Cognitive Function and the Relationship With Health Literacy and Secondary Prevention in Patients With Acute Coronary Syndrome at Early Discharge

Abstract

Background: Cognitive impairment (CI) may contribute to difficulties in understanding and implementing secondary prevention behavior change after acute coronary syndrome (ACS), but the association is poorly understood. Objectives: The aim of this study was to explore the prevalence of CI in patients 4 weeks post ACS and the association with health literacy and secondary prevention. Methods: Patients with ACS who were free from visual deficits, auditory impairment, and dementia diagnoses were recruited and assessed 4 weeks post discharge for cognitive function (Montreal Cognitive Assessment and Hopkins Verbal Learning Test), health literacy (Newest Vital Sign), depression (Patient Health Questionnaire), physical activity (Fitbit Activity Tracker and Physical Activity Scale for the Elderly), and medication knowledge and adherence. Results: Participants (n = 45) had an average age of 65 ± 11 years, 82% were male, 64% were married/partnered, and 82% had high school education or higher. Overall CI was identified in 28.9% (n = 13/45) of the patients 4 weeks after discharge, which was composed of patients detected on both the Montreal Cognitive Assessment and Hopkins Verbal Learning Test (n = 3), patients detected on Montreal Cognitive Assessment alone (n = 6), and patients detected on Hopkins Verbal Learning Test alone (n = 4). Fewer patients with CI had adequate health literacy (61.4%) than patients with normal cognition (90.3%, P = .024). Significant correlations were found between Hopkins Verbal Learning Test scores and medication knowledge (0.4, P = .008) and adherence (0.33, P = .029). Conclusions: In this exploratory study, 30% of patients with ACS demonstrated CI at 4 weeks post discharge. Two screening instruments were required to identify all cases. Cognitive impairment was significantly associated with health literacy and worth further investigation.

Age and Marital Status Predict Mild Cognitive Impairment During Acute Coronary Syndrome Admission

“…14 Although the MoCA is highly sensitive for vascular cognitive impairment, we used 2 cognitive screens because authors of previous studies have identified cases of MCI that would have gone undetected without the use of a second instrument. 10 This was replicated in this study with the MoCA failing to detect 3 of 81 positive HVLT screens (3.7%) and the HVLT failing to detect 31 of 81 (38.3%) of the positive MoCA screens, likely due to the MoCA testing several cognitive domains compared with the HVLT testing only new verbal learning. The prevalence of MCI has been identified in 28.9% at 4 weeks post ACS using 2 cognitive screens, and 62.5% single-domain and 22.5% multiple-domain MCI at cardiac rehabilitation entry using a battery of 5 neuropsychological tests.…”

“…The prevalence of MCI has been identified in 28.9% at 4 weeks post ACS using 2 cognitive screens, and 62.5% single-domain and 22.5% multiple-domain MCI at cardiac rehabilitation entry using a battery of 5 neuropsychological tests. 10,12 One for these high MCI rates in ACS could be the shared pathology and coexistence of vascular cognitive impairment and coronary heart disease. 7 Neurovascular dysfunction, increased blood-brain barrier permeability, and microvascular thrombosis are all mediated by endothelial damage, which is triggered by vascular risk factors.…”

“…Although functional independence is unimpeded in MCI, 9 problems with memory and thinking present barriers to learning disease management strategies. Mild cognitive impairment is associated with lower medication adherence and health literacy levels, essential for the management of heart disease 10 . As self-management of cardiovascular disease requires cognitive application, 11 MCI may contribute to poorer outcomes after ACS 12 …”

“…12 However, studies exploring prevalence rates and cognitive domains most affected during ACS admission are lacking and generally use a single cognitive screening instrument, instead of 2 screens, which has been demonstrated to yield a more accurate representation. 10 Screening for MCI during ACS is beneficial because, before discharge, ACS inpatients have large amounts of complex information to process regarding managing their condition, which then must be initiated post discharge. Screening also provides an ideal opportunity to make referrals for a more thorough assessment and can inform management plans or opportunities for secondary dementia prevention.…”

“…Mild cognitive impairment is associated with lower medication adherence and health literacy levels, essential for the management of heart disease. 10 As self-management of cardiovascular disease requires cognitive application, 11 MCI may contribute to poorer outcomes after ACS. 12 Mild cognitive impairment is often insidious and subtle in presentation and therefore not always apparent to patients or their families and healthcare staff.…”