Does cognitive impairment predict poor self-care in patients with heart failure?

Thirty-Day Readmission Risk Model for Older Adults Hospitalized With Acute Myocardial Infarction

BACKGROUND

Early readmissions among older adults hospitalized for acute myocardial infarction (AMI) are costly and difficult to predict. Aging-related functional impairments may inform risk prediction but are unavailable in most studies. Our objective was to, therefore, develop and validate an AMI readmission risk model for older patients who considered functional impairments and was suitable for use before hospital discharge.

METHODS AND RESULTS

SILVER-AMI (Comprehensive Evaluation of Risk in Older Adults with AMI) is a prospective cohort study of 3006 patients of age ≥75 years hospitalized with AMI at 94 US hospitals. Participants underwent in-hospital assessment of functional impairments including cognition, vision, hearing, and mobility. Other variables plausibly associated with readmissions were also collected. The outcome was all-cause readmission at 30 days. We used backward selection and Bayesian model averaging to derive (N=2004) a risk model that was subsequently validated (N=1002). Mean age was 81.5 years, 44.4% were women, and 10.5% were nonwhite. Within 30 days, 547 participants (18.2%) were readmitted. Readmitted participants were older, had more comorbidities, and had a higher prevalence of functional impairments, including activities of daily living disability (17.0% versus 13.0%; P=0.013) and impaired functional mobility (72.5% versus 53.6%; P<0.001). The final risk model included 8 variables: functional mobility, ejection fraction, chronic obstructive pulmonary disease, arrhythmia, acute kidney injury, first diastolic blood pressure, P2Y12 inhibitor use, and general health status. Functional mobility was the only functional impairment variable retained but was the strongest predictor. The model was well calibrated (Hosmer-Lemeshow P value >0.05) with moderate discrimination (C statistics: 0.65 derivation cohort and 0.63 validation cohort). Functional mobility significantly improved performance of the risk model (net reclassification improvement index =20%; P<0.001).

CONCLUSIONS

In our final risk model, functional mobility, previously not included in readmission risk models, was the strongest predictor of 30-day readmission among older adults after AMI. The modest discrimination indicates that much of the variability in readmission risk among this population remains unexplained by patient-level factors.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01755052.

Patient and caregiver contributions to self-care in multiple chronic conditions: A multilevel modelling analysis

BACKGROUND

Multiple chronic conditions (MCC) are highly prevalent worldwide, especially among older populations. Patient self-care and care partner (or caregiver) contributions to self-care are recommended to reduce the impact of MCC and improve patients' outcomes.

OBJECTIVES

To describe patient self-care and care partner contributions to self-care and to identify determinants of patient self-care and care partner contributions to self-care at the patient and care partner level.

DESIGN

Multicentre cross-sectional study.

SETTING

Outpatient and community settings in Italy.

PARTICIPANTS

A sample of 340 patients with MCC and care partner dyads was recruited between 2017 and 2018.

METHODS

We measured patient's self-care and care partner contributions to self-care in dyads using the Self-care of Chronic Illness Inventory and the Caregiver Contribution to Self-care of Chronic Illness Inventory. To control for dyadic interdependence, we performed a multilevel modelling analysis.

RESULTS

Patients' and care partners' mean ages were 76.65 (± 7.27) and 54.32 (± 15.25), respectively. Most care partners were female and adult children or grandchildren. The most prevalent chronic conditions in patients were diabetes (74%) and heart failure (34%). Patients and care partners reported higher levels of self-care monitoring than self-care maintenance and management behaviours. Important patient clinical determinants of self-care included cognitive status, number of medications and type of chronic condition. Care partner determinants of self-care contributions included age, gender, education, perceived income, care partner burden, caregiving hours per week and the presence of a secondary care partner.

CONCLUSIONS

Our findings support the importance of taking a dyadic approach when focusing on patients with MCC and their care partners. More dyadic longitudinal research is recommended to reveal the modifiable determinants of self-care and the complex relationships between patients and care partners in the context of MCC.

The relevance of a multidomain geriatric assessment in older patients with heart failure

Aims

Physical frailty screening is more commonly performed at outpatient heart failure (HF) clinics. However, this does not incorporate other common geriatric domains. This study assesses whether a multidomain geriatric assessment, in comparison with HF severity or physical frailty, is associated with short‐term adverse outcomes.

Methods and results

This is a prospective cohort study of 197 patients with HF (mean age 78, 44% female) attending outpatient HF clinics. HF severity was assessed with New York Heart Association class (I‐II versus III‐IV) and N‐terminal pro b‐type natriuretic peptide levels. Physical frailty was assessed with the Fried frailty criteria (not frail, pre‐frail, and frail). The following geriatric domains were assessed: physical function, nutrition, polypharmacy, cognition, and dependency in activities of daily living. Logistic regression analyses adjusted for age, sex, diabetes and kidney function assessed 3 month risk of adverse health outcomes (emergency department visits, hospital admissions, and/or death) according to HF severity, physical frailty, and number of affected domains. Number (%) of patients with HF with no, 1, 2, and ≥3 domains affected were 36 (18%), 61 (31%), 58 (29%), and 42 (21%). Seventy‐four adverse outcomes were experienced in 50 patients at follow‐up. Severity of HF and physical frailty were not significantly associated with an increased risk of adverse health outcomes. However, increasing number of affected domains were significantly associated with an increased risk of adverse outcomes. Compared with no domains affected, odds ratios (95% confidence interval) for 1, 2, and ≥3 domains were 1.8 (0.5–6.5), 4.5 (1.3–15.4), and 7.2 (2.0–26.3) (P‐trend <0.01). Further adjustment for HF severity and frailty status slightly attenuated the effect estimates (P‐trend 0.02).

Conclusions

Having limitations in multiple domains appears more strongly associated with short‐term adverse outcomes than HF severity and physical frailty. This may illustrate the potential added value of a multidomain geriatric assessment in the evaluation and treatment of patients with HF with respect to relevant short‐term health outcomes.

Cardiac disease and stroke: Practical implications for personalised care in cardiac-stroke patients. A state of the art review supported by the Association of Cardiovascular Nursing and Allied Professions

Cardiac and stroke conditions often coexist because of common risk factors. The occurrence of stroke may have significant consequences for patients with cardiac conditions and their caregivers and poses a major burden on their lives. Although both cardiac and stroke conditions are highly prevalent, primary stroke prevention in cardiac patients is crucial to avert disabling limitations or even mortality. In addition, specific interventions may be needed in the rehabilitation and follow-up of these patients. However, healthcare systems are often fragmented and are not integrated enough to provide specifically structured and individualised management for the cardiac-stroke patient. Cardiac rehabilitation or secondary prevention services are crucial from this perspective, although referral and attendance rates are often suboptimal. This state of the art review outlines the significance of primary stroke prevention in cardiac patients, highlights specific challenges that cardiac-stroke patients and their caregivers may experience, examines the availability of and need for structured, personalised care, and describes potential implications for consideration in daily practice.

Cognitive Function in Cardiac Patients: Exploring the Occupational Therapy Role in Lifestyle Medicine

Patients with cardiac dysfunction are at increased risk of mild cognitive impairment, which can affect their ability to successfully engage in daily activities important for home and community safety and in maintaining health and well-being. This risk increases in accordance with the number of cardiac conditions and cardiovascular risk factors or comorbidities. Occupational therapy has a role in chronic disease management in assessing and improving functional abilities affected by physical, emotional, and cognitive domains. With a holistic and client-centered approach, occupational therapy can complement lifestyle medicine principles through promotion and enablement of engagement in purposeful activity and self-management practices. It is suggested that the clinical management of patients with cardiac dysfunction expands beyond the traditional physical aspects of care to encompass cognitive considerations and incorporate occupational therapy in practice.

Prevalence and Progression of Cognitive Impairment in Atrial Fibrillation Patients after Treatment with Catheter Ablation or Drug Therapy

Purpose

In atrial fibrillation (AF) patients, the effect of catheter ablation or drug therapy on cognition is currently not well investigated. Therefore, we prospectively evaluated AF patients who were either treated 'with drug therapy or underwent catheter ablation for the prevalence and progression of cognitive impairment (CI).

Methods

Randomized participants of the CABANA trial (catheter ablation versus antiarrhythmic drug therapy for atrial fibrillation) and the CASTLE-AF (catheter ablation versus standard conventional treatment in patients with left ventricular dysfunction and atrial fibrillation) study were assessed twice within 6 months by Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) in our institution.

Results

Forty-five patients from both trials were investigated, and twenty-eight patients received catheter ablation, whereas seventeen patients received drug therapy for rhythm or rate control. The mean age of the twenty-one CABANA trial patients (AF group) was 68.8 ± 7.0 years and of the twenty-four CASTLE-AF study patients (AF/HF group) was 66.8 ± 8.1 years, respectively. Mean time from ablation/randomization to the first interview was 16.8 ± 11 months in the AF group and 28.3 ± 18.4 months in the AF/HF group, respectively. All patients investigated were classified as cognitively impaired with mean cutoff scores <24 by MoCA. Overall, we could not detect significant differences in medically treated versus catheter ablation patients within both groups in mean MMSE or MoCA scores between the first and the second interview (p > 0.09). Moreover, patients who received catheter ablation did not show statistically significant differences in the prevalence or progression of cognitive impairment compared to patients who were treated medically, neither within the two groups nor between AF and AF/HF patients (p > 0.05).

Conclusions

Prevalence of cognitive impairment in AF patients with comorbidities is substantial. However, in this preliminary prospective study, no apparent impact of AF pretreatment on the prevalence and course of cognitive impairment could be observed.

Measuring within-day cognitive performance using the experience sampling method: A pilot study in a healthy population

Introduction

People with depression, anxiety, or psychosis often complain of confusion, problems concentrating or difficulties cognitively appraising contextual cues. The same applies to people with neurodegenerative diseases or brain damage such as dementia or stroke. Assessments of those cognitive difficulties often occurs in cross-sectional and controlled clinical settings. Information on daily moment-to-moment cognitive fluctuations and its relation to affect and context is lacking. The development and evaluation of a digital cognition task is presented. It enables the fine-grained mapping of cognition and its relation to mood, intrapersonal factors and context.

Methods

The momentary Digit Symbol Substitution Task is a modified digital version of the original paper-and-pencil task, with a duration of 30 seconds and implemented in an experience sampling protocol (8 semi-random assessments a day on 6 consecutive days). It was tested in the healthy population (N = 40). Descriptive statistics and multilevel regression analyses were used to determine initial feasibility and assess cognitive patterns in everyday life. Cognition outcome measures were the number of trials within the 30-second sessions and the percentage of correct trials.

Results

Subjects reported the task to be easy, pleasant and do-able. On average, participants completed 11 trials with 97% accuracy per 30-second session. Cognitive variation was related to mood, with an interaction between positive and negative affect for accuracy (% correct) (p = .001) and an association between positive affect and speed (number of trials) (p = .01). Specifically, cheerful, irritated and anxious seem to covary with cognition. Distraction and location are relevant contextual factors. The number of trials showed a learning effect (p < .001) and was sensitive to age (p < .001).

Conclusion

Implementing a digital cognition task within an experience-sampling paradigm shows promise. Fine-tuning in further research and in clinical samples is needed. Gaining insight into cognitive functioning could help patients navigate and adjust the demands of daily life.

Cognitive Function in Dementia-Free Subjects and Survival in Old Age: The PROSPER Study

BACKGROUND

Impairment in domain-specific cognitive function is associated with the increased risk of mortality. We prospectively evaluated the association of executive function and memory with the risk of long-term mortality in dementia-free older subjects. Moreover, we investigated the role of structural brain abnormalities in this association.

METHODS

We included 547 dementia-free participants (mean age 78 years, 56.5% male) from the nested magnetic resonance imaging sub-study of the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER). Cox proportional hazard models were used to model 10-year risk of all-cause, cardiovascular, and noncardiovascular mortality in relation to performance in executive function and memory. Moreover, we evaluated the role of total brain parenchymal volume, cerebral blood flow, white matter hyperintensity, and the presence of microbleeds and infarcts in the link between cognitive function and mortality.

RESULTS

In the multivariable model, lower performance in executive function was associated with greater risk of all-cause (hazard ratio [HR] 1.49; 95% confidence interval [CI], 1.31-1.70), cardiovascular (HR 1.69; 95% CI, 1.36-2.11), and noncardiovascular (HR 1.36; 95% CI, 1.15-1.62) mortality. Similarly, poorer performance in memory tests associated with higher risk of all-cause (HR 1.47; 95% CI, 1.29-1.68), cardiovascular (HR 1.45; 95% CI, 1.15-1.83), and noncardiovascular (HR 1.49; 95% CI, 1.27-1.76) mortality. The associations were similar in subjects with various levels of brain structural abnormalities and cerebral blood flow (all P for interaction ≫ .05).

CONCLUSIONS

Poorer performance in both executive function and memory tests associates with all-cause, cardiovascular, and noncardiovascular mortality in elderly individuals. This association is independent of cardiovascular risk factors and diseases, brain structural abnormalities, and cerebral blood flow.

Heart Failure and Cognitive Impairment: Clinical Relevance and Therapeutic Considerations

Heart failure (HF) is a devastating condition characterized by poor quality of life, numerous complications, high rate of readmission and increased mortality. HF is the most common cause of hospitalization in the United States especially among people over the age of 64 years. The number of people grappling with the ill effects of HF is on the rise as the number of people living to an old age is also on the increase.

Several factors have been attributed to these high readmission and mortality rates among which are; poor adherence with therapy, inability to keep up with clinic appointments and even failure to recognize early symptoms of HF deterioration which may be a result of cognitive impairment.

Therefore, this review seeks to compile the most recent information about the links between HF and dementia or cognitive impairment. We also assessed the prognostic consequences of cognitive impairment complicating HF, therapeutic strategies among patients with HF and focus on future areas of research that would reduce the prevalence of cognitive impairment, reduce its severity and also ameliorate the effect of cognitive impairment coexisting with HF.

Physical Function, Frailty, Cognition, Depression, and Quality of Life in Hospitalized Adults ≥60 Years With Acute Decompensated Heart Failure With Preserved Versus Reduced Ejection Fraction

BACKGROUND

Older hospitalized acute decompensated heart failure (HF) patients have persistently poor outcomes and delayed recovery regardless of ejection fraction (EF). We hypothesized that impairments in physical function, frailty, cognition, mood, and quality of life (QoL) potentially contributing to poor clinical outcomes would be similarly severe in acute decompensated HF patients ≥60 years of age with preserved versus reduced EF (HFpEF and HFrEF).

METHODS AND RESULTS

In 202 consecutive older (≥60 years) hospitalized acute decompensated HF patients in a multicenter trial, we prospectively performed at baseline: short physical performance battery, 6-minute walk distance, frailty assessment, Geriatric Depression Scale, Montreal Cognitive Assessment, and QoL assessments. Older acute decompensated HFpEF (EF ≥45%, n=96) and HFrEF (EF <45%, n=106) patients had similar impairments in all physical function measures (short physical performance battery [5.9±0.3 versus 6.2±0.2]; 6-minute walk distance [184±10 versus 186±9 m]; and gait speed [0.60±0.02 versus 0.61±0.02 m/s]) and rates of frailty (55% versus 52%; P=0.70) and cognitive impairment (77% versus 81%; P=0.56) when adjusted for differences in sex, body mass index, and comorbidities. However, depression and QoL were consistently worse in HFpEF versus HFrEF. Depression was usually unrecognized clinically with 38% having Geriatric Depression Scale ≥5 and no documented history of depression.

CONCLUSIONS

Patients ≥60 years hospitalized with acute decompensated HF patients have broad, marked impairments in physical function and high rates of frailty and impaired cognition: these impairments are similar in HFpEF versus HFrEF. Further, depression was common and QoL was reduced, and both were worse in HFpEF than HFrEF. Depression was usually unrecognized clinically. These findings suggest opportunities for novel interventions to improve these important patient-centered outcomes.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02196038.

Psychosocial Evaluation of Candidates for Heart Transplant and Ventricular Assist Devices: Beyond the Current Consensus

Advanced heart failure therapies, including heart transplantation and durable mechanical circulatory support, are available to a limited number of patients because of the scarcity of donors, expense, and large burden of care. The importance of psychological and social determinants of health, including cognitive status, health literacy, psychopathology, social support, medical adherence, and substance abuse, are emphasized in advanced heart failure and further amplified in the context of mechanical circulatory support and heart transplantation. The psychosocial assessment of advanced heart failure therapy candidates remains largely subjective, requiring a multidisciplinary evaluation, which may include psychiatrists, social workers, case managers, financial coordinators, pharmacists, and clinicians. Objective tools—including the Stanford Integrated Psychosocial Assessment for Transplantation, Psychosocial Assessment of Candidates for Transplantation, and Transplant Evaluation Rating Scale—were developed and validated in limited populations to help standardize the evaluation process. Small, retrospective studies have inconsistently shown that these tools may predict clinical outcomes in the transplant population, with higher-risk scores associated with readmissions, rejection episodes, and infections. However, it has been more difficult to show that these tools can predict mortality, and their applicability to the mechanical circulatory support population is less studied. The International Society for Heart and Lung Transplantation released a consensus statement in 2018 to promote consistency of psychosocial evaluation across advanced heart failure programs, but it lacks specific recommendations given the current state of evidence. This state-of-the-art review expands on the current consensus by critically reviewing current studies supporting available objective assessment tools, proposing a psychosocial evaluation framework that uses a multidisciplinary approach and offering future directions for research.

Self-management of heart failure in dementia and cognitive impairment: a systematic review

BACKGROUND

The cornerstone of effective management in heart failure (HF) is the ability to self-care. Aims include i) To determine factors influencing self-care in HF patients with cognitive impairment (CI) and ii) to determine the influence of cognitive domains on self-care in patients with HF and CI.

METHODS

MEDLINE, CINAHL, EMBASE, EBSCOHost, PsychINFO, ProQuest Research Library, Health Technology Assessment Database, The Cochrane Library, Web of Science and Scopus databases were systematically searched. Original research describing the relationship between cognition and HF self-care in community-dwelling older persons with dementia/CI in English, published in a peer-reviewed journal from 1^stJanuary(2000)-22^ndMarch(2016) was identified. Study and population characteristics, data sources, self-care processes, methods of cognitive assessment, cognitive domains affected, study outcomes, impact of impairment, and other risk factors of self-care impairment were abstracted by two reviewers.

RESULTS

Of 10,688 studies identified, 14 met the inclusion criteria. Patients with HF and CI ranged from 14 to 73%. Where reported, self-care maintenance adequacy ranged from 50 to 61%; self-care management adequacy ranged from 14 to 36% and self-care confidence adequacy ranged from 0 to 44% on the Self-care of Heart Failure Index (SCHFI). All but one study predicted poor self-care ability according to poor outcome on cognitive testing. Additionally, specific cognitive domain deficits impaired self-care. Subjects with lower cognitive scores were less likely to seek assistance while subjects with depression had poor self-care abilities.

CONCLUSIONS

Clinicians must consider the type and severity of impairments in cognitive domains to tailor management. Awareness of depression, self-confidence and support access may modulate self-care ability.

Psychoeducation for chronic cognitive impairment and reduced early readmissions amongst pulmonary inpatients

Patients with chronic pulmonary disease have been found to have among the highest rates of early (30 days) readmissions by the Center for Medicare and Medicaid Services. Proactive identification and psychoeducational intervention for the effect of chronic cognitive impairment on readmission have not been tested in this population. This is a pre-post quality improvement study for service-wide inpatient pulmonary readmission rates in chronic pulmonary disease. We examined the impact of screening patients for likely cognitive impairment and providing patients/families with psychoeducation regarding 'forgetfulness' on 30-day readmission rates on an inpatient pulmonary service. We observed a 50% decline in early readmissions (25.7% > 12.3%) for the inpatient pulmonary service after initiation of screening and psychoeducation of patients/families for improved adherence despite cognitive impairment (t = -2.53, df= 17, p = 0.011). A randomly assigned, controlled clinical trial is warranted.

Prognostic Importance of Hippocampal Atrophy in Patients With Chronic Heart Failure

Mild cognitive impairment (MCI) impedes a patient's decision-making ability to support self-care and is associated with increased mortality in patients with chronic heart failure (CHF). Thus, screening for MCI is very important. The assessment of hippocampal atrophy using magnetic resonance imaging can effectively diagnose early MCI. The purpose of this study was to assess the prevalence and prognostic significance of hippocampal atrophy using magnetic resonance imaging in patient with CHF. Of the 491 patients with CHF included in the study, 170 demonstrated hippocampal atrophy. Patients with hippocampal atrophy were older, and showed a higher rate of renal dysfunction and cardiac events than patients without hippocampal atrophy. A total of 180 cardiac events occurred during the follow-up period. A Cox proportional hazards regression model and Kaplan-Meier analysis showed that hippocampal atrophy was significantly associated with cardiac events. In conclusion, hippocampal atrophy is a significant and independent predictor of poor prognosis in patients with CHF and can aid risk stratification of these patients.

Investigating self-care in a sample of patients with decompensated heart failure: A cross-sectional study

BACKGROUND

There is scarce evidence relating to self-care of heart failure (HF) in Spain. In particular, there is a need to establish patients' level of understanding of HF, as well as their ability to recognise signs and symptoms of decompensation.

PATIENTS AND METHODS

Cross-sectional study to determine the level of self-care in a population of Spanish patients admitted to hospital with a primary diagnosis of decompensated HF. A convenience sample of 108 patients (50 women and 58 men) aged 83±8 were recruited to participate in this study.

RESULTS

The Self-Care of Heart Failure Index version 6.2 was used to quantify self-care in our sample. Mean and standard deviation from the Self-Care of Heart Failure Index self-care maintenance subscale were: a) "exercise for 30 minutes", 1±1; b) "forget to take one of your medicines", 2±2; c) "ask for low-salt items when eating out or visiting others", 2±1. A percentage of 67.6 had experienced shortness of breath or ankle swelling in the past month. However, the vast majority of our patients were unlikely to independently implement a remedy: a) reduce salt, 2±1; b) reduce fluid intake, 1±1; c) take an extra diuretic, 1±1. Over 50% of our sample felt confident or very confident at following professional advice (3±1), keeping themselves free of symptoms (3±1), recognizing changes in their condition (3±1) and evaluating the significance of such changes (3±1).

CONCLUSIONS

HF patients have a significantly low level of self-care when compared with HF patients from other countries, especially when it comes to managing their condition. Self-care promotion should be a priority for all healthcare professionals involved in the care and management of HF patients.

Impairment of cognitive functions in congestive cardiac failure patients

BACKGROUND

Congestive cardiac failure (CCF) patients show several neuropsychological impairments and reduced quality of life and impairment of functioning.

OBJECTIVE

The objective of this study was to recognize the deficits in cognition in CCF patients and comparing this cognitive function in the same number of healthy participants.

MATERIALS AND METHODS

A case-control study design was adopted. The study was conducted in the cardiology department of a tertiary care hospital. Convenience sampling was done. Twenty-one participants with CCF (New York Cardiac Association - Class III severity) and 21 healthy participants participated in the study. Each participant in the control group was screened by the General Health Questionnaire-12-item version. We evaluated both groups for the various domains of their cognitive function using a comprehensive battery of neuropsychological tests. Student's t-test was used to analyze the difference between the means for the study variables.

RESULTS

We observed that attention, executive function, working memory, psychomotor speed, and visuospatial ability were impaired in the patients with CCF compared to the controls. However, they did not differ significantly in language function.

CONCLUSIONS

Cognitive functioning is significantly impaired in CCF patients.

Construct Validity of the Multi-Source Interference Task to Examine Attention in Heart Failure

BACKGROUND

Patients with heart failure (HF) are at risk of cognitive dysfunction, including decreased directed attention. Directed attention is critical for performing daily activities including HF self-care by facilitating one to follow instructions or train-of-thought when there are interferences in which presented stimuli are in conflict with one another. The Multi-Source Interference Task (MSIT) is a computerized neuropsychological test that examines the function of the dorsal anterior cingulate cortex, the neurological substrate for directed attention. However, the MSIT has not been used in past HF studies.

OBJECTIVE

The purpose of the study was to examine construct validity of the MSIT in HF.

METHODS

Baseline data were obtained from a cognitive intervention study among patients with HF (n = 22) and age- and education-matched healthy adults (n = 20). Construct validity was evaluated using t tests to examine differences between patients with HF and healthy adults and congruent and incongruent MSIT trials. Pearson's correlations were computed to examine relationships between the MSIT and Trail-Making Test, Stroop Test, and Attentional Function Index.

RESULTS

Compared with healthy adults, patients with HF demonstrated worse performance (i.e., slower response times and higher error rates) on MSIT. Patients with HF had worse performance on MSIT incongruent trials than congruent trials. Interference z scores of MSIT did not correlate with Trail-Making Tests A and B and Stroop Test interference z scores, but the MSIT interference z scores correlated with perceived attention function measured by Attentional Function Index.

DISCUSSION

Construct validity of the MSIT was supported, in part, among patients with HF. The MSIT is a sensitive measure of detecting worse directed attention among patients with HF compared with healthy adults. The preliminary findings support the use of the MSIT as a measure of directed attention in HF. Confirmation is warranted for current findings in larger samples.

Cognitive screening in chronic obstructive pulmonary disease: patient's perspectives

Purpose: Cognitive impairment is highly prevalent (61%) in chronic obstructive pulmonary disease (COPD). International guidelines recommend providing self-management education through resource-intensive, pulmonary rehabilitation programs, yet screening for deficits likely to interfere with learning have received insufficient attention. Concerns over cognitive testing as confronting are described by health professionals as a barrier to screening, but with minimal empiric data. This study explored views on cognitive impairment and screening in patients with COPD.Design: Qualitative study, focus groups.Methods: Participants with COPD were recruited from a respiratory service at a regional hospital. Conversations were recorded, transcribed verbatim, and analyzed using thematic analysis.Results: Focus groups were undertaken between February and May 2014. Fifteen patients, with a diagnosis of COPD and mean age of 73, participated. Thematic analysis resulted in four overall themes: (1) limited awareness of the connection between cognitive change and COPD; (2) cognitive change as part of normal ageing; (3) current strategies for self-management activities and cognition functioning; and (4) attitudes to cognitive testing.Conclusions: This study identified that participants were open to discussing issues of cognitive function suggesting that normalizing discussion around cognitive change presents an opportunity to introduce screening within routine assessments. Identifying cognitive impairment provides opportunity to tailor rehabilitation for those at risk of sub-optimal self-management.Implications for RehabilitationChanges in cognition are recognized as a barrier to optimal self-management and rehabilitation efficacy in chronic disease.This study identified that participants were open to discussing issues of cognitive function suggesting that normalizing discussion around cognitive change presents an opportunity to introduce screening within routine assessments.Identifying cognitive impairment provides opportunity to tailor rehabilitation for those at risk of sub-optimal self-management.

Patient Experiences of Web-Based Cognitive Behavioral Therapy for Heart Failure and Depression: Qualitative Study

Background

Web-based cognitive behavioral therapy (wCBT) has been proposed as a possible treatment for patients with heart failure and depressive symptoms. Depressive symptoms are common in patients with heart failure and such symptoms are known to significantly worsen their health. Although there are promising results on the effect of wCBT, there is a knowledge gap regarding how persons with chronic heart failure and depressive symptoms experience wCBT.

Objective

The aim of this study was to explore and describe the experiences of participating and receiving health care through a wCBT intervention among persons with heart failure and depressive symptoms.

Methods

In this qualitative, inductive, exploratory, and descriptive study, participants with experiences of a wCBT program were interviewed. The participants were included through purposeful sampling among participants previously included in a quantitative study on wCBT. Overall, 13 participants consented to take part in this study and were interviewed via telephone using an interview guide. Verbatim transcripts from the interviews were qualitatively analyzed following the recommendations discussed by Patton in Qualitative Research & Evaluation Methods: Integrating Theory and Practice. After coding each interview, codes were formed into categories.

Results

Overall, six categories were identified during the analysis process. They were as follows: “Something other than usual health care,” “Relevance and recognition,” “Flexible, understandable, and safe,” “Technical problems,” “Improvements by real-time contact,” and “Managing my life better.” One central and common pattern in the findings was that participants experienced the wCBT program as something they did themselves and many participants described the program as a form of self-care.

Conclusions

Persons with heart failure and depressive symptoms described wCBT as challenging. This was due to participants balancing the urge for real-time contact with perceived anonymity and not postponing the work with the program. wCBT appears to be a valuable tool for managing depressive symptoms.

Cognitive impairment predicts mortality in outpatient veterans with heart failure

BACKGROUND

In our prior study of 250 outpatient veterans with heart failure (HF), 58% had unrecognized cognitive impairment (CI) which was linked to worsened medication adherence. Literature suggests HF patients with CI have poorer clinical outcomes including higher mortality.

OBJECTIVE

The study is to examine mortality rates in outpatients with HF and undiagnosed CI compared to their cognitively intact peers.

METHODS

This is a retrospective study for all-cause mortality.

RESULTS

During the 3-year follow up, 64/250 (25.6%) patients died: 20/106 (18.9%) with no CI, 29/104 (27.9%) with mild CI, and 15/40 (37.5%) with severe CI. Patients with CI were at increased risk for mortality (hazard ratio 1.82, p = 0.038). Those with severe CI had the worst outcome (hazard ratio 2.710, p = 0.011).

CONCLUSIONS

CI was an independent risk factor for mortality in patients with heart failure when controlling for age and markers of disease severity. Cognitive screening should be performed routinely to identify patients at greater risk for adverse outcomes.

Cognitive Function Predicts Risk for Clinically Significant Weight Gain in Adults With Heart Failure

BACKGROUND

Few investigators have examined whether cognitive deficits predict poorer self-care of weight management recommendations and weight gain in adults with heart failure.

OBJECTIVE

The purposes of this study were (1) to examine whether cognition is associated with adherence to daily weighing and weight gain incidence and (2) to explore self-reported symptom perception and management when a weight increase occurs.

METHODS

In this observational study, participants completed neuropsychological testing, were given an electronic scale, and were instructed to record their weight for 21 days. Data for 301 participants were collected at baseline and 3 weeks after weight monitoring.

RESULTS

At baseline, only 35% of the enrolled respondents knew when to call their physician for increased weight gain, and 37% of the analyzed sample (n = 110/301) experienced a clinically significant weight gain. Regressions tested whether baseline attention, executive function, or memory predicted adherence to daily weighing and the likelihood of weight gain incidence. In unadjusted and adjusted covariate analyses, none of the cognitive domains predicted adherence to daily weighing (P ≥ .375); however, all 3 cognitive domains predicted an increased risk of a clinically significant weight gain (P ≤ .05). Importantly, 65% of participants with a weight gain did not identify this symptom on self-report questions.

CONCLUSIONS

Although cognitive deficits are not associated with adherence to daily weighing, adults with cognitive deficits may be at an increased risk for experiencing a clinically significant weight gain, and most do not perceive symptoms.

CLINICAL IMPLICATIONS

Adults with heart failure require more than directions on self-care related to weight monitoring.

Family Consultation to Reduce Early Hospital Readmissions among Patients with End Stage Kidney Disease: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

The US Centers for Medicare and Medicaid Services have mandated reducing early (30-day) hospital readmissions to improve patient care and reduce costs. Patients with ESKD have elevated early readmission rates, due in part to complex medical regimens but also cognitive impairment, literacy difficulties, low social support, and mood problems. We developed a brief family consultation intervention to address these risk factors and tested whether it would reduce early readmissions.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

One hundred twenty hospitalized adults with ESKD (mean age=58 years; 50% men; 86% black, 14% white) were recruited from an urban, inpatient nephrology unit. Patients were randomized to the family consultation (n=60) or treatment-as-usual control (n=60) condition. Family consultations, conducted before discharge at bedside or via telephone, educated the family about the patient's cognitive and behavioral risk factors for readmission, particularly cognitive impairment, and how to compensate for them. Blinded medical record reviews were conducted 30 days later to determine readmission status (primary outcome) and any hospital return visit (readmission, emergency department, or observation; secondary outcome). Logistic regressions tested the effects of the consultation versus control on these outcomes.

RESULTS

Primary analyses were intent-to-treat. The risk of a 30-day readmission after family consultation (n=12, 20%) was 0.54 compared with treatment-as-usual controls (n=19, 32%), although this effect was not statistically significant (odds ratio, 0.54; 95% confidence interval, 0.23 to 1.24; P=0.15). A similar magnitude, nonsignificant result was observed for any 30-day hospital return visit: family consultation (n=19, 32%) versus controls (n=28, 47%; odds ratio, 0.53; 95% confidence interval, 0.25 to 1.1; P=0.09). Per protocol analyses (excluding three patients who did not receive the assigned consultation) revealed similar results.

CONCLUSIONS

A brief consultation with family members about the patient's cognitive and psychosocial risk factors had no significant effect on 30-day hospital readmission in patients with ESKD.

Diagnostic Accuracy of Cognitive Screening Instruments in Heart Failure: A Systematic Review

BACKGROUND

Cognitive impairment is prevalent in heart failure (HF) with severe consequences, including increased risk of mortality and reduced ability to self-manage HF symptoms. Identifying cognitive impairment through screening would assist clinicians in managing HF and comorbid cognitive impairment. However, the accuracy of cognitive screening instruments for HF has not been adequately determined.

OBJECTIVE

The aim of this study was to determine the diagnostic accuracy of cognitive screening instruments in screening for mild cognitive impairment (MCI) in HF patients.

METHODS

A systematic review of major electronic bibliographic databases was searched from January 1999 to June 2013. Inclusion criteria were as follows: primary studies examining cognitive impairment in HF, administration of a cognitive screening instrument and neuropsychological test battery, and cognitive impairment indicated by performance on neuropsychological tests 1.5 SDs less than that of normative data. Methodological rigor of included publications was evaluated using 2 bias risk instruments: QUality Assessment of Diagnostic Accuracy Studies and STAndards for the Reporting of Diagnostic accuracy studies. The precision, accuracy, and receiver operating characteristic curves of the Mini Mental State Examination were computed.

RESULTS

From 593 citations identified, 8 publications met inclusion criteria. Risk of bias included selective HF patient samples, and no study examined the diagnostic test accuracy of the cognitive screening instruments. The Mini Mental State Examination had low sensitivity (26%) and high specificity (95%) with a score of 28 or less as the optimal threshold for MCI screening.

CONCLUSIONS

Screening for cognitive impairment in HF is recommended; however, future studies need to establish the diagnostic accuracy of screening instruments of MCI in this population.

Gender Differences in Cognitive Test Performance in Adults With Heart Failure

BACKGROUND

Cognitive deficits are found in up to 73% of persons with heart failure (HF) and are associated with increased mortality and other poor clinical outcomes. It is known that women have better memory test performance than men do in healthy samples, but gender differences in cognitive performance in the context of HF are not well understood and may have important clinical implications.

OBJECTIVE

The objective of this study was to examine possible gender differences in cognitive function in a sample of individuals with HF (98.9% New York Heart Association class II and III).

METHODS

A total of 183 adults with HF (116 men and 67 women) completed a neuropsychological test battery as part of a larger project. Measures were chosen to assess functioning in attention/executive function and memory.

RESULTS

After controlling for demographic and medical factors, multivariate analysis of covariance revealed that men and women differed on memory test performance (λ = 0.90, F4, 169 = 4.76, P = .001). Post hoc comparisons revealed that women performed better on California Verbal Learning Test Learning, Short Recall, and Delayed Recall. No differences emerged on tests of attention/executive function (λ = 0.97, F5, 168 = 0.96, P = .44).

CONCLUSIONS

In this sample of persons with HF, men exhibited poorer performance on memory measures than women did. Future studies are needed to determine the underlying mechanisms for this pattern and its possible influence on daily function.

Living Arrangements Modify the Relationship Between Depressive Symptoms and Self-care in Patients With Heart Failure

BACKGROUND

Depressive symptoms hinder heart failure patients' engagement in self-care. As social support helps improve self-care and decrease depressive symptoms, it is possible that social support buffers the negative impact of depressive symptoms on self-care.

OBJECTIVE

The purpose of this study is to examine the effect of living arrangements as an indicator of social support on the relationship between depressive symptoms and self-care in heart failure patients.

METHODS

Stable heart failure patients (N = 206) completed the Patient Health Questionnaire-9 to measure depressive symptoms. Self-care (maintenance, management, and confidence) was measured with the Self-Care of Heart Failure Index. Path analyses were used to examine associations among depressive symptoms and the self-care constructs by living arrangements.

RESULTS

Depressive symptoms had a direct effect on self-care maintenance and management (standardized β = -0.362 and -0.351, respectively), but not on self-care confidence in patients living alone. Depressive symptoms had no direct or indirect effect on any of the 3 self-care constructs in patients living with someone.

CONCLUSIONS

Depressive symptoms had negative effects on self-care in patients living alone, but were not related to self-care in patients living with someone. Our results suggest that negative effects of depressive symptoms on self-care are buffered by social support.

Cognitive decline in heart failure

Cognitive impairment (CI) is common in older adults with heart failure (HF). The prevalence of CI is higher among patients with HF than in those without. The spectrum of CI in HF is similar to that observed in the general population and may range from delirium to isolated memory or non-memory-related deficits to dementia. Both HF with reduced ejection fraction and HF with preserved ejection fraction have been associated with defects in different domains of cognition. Numerous risk factors have been shown to contribute to CI in HF. Additionally, various pathophysiological mechanisms related to HF can contribute to cognitive decline. These conditions are not routinely screened for in clinical practice settings with HF populations, and guidelines on optimal assessment strategies are lacking. Validated tools and criteria should be used to differentiate acute cognitive decline (delirium) from chronic cognitive decline such as mild cognitive impairment and dementia. CI in HF has been associated with higher rates of disability and impairment in self-care activities that may in turn increase healthcare cost, hospital readmission and mortality. Early detection of CI may improve clinical outcomes in older adults with HF. Appropriate HF management strategies may also help to reduce CI in patients with HF, and future research is needed to develop and test newer and more effective interventions to improve outcomes in patients with HF and CI.

Cerebral Perfusion Enhancing Interventions: A New Strategy for the Prevention of Alzheimer Dementia

Cardiovascular and cerebrovascular diseases are major risk factors in the development of cognitive impairment and Alzheimer's disease (AD). These cardio-cerebral disorders promote a variety of vascular risk factors which in the presence of advancing age are prone to markedly reduce cerebral perfusion and create a neuronal energy crisis. Long-term hypoperfusion of the brain evolves mainly from cardiac structural pathology and brain vascular insufficiency. Brain hypoperfusion in the elderly is strongly associated with the development of mild cognitive impairment (MCI) and both conditions are presumed to be precursors of Alzheimer dementia. A therapeutic target to prevent or treat MCI and consequently reduce the incidence of AD aims to elevate cerebral perfusion using novel pharmacological agents. As reviewed here, the experimental pharmaca include the use of Rho kinase inhibitors, neurometabolic energy boosters, sirtuins and vascular growth factors. In addition, a compelling new technique in laser medicine called photobiomodulation is reviewed. Photobiomodulation is based on the use of low level laser therapy to stimulate mitochondrial energy production non-invasively in nerve cells. The use of novel pharmaca and photobiomodulation may become important tools in the treatment or prevention of cognitive decline that can lead to dementia.

Factors Related to Self-Care in Heart Failure Patients According to the Middle-Range Theory of Self-Care of Chronic Illness: a Literature Update

Purpose of the Review

As described in the theory of self-care in chronic illness, there is a wide range of factors that can influence self-care behavior. The purpose of this paper is to summarize the recent heart failure literature on these related factors in order to provide an overview on which factors might be suitable to be considered to make self-care interventions more successful.

Recent Findings

Recent studies in heart failure patients confirm that factors described in the theory of self-care of chronic illness are relevant for heart failure patients.

Summary

Experiences and skills, motivation, habits, cultural beliefs and values, functional and cognitive abilities, confidence, and support and access to care are all important to consider when developing or improving interventions for patients with heart failure and their families. Additional personal and contextual factors that might influence self-care need to be explored and included in future studies and theory development efforts.

Detecting and Managing Cognitive Impairment to Improve Engagement in Heart Failure Self-Care

PURPOSE OF THE REVIEW

The purpose of this review was to examine the recent literature on detecting cognitive impairment in patients with heart failure (HF) and the evidence indicating any ramifications of cognitive impairment on patient engagement in HF self-care.

RECENT FINDINGS

Mild cognitive impairment (MCI) is common in HF and impacts on patients' engagement in self-care, yet it is frequently not detected. The use of screening tools, even when brief, improves detection of MCI. However, the most sensitive, specific and feasible screening measure to use in practice is yet to be identified. A full neuropsychological assessment is required to determine a diagnosis of cognitive impairment and to identify the specific areas of cognitive deficit. In patients with HF, there appears to be differing clusters of cognitive deficits. Identification of these deficits may help inform the application of specific cognitive training strategies to ameliorating cognitive changes in HF patients and potentially enhance engagement in self-care. Screening for cognitive impairment is crucial in the management of HF patients to ensure that potential self-care deficits are prevented. The optimal screening tool is yet to be identified.

Self-care in heart failure patients

Objective:

to describe self-care behavior and its associated factors in a sample of heart failure Brazilian patients.

Method:

descriptive cross-sectional study with non-probabilistic sample of 116 ambulatory patients undergoing heart failure treatment. Self-care was evaluated using the Self-Care of Heart Failure Index, (scores ≥70 points=appropriate self-care). Association tests were applied, considering a descriptive level of 0.05.

Results:

the mean age of participants was 57.7 (SD =11.3) years; 54.3% were male; the mean schooling was 5.5 (SD = 4.0) years; and 74.1% had functional class II-III. The mean scores on the subscales of the Self-Care of Heart Failure Index indicated inappropriate self-care (self-care maintenance: 53.2 (SD =14.3), selfcare management: 50.0 (SD = 20.3) and self-care confidence: 52.6 (SD=22.7)) and it was found low frequencies of participants with appropriate self-care (self-care maintenance, 6.9%), self-care management (14.7%) and self-care confidence (19%). Higher scores of the Self-Care of Heart Failure Index were associated with: reduced left ventricular ejection fraction (p=0.001), longer time of experience with the disease (p=0.05) and joint monitoring by physician and nurse (p=0.007).

Conclusion:

investments are needed to improve the self-care behavior and the nursing can play a relevant role in this improvement.

The effect of education through motivational interviewing compared with conventional education on self-care behaviors in heart failure patients with depression

OBJECTIVE

To determine the effect of education based on motivational interviewing on self-care behaviors in heart failure patients with depression.

METHODS

In this study, 82 patients suffering from heart failure whose depression had been confirmed were selected and divided into two groups. The Self-Care Heart Failure Index was utilized to evaluate self-care behavior. The intervention group received four sessions of self-care behavior education based on the principles of motivational interviewing, and the control group received four sessions of conventional education on self-care behavior. At 8 weeks after finishing the interventions, the self-care behaviors of both groups were evaluated. Data were analyzed using paired and independent t-tests, Chi-square, and analysis of covariance, as appropriate.

RESULTS

The average increase in the overall scores and the scores on the three sub-scales of self-care behavior (maintenance, management, and confidence) of the heart failure patients with depression were significantly higher after education based on motivational interviewing than after conventional self-care education (p<0.05).

CONCLUSIONS

Motivational interviewing had a significant positive effect on self-care behaviors in patients with heart failure and depression.

PRACTICE IMPLICATIONS

Due to the effectiveness of the MI, using motivational interviewing for education in depressed HF patients is recommended.

Self-Efficacy and Health-Related Quality of Life Among Heart Failure Patients in Singapore: A Descriptive Correlational Study

Introduction: Heart failure (HF) accounts for 30% of all global deaths and Asians are likely to suffer from HF 10 years earlier than their Western counterparts. Low self-efficacy and poor health-related quality of life (HRQoL) have been reported in patients with HF. Methodology: A descriptive correlational design was adopted to investigate the associations between self-efficacy and HRQoL in 91 patients with HF in Singapore. Results: Patients with HF demonstrated moderately good self-efficacy ( M = 3.05, SD = 0.61) and HRQoL ( M = 22.48, SD = 18.99). Significant differences were found between total self-efficacy scores and education levels ( p = .05), and between overall HRQoL and smoking status ( p < .05). Self-efficacy was not significantly correlated to HRQoL. Smoking status, HF classification, and self-efficacy in maintaining function predicted HRQoL. Discussion: Health care professionals should assess each patient’s demographics, smoking status, and clinical condition before delivering individualized education to enhance their self-efficacy and, in turn, overall HRQoL.

Atrophy of the parahippocampal gyrus is prominent in heart failure patients without dementia

Aims

The exacerbation of heart failure (HF) induces brain damage and cognitive impairment (CI), which frequently attenuates the effects of treatment. However, it is not clear whether HF patients without clinical dementia demonstrate increased risk of CI. We examined whether local atrophy in the parahippocampal gyrus, a potential predictor of CI, is prominent in HF patients without clinical dementia.

Methods and results

Twenty stable HF patients with a history of admission due to decompensated HF or presentation of apparent pulmonary congestion following chest X‐ray and 17 controls were enrolled in this observational, analytical, cross‐sectional, case‐control study. Patients with dementia were excluded from this study based on the results of cognitive assessment. Three‐dimensional T1 weighted magnetic resonance image analysis was performed to evaluate the severity of local brain atrophy using software based on statistical parametric mapping. Z‐score values were calculated to evaluate the severity of atrophy in the total brain and parahippocampal gyrus. The severity of total brain atrophy was similar between HF patients (8.0 ± 2.9%) and controls (6.5 ± 3.1%). However, the Z‐score was significantly higher in the HF group (1.12 ± 0.49) in comparison with the control group (0.63 ± 0.36, P = 0.002). The Z‐score value did not correlate with age, ejection fraction, left atrial dimension, left ventricular dimensions, or brain natriuretic peptides in the HF group but did correlate with the Clinical Frailty Scale.

Conclusions

Local atrophy in the parahippocampal gyrus was prominent in HF patients without clinical dementia. This finding showed that HF patients without dementia feature a potential risk for developing CI.

Heart Failure-Induced Brain Injury

Heart failure (HF) is a systemic illness with grave implications for bodily functions. The brain, among other vital organs, often suffers insults as a result of HF, and both anatomic and functional brain abnormalities were found in the HF population. This injury was demonstrated across a wide range of clinical conditions and cardiac functions and was shown to affect patients' outcomes. Although reduced cardiac output and high burden of cardiovascular risk factors are the prevailing explanations for these findings, there are data showing the involvement of neurohormonal, nutritional, and inflammatory mechanisms in this complex process. Here, the authors review the suggested pathophysiology behind brain injury in HF, describe its effect on patients' outcomes, offer a diagnostic approach, and discuss possible therapeutic options.