need to invest in all the various services and multidisciplinary teams so we can address each and every one of these. Some of this might sound like a little bit pie in the sky, but I don't know how we're gonna otherwise deal with the increasing complexity. Every few years, it just gets more and more complex. So I think, I don't know, my approach has been, I think we have to continue reaching for the sky. I think we need to continue to characterize the challenges and the limitations and the way we deliver care. And we need to try to do better. Bharag, I know that you at Cornell have a really unique setup with your HFPEF clinic. Can you give us just a brief taste of how you guys approach it? Yeah, so in our HFPEF and cardiac amyloidosis program, we formally implement the domain management approach where we are assessing multiple health domains with a host of survey questions and short physical performance battery. So we are actually assessing every new patient that comes through the door. We're assessing for polypharmacy and multimorbidity, which is fairly easy, that's based on EMR, but malnutrition, under the mind-brain domain, we're screening for depressive symptoms and cognition. Under the physical domain, we're screening for falls and frailty. And under the social environment domain, we're screening for loneliness and social isolation. This program has a major research arm to it. And so I have been fortunate to pool resources and uniquely be able to administer these surveys and incorporate the data actually in real time. So we actually create a little patient report card before I walk in the room. I already know what these domains look like. And Dr. Gordesky, to your point that you made earlier, it changes how we talk to patients. It changes how we educate them. It changes how we counsel them. Rather than changing four medicines at once, I might change one. And then rather than saying, I'll see you in six months, I might see you in a couple of weeks, just to make sure or increase the number of touch points to make sure that we're on the right trajectory. And I recognize that that's not happening everywhere, but I'm working. I also do some implementation science. So I'm working to try to figure out how can we incorporate models like this more broadly? Thanks for the question. And thanks for doing it and failing fast or failing slow. I don't know, just teach us how to do it. And the rest of us are watching you, so keep going. So as we're kind of running up on the hour, I guess I would just pose this one last question for everyone. What do you, we've touched on some of these things, but I wonder if you could sort of highlight the top one or two things that you feel are our biggest unmet needs or knowledge gaps related to cognitive impairment in our patients with heart failure. So maybe we'll start with, we'll go from left to right on my screen. So Dr. Gorodetsky. I'm especially interested in reducing hospitalizations like all of us and the government. And we've done research over the last decade showing that patients being discharged from the hospital after hospitalization for acute heart failure who have no cognitive impairment, who their cognition is normal, their readmission rate at 30 days is about 22, 23%, the national average. And we also in our study found that on the other hand, patients with cognitive impairment coming out of the hospital after admission for heart failure, their readmission rate is 50% in a month. So I'm interested in seeing whether our observation is actually generalizable to other healthcare systems like yours and everybody who's listening. So I think that's an important research question. And another important research question is what are we going to do about it? Because right now in all of our hospitals across the United States, I bet you that every single patient being discharged from the hospital after hospitalization for heart failure gets the same type of approach and intervention peanut buttered on them. But I would argue that that's not a good use of resources. The people who have or whose cognition is intact probably need less of our time and the people who are cognitively impaired need more of our time. So trying to figure out what to do with that is something that's very interesting to me and I think is an important avenue of research. And that's all covered in the encyclopedia they get as they're getting wheeled to the elevator, right? To leave, right? So Dr. White-Williams. I think for me, it's really everything has such, it's all interconnected. So one issue isn't more important than the other issue. And so we have to look at cognition. We have to look at health literacy. We have to look at comorbidities. We have to look at social determinants of health because even patients with insurance have trouble managing. And so we won't know that unless we sit down and have a conversation with the patient and their social circle because sometimes that social circle knows more than the patient is willing to tell us. So I think it's really that holistic looking at everything so that we can make the best plan of care for the patient. Great, thanks. And Dr. Goyal. Yeah, I guess I'll build on some of the stuff that's come up during this conversation and some of the questions in the chat. I think we know, look, cognitive impairment is common. It's important. I think the statement outlined this. It's important with implications across multiple domains. There are ways to identify it and there are things that we can do about it at this moment. All that's outlined in the statement. The next question is, well, how do we get everyone to actually do the stuff? And I mentioned payers and I mentioned healthcare systems, but this scientific statement was commissioned by the Heart Failure Society of America. And so my question would be, what can we as our community, as heart failure clinicians and researchers and more broadly Heart Failure Society of America, what can we do to make this a reality across the country, not just at Cornell pooling research members, but everywhere, rural community, academic centers across the board? That's my burning question. And I hope that we can make a difference in the coming years. Great, thanks. Dr. Gordesky, you wanna close us out? Yes, first of all, I wanna thank you guys, my co-panelists and co-authors for joining us tonight. I wanna thank the Heart Failure Society of America for commissioning the statement. And they made it clear that cognitive impairment is in our lane too. This is something that all of us as heart failure clinicians of all types need to care about. So thank you for putting that in the spotlight and inviting us to write the statement and inviting us to give the seminar and looking forward to seeing everybody again soon. Good night, everybody.

Dr. Gorodetsky

cognitive impairment

heart failure

learning objectives

scientific statement

prevalence

etiologic contributors

interdisciplinary collaboration

Mini-COG

patient outcomes