Background
Aim
Methods
Definitions
Data sources and searches
Study selection
Data extraction and quality assessment
Role of the funding source
Results
Study and population characteristics
Author | Country | Aim | Study Duration (months) | Data Type | Study Design | Method(s) of data collection | Setting | Population setting | Population size (n) | Age mean and range | Female (n and/or %) | HF severity (n and/or %) | Cognitive impairment test(s) and cutoff scores | Cognitive Impairment (n and/or %) | Comorbidities (n and/or %)* | Quality Assessment |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Alosco, 2012 | USA | To examine whether cognitive functioning is associated with poorer Adh to treatment recommendations | – | Cross Sectional | Obs | Ques, Exam | Primary Care/Cardiology Practice | Urban | 149 | 68.1 (SD = 10.7) | 37% | NYHA II/III LVEF: 41.0 (SD = 14.8) | – | – | Diabetes: 34% Depression: 22% Hypertension: 72% Myocardial Infarct: 52% | Fair |
Alosco, 2012 | USA | To examine whether cognitive functioning is able to predict ADL performance | – | Cross Sectional | Obs | Ques, Exam | Primary Care/Cardiology Practice | Urban | 122 | 68.5 (SD = 9.4) | 35% | NYHA II/III | MMSE | – | Diabetes: 33% Hypertension: 66% Myocardial Infarct: 54% | Fair |
Alosco, 2014 | USA | To examine the association between EF and IADL in HF patients & to examine the association between executive dysfunction and unhealthy lifestyle behaviors. | – | Cross Sectional | Obs | Ques, Exam | – | Urban | 179 | 68.1 (SD = 10.3) | 36% | NYHA II/III/IV LVEF: 41.0 (SD = 15.1) | – | – | Diabetes: 37% Hypertension: 70% | Fair |
Cameron, 2009 | AUS | To test a conceptual model of factors drawn from the literature as determinants of chronic HF SC | – | Cross Sectional | Obs | Int | Inpatient | Urban | 50 | 73 (SD = 11) | 12 (24%) | NYHA III/IV: 25 (50%) | MMSE (< 27) | 18 (36%) | Mild/Moderate: 32 (64%) Severe: 18 (36%) | Good |
Dickson, 2008 | USA | To explore how attitudes, self-efficacy and cognition influence the decision making processes underlying HF SC. | – | Cross Sectional | Obs | Int | Outpatient | Urban | 41 | 49.2 (SD = 10.5) Range: 25–65 | 15 (37%) | NYHA II/III Mean ejection fraction: 34% | – | – | Mild: 17 (41%) Moderate: 20 (49%) Severe: 4 (10%) | Fair |
Habota, 2015 | AUS | To compare prospective memory ability of CHF patients and matched controls | 3 | Cross Sectional | Obs | Int | Outpatient | Urban | 30 | 70.0 (SD = 11.9) Range: 40–86 | 37% | NYHA III/IV: (30%) | ACE-R | – | Diabetes: 5 (17%) Hypertension: 20 (67%) | Fair |
Harkness, 2014 | CAN | To determine if MCI was significantly associated with SC management in a community dwelling sample of older HF patients | – | Cross Sectional | Obs | Ques, Exam | Outpatient | Urban | 100 | 72.4 (SD = 9.8) | 32% | NYHA III: 43 (43%) LVEF≤45: 90% | MoCA (< 26, < 24 – CVS cutoff) | < 26: 73% < 24: 56% | AF: 54 (54%) Diabetes: 43 (43%) Depression: 12 (12%) Hypertension: 73 (73%) | Good |
Hawkins, 2012 | USA | To describe the prevalence and severity of CI in an OP veteran population with HF and to describe the cognitive domains affected. To examine the clinical and demographic variables associated with CI and to determine the relationship between CI and MA | – | Prospective | Coh | Int, Exam | Outpatient/General Medical Clinic | Urban | 251 | 66 (SD = 9.8) Range: 33–93 | 4 (1.6%) | LVEF: 37.5 (SD = 16.9) | SLUMS (< 27 with HSQ, < 25 with-out) | 144 (58%)‡ | AF: 82 (32.7%) Diabetes: 134 (53.4%) Depression: 76 (30.3%)‡ Hypertension: 193 (76.9%) | Good |
Hjelm, 2015 | SWE | To a) test the association between cognitive function and SC in HF patients, b) explore which cognitive areas were affected, c) determine if DP moderated the association between cognitive function and SC. | – | Cross Sectional | Obs | Ques, Exam | Outpatient | Urban | 142 | Median: 72, Range: 65–79 | 45 (32%) | NYHA III/IV: 55 (39%) LVEF< 40: 102 (72%) | MMSE | – | Mild: 116 (82%) Moderate: 22 (15%) Severe: 3 (2%) | Good |
Karlsson, 2005 | SWE | To assess the effect of a nurse based management program to increase HF patients’ knowledge about disease and SC. To compare these results to gender and cognitive function | 6 | Prospective | RCT | Ques, Int | Outpatient | Urban | Interv: 72 Control: 74 | 76, SD = 8 vs. 76 SD = 7§ | 31 (43%) vs. 33 (45%)§ | NYHA III/IV: 31 (43%) vs. 22 (30%)§ LVEF: 33 (SD = 12) vs. 35 (SD = 10)§ | MMSE | – | Diabetes: 17 (24%) vs. 15 (20%)§ Hypertension: 30 (42%) vs. 21 (28%)§|| | Fair |
Kim, 2015 | KOR | To examine a) global cognition, M and EF, b) differences in these domains when comparing asymptomatic and symptomatic HF c) the association between cognitive function and SC Adh in HF patients d) the influence of the cognitive domains on MACE | 24 | Prospective | Coh | Int | Outpatient | Urban | 86 | 58.3 (SD = 12.9) | 28 (34%) | NYHA III/IV: 8 (9%) LVEF: 51 (SD = 15) | K-MMSE (< 23.5) | 28 (33%) | AF: 15 (17%) Diabetes: 13 (15%) | Fair |
Lee, 2013 | USA | To quantify the relationship between MCI and, SC and consulting behaviours | – | Cross Sectional | Obs | Ques, Exam | Outpatient | Urban | 148 | 56.9 (SD = 12.4) | 57 (39%) | NYHA III/IV: 87 (59%) LVEF: 28 (SD = 12) | MoCA (< 26, < 24 – CVS cutoff) | < 26: 49 (33%) < 24: 21 (14%) | Mild: 95 (64%) Moderate: 44 (30%) Severe: 9 (6%) | Good |
Smeulders, 2010 | NED | To identify the characteristics of CHF patients that benefitted most from the CDSMP | 27 | Prospective | RCT | Ques, Int (T) | Outpatient | Urban | Interv: 186 Control: 131 | 66.7 (SD = 10.6), 66.6 (SD = 11.0) vs. 66.8 (SD = 10.1)§ | 45 (24.2%) vs. 42 (32.1%)§ | NYHA III: 66 (36%) vs. 40 (31%)§ | TICS (< 33.0) | 99 (53.2%) vs. 78 (59.5%)§ | – | Fair |
Vellone, 2015 | ITA | To determine whether SC confidence mediates the relationship between cognition and SC behaviours | – | Cross Sectional | Obs | Int | Outpatient | Urban | 628 | 73.0 (SD = 11.3) | 266 (42.6%) | NYHA III/IV: 340 (54.1%) LVEF: 43.1 (SD = 11.6) | MMSE | – | – | Fair |
Cognitive impairment
Cognitive Domains | Self-care | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Author | Country | Method of neuropsychological testing | Assessment of Cognitive Impairment | Cognitive Impairment scores (mean) | Attention and Information Processing | Language | Visuospatial Ability and Praxis | Learning and Memory | Executive Function | Assessment of Self-care | Self-care maintenance | Self-care management | Self-care confidence |
Alosco, 2012 | USA | Exam | None | – | TMTA: 40.7 (SD = 14.9) DSC: 50.5 (SD = 14.2) | BNT: 53.5 (SD = 5.7) AFT: 19.5 (SD = 5.1) | TMTA: 40.7 (SD = 14.9) | CVLT: SDFR = 7.6, (SD = 3.2) LDFR: 8.1 (SD = 3.3) Recognition: 13.60 (SD = 2.05) | TMTB: 127.7 (SD = 77.2) LNS: 8.9 (SD = 2.5) SCWIE: 0.1 (SD = 7.4) | Treatment Adherence (Self-Reported) | Drs Appointment: (94.8/100, SD = 16.8): 3% Non-adherenta Medication Management: (96.1/100, SD = 11.5) - 1% Non-adherenta Diet: (69.8/100, SD = 24.0) - 32% Non-adherenta Exercise: (57.7/100, SD = 33.1) - 49% Non- adherenta Smoking Abstinence: (94.1/100, SD = 21.0) - 7% Non-adherenta Alcohol Abstinence: (91.1/100, SD = 23.6) - 7% Non-adherenta | – | – |
Alosco, 2012 | USA | Exam | MMSE | 27.7 (SD = 1.8) | TMTA: 39.0, (SD = 13.5) | – | TMTA: 39.0, (SD = 13.5) | – | TMTB: 115.8, (SD = 58.2) | Activities of Daily Living | Shopping (1.68/2.00, SD = 0.58) Food preparation (1.46/2.00, SD = 0.84) Feeding (1.98/2.00, SD = 0.13) Transport (1.94/2.00, SD = 0.23) Medication Management (1.91/2.00, SD = 0.34) Telephone Usage (1.98/2.00, SD = 0.20) | – | – |
Alosco, 2014 | USA | Exam | None | – | DSC: 49.2, (SD = 14.7)- 11% impairedb | AFT:19.1, SD = 4.9) – 3% impairedb | – | CFT: LDR 13.0, (SD = 6.2) - 9% impairedb | FAB: 15.5 (SD = 2.6) - 30% impairedb LNS: 8.8 (SD = 2.5) - 6% impairedb | Instrumental Activities of Daily Living | Shopping - 27%c Food Preparation - 32%c Transport - 8%c Medication Management - 6%c Telephone Usage - 2%c | – | – |
Cameron, 2009 | AUS | Interview | MMSE | – | – | – | – | – | – | Self-Care Heart Failure Index | 67.8/100 (SD = 17.3) 52% had adequated scores | 50.1/100 (SD = 16.6), 12% had adequated scores | 62.0/100 (SD = 20.0), 36% had adequated scores |
Dickson, 2008 | USA | Interview | None | – | DSS, LNS | – | DSS | DSS: PMR - 46.3% had impaired memory, LNS | LNS | Self-Care Heart Failure Index | 71.6/100 (SD = 14.3), 61% had adequated scores | 71.3/100 (SD = 18.6), 44% had adequated scores | – |
Habota, 2015 | AUS | Interview | ACE-R | 90.8 (SD = 4.6) | – | – | – | WAIS-IV DS (working memory), RAVT (verbal memory) VW (prospective memory) | TMT (TMTB-TMTA) (cognitive flexibility) HSCT (inhibition) Verbal fluency from ACE-R (initiation) | Prospective Memory | Virtual Week (ability to recall daily tasks) | – | – |
Harkness, 2014 | CAN | Exam | MoCA | – | – | – | – | – | – | Self-Care Heart Failure Index | 67.1/100 (SD = 16.0). 50% had adequated scores | 51.1/100 (SD = 23.6), 21% had adequated scores | 55.4/100 (SD = 20.0), 22% had adequated scores |
Hawkins, 2012 | USA | Exam | SLUMS | 24.4 (SD = 4.0) | WAIS-IV DS: z = −0.60, SD = 0.88, (NS) and WAIS-IV LNS: z = −0.56, SD = 0.68, (NS) Trails A: z = − 0.80, SD = 0.99, (NS) RBANS coding: z = −1.20, SD = 0.87, (NS) | RBANS PN: z = 0.23, SD = 1.24, (NS) RBANS SF: z= − 0.86, SD = 0.88, (NS) AFT: z = − 0.57, SD = 1.17, (NS) | RBANS FC: z = 0.67, SD = 1.53, (NS) RBANS LO: z = 0.10, SD = 0.85, (NS) WAIS-IV MR: z = − 0.20, SD = 0.98, (NS) | RBANS LL: z = − 1.90, SD = 0.96, (S) RBANS SM: z = − 1.59, SD = 1.08, (S) RBANS LR: z = − 1.25, SD = 0.91, (NS) RBANS LRR: z = − 1.80, SD = 1.84, (S) RBANS SR: z = − 1.84, SD = 1.21, (S) RBANS RF: z = − 0.36, SD = 1.04, (NS) | COWA: z = − 0.74, SD = 0.90, (NS) Trails B: z = − 0.73, SD = 1.04, (NS) WAIS-IV similarities: z = − 0.17, SD = 0.70, (NS) | Medication Adherence | Medication Adherence: Normal vs. Mild cognitive impairment - 78.1% vs. 70.7%, p = 0.017, Mild cognitive impairment vs. dementia: 70.7% vs. 73.3%, p = 0.31 | – | – |
Hjelm, 2015 | SWE | Exam | MMSE | – | TMTA | – | TMTA, ROCF, BDT | ROCF, MOS, WKT | TMTB | EHFScBS-9 | EHFScBS-9 (under diet, medication adherence) | EHFScBS-9 (under symptom monitoring and recognition) | – |
Karlsson, 2005 | SWE | Interview | MMSE | Intervention vs. control: 26.8 (SD = 3.3) vs. 26.9 (SD = 3.0) | – | – | – | – | – | Heart Failure Knowledge | – | – | – |
Kim, 2015 | KOR | Interview | K-MMSE | 26.4 (SD = 5.3) | – | – | – | Seoul VLT: IR:15.5 (SD = 5.8) - 65% < normal DR: 4.8 (SD = 2.3) - 65% < normal | COWA: 20.1 (SD = 10.2) - 61% < normal | Self-Care Heart Failure Index | 55.4/100 (SD = 14.3) 15% had adequated scores | 34.0/100 (SD = 12.8), 0% had adequated scorese | 52.1/100 (SD = 17.6), 14% had adequated scores |
Lee, 2013 | USA | Exam | MoCA | – | – | – | – | – | – | Self-Care Heart Failure Index / EHFScBS-9 | 69.2/100 (SD = 14.3) | 67.3/100 (SD = 19.0) | 63.9/100 (SD = 19.9) |
Smeulders, 2010 | NED | Tele-Interview | TICS | Intervention vs. control: 32.7 (SD = 3.3) vs. 32.4 (SD = 3.1) | – | – | – | – | – | KCCQ | Cardiac Quality of Life | – | – |
Vellone, 2015 | ITA | Interview | MMSE | 23.3 (SD = 6.3) | – | – | – | – | – | Self-Care Heart Failure Index | 55.0/100 (SD = 15.7) | 53.2/100 (SD = 20.0) | 54.0/100 (SD = 20.6) |
Self-care
Self-care maintenance
Impact of cognitive impairment and domains on self-care
Author | Study Outcome (n and/or %) | Impact of Cognitive Impairment on Self- care | Other Risk Factors for Self-Care Impairment | Suggested Strategies/Intervention |
---|---|---|---|---|
Alosco, 2012 | Adherence Score: 84.0/100 SD = 11.6. 16% were Non-Adherenta | ↓Attention:↓Doctor’s Appointment Adherence (r(138) = 0.29, p < 0.001) & ↓Medication Management (r(138) = 0.25, p < 0.01). ↓Executive Function: ↓Doctor’s Appointment Adherence (r(138) = 0.29, p < 0.001). ↓Language:↓Medication Management (r(138) = 0.28, p < 0.01) &↓Diet Adherence (r(138) = 0.17, p = 0.04) | Myocardial infarction is associated with↑ treatment adherence (ß = 0.23, p = 0.01) | Cognitive function assessment can influence the course of heart failure management |
Alosco, 2012 | Activities of daily living score: 25.2/28 (SD = 3.4) | ↓TMTA performance (Attention, Visuospatial): ↓Medication Management (ß = − 0.24, p < 0.05) ↓MMSE:↓Driving scores (ß = − 0.25, p < 0.001) | – | Regular screening of cognitive impairment can provide information about self-care behaviors |
Alosco, 2014 | Instrumental activities of daily living score: 13.5/16 (SD = 2.9). ↓Executive function: ↑Cigarette smoking (r(167) = − 0.20, p = 0.01) | ↓Executive function: ↓Instrumental activities of daily living performance (ß = 0.24, p = 0.01) – Especially food preparation (r(167) = 0.16, p < 0.03) & medication management (r(167) = 0.15, p = 0.05). ↓Executive function associated with ↑cigarette use (r(167) = − 0.20, p = 0.01). | Male (ß = − 0.29, p < 0.001), Diabetes (ß= − 0.19, p = 0.01) Depression (ß = − 0.15, p = 0.04) associated with↓instrumental activities of daily living performance | Technological devices which promote executive function could improve self-care outcomes. |
Cameron, 2009 | Self-care maintenance: 67.8/100, SD = 17.3 Self-care management: 50.1/100, SD = 16.6 Self-care confidence: 62.0/100, SD = 20.0 The 7 variable modelb = 39% of variance in Self-care maintenance & 38% of variance in Self-care management | Cognitive function non-significant factor in 7 variable model however when omitted from the model, 6 variables explain ↓4% of the variance in self-care maintenance (39% - > 35%). This was also seen in self-care management (38 - > 34%) | Self-care maintenance: ↑Age: ↑Self-care maintenance (ß = 0.51, p < 0.01); Significant comorbidity (CCSI≥4): ↑Self-care maintenance (ß = 0.34, p = 0.02). Self-care management: Male: ↓Self-care management (ß = − 0.33, p = 0.02); No significant comorbidity (CCSI< 4) (ß = 0.33, p = 0.03): ↑Self-care management; Depression: ↑Self-care management (ß = 0.32, p = 0.04); ↓Self-care confidence: ↓Self-care management (ß = 0.39, p < 0.01) | Screening for modifiable and non-modifiable factors can ↑ health outcomes and follow up strategies |
Dickson, 2008 | Self-care management: (71.3/100, SD = 18.6) 44% had adequate scores (>70). Self-care maintenance: (71.6/99.99, SD = 14.3) 61% had adequate scores (>70). Significant difference in self-care maintenance and self-care management between expertc, noviced and inconsistent groupse (p = 0.001). | ‘Inconsistent’ group: Cognitive impairment (DSS < 26) had ↑self-care management and ↑self-care maintenance scores vs. ‘↓ vigilant’ and ‘discordant’ (p = 0.02 to 0.03). | – | Developing self-efficacy in difficult situations will lead to (+) self-care decisions and help overcome temptations which leads to ↑self-care confidence |
Habota, 2015 | Trend: Congestive heart failure (mean = 0.5, SD = 0.4) performing ↓ than controls (mean = 0.6, SD = 0.3). For the proportion of tasks missed, there was a main effect of group (F(1,57) = 4.52, p = 0.038, ηp2 = 0.07). The congestive heart failure group (mean = 0.26, SD = 0.31) missed ↑ tasks than the control group (mean = 0.16, SD = 0.21). | – | – | ↑Self-care adherence may need to include prospective memory training |
Harkness, 2014 | Self-care management: MoCA score < 26 (mild cognitive impairment) scored significantly ↓ vs. scores ≥26 (48.1/100 (SD = 24) vs. 59.3/100 (SD = 22), p = 0.035). Also observed with the MoCA cutoff at < 24 and ≥ 24, (45.6/100 (SD = 23) vs. 58.1/100 (SD = 23), p = 0.008) | MoCA was a significant factor (B = 1.784, p = 0.001) in model for self-care management (F(3,96) = 7.04, p < 0.001). Mild cognitively impaired participants (both < 26 and < 24) were ↓ likely to call a doctor or nurse for guidance (52% vs. 89%, p = 0.001, 46% vs. 82%, p < 0.001 respectively) | – | Formal screening for mild cognitive impairment can help to identify individuals who are risk of self-care management difficulty and of delaying assistance from a health care provider. Experiential learning and problem solving skills are important for the elderly. |
Hawkins, 2012 | Cognitive impairment present in 57.6%. Verbal learning, immediate memory, and delayed verbal memory were found to be impaired. Associations with cognitive impairment: Age (OR = 1.42, 95%CI = 1.03–1.95, p = 0.031); African American race (OR = 3.59, 95%CI = 1.90–6.81, p < 0.01); Depression (OR = 1.43, 95%CI = 1.12–1.83, p = 0.004); Former alcohol use (OR = 2.13, 95%CI = 1.06–4.31, p = 0.034); missed follow up of pill count (OR = 2.03, 95%CI = 1.20–3.45, p = 0.009). Medication adherence ↑ in participants with no CI vs. MCI (78.1% vs. 70.7%, p = 0.017) | – | – | Screen patients for cognitive impairment and depression. Interventions should look to target verbal learning, verbal memory and delayed verbal memory |
Hjelm, 2015 | Psychomotor speed associated with self-care (ß = − 0.09, t(99) = −2.92, p = 0.004). No moderating effects of depression were found. | – | – | Screening for impaired psychomotor speed to identify patients in need of individualized self-care teaching. |
Karlsson, 2005 | Intervention group did not have ↑ knowledge vs. control group after 6 months (13.2 (SD = 3.4) vs. 12.7 (SD = 3.3), NS). | MMSE< 24 had ↓ scores in self-care and heart failure knowledge vs. MMSE≥24 (10.1 (SD = 3.6) vs. 12.8 (SD = 3.4), p < 0.01) at baseline. There was no difference between the 2 groups after 6 months. | – | Education of patients should be given individually and given through different means (verbal, written, electronic) |
Kim, 2015 | NYHA I (asymptomatic) vs. NYHA≥II (symptomatic): Global function (27.8 (SD = 2.5) vs. 24.9 (SD = 4.4), p = 0.001), Memory (17.5 (SD = 5.7) vs. 13.4 (SD = 5.2), p = 0.001), executive function (23.4 (SD = 9.8) vs. 16.9 (SD = 9.6), p = 0.002) Also observed in self-care confidence (57.0 (SD = 17.4) vs. 53.2 (SD = 13.8), p = 0.009). | Delayed recall memory predicted self-care confidence adequacy (OR = 1.41, 95%CI = 1.03–1.92, p = 0.033). MACE had ↓ K-MMSE scores vs. ‘event free’ (23.9 vs. 27.1, t = 2.30, p = 0.024). | – | – |
Lee, 2013 | MoCA < 26: ↓Self-care management scores vs. MoCA ≥26 (difference = 8.2%, SD = 3.8%, p = 0.043). MoCA < 24: ↓Adjusted self-care maintenance (difference = 13.8%, SD = 5.4%, p = 0.014) and self-care management scores (difference = 21.4%, SD = 8.0%, p = 0.014) vs. participants with scores ≥24. MoCA < 24 also had significantly lower EHFScBS scores (difference = 38.3%, SD = 11.2%, p = 0.001) | MoCA < 24 had worse adjusted consulting behavior scores (difference = 50.7%, SD = 15.3%, p = 0.001) | – | Cognition should be assessed with clinically appropriate tools (e.g. employing the MoCA cutoff of < 24). Systematic screening for mild cognitive impairment |
Smeulders, 2010 | Participants with TICS< 33 had worse cardiac quality of life at first follow up (Difference = − 6.3, p = 0.027, 95%CI = − 11.9 to − 0.7). Scores were not significantly different at 6 and 12 months. | – | – | Encourage patients with ↓education levels to participate in CDSMP classes. Tailor CDSMP to cognitively impaired patients. Screen for cognitive status and education level. |
Vellone, 2015 | MMSE score influenced self-care maintenance and self-care management through the mediating effects of self-care confidence MMSE predicted self-care confidence. Self-care confidence predicted self-care management and self-care maintenance. Cognition does not have a direct effect on self-care. It only influenced self-care through its effect on self-care confidence | – | Self-care maintenance ↑Illness duration predicted ↑self-care maintenance Self-care management: ↑NYHA class predicted ↓self-care management Self-care confidence: ↓Age and female gender predicted ↑self-care confidence | Interventions that ↑ self-care confidence may ↑self-care even in patients with cognitive impairment. Reward patients for small successes in their adherence to self-care behaviors. Introduce patients to others in the same situation who are proficient at self-care. Tell patients that they are able to be proficient at self-care. Provide and encourage support for patients. |
Relationship between global cognition and self-care
Other risk factors for self-care impairment
Discussion
Statement of key findings
Self-care domain adequacy in cognitive impairment
Cognitive impairment and lifestyle adherence
Seeking help
The effect of depression on self-care
Education programs
Strengths and limitations
Implications for health policy
Task | Sub Task | Impairments | Recommendations |
Understanding and Monitoring symptoms | Education Programs | Patients with better cognitive function may benefit more from self-management programs than those with worse cognition in the short term [17]. | Clinicians should consider baseline education status to deliver information appropriately as well as ascertain the benefit patients with HF and CI may obtain by undertaking self-management programs. |
Seeking Help | Poor global cognition correlated with worse consulting behaviors [29, 31]. Making decisions to seek help is complex and requires an understanding of HF. Executive function deficits in CI subjects may impair recognition of symptoms and problem-solving hence may delay initiation of self-management as well an inability to recognize who, when or why they need to seek assistance. HF patients with deficits in IADL, language and attention deficits may not have an ability to engage in communication facilities (e.g. telecommunications, driving to the clinic, making appointments online or by phone) [29]. | Clinicians should be aware of the impact of executive function on communication difficulties for persons with HF and CI. Cognitive tests geared towards executive function assessment should be utilized. Clinicians should provide resources for and communication solutions for allow easy access to healthcare for persons with HF and CI Teaching patients select few response options for clinical scenarios may provide a baseline to refer to when a response is required spontaneously Provision of in-home prompts including wall calendars, blister packs, management flow charts etc. Where possible provide home visits or an escort to clinical appointments Establishing an appointment and healthcare support routine that does not vary. | |
Adherence to Lifestyle and Treatment | Psychological Status | Psychological status has been demonstrated to have an influence on self-care behaviors [47] through patient perceived self-efficacy or indirectly, through effects on memory and executive function [48]. A diagnosis of depression was found to be predictive of lower IADL abilities and self-care management [22, 25]. | Clinicians may benefit from screening for and appropriately treating depression in patients with heart failure in order to prevent the associated adverse affects it may have on self-care. |
Personal motivation | Cognitive decline not only diminishes functional abilities, it may dampen the influence of personal factors related to self-care [9, 37]. These include belief in treatment of the disease, information sources, personal and cultural values that would otherwise influence self-care in a positive manner. | Clinicians should endeavor to convey how health care goals may serve the patient’s personally valued goals and priorities in life. | |
Cognition | Patients who either had impairments in multiple separate domains or global cognition had poor self-care maintenance abilities. These were namely medication adherence, compliance with lifestyle recommendations or requiring assistance with ADLs. | By elucidating the relationship between impairment in specific cognitive domains and self-care as well as identifying factors that may modulate self-care abilities, clinicians may tailor management. | |
Managing Other Medical Conditions | Having a comorbid disease was related to better management and maintenance behaviours [25]. Patients being well versed with and used to self-care practices or, where increasing symptoms or reduced functional capacity may motivate self-care behaviours. Increased burden of comorbidities and symptoms may be detrimental for patients. Increased symptoms burden may limit functional capacity and that could lead to increasing social support. | Clinicians should be aware of pre-existing disease which may aid patients who are well versed in self-management or in contrast, may detract from management of concurrent illness or where symptom burden may hinder self-care abilities. Multidisciplinary and multispecialty input may be required to ensure appropriate management of comorbid conditions. | |
General Self-Care Behaviors | Self-care confidence that was impaired by poor cognition thus leading to worse self-care behaviours [32]. Self-efficacy and a positive attitude towards disease was important in facilitating appropriate or “expert” self-care behaviours [9]. | Clinicians may target confidence through problem solving and experiential learning in HF patients with CI may improve self-care functions even in the context of cognitive decline [57]. |