Predictors of Motor Tasks Essential for Daily Activities Among Persons With Heart Failure

Association of cardiovascular disease with health-related quality of life among older women with early-stage breast cancer undergoing adjuvant endocrine therapy

INTRODUCTION

Due to the improved overall survival and life expectancy of older women with breast cancer, cardiovascular disease (CVD) arose as the primary cause of non-cancer-related deaths in this population. Therefore, assessing the health-related quality of life (HRQoL) of breast cancer patients with comorbid CVD is becoming increasingly vital. Our study aimed to evaluate the association between comorbid CVD and HRQoL among older women with early-stage breast cancer who are receiving adjuvant endocrine therapy (AET) in the United States.

MATERIALS AND METHODS

We conducted a retrospective cohort study using the 2006-2017 Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey data. We identified female patients over the age of 65 who were diagnosed with stage I-III hormone receptor-positive breast cancer and treated with AET. HRQoL was assessed by the physical and mental component summary (PCS & MCS) in the health survey. CVD was defined as a history of acute myocardial infarction (AMI), congestive heart failure (CHF), angina, stroke, or other heart-related conditions. We performed multivariate linear regression models while controlling for covariates.

RESULTS

Among 3,904 older women, a history of CHF [β = -1.97, p = 0.025], stroke [β = -3.00, p < 0.010], or other heart-related condition [β = -1.10, p = 0.046] was significantly associated with lower PCS. However, no significant differences in PCS scores were found between women with a history of AMI or angina and those without these conditions. Having a history of CHF [β = -1.72, p = 0.033] or stroke [β = -1.48, p = 0.038] was significantly associated with lower MCS, whereas a history of angina, AMI, or other heart conditions was not associated with significant differences in MCS. Our study did not observe any significant differences in PCS and MCS between the two types AETs.

DISCUSSION

The study found that older women with early-stage breast cancer who were being treated with AETs had a lower HRQoL if they had a history of CHF or stroke. These comorbidities were identified as strong predictors for decreased HRQoL. The findings highlight the significance of managing cardiovascular diseases in such patients for better HRQoL while they receive AET treatment.

Association Between Poorer Cognitive Function and Reduced Objectively Monitored Medication Adherence in Patients With Heart Failure

BACKGROUND

Subclinical cognitive impairment is prevalent in heart failure (HF); however, its role in important clinical outcomes, such as HF treatment adherence, is unclear. Given the complex polypharmacy in HF treatment, cognitive deficits may be important in predicting medication management. Thus, the objective of the current study was to examine the impact of cognitive function on medication adherence among community-dwelling patients with HF using objective assessments.

METHODS AND RESULTS

A prospective observational cohort design of 309 community-dwelling patients with HF (59.7% male, 68.7±9.7 years) and no history of dementia or neurological disease. Cognition was assessed using a neuropsychological battery at baseline. Medication adherence was objectively measured for 21 days using an electronic pillbox. Regression analyses tested whether attention, executive function, or memory predicted 21-day medication adherence. In unadjusted analyses, lower scores on all 3 cognitive domains predicted poorer medication adherence (β=0.52-85; P=0.001-0.009). After adjusting for demographic, clinical, and psychosocial variables, memory continued to predict medication adherence (β=0.51; P=0.008), whereas executive function (β=0.24; P=0.075) and attention were no longer a predictor (β=0.34; P=0.131).

CONCLUSIONS

Poorer cognitive function, especially in regard to memory, predicted reduced medication adherence among patients with HF and no history of dementia. This effect remained after adjustment for factors known to predict adherence, such as depressed mood, social support, and disease severity level. Future studies should examine the link from cognitive impairment and medication nonadherence to clinical outcomes (eg, hospitalization and mortality).

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01461629.

Use of the Late-Life Function and Disability Instrument for Measuring Physical Functioning in Patients With Heart Failure

BACKGROUND AND PURPOSE

We evaluated the psychometric properties of the functioning component of the Late-Life Function and Disability Instrument (LLFDI) in individuals with heart failure (HF).

METHODS

Factor analyses were used (N = 151) to assess the dimensionality and structure of the basic and advanced lower extremity function subscales. Rasch model scores were compared to the raw means of the items.

RESULTS

Rasch scores correlated with the raw means of the items at r = .96, indicating raw means are comparable to the more complicated Rasch analysis in estimating physical functioning using the basic and advanced subscales.

CONCLUSIONS

The lower extremity physical functioning subscales of the LLFDI have potential as a clinical assessment tool to identify HF patients who are at high risk for functional limitations.

The association between cognitive function and objective adherence to dietary sodium guidelines in patients with heart failure

BACKGROUND

Although cognitive impairment is common in heart failure (HF) patients, its effects on sodium adherence recommendations are unknown.

PURPOSE

Our aim is to examine if cognitive function is associated with patient sodium adherence.

METHODS

Sodium collection/excretion and cognitive function were assessed for 339 HF patients over a 5-8-week period. Neuropsychological testing was performed at baseline (Visit 1), whereas two 24-hour urine samples were collected within 7 weeks postbaseline. The ability to collect two 24-hour urine samples and the estimation of sodium excretion levels from these samples were used to estimate sodium adherence recommendations.

RESULTS

Nearly half (47%) of the study participants (n=159) were unable to give two valid 24-hour urine samples. Participants who were unable to adhere to two valid 24-hour urine samples had significantly poorer attention and global cognition tests (P<0.044), with a trend for poorer executive function (P=0.064). Among those with valid samples, urine sodium level was not associated with global cognitive function, attention, executive function, or memory after adjusting for covariates. Female sex was associated with lower sodium excretion (all P<0.01); individuals with knowledge of sodium guidelines had less intake of sodium, resulting in excretion of less sodium (all P≤0.03). Conversely, higher socioeconomic status (SES) and body mass index (BMI) were associated with greater sodium (all P≤0.02 and P≤0.01).

CONCLUSION

Adherence to urine sodium collection was poor, especially among those with poorer cognitive function. Sodium consumption exceeded recommended amounts and was unrelated to cognitive function. Interventions for improving sodium adherence should focus on at-risk groups (high SES and BMI) and at improving knowledge of recommended salt intake.

Greater body mass index is associated with poorer cognitive functioning in male heart failure patients

BACKGROUND

Heart failure (HF) and obesity are associated with cognitive impairment. However, few studies have investigated the relationship between adiposity and cognitive functioning in HF for each sex, despite observed sex differences in HF prognosis. We tested the hypothesis that greater body mass index (BMI) would be associated with poorer cognitive functioning, especially in men, in sex-stratified analyses.

METHODS AND RESULTS

Participants were 231 HF patients (34% female, 24% nonwhite, average age 68.7 ± 7.3 years). Height and weight were used to compute BMI. A neuropsychology battery tested global cognitive function, memory, attention, and executive function. Composites were created using averages of age-adjusted scaled scores. Regressions adjusting for demographic and medical factors were conducted. The sample was predominantly overweight/obese (76.2%). For men, greater BMI predicted poorer attention (ΔR(2) = 0.03; β = -0.18; P = .01) and executive function (ΔR(2) = 0.02; β = -0.13; P = .04); these effects were largely driven by men with severe obesity (BMI ≥40 kg/m(2)). BMI did not predict memory (P = .69) or global cognitive functioning (P = .08). In women, greater BMI was not associated with any cognitive variable (all P ≥ .09).

DISCUSSION

Higher BMI was associated with poorer attention and executive function in male HF patients, especially those with severe obesity. These patients may therefore have more difficulties with the HF treatment regimen and may have poorer outcomes.

Executive dysfunction is independently associated with reduced functional independence in heart failure

AIMS AND OBJECTIVES

To examine the independent association between executive function with instrumental activities of daily living and health behaviours in older adults with heart failure.

BACKGROUND

Executive function is an important contributor to functional independence as it consists of cognitive processes needed for decision-making, planning, organising and behavioural monitoring. Impairment in this domain is common in heart failure patients and associated with reduced performance of instrumental activities of daily living in many medical and neurological populations. However, the contribution of executive functions to functional independence and healthy lifestyle choices in heart failure patients has not been fully examined.

DESIGN

Cross-sectional analyses.

METHODS

One hundred and seventy-five heart failure patients completed a neuropsychological battery and echocardiogram. Participants also completed the Lawton-Brody Instrumental Activities of Daily Living Scale and reported current cigarette use.

RESULTS

Hierarchical regressions revealed that reduced executive function was independently associated with worse instrumental activity of daily living performance with a specific association for decreased ability to manage medications. Partial correlations showed that executive dysfunction was associated with current cigarette use.

CONCLUSIONS

Our findings suggest that executive dysfunction is associated with poorer functional independence and contributes to unhealthy behaviours in heart failure. Future studies should examine whether heart failure patients benefit from formal organisation schema (i.e. pill organisers) to maintain independence.

RELEVANCE TO CLINICAL PRACTICE

Screening of executive function in heart failure patients may provide key insight into their ability to perform daily tasks, including the management of treatment recommendations.

A combined aerobic and resistance exercise program improves physical functional performance in patients with heart failure: a pilot study

BACKGROUND

Recent guidelines for exercise in patients with heart failure (HF) recommended aerobic and resistance exercise as being safe and effective; however, the clinical and functional significance of these combined training modalities has not been established. In this pilot study, combined aerobic and resistance training was hypothesized to improve physical function, muscle strength, and health-related quality of life (HRQOL) compared with an attention control wait list (ACWL).

METHODS

The 10-item Continuous Scale Physical Functional Performance Test (CS-PFP10), which simulates common household chores; muscle strength (handgrip and knee extension); and HRQOL (Kansas City Cardiomyopathy Questionnaire) were evaluated at baseline (T1) and at 12 weeks (T2). The home-based moderate-intensity walking and resistance training program was performed 5 days a week.

RESULTS

Twenty-four New York Heart Association class II to III HF patients (mean [SD] age, 60 [10] years; mean [SD] left ventricular ejection fraction, 25% [9%]) were randomized to a combined aerobic and resistance exercise program or to an ACWL group. Of the total group, 58% were New York Heart Association class III HF patients, 50% were white, and 50% were female. The CS-PFP10 total scores were significantly increased in the exercise group, from 45 (18) to 56 (16). The Kansas City Cardiomyopathy Questionnaire overall summary score was significantly improved (P < .001) at T2 in the exercise intervention group compared with the ACWL group.

CONCLUSIONS

Participants provided the home-based, combined aerobic and resistance exercise program had significantly improved physical function, muscle strength, symptom severity, and HRQOL compared with the ACWL group. The findings of this study must be interpreted cautiously owing to the limitations of a small sample, data collection from a single center, and differences between control and interventions groups at baseline. A combined aerobic and resistance exercise approach may improve physical function in stable HF patients, but further study in a larger, more diverse population is recommended. However, in this study, the CS-PFP10 instrument demonstrated its ability to identify functional health status in HF patients and thus warrants further testing in a larger sample for possible use in clinical practice.

Depression is associated with reduced physical activity in persons with heart failure

OBJECTIVE

Reduced physical activity is common in persons with heart failure (HF). However, studies of correlates and modifiers of physical activity in this population rarely employ objective measures. Motivational and mood related factors that may exacerbate inactivity in HF patients are also rarely investigated. In this study, we examined the relationship between physical activity as assessed by accelerometry, and depression in older adults with HF.

METHODS

At baseline, older adults with HF (N = 96; 69.81 ± 8.79) wore an accelerometer for seven days, and completed a brief fitness assessment, neuropsychological testing, and psychosocial measures including the Beck Depression Inventory-II (BDI-II). Medical and demographic history was obtained through record review and self-report.

RESULTS

Accelerometer measures showed that HF patients averaged 587 minutes of sedentary time and just 0.31 minutes of vigorous activity per day. Lower daily step count was associated with poorer quality of life and reduced cognitive function. A multiple linear regression adjusting for important demographic and medical variables found that greater number of depressive symptoms on the BDI-II independently predicted lower physical activity levels.

CONCLUSION

Consistent with past work, the current study found that low physical activity is common in older adults with HF. Depression is an independent predictor of physical activity in older adults with HF and reduced physical activity is associated with numerous adverse psychosocial outcomes. Future studies need to determine whether treatment of depression can boost physical activity and thus improve health outcomes in this population.

The additive effects of type-2 diabetes on cognitive function in older adults with heart failure

Background. Medical comorbidity has been theorized to contribute to cognitive impairment in heart failure (HF) patients. Specifically, type-2 diabetes mellitus (T2DM), a common coexisting condition among HF patients, may be an independent predictor of cognitive impairment. Nonetheless, the relationships between T2DM and other risk factors for cognitive impairment among persons with HF are unclear. Methods. Persons with HF (N = 169, 34.3% women, age 68.57 ± 10.28 years) completed neuropsychological testing within a framework of an ongoing study. History of T2DM, along with other medical characteristics, was ascertained through a review of participants' medical charts and self-report. Results. Many participants (34.9%) had a comorbid T2DM diagnosis. After adjustment for demographic and medical characteristics, HF patients with T2DM evidenced significantly greater impairments across multiple cognitive domains than HF patients without T2DM: λ = .92, F(5, 156) = 2.82, P = .018. Post hoc tests revealed significant associations between T2DM and attention (P = .003), executive function (P = .032), and motor functioning (P = .008). Conclusion. The findings suggest additive contributions of T2DM and HF to impairments in attention, executive function, and motor function. Future work is needed to elucidate the mechanisms by which T2DM exacerbates cognitive impairment in HF.

Cognitive impairment is independently associated with reduced instrumental activities of daily living in persons with heart failure

BACKGROUND

Heart failure (HF) is a disabling disease that often affects instrumental activities of daily living (instrumental ADLs). Despite high rates of disability in this population, little is known about the effects of cognitive impairment on instrumental ADLs in this population.

OBJECTIVE

The current study examined whether cognitive functioning predicts instrumental ADL performance in persons with HF.

METHODS

Persons with HF (N = 122; 68.49 [SD, 9.43] years; 35.2% female) completed neuropsychological testing, fitness assessment, and self-reported instrumental and basic ADL function as part of a larger protocol. Neuropsychological tests included the Mini-Mental State Examination and Trail Making Tests A and B. The 2-minute step test estimated fitness. Instrumental and basic ADL function was based on self-report on the Lawton-Brody Activities of Daily Living Scale. Hierarchical regression analyses were used to determine the independent contribution of cognitive function to ADLs in HF.

RESULTS

Heart failure patients reported high rates of impairments in instrumental ADLs, but indicated requiring little or no assistance with basic ADLs. Cognitive function showed incremental predictive validity for driving (R(2) change = .07, P = .03) and medication management (R(2) change = .14, P < .001). In each case, poorer neuropsychological test performance was associated with poorer instrumental ADL function.

CONCLUSION

In persons with HF, cognitive performance is an independent predictor of independence in driving and medication management. Strategies to maintain or improve cognitive functioning in HF may help patients remain functionally independent in their daily living.

Evaluation of frailty in older adults with cardiovascular disease: incorporating physical performance measures

Rapid growth in the numbers of older adults with cardiovascular disease (CVD) is raising awareness and concern of the impact that common geriatric syndromes such as frailty may have on clinical outcomes, health-related quality of life, and rising economic burden associated with healthcare. Increasingly, frailty is recognized to be a highly prevalent and important risk factor that is associated with adverse cardiovascular outcomes. A limitation of previous studies in patients with CVD has been the lack of a consistent definition and measures to evaluate frailty. In this review, building upon the work of Fried and colleagues, a definition of frailty is provided that is applicable for evaluating frailty in older adults with CVD. Simple, well-established performance-based measures widely used in comprehensive geriatric assessment are recommended that can be readily implemented by nurses in most practice settings. The limited studies conducted in older adults with CVD have shown physical performance measures to be highly predictive of clinical outcomes. Implications for practice and areas for future research are described for the growing numbers of elderly cardiac patients who are frail frailty and at risk for disability.

The 2-minute step test is independently associated with cognitive function in older adults with heart failure

BACKGROUND AND AIMS

Cognitive impairment is common in persons with heart failure (HF), and measures like the 6-minute walk test (6MWT) are known to correspond to level of impairment. The 2- minute step test (2MST) has been suggested as a more practical alternative to the 6MWT, though no study has examined whether it is associated with cognitive impairment in persons with HF. This study examined whether the 2MST is associated with cognitive function in older adults with HF.

METHODS

Older adults with HF (n=145; 68.97±9.31 yrs) completed the 2MST and a neuropsychological test battery that assessed function in multiple cognitive domains.

RESULTS

Consistent with past work, HF patients exhibited high rates of cognitive impairment. Hierarchical regression analyses adjusting for demographic and medical characteristics found that the 2MST accounted for unique variance in global cognitive function (ΔR²=0.09, p<0.001), executive function (ΔR²=0.03, p<0.05), and language (ΔR²=0.10, p<0.001). A trend emerged for attention (ΔR²=0.02, p=0.09). Follow-up tests indicated that better 2MST performance was significantly correlated with better global cognitive function, attention, executive, and language test performance.

CONCLUSION

The current results indicate that the 2MST is associated with cognitive function in older adults with HF. Further work is needed to clarify underlying mechanisms for this association and the value of implementing the 2MST during routine visits.