Cognitive impairment (CI) is a multifaceted entity that entails more than just memory loss. Deficits in other domains, most importantly executive function, can have profound effects on health outcomes in afflicted patients. The prevalence of CI among the heart failure population is exceedingly high, and even higher so among patients with advanced heart failure (AHF). These patients display consistent declines in memory, attention, psychomotor abilities, and executive function. Such deficits interfere with patients' abilities to recognize worsening symptoms, adhere to complex medication regimens, and make sound decisions pertaining to medical care. Regular evaluation of cognitive status using instruments such as the Montreal Cognitive Assessment is a fast, reliable method that allows physicians who treat patients with AHF to anticipate these obstacles to treatment and act accordingly. Referral for more comprehensive neuropsychological evaluation should be considered for patients with unexplained declines from baseline, legal determination of competence, and for heart transplant or ventricular assist device placement candidates.