Cognitive impairment in heart failure

The clinical syndrome of heart failure is one of the leading causes of hospitalisation and mortality in older adults. Due to ageing of the general population and improved survival from cardiac disease the prevalence of heart failure is rising. Despite the fact that the majority of patients with heart failure are aged over 65 years old, many with multiple co-morbidities, the association between cognitive impairment and heart failure has received relatively little research interest compared to other aspects of cardiac disease. The presence of concomitant cognitive impairment has implications for the management of patients with heart failure in the community. There are many evidence based pharmacological therapies used in heart failure management which obviously rely on patient education regarding compliance. Also central to the treatment of heart failure is patient self-monitoring for signs indicative of clinical deterioration which may prompt them to seek medical assistance or initiate a therapeutic intervention e.g. taking additional diuretic. Adherence and self-management may be jeopardised by cognitive impairment. Formal diagnosis of cognitive impairment requires evidence of abnormalities on neuropsychological testing (typically a result ≥1.5 standard deviation below the age-standardised mean) in at least one cognitive domain. Cognitive impairment is associated with an increased risk of dementia and people with mild cognitive impairment develop dementia at a rate of 10-15% per year, compared with a rate of 1-2% per year in healthy controls.1 Cognitive impairment has been reported in a variety of cardiovascular disorders. It is well documented among patients with hypertension, atrial fibrillation and coronary artery disease, especially after coronary artery bypass grafting. This background is relevant to the study of patients with heart failure as many, if not most, have a history of one or more of these co-morbidities. A systematic review of the literature to date has shown a wide variation in the reported prevalence of cognitive impairment in heart failure. This range in variation probably reflects small study sample sizes, differences in the heart failure populations studied (inpatients versus outpatients), neuropsychological tests employed and threshold values used to define cognitive impairment. The main aim of this study was to identify the prevalence of cognitive impairment in a representative sample of heart failure patients and to examine whether this association was due to heart failure per se rather than the common cardiovascular co-morbidities that often accompany it such as atherosclerosis and atrial fibrillation. Of the 817 potential participants screened, 344 were included in this study. The study cohort included 196 patients with HF, 61 patients with ischaemic heart disease and no HF and 87 healthy control participants. The HF cohort consisted of 70 patients with HF and coronary artery disease in sinus rhythm, 51 patients with no coronary artery disease in sinus rhythm and 75 patients with HF and atrial fibrillation. All patients with HF had evidence of HF-REF with a LVEF <45% on transthoracic echocardiography. The majority of the cohort was male and elderly. HF patients with AF were more likely to have multiple co-morbidities. Patients recruited from cardiac rehabilitation clinics had proven coronary artery disease, no clinical HF and a LVEF >55%. The ischaemic heart disease group were relatively well matched to healthy controls who had no previous diagnosis of any chronic illness, prescribed no regular medication and also had a LVEF >55%. All participants underwent the same baseline investigations and there were no obvious differences in baseline demographics between each of the cohorts. All 344 participants attended for 2 study visits. Baseline investigations including physiological measurements, electrocardiography, echocardiography and laboratory testing were all completed at the initial screening visit. Participants were then invited to attend their second study visit within 10 days of the screening visit. 342 participants completed all neuropsychological assessments (2 participants failed to complete 1 questionnaire). A full comprehensive battery of neuropsychological assessment tools were administered in the 90 minute study visit. These included three global cognitive screening assessment tools (mini mental state examination, Montreal cognitive assessment tool and the repeatable battery for the assessment of neuropsychological status) and additional measures of executive function (an area we believe has been understudied to date). In total there were 9 cognitive tests performed. These were generally well tolerated. Data were also collected using quality of life questionnaires and health status measures. In addition to this, carers of the study participant were asked to complete a measure of caregiver strain and an informant questionnaire on cognitive decline. The prevalence of cognitive impairment varied significantly depending on the neuropsychological assessment tool used and cut-off value used to define cognitive impairment. Despite this, all assessment tools showed the same pattern of results with those patients with heart failure and atrial fibrillation having poorer cognitive performance than those with heart failure in sinus rhythm. Cognitive impairment was also more common in patients with cardiac disease (either coronary artery disease or heart failure) than age-, sex- and education-matched healthy controls, even after adjustment for common vascular risk factors.

Cultural citizenship and its implications for citizenship education: Chinese university students’ civic experience in relation to mass media and the university citizenship curriculum

A growing body of research has argued that university citizenship curricula are inefficient in promoting civic participation, while there is a tendency towards a broader citizenship understanding and new forms of civic engagements and citizenship learning in everyday life. The notion of cultural citizenship in this thesis concentrates on media practices’ relation to civic expression and civic engagement. This research thus argues that not enough attention has been paid to the effects of citizenship education policy on students and students’ active citizenship learning in China. This thesis examines the civic experience of university students in China in the parallel contexts of widespread adoption of mass media and of university citizenship education courses, which have been explicitly mandatory for promoting civic morality education in Chinese universities since 2007. This research project raises significant questions about the meditating influences of these two contexts on students’ perceptions of civic knowledge and civic participation, with particular interest to examine whether and how the notion of cultural citizenship could be applied in the Chinese context and whether it could provide certain implications for citizenship education in China. University students in one university in Beijing contributed to this research by providing both quantitative and qualitative data collected from mixed-methods research. 212 participants contributed to the questionnaire data collection and 12 students took part in interviews. Guided by the theoretical framework of cultural citizenship, a central focus of this study is to explore whether new forms of civic engagement and civic learning and a new direction of citizenship understanding can be identified among university students’ mass media use. The study examines the patterns of students’ mass media use and its relationship to civic participation, and also explores the ways in which mass media shape students and how they interact and perform through the media use. In addition, this study discusses questions about how national context, citizenship tradition and civic education curricula relate to students’ civic perceptions, civic participation and civic motivation in their enactment of cultural citizenship. It thus tries to provide insights and identify problems associated with citizenship courses in Chinese universities. The research finds that Chinese university students can also identify civic issues and engage in civic participation through the influence of mass media, thus indicating the application of cultural citizenship in the wider higher education arena in China. In particular, the findings demonstrate that students’ citizenship knowledge has been influenced by their entertainment experiences with TV programs, social networks and movies. However, the study argues that the full enactment of cultural citizenship in China is conditional with regards to characteristics related to two prerequisites: the quality of participation and the influence of the public sphere in the Chinese context. Most students in the study are found to be inactive civic participants in their everyday lives, especially in political participation. Students express their willingness to take part in civic activities, but they feel constrained by both the current citizenship education curriculum in universities and the strict national policy framework. They mainly choose to accept ideological and political education for the sake of personal development rather than to actively resist it, however, they employ creative ways online to express civic opinions and conduct civic discussion. This can be conceptualised as the cultural dimension of citizenship observed from students who are not passively prescribed by traditional citizenship but who have opportunities to build their own civic understanding in everyday life. These findings lead to the conclusion that the notion of cultural citizenship not only provides a new mode of civic learning for Chinese students but also offers a new direction for configuring citizenship in China. This study enriches the existing global literature on cultural citizenship by providing contemporary evidence from China which is a developing democratic country, as well as offering useful information for Chinese university practitioners, policy makers and citizenship researchers on possible directions for citizenship understanding and citizenship education. In particular, it indicates that it is important for efforts to be made to generate a culture of authentic civic participation for students in the university as well as to promote the development of the public sphere in the community and the country generally.