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. Author manuscript; available in PMC: 2022 Jul 1.
Published in final edited form as: Am J Med. 2021 Mar 15;134(7):910–917. doi: 10.1016/j.amjmed.2021.03.003

Presentation, Treatment, and Outcomes of Older Adults Hospitalized for Acute Myocardial Infarction according to Cognitive Status: the SILVER-AMI Study

Alexandra M Hajduk 1, Jane S Saczynski 2, Sui Tsang 1, Mary E Geda 1, John A Dodson 3,4, Gregory M Ouellet 1, Robert J Goldberg 5, Sarwat I Chaudhry 1
PMCID: PMC8243828  NIHMSID: NIHMS1697140  PMID: 33737057

Abstract

Introduction:

While survival after acute myocardial infarction has improved substantially, older adults remain at heightened risk for poor hospital readmissions and death. Evidence for the role of cognitive impairment in older myocardial infarction survivors’ risk for these outcomes is limited.

Methods:

3,006 patients age ≥75 hospitalized with acute myocardial infarction (mean age 82±5 years, 56% male) were recruited from 94 U.S. hospitals. Cognition was assessed using the Telephone Interview for Cognitive Status; scores of <27 and <22 indicated mild and moderate/severe impairment. Readmissions and death at six months post-discharge were ascertained via participant report and medical record review. Associations between cognitive and outcomes were evaluated with multivariable-adjusted logistic regression.

Results:

Mild and moderate/severe cognitive impairment were present in 11% and 6% of the cohort. Readmission and death at six months occurred in 41% and 9% of participants. Mild and moderate/severe cognitive impairment were associated with increased risk of readmission (ORs=1.36, 95%CI 1.08–1.72 and 1.58, 95%CI 1.18–2.12, respectively) and death (ORs=2.19, 95%CI 1.54–3.11 and 3.82, 95%CI 2.63–5.56, respectively) in unadjusted analyses. Significant associations between moderate/severe cognitive impairment and death persisted after adjustment for demographics, myocardial infarction characteristics, comorbidity burden, functional status, and depression (OR=1.69, 95%CI 1.10–2.59), but not for readmissions.

Conclusions:

Moderate-to-severe cognitive impairment is associated with heightened risk of death in older acute myocardial infarction patients in the months after hospitalization, but not with readmission. Routine cognitive screening may identify older myocardial infarction survivors at risk for poor outcomes, who may benefit from closer oversight and support in the post-discharge period.

Keywords: Acute myocardial infarction, cognition, older adults, outcomes

Introduction

Although adults age 75 and older comprise only 6% of the US population, up to 40% of acute myocardial infarctions, 60% of acute myocardial infarction deaths, and two thirds of all cardiovascular deaths in the United States come from this older age group.1,2 Despite the overall higher risk for poor outcomes associated with age, significant heterogeneity exists in prognosis among older acute myocardial infarction survivors, and attempts to prognosticate outcomes in older adults using traditional clinical parameters alone have had limited success.3 Increasing evidence suggests that older acute myocardial infarction survivors’ risk for poor outcomes is multifactorial and may be impacted not only by patients’ clinical and demographic characteristics but by aging-related impairments4–6 as well.

One aging-related factor that has garnered increasing interest in relation to cardiovascular outcomes in older adults is cognitive status. Cognitive impairment (Cl) affects up to half of older acute myocardial infarction patients during the month after discharge7- this high rate of impairment may reflect the increased prevalence of Cl in older adults or the direct effects of myocardial ischemia8,9 or hospitalization10 on cognition. Cognitive impairment may impact olde acute myocardial infarction patients’ ability to perform critical disease management tasks, including health maintenance (e.g., medication adherence), symptom monitoring, and coordination of care.11

Despite its prevalence and potential prognostic importance, the association between cognitive status and outcomes in older acute myocardial infarction survivors remains unclear. The few studies that have examined CI as a predictor of outcomes have reported mixed results.7,12,13 Importantly, prior studies often used measures of cognition collected before or after, not during, acute myocardial infarction hospitalization,7,12,14 and thus did not characterize cognitive status during admission, during which treatment decisions are made and important information about disease management is communicated to patients. The objective of this study was therefore to examine the association of cognition, measured during hospitalization, with risk of mortality and readmissions at six months post-discharge in a large prospective sample of acute myocardial infarction patients age 75 and older.

Methods

Data from the ComprehenSIVe Evaluation of Risk Factors in Older Patients with Acute Myocardial Infarction (SILVER-AMI) study, a prospective longitudinal study of 3041 adults age ≥75 hospitalized with acute myocardial infarction (NIH R01HL115295), were used in this investigation. Details of SILVER-AMI have been published previously.15 Participants were recruited from 94 academic and community hospitals across the United States. Site coordinators reviewed hospital admission records daily to identify potentially eligible participants and performed medical record review to confirm acute myocardial infarction diagnosis in accordance with the Third Universal Definition of Myocardial Infarction.16 Site coordinators approached eligible patients, explained the scope of the study, and obtained written informed consent. Participants with cognitive impairment (including dementia) were, by design, included in the study, but capacity to consent to participate in research was evaluated17 in patients with decisional capacity concerns, and proxy consent was obtained for patients with diminished capacity. Patients were ineligible if they had initial troponin elevation >24 hours after admission, were transferred from another hospital after >24 hours, were incarcerated, or were unable to provide informed consent with no proxy available. All study protocols were approved by the Institutional Review Boards at Yale and all participating sites.

Participants underwent a structured interview and physical assessment during acute myocardial infarction hospitalization to collect information on geriatric impairments (cognition, mobility, hearing, vision, etc.), functional status, demographics, and psychosocial factors. Cognition was assessed during the baseline interview using the Telephone Interview for Cognitive Status18, an 11-item performance-based assessment that has been validated in samples of older adult inpatients.19 The TICS, similar to the Mini-mental State Examination, evaluates global cognition and satisfactorily discriminates mild cognitive impairment and dementia from normal cognition,20 but has the advantage of being administrable to participants with vision impairment (or hospitalized participants who left their glasses at home). Scores on the TICS range from 0 to 41; scores of <27 and <23 were used to indicate mild and moderate/severe cognitive impairment, respectively, corresponding to scores of <27 and <24 on the Mini-mental State Examination.21

All-cause mortality and readmissions during the six months after discharge for the index acute myocardial infarction admission were evaluated as outcomes. Mortality was ascertained primarily via medical record review and death certificates, but in rare cases via obituaries or secondhand report (i.e., from a family member). Readmissions, defined as any overnight hospital stay, were identified through two independent sources, a review of hospital admissions by the enrolling study coordinator and participant self-report. Upon identification, the study team collected medical records for adjudication. All deaths and readmissions were double-adjudicated for confirmation of event and details by a physician panel.

We examined several covariates for inclusion in our multivariable-adjusted models based on prior literature on cognitive impairment;7,12–14 these included demographics (age, sex, race, education, marital status, cohabitation status), acute myocardial infarction characteristics (type, peak troponin, in-hospital revascularization), comorbidities (hypertension, prior myocardial infarction, prior revascularization, arrhythmia, heart failure, peripheral vascular disease, stroke, COPD, chronic lung disease, cancer, smoking history, Charlson Index), in-hospital complications (acute kidney injury, arrhythmia, bleed, heart failure), discharge location, geriatric impairments (preadmission impairment in ADLs or ¼ mile mobility, hearing impairment, vision impairment, grip strength) and psychosocial characteristics (depression, social support).

We generated descriptive statistics for the participants according to cognitive status using analyses of variance, Kruskal-Wallis, and chi-square tests as applicable. Missing data (<5% for all variables except Timed Up and Go) was addressed using multiple imputation via chained equations. We evaluated the association between cognitive status and mortality and readmissions at six months post-discharge using multivariable-adjusted logistic regression. All analyses were performed in Stata 15.

Results

This analysis included 3,006 of 3,041 participants enrolled in the SILVER-AMI study, due to death in 35 participants before discharge from the index hospitalization. Data for outcomes were complete in 99.9% of the sample, and 98.4% of the sample had complete cognitive data. The mean age of the sample was 81.6 (SD=5.0) years, and 56.0% of the sample was male (Table 1). Cognitive impairment was present in 18% of the sample- 11% mild impairment and 7% moderate-to-severe impairment.

Table 1.

Sample Characteristics According to Cognitive Status during AMI Hospitalization

Cognitive Status during AMI Hospitalization
Not Impaired (n=2451) Mild Impairment (n=314) Moderate/Severe Impairment (n=192) p
Demographie
 Age, mean(SD) 81.2 (4.8) 83.2 (5.6) 83.6 (5.7) <.001
 Sex, male 1421 (58.0) 143 (45.5) 89 (46.4) <.001
 Race, nonwhite 197 (8.2) 59 (19.1) 52 (28.1) <.001
 Education ≤HS 1301 (53.4) 228 (74.3) 147 (77.4) <.001
 Marital status, unmarried 1147 (46.9) 197 (62.7) 111 (58.4) <.001
 Cohabitation status 931 (38.0) 135 (43.0) 61 (31.8) .040
Clinical
 MI type
  STEMI 646 (26.4) 83 (26.4) 46 (24.0) .76
  NSTEMI 1805 (73.6) 231 (73.6) 14. (76.0)
 Comorbidities
  Atrial fibrillation 606 (24.7) 88 (28.0) 41 (. 1.4) .23
  Heart failure 424 (17.3) 78 (24.8) 45 (23.4) .001
  Hypertension 2062 (84.1) 283 (90.1) 174 (90.6) .002
  Peripheral vascular disease 284 (11.6) 40 (12.7) 31 (16.2) .16
  Stroke or TIA 335 (13.7) 74 (23.6) 51 (26.6) <.001
  Prior MI 656 (26.8) 83 (26.4) 62 (32.3) .24
  COPD 338 (13.8) 43 (13.7) 32 (16.7) .54
  Chronic kidney disease 1418 (57.9) 219 (69.8) 134 (69.8) <.001
  Diabetes mellitus 862 (35.2) 149 (47.5) 86 (45.8) <.001
  Charlson score, median 3(2–5) 3 (2–5) 4 (3–6) <.001
 In-hosp procedures
  Cardiac catheterization only 409 (16.7) 51 (16.2) 27 (14.1) <.001
  PCI 130 (58.4) 159 (50.6) 86 (44.8)
  CABG 299 ( 2.2) 34 (10.8) 16 (8.3)
Geriatrie Impairments
  ADL impairment (pre-AMI) 54 (10.4) 87 (27.7) 59 (30.9) <.001
  Mobility impairment (TUG) 257 (60.7) 226 (88.3) 149 (93.1) <.001
  Hearing impairment 314 (13.0) 49 (15.9) 36 (19.1) <.001
  Vision impairment 172 (7.0) 44 (14.0) 35 (18.3) <.001
  Grip strength 1417 (60.0) 221 (73.9) 142 (81.6) <.001
  History of >1 Fall in past year 442 (18.1) 89 (28.4) 52 (28.0) <.001
  Unintentional weight loss >10 lb 490 (20.1) 104 (33.4) 66 (35.3) <.001
Psyehosoeial & Lifestyle
  Self-rated health, p oor 215 (8.8) 44 (14.1) 29 (15.3) <.001
  Depression 318 (13.3) 63 (21.2) 35 (20.4) <.001
  Social support, median (IQR) 24 (20–25) 22 (18–25) 23 (17–25( <.001
  Smoking status 1378 (56.5) 166 (53.4) 90 (48.7) <.001
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Table 1 presents presentation characteristics of the sample according to cognitive status. Participants with mild and moderate-to-severe cognitive impairment tended to be older, female, nonwhite, and have lower education. They were more likely to be unmarried, but only mildly impaired participants were more likely to live alone than participants without cognitive impairment. Type of myocardial infarction(i.e., STEMI or NSTEMI) did not differ by cognitive status, however, heart failure, hypertension, cerebrovascular disease, kidney disease, and diabetes were more prevalent among the cognitively impaired groups. Geriatric impairments, including limitations in activities of daily living, mobility impairment, hearing and vision impairment, grip strength weakness, falls, and unintentional weight loss, were all more prevalent in the cognitively impaired groups. Participants with cognitive impairment were also more likely to report poor self-rated health and social support, but were less likely to report a history of smoking.

Receipt of invasive cardiac diagnostic approaches and treatments including cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass grafting differed in a dose-response manner according to increasing severity of CI (Table 1, Figure 1). Seventy-five percent of participants without CI underwent cardiac catheterization, compared with two-thirds of participants with mild CI and approximately three-fifths of participants with moderate-to-severe impairment (p=.001). Twelve percent and eleven percent of participants with no and mild CIunderwent coronary bypass surgery, compared to 8% of participants with moderate-to-severe impairment (NS). Only 13% of participants without CI did not receive any invasive cardiac treatments, compared with 22% and 33% of participants with mild and moderate-to-severe impairment, respectively.

Figure 1.

Figure 1.

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Treatments for Acute Myocardial Infarction during the Index Admission, by Cognitive Status

The incidence of all-cause death and readmissions at six months post-discharge were 8.9% and 40.7%, respectively. Participants without cognitive impairment had the lowest rates of mortality (7%) and readmission (39%), compared with participants with mild (14% died and 47% readmitted) and moderate-to-severe impairment (22% died and 50% readmitted; Figure 2). Unadjusted odds ratio for mortality were 2.18 (95% CI 1.54–3.11) and 3.82 (2.63–5.56) for participants with mild and moderate-to-severe CI, compared with participants without CI. These estimates attenuated after adjusting for demographic, clinical, and psychosocial characteristics, as well as geriatric impairments, so that increased risk of death was significantly higher only among participants with moderate-to-severe CI (OR=1.69, 95%CI 1.10–2.59). Participants with mild and moderate-to-severe CI were more likely to experience a readmission during the six months after discharge (ORs=1.36, 95%CI=1.08–1.72 and 1.58, 95%CI=1.18–2.11, respectively) in unadjusted analyses, but these associations became non-significant after adjustment (Figure 3).

Figure 2.

Figure 2.

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All-cause Hospital Readmissions and Mortality at 6 Months after AMI Discharge, by Cognitive Status

Figure 3.

Figure 3.

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Multivariable-adjusted* Odds Ratios for Association Between Cognitive Status and Readmission and Mortality at Six Months Postdischarge for Older Survivors of AMI

Notes: Reference group= no cognitive impairment.

*Adjusted for age, sex, race, education, AMI type, comorbidity burden, functional impairment, depression, and in-hospital management of AMI during index admission

Discussion

In this multicenter prospective cohort study of more than 3,000 adults age 75 and older hospitalized for acute myocardial infarction, we found that nearly one-fifth of our older adult cohort exhibited CI during hospitalization, and that moderate-to-severe CI was associated with increased risk of mortality at six months post-discharge. Notably, CI did not have a significant impact on hospital readmissions within six months of discharge after adjustment for other important covariates. The study findings support assessment of cognition among hospitalized acute myocardial infarction patients, and provide insight into which cognitively impaired patients may benefit from greater support or monitoring after hospital discharge.

The prevalence of CI reported in our study is greater than that reported in the National Cardiovascular Data Registry Chest Pain-MI Registry,13 with rates of 5% and 2.5% of mild and moderate/severe impairment, respectively, compared with 11% and 7% in SILVER-AMI. Whereas older age in SILVER-AMI (mean age= 82) compared with the National Cardiovascular Data Registry Chest Pain-MI Registry (mean age ~75) may account for some of this difference, differences in the method of ascertainment of cognitive status may also play a role. SILVER-AMI assessed cognition via an objective performance-based measure performed in real time during hospitalization, whereas cognition was abstracted from the medical record in the National Cardiovascular Data Registry Chest Pain-MI cohort.13 CI is notoriously under-reported in the medical record,22,23 so this method of ascertainment likely resulted in lower prevalence of CI, particularly mild impairment, being reported. Notably, since the SILVER-AMI study excluded participants with overt dementia or delirium for whom a proxy respondent was not available, the prevalence of CI in our cohort is likely lower than the actual prevalence among older hospitalized patients.

While both mild and moderate-to-severe CI were associated with substantially increased risk of death at six months post-discharge, the association persisted only among patients with moderate-to-severe impairment after adjustment for influential covariates. We believe the explanation for increased risk of death among acute myocardial infarction patients with moderate-to-severe CI to be multifactorial. First, moderate-to-severe CI may hinder patients’ ability to perform critical disease management tasks after discharge for acute myocardial infarction, such as medication management, symptom monitoring, and lifestyle changes. Second, increased risk of death may be at least partially attributable to lower rates of invasive cardiac treatments, as found in prior studies.14 Third, CI may reflect a generalized frail state24 that is poorly equipped to handle stressors such as acute myocardial infarction and hospitalization and predisposes toward poor clinical outcomes- we believe this to be the most tenable rationale for the association between CI and death after acute myocardial infarction.

Our finding that CI of any severity was not associated with risk of readmission is in line with other similarly null reports,25 although other studies have reported significant associations.26 It is important to note that CI, both mild and moderate-to-severe, were associated with increased risk of readmission in our unadjusted model. However, we posit that adjustment for other important geriatric impairments, such as mobility impairment, a marker of frailty which has been shown to be an extremely potent predictor of outcomes among older acute myocardial infarction patients,5,27 may outweigh the risks posed by CI for readmission- these important factors have not been adjusted for in prior studies. It is also possible that the traumatic nature of hospitalization (e.g., poor sleep and diet, anxiety about one’s health) may cause participants whose cognition is assessed during hospitalization to score lower than they would if assessed in a non-hospital setting; this, in turn, may dilute the association between cognitive status and outcomes assessed several months after discharge, by when cognitive status may have recovered. Nonetheless, assessment of cognition during hospitalization captures the mental capacity of patients during a time when important treatment decisions are being made and discharge instruction are communicated. In addition, in-hospital screening is feasible and, given the current lack of consensus on cognitive screening during primary care visits, prehospitalization cognitive screening is not routinely performed. Lastly, it is possible that the degree of CI among participants in the mild CI group (scores correspond to MMSE scores of 24–26) was not sufficient to adversely impact disease self-management tasks (e.g., medication management, symptom monitoring) that may lead to increased risk of readmission, or that patients with CI received more post-discharge support from paid or informal caregivers in managing their disease than patients without CI, thereby attenuating the risk of readmission.

We used a simple screening test to assess cognitive status in SILVER-AMI, similar to previous studies.7,28 The 11-item TICS,18 which requires neither reading not writing, is an ideal tool to use among older hospitalized participants who may be dealing with visual impairments (either due to organic disease or forgetting glasses at home) or limited in writing ability for various reasons (e.g., weakness, Parkinsonism). We advocate that brief cognitive screeners such as the TICS or similar measures such as the Montreal Cognitive Assessment29 (of which there are reading- and writing- free versions30) be used to assess cognition in all acute myocardial infarction patients during hospitalization. These tools take 5–10 minutes to complete require minimal training, and may help clinicians in treatment decision-making and discharge planning that suits the unique care needs and preferences of patients with CI. Supports that may be particularly helpful to older acute myocardial infarction patients with CI may include involving family caregivers in treatment decision-making and discharge planning (including discussions about goals of care31, which may focus more on patient-centered outcomes such as home days32 or maintaining function and comfort, rather than longevity33), setting up early and frequent post-discharge follow-up, and providing home health services to support new disease management tasks and recovery in the early post-discharge period.

This study is strengthened by the use of a large contemporary cohort of older acute myocardial infarction patients who underwent cognitive testing during the critical hospitalization period, when much of treatment decision-making and plans for disease management are communicated between clinicians and caregivers. Our dataset was nearly complete with regard to our primary predictor and outcomes, and we utilized multiple imputation to account for the small amounts of missing data in these variables and our covariates. In addition to assessing cognition using a validated instrument whose brevity and ease of administration make it feasible for use in a busy hospital setting, we were able to account for other important geriatric impairments that have strong influences on clinical outcomes in older acute myocardial infarction patients. These strengths are balanced by some limitations. We used a screening instrument to assess cognition, not a full neurocognitive assessment. We excluded patients with overt dementia or delirium who did not have a proxy available to provide consent and assist with assessments, potentially resulting in lower prevalence and severity of CI in our cohort. We defined mortality and readmission as all-cause at six months post-discharge, events which may or may not be connected to the initial acute myocardial infarction.

In conclusion, we found that CI was prevalent among older patients hospitalized for acute myocardial infarction and associated with increased risk of midterm mortality. Cognitive screening of acute myocardial infarction patients in the hospital may help to facilitate shared decision-making and identify patients who may benefit from tailored discharge planning and intensive follow-up.

SILVER CI and Outcomes- Clinical Significance.

  • In this nationwide study of 3,041 adults age 75 and older hospitalized for acute myocardial infarction, cognitive impairment was present in 17% of participants and was associated with higher risk of mortality, but not readmissions, at six months post-discharge.

  • Cognitive status should be routinely assessed in older patients hospitalized with acute myocardial infarction to identify patients who may benefit from closer oversight or more intensive support during the post-discharge period.

Funding:

National Institutes of Health NHLBI R01HL115295 (AMH, ST, MEG, JAD, SIC), NIA T32 AG019134 (AMH), NIA P30AG021342 (AMH, MEG, SIC)

Footnotes

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Conflicts of Interest: None.

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