Cognitive influences on self-care decision making in persons with heart failure

doi:10.1016/j.ahj.2007.04.058

American Heart Journal

Volume 154, Issue 3, September 2007, Pages 424-431

https://doi.org/10.1016/j.ahj.2007.04.058 Get rights and content

Background

Despite advances in management, heart failure is associated with high rates of hospitalization, poor quality of life, and early death. Education intended to improve patients' abilities to care for themselves is an integral component of disease management programs. True self-care requires that patients make decisions about symptoms, but the cognitive deficits documented in 30% to 50% of the heart failure population may make daily decision making challenging. After describing heart failure self-care as a naturalistic decision making process, we explore cognitive deficits known to exist in persons with heart failure. Problems in heart failure self-care are analyzed in relation to neural alterations associated with heart failure. As a neural process, decision making has been traced to regions of the prefrontal cortex, the same areas that are affected by ischemia, infarction, and hypoxemia in heart failure. Resulting deficits in memory, attention, and executive function may impair the perception and interpretation of early symptoms and reasoning and, thereby, delay early treatment implementation.

Conclusions

There is compelling evidence that the neural processes critical to decision making are located in the same structures that are affected by heart failure. Because self-care requires the cognitive ability to learn, perceive, interpret, and respond, research is needed to discern how neural deficits affects these abilities, decision-making, and self-care behaviors.

Section snippets

Self-care in heart failure as a decision making process

Self-care is an active process intended to maintain health through treatment adherence, symptom monitoring, recognition, and treatment and an evaluative process whereby learning occurs in response to prior self-care. Managing an illness such as heart failure requires that symptoms are recognized early and treated quickly.⁶ Yet, numerous studies have demonstrated that dietary indiscretion, medication nonadherence, and failure to detect and act upon early symptoms of fluid retention are primary

Overview of patient decision making

Most of patient decision making research has focused on studies of patient choices about specific treatment options, informed consent, advanced directives, or general treatment preferences. When choosing between limited options, the problem-solving task is discrete, and the decision is made based on static choices. That is, patients weigh the specific options and make one decision, for example, choosing surgery over radiation therapy as cancer treatment. Although researchers have attempted to

Cognitive impairment in heart failure

Cognitive function refers to the information-processing abilities of attention, learning and memory, executive function (eg, cognitive flexibility and abstract reasoning), visual-spatial and visual-construction skills, psychomotor abilities, perceptual skills and language—functions critical to self-care. Cognitive deficits have been demonstrated in persons with heart failure using general cognitive measures such as the Mini-Mental Status Examination⁸ and neuropsychological testing. Two leading

Cognition and decision making in heart failure self-care

Cognitive impairment may contribute to failed self-care in 2 ways. Deficits in memory and attention may impair treatment adherence, one aspect of self-care, because of forgetfulness and poor learning ability. In a study testing the effect of standardized one-on-one instruction and written information about the treatment regimen on medication adherence, more than 50% of patients with clinically stable heart failure were unable to name their medications or dosages, and 75% failed to remember to

Neural processing and the effect on self-care decision making

Self-care decision making requires that symptoms are perceived and interpreted. A timely response to symptoms requires the ability to reason, make associations, and foresee consequences of actions. The ability to learn, thereby improving self-care decision making in the future, assumes memory.

Treatment seeking delay in response to early symptoms could reflect neural processing problems manifested in increased deliberation time. Impaired symptom perception has been identified as a mechanism

Conclusion

True self-care is a decision-making process requiring the cognitive ability to learn, perceive, interpret, reason, and respond. Cerebral ischemia, infarction, and hypoxemia impair concentration, memory, and processing abilities. These deficits, which have been shown to occur in persons with heart failure, may affect naturalistic decision-making ability through their influence on knowledge acquisition, interpretation of physical sensations, use of prior experience, and skill development. We

References (50)

K. Schwarz et al.
Identification of factors predictive of hospital readmissions for patients with heart failure
Heart Lung
(2003)
B. Riegel et al.
Psychometric testing of the self-care of heart failure index
J Card Fail
(2004)
J. Rockwell et al.
Predictors of self-care in persons with heart failure
Heart Lung
(2001)
F. McAlister et al.
A systematic review of randomized trials of disease management programs in heart failure
Am J Med
(2001)
M. Bouvy et al.
Effect of a pharmacist-led intervention on diuretic compliance in heart failure patients: a randomized controlled study
J Card Fail
(2003)
B. Carlson et al.
Self-care abilities of patients with heart failure
Heart Lung
(2001)
C. Horowitz et al.
A story of maladies, misconceptions and mishaps: effective management of heart failure
Soc Sci Med
(2004)
B. Riegel et al.
Facilitators and barriers to heart failure self-care
Patient Educ Couns
(2002)
H. Coleridge et al.
Afferent pathways involved in reflex regulation of airway smooth muscle
Pharmacol Ther
(1989)
A. von Leupoldt et al.
Cortical substrates for the perception of dyspnea
Chest
(2005)

D. Krawczyk

Contributions of the prefrontal cortex to the neural basis of human decision making

Neurosci Biobehav Rev

(2002)

L. Evangelista et al.

Treatment-seeking delays in heart failure patients

J Heart Lung Transplant

(2000)

H. Krumholz et al.

Randomized trial of an education and support intervention to prevent readmission of patients with heart failure

J Am Coll Cardiol

(2002)

W. Rosamond et al.

Heart Disease and Stroke Statistics—2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee

Circulation

(2007)

H. Krumholz et al.

Readmission after hospitalization for congestive heart failure among Medicare beneficiaries

Arch Intern Med

(1997)

D. Benatar et al.

Outcomes of chronic heart failure

Arch Intern Med

(2003)

A. Stromberg

The crucial role of patient education in heart failure

Eur J Heart Fail

(2005)

S. Bennett et al.

Cognitive deficits in patients with heart failure: a review of the literature

J Cardiovasc Nurs

(2003)

G. Zuccala et al.

Hypotension and cognitive impairment: selective association in patients with heart failure

Neurology

(2001)

C. Callahan et al.

Documentation and evaluation of cognitive impairment in elderly primary care patients

Ann Intern Med

(1995)

S. Bennett et al.

Characterization of the precipitants of hospitalization for heart failure decompensation

Am J Crit Care

(1998)

B. Gonzales et al.

Nurse evaluation of patients in a new multidisciplinary heart failure unit in Spain

Eur J Cardiovasc Nurs

(2004)

C. Jurgens

Somatic awareness, uncertainty, and delay in care-seeking in acute heart failure

Res Nurs Health

(2006)

B. Paterson et al.

Critical analysis of everyday self-care decision making in chronic illness

J Adv Nurs

(2001)

R. Lipshitz et al.

Taking stock of naturalistic decision making

J Behav Decis Mak

(2001)

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Application of Haddon strategy training on self-care behavior and disease consequences in heart failure: Haddon strategy on self-care behavior and disease consequences in heart failure
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Heart failure affects the physical, physiological, social, and activities of individuals. The study aimed to teach preventive behavior with Haddon strategy on self-care behavior and the consequences of heart failure.
In this clinical trial, 96 patients with heart failure were randomly assigned to two groups. The Haddon group was educated with Haddon prevention strategies three times a week, for 60 minutes. A demographic questionnaire, self-care index, and consequences checklist were filled in both groups at the start of the study, discharge time, and one month after the last training session. Statistical analysis was done using independent t-test, paired t-test, chi-square, Fisher and analysis of covariance, Friedman, and Cochran Q in SPSS with version 23.
Self-care behavior in the Haddon group after training significantly increased (p < 0.001). Disease consequences were significantly reduced in the Haddon group after training (p < 0.05). The consequences of the disease in Haddon group decreased during 4 weeks of monitoring and the changes were significant (p < 0.001).
It is suggested that this educational method could be used to increase self-care behavior, prevent hospitalizations, decrease symptoms, and improve quality of life for patients with heart failure.
Nurses can identify and manage risk factors for heart disease using the Haddon strategy.
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Objectives: This study aimed to examine the influence of cognitive impairment on preventive health services utilization among older adults.
Methods: The study sample came from 1995 to 2014 waves of the Health and Retirement Study (HRS), consisting of 19,644 adults aged 51 years or older. Mixed-effects logistic regression was used to analyze the influence of cognitive impairment, measured using the Telephone Interview for Cognitive Status, on the utilization of four types of preventive health care services, including flu shots, cholesterol tests, mammography for women, and prostate cancer screening for men.
Results: Persons with cognitive impairment with no dementia were less likely to receive cholesterol tests (OR=0.68, 95% CI=0.64–0.73, p<.001), flu shots (OR=0.86, CI=0.80–0.92, p<.001), mammograms (OR=0.88, CI=0.78–0.99, p<.05), and prostate cancer screenings (OR=0.71, CI=0.71–0.98, p<.05) compared with those without cognitive impairment. Having dementia was associated with a lower odds of receiving cholesterol tests (OR=0.42, CI=0.38–0.47, p<.001), flu shots (OR=0.65, CI=0.57–0.74, p<.001), mammograms (OR=0.70, CI=0.55–0.89, p<.01), and prostate cancer screening (OR=0.68, CI=0.47–0.99, p<.05).
Conclusions: Cognitive impairment with or without dementia is a significant barrier to utilizing preventive health services among older adults. Targeted health promotion prevention and intervention strategies and caregiver education are warranted to improve preventive services among older adults with cognitive impairment.
Heart failure impairs mood and memory in male rats and down-regulates the expression of numerous genes important for synaptic plasticity in related brain regions
2021, Behavioural Brain Research
Citation Excerpt :
It is now becoming well-accepted that, in addition to neurohumoral activation and the associated systemic cardiac, renal and vascular complications, HF is comorbid with depression, anxiety and memory deficits, both in human patients [6–10] and experimental animal models [11,12]. These mood and cognitive disturbances have serious implications for quality of life and self-care in patients who have HF because hospital readmission and mortality rates are significantly higher in HF patients that have depression and/or cognitive impairments compared to HF patients without these comorbidities [9,13–15]. It is critical to identify the neurobiological mechanisms and substrates that underlie HF-induced mood and cognitive disturbances HF in order to identify treatments that may improve quality of life and decrease mortality in this prevalent disease.
Chronic heart failure (HF) is a serious disorder that afflicts more than 26 million patients worldwide. HF is comorbid with depression, anxiety and memory deficits that have serious implications for quality of life and self-care in patients who have HF. Still, there are few studies that have assessed the effects of severely reduced ejection fraction (≤40 %) on cognition in non-human animal models. Moreover, limited information is available regarding the effects of HF on genetic markers of synaptic plasticity in brain areas critical for memory and mood regulation. We induced HF in male rats and tested mood and anxiety (sucrose preference and elevated plus maze) and memory (spontaneous alternation and inhibitory avoidance) and measured the simultaneous expression of 84 synaptic plasticity-associated genes in dorsal (DH) and ventral hippocampus (VH), basolateral (BLA) and central amygdala (CeA) and prefrontal cortex (PFC). We also included the hypothalamic paraventricular nucleus (PVN), which is implicated in neurohumoral activation in HF. Our results show that rats with severely reduced ejection fraction recapitulate behavioral symptoms seen in patients with chronic HF including, increased anxiety and impaired memory in both tasks. HF also downregulated several synaptic-plasticity genes in PFC and PVN, moderate decreases in DH and CeA and minimal effects in BLA and VH. Collectively, these findings identify candidate brain areas and molecular mechanisms underlying HF-induced disturbances in mood and memory.
“When you're homeless, they look down on you”: A qualitative, community-based study of homeless individuals with heart failure
2021, Heart and Lung
Citation Excerpt :
Outpatient HF care involves intensive self-management (SM): individuals with HF are expected to monitor weight gain, modulate dietary intake, adhere to complex medication regimens, and actively engage with nurses and physicians regarding their care.5 Improved HF SM is associated with improved HF outcomes,6 but for many patients, the complexity of SM behaviors makes it difficult to avoid exacerbations and readmission.7,8 A growing body of literature documents the challenges faced by homeless individuals in SM of chronic conditions such as diabetes mellitus, including difficulties with health prioritization and expenses.9
Outpatient heart failure (HF) care involves intensive self-management (SM). Effective HF SM is associated with improved outcomes. Homelessness poses challenges to successful SM.
To identify the ways in which homelessness may impede successful SM of HF and engagement with the healthcare system.
We conducted open-ended, semi-structured interviews with homeless adults with HF. Data were analyzed by a multidisciplinary team using a grounded theory approach.
We interviewed 19 participants, 11 (58%) of whom were homeless at the time of interview. Interviews revealed a combination of influences on HF SM. Major themes included instability and lack of routine, tradeoffs between basic necessities and HF SM, and stigmatization by healthcare providers.
Anticipatory guidance aimed at the unique challenges faced by homeless individuals with HF may aid successful SM. HF providers should simlpify medication regimes and engage in non-stigmatizing discourse. Larger-scale interventions include the creation of medical respite programs.
Cognitive impairment measured by Mini-Cog provides additive prognostic information in elderly patients with heart failure
2020, Journal of Cardiology
Citation Excerpt :
Given that our results suggest that performing both tests does not contribute to better prognostication, Mini-Cog may be one of recommendable CI screening tools which is clinically feasible and prognostically relevant. Some previous studies reported that CI is related to poor self-management skills, such as medication adherence [24], self-confidence [25], and decision-making [26]. Hawkins et al. reported that CI was independently associated with reduced heart failure knowledge and health literacy in patients with heart failure [27], which were suggested to be associated with poor prognosis [28].
There has been no study elucidating whether cognitive impairment (CI) can provide additive prognostic information besides that provided by preexisting prognostic factors in elderly patients with heart failure. This study examined whether CI can provide additive prognostic information in elderly patients with heart failure.
This multicenter retrospective study included 352 patients with heart failure aged ≥75 years. We administered the Mini-Mental State Examination (MMSE) and Mini-Cog test to assess CI. The Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score was used as a model to incorporate the preexisting prognostic factors. All-cause mortality was considered the prognostic outcome.
The median age was 85 years old, 47.7% were male. According to MMSE and Mini-Cog, 167 (47.4%) and 159 (45.2%) patients had CI, respectively. The agreement between MMSE and Mini-Cog was fairly low (Cohen’s kappa coefficient 0.37). During the follow-up period of median 346 days, 53 patients (15.1%) died. In multivariate Cox regression analysis, CI defined by MMSE and Mini-cog were individually associated with worse prognosis in older heart failure patients even after adjustment for MAGGIC risk model and log B-type natriuretic peptide levels [CI defined by MMSE, HR: 2.05 (95%CI: 1.16−3.61); and CI defined by Mini-Cog, HR:2.57 (95%CI: 1.46–4.53)]. The area under the curve of receiver operator characteristics curve was numerically greater for Mini-Cog than for MMSE (0.59 vs. 0.52, p = 0.109). Moreover, significant net reclassification improvement was observed when CI defined by Mini-Cog, but not on CI defined by MMSE, was added to the MAGGIC score, and when Mini-Cog, instead of MMSE, was used as a CI assessment tool (0.41, p = 0.004).
Among elderly hospitalized patients with heart failure, CI should be considered as a critical factor for prognosis prediction. Mini-Cog is a potentially preferable tool to assess CI in terms of providing prognostically relevant information compared to MMSE.
Comprehensive Geriatric Assessment in the Management of Older Patients With Cardiovascular Disease
2020, Mayo Clinic Proceedings
Cardiovascular disease (CVD) disproportionately affects older adults. It is expected that by 2030, one in five people in the United States will be older than 65 years. Individuals with CVD now live longer due, in part, to current prevention and treatment approaches. Addressing the needs of older individuals requires inclusion and assessment of frailty, multimorbidity, depression, quality of life, and cognition. Despite the conceptual relevance and prognostic importance of these factors, they are seldom formally evaluated in clinical practice. Further, although these constructs coexist with traditional cardiovascular risk factors, their exact prevalence and prognostic impact remain largely unknown. Development of the right decision tools, which include these variables, can facilitate patient-centered care for older adults. These gaps in knowledge hinder optimal care use and underscore the need to rigorously evaluate the optimal constructs for providing care to older adults. In this review, we describe available tools to examine the prognostic role of age-related factors in patients with CVD.

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Progress in CardiologyCognitive influences on self-care decision making in persons with heart failure

Background

Conclusions

Section snippets

Self-care in heart failure as a decision making process

Overview of patient decision making

Cognitive impairment in heart failure

Cognition and decision making in heart failure self-care

Neural processing and the effect on self-care decision making

Conclusion

Heart Lung

J Card Fail

Heart Lung

Am J Med

J Card Fail

Heart Lung

Soc Sci Med

Patient Educ Couns

Pharmacol Ther

Chest

Neurosci Biobehav Rev

J Heart Lung Transplant

J Am Coll Cardiol

Heart Disease and Stroke Statistics—2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee

Circulation

Readmission after hospitalization for congestive heart failure among Medicare beneficiaries

Arch Intern Med

Outcomes of chronic heart failure

Arch Intern Med

The crucial role of patient education in heart failure

Eur J Heart Fail

Cognitive deficits in patients with heart failure: a review of the literature

J Cardiovasc Nurs

Hypotension and cognitive impairment: selective association in patients with heart failure

Neurology

Documentation and evaluation of cognitive impairment in elderly primary care patients

Ann Intern Med

Characterization of the precipitants of hospitalization for heart failure decompensation

Am J Crit Care

Nurse evaluation of patients in a new multidisciplinary heart failure unit in Spain

Eur J Cardiovasc Nurs

Somatic awareness, uncertainty, and delay in care-seeking in acute heart failure

Res Nurs Health

Critical analysis of everyday self-care decision making in chronic illness

J Adv Nurs

Taking stock of naturalistic decision making

J Behav Decis Mak

Progress in Cardiology
Cognitive influences on self-care decision making in persons with heart failure