The Effect of Dementia on Medication Use and Adherence Among Medicare Beneficiaries With Chronic Heart Failure

Abstract

Background Alzheimer disease and related disorders (ADRD) are prevalent in older adults, increase the costs of chronic heart failure (CHF) management, and may be associated with undertreatment of cardiovascular disease. Objective The purpose of our study was to determine the relationship between comorbid ADRD and CHF medication use and adherence among Medicare beneficiaries with CHF. Methods This 2-year (1/1/2006–12/31/2007) cross-sectional study used data from the Chronic Condition Data Warehouse of the Centers for Medicare and Medicaid Services. Medicare beneficiaries with evidence of CHF who had systolic dysfunction and Medicare Parts A, B, and D coverage during the entire study period were included. ADRD was identified based on diagnostic codes using the Chronic Condition Data Warehouse algorithm. CHF evidence-based medications (EBMs) were selected based on published guidelines: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, selected β-blockers, aldosterone antagonists, and selected vasodilators. Measures of EBMs included a binary measure of any EBM use and medication possession ratio among users. Results Of 9827 beneficiaries with CHF and systolic dysfunction, 24.2% had a diagnosis of ADRD. Beneficiaries with ADRD were older (80.8 vs 73.6 years; P < 0.0001) and more likely to be female (69.3% vs 58.1%; P < 0.0001). Overall EBM use was lower in patients with CHF and ADRD compared with patients with CHF but no ADRD (85.3% vs 91.2%; P < 0.0001). Lower use among those with ADRD was consistent across all EBM classes except vasodilators. Among beneficiaries receiving EBM, those with ADRD had a slightly higher mean medication possession ratio for EBM compared with those without ADRD (0.86 vs 0.84; P = 0.0001). Conclusions EBM medication adherence was high in this population, regardless of ADRD status. However, patients with ADRD had lower EBM use compared with those without ADRD. Low use of specific EBM medications such as β-blockers was found in both groups. Therefore, interventions targeting increased treatment with specific EBMs for CHF, even among patients with ADRD, may be of benefit and could help reduce CHF-related hospitalizations.

Increases in the Risk of Cognitive Impairment and Alterations of Cerebral β-amyloid Metabolism in Mouse Model of Heart Failure

“…We found that the level of inflammation and amyloid metabolism is gender specific, which is in line with the results of multicenter studies which show that of the patients with CHF and systolic dysfunction, a large percentage has a diagnosis of Alzheimer’s disease and related disorders [21], and that women have a higher morbidity of dementia [20], [21].…”

“…Whereas causal relationships between CHF and AD for human [21] have been described, animal studies are rare. Here we presented data indicating that CHF can increase a gender specific risk of developing cognitive dysfunction by modulation of amyloid processing and inflammation detected at the level of gene transcription and translation.…”

“…In addition, a pharmaco-epidemiological survey indicated that digoxin, a drug used to treat congestive heart failure and atrial fibrillation improves cognitive performance among senile patients with heart failure [19]. Although, there are several indications suggesting a tight connection between heart disease and declining cognitive abilities in human [20], [21], a mouse model to study such relationship as well as the effect of heart failure on amyloid metabolism, a protein marker for AD is so far missing.…”

Cardiovascular drug use among people with cognitive impairment living in nursing homes in northern Sweden

“…The regression analysis performed revealed two other factors besides higher cognitive score associated with the use of ACEI/ARBs and β-blockers, namely lower age and higher ADL score. Similar results have been found in a study performed in the USA, where people with Alzheimer's disease and concomitant heart failure were less likely to receive evidence-based medications (ACEI/ARBs, selective β-blockers and MRAs) than people with heart failure without comorbid Alzheimer's disease [49]. Another study performed in Sweden found that people with cognitive impairment were treated to a lesser extent with ACEIs and β-blockers compared with people with MMSE > 23, indicating under-treatment of some cardiovascular diseases among the elderly with cognitive impairment.…”

Heart failure and cognitive dysfunction

“…Non-centrally active angiotensin-converting enzyme inhibitors are associated with a greater risk of dementia and functional disability [48]. Vasodilation, which increases the use of cerebral hypoperfusion are more commonly used in heart failure patients with dementia, than other heart failure drugs [49]. Surprisingly, the use of digoxin in heart failure improved cognition, presumably related to an increase in cardiac output [50].…”