Table 4 Advice for Clinical Management of Patients with Heart Failure and Cognitive Impairment

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].

Those with lower educational status may benefit more from programs. Poorly educated subjects may be less skilled with respect to self-management at baseline and hence may have more to learn from such programs [54,55,56].

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.

However, several studies have also identified that provision of education, treatment and lifestyle instructions alone are not adequate to uphold appropriate self-care behavior [50, 51],

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].