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Cognitive function in elderly patients with chronic heart failure
Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Health Sciences. (Institution for medical and health science)
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Introduction

Approximately 1-2% of the adult population in developed countries suffer from heart failure (HF), with the prevalence rising to more than 10% among patients 80 years of age or older. The HF syndrome is associated with elevated mortality and morbidity, and decreased quality of life. Cognitive dysfunction has been reported in patients suffering from a variety of cardiovascular disorders. However, few studies have systematically assessed cognitive performance in HF patients, its prevalence and other factors influencing cognition in HF patients. Further, it is of great interest to understand the relationship between self-care in HF and cognition. It may be important to screen for cognitive dysfunction as it may influence HF patients’ ability to perform self-care, e.g. make lifestyle changes, adhere to medical treatment and monitor, evaluate and treat symptoms of deterioration.

Aim

The overall aim of this thesis was to explore cognitive function in elderly patients with chronic heart failure with focus on prevalence, risk factors, sleep and self-care.

Design and method

This thesis is based on four quantitative studies. The data from study I and II were collected in a prospective longitudinal design, including Swedish same-sex twin pairs born in 1913 or earlier in Sweden. The study was conducted 1991-2002 and a total of 702 individuals aged 80 and older were included.

Study III and IV had a cross- sectional design and included stable HF patients, median 72 years of age, living in the community in the south of Sweden. Data were collected between 2009 and 2012. Study III included a total of 137 patients and Study IV included 142 patients.

Results

Study I found that  octogenarians with HF had significantly poorer spatial performance and episodic memory, and that the episodic memory declined more over time compared to a non-HF population of the same ages.

Study II showed that octogenarians with HF had a significantly higher prevalence of vascular dementia, 16% vs. 6%, and all types of dementia, 40% vs. 30%, than those not diagnosed with HF. Factors related to dementia in individuals with HF were depression, hypertension and increased levels of homocysteine. Diabetes was associated with an increased risk for vascular dementia.

In study III we found that  HF patients with sleep disordered breathing (SDB) (apnoea-hypopnoea index >15) had significantly higher saturation time < 90%, more difficulties maintaining sleep and lower levels of daytime sleepiness compared to those in the non-SDB group. Cognitive function did not differ between the SDB and the non-SDB-group. Only insomnia was associated with a decreased global cognititive function measured with the Mini Mental State Examination instrument.

Finally, in study IV, the relationship between self-care and different dimensions of cognitive function was explored. Psycho- and visuomotor function (speed and attention) was the only dimension of cognitive function associated with self-care.

Conclusion

Octogenarians suffering from HF have a decreased performance in spatial and episodic memory and they also have a higher risk for developing dementia. Cognitive dysfunction as well as higher prevalence of dementia can contribute to decreased adherence to prescribed therapy and self-care management, and lead to other socio-behavioural problems.  

Self-care was found to be associated with psychomotor speed. This may influence sustained attention negatively and the ability to carry out more than one task at the same time. This may lead to decreased attention for receiving and understanding information on self-care.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2013. , 72 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1365
Keyword [en]
Chronic heart failure, cognitive dysfunction, dementia, elderly, oldest-old, prevalence, risk factors, self-care, sleep
National Category
Nursing
Identifiers
URN: urn:nbn:se:liu:diva-96398ISBN: 978-91-7519-602-2 (print)OAI: oai:DiVA.org:liu-96398DiVA: diva2:641584
Public defence
2013-09-13, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Projects
Thesis
Funder
Swedish Heart Lung Foundation
Available from: 2013-08-27 Created: 2013-08-18 Last updated: 2013-09-03Bibliographically approved
List of papers
1. The influence of heart failure on longitudinal changes in cognition among individuals 80 years of age and older
Open this publication in new window or tab >>The influence of heart failure on longitudinal changes in cognition among individuals 80 years of age and older
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2012 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 21, no 7-8, 994-1003 p.Article in journal (Refereed) Published
Abstract [en]

Aim.  The aim of this study was to examine the relationship between heart failure and specific cognitive abilities in octogenarians with regard to level and change over time.

Background.  Cognitive impairment is influenced by many factors, and the impact of heart failure is debated. Intact cognitive ability is crucial for successful self-care in patients with heart failure. Middle-aged patients with heart failure seem to have an increased risk of cognitive impairment. No studies have examined the association between heart failure and longitudinal cognitive changes in octogenarians (individuals 80 years and older).

Design.  A prospective longitudinal design.

Methods.  Cognitive tests were carried out five times (1991–2002) in 702 octogenarians from the Swedish Twin Registry, including same-sex twin pairs. The test battery included the measurement of processing speed, visuospatial ability, short-term, episodic and semantic memory. Latent growth curve modelling was employed to measure change and performance over time and compares the group diagnosed with heart failure to individuals without a heart failure diagnosis.

Results.  At baseline, the participants’ mean age was 83·5 years, 67% were women and 13% suffered from heart failure. Individuals diagnosed with heart failure scored significantly lower in spatial abilities and episodic memory than participants not diagnosed with heart failure. Moreover, measures of episodic memory declined more over time in individuals diagnosed with heart failure. There were no significant differences between the groups in other cognitive tests.

Conclusion.  Spatial problems and episodic memory have implications for everyday life. This might contribute to decreased adherence to prescribed therapy and self-care management and lead to socio-behavioural problems because of an impaired capacity to drive, read and write.

Relevance to clinical practice.  Nurses should take into account in their assessment that cognitive impairment may restrain elderly heart failure patient’s ability to make decisions and perform self-care actions. Patient education strategies should also be adapted to cognitive ability.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2012
Keyword
chronic heart failure, cognitive dysfunction, episodic memory, heart failure, neuropsychological testing, octogenarians, patient education, self-care, spatial abilities
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-74495 (URN)10.1111/j.1365-2702.2011.03817.x (DOI)000301427600012 ()21883570 (PubMedID)
Note

funding agencies|Health Research Council in the South-East of Sweden||Faculty of Health Science at LinkopingUniversity||US National Institute on Aging of the National Institutes of Health| NIA:AG08861 |Swedish Council for Working Life and Social Research||Adlerbertska Foundation||Hjalmar Svensson Foundation||Knut and Alice Wallenberg Foundation||Wennergren Foundations||Wilhelm and Martina Lundgrens Foundation||Department of Medical Epidemiology and Biostatistics||Karolinska Institute, Stockholm, Institute of Gerontology, School of Health Sciences, Jonkoping||

Available from: 2012-01-30 Created: 2012-01-30 Last updated: 2017-12-08Bibliographically approved
2. Factors Associated With Increased Risk for Dementia in Individuals Age 80 Years or Older With Congestive Heart Failure
Open this publication in new window or tab >>Factors Associated With Increased Risk for Dementia in Individuals Age 80 Years or Older With Congestive Heart Failure
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2014 (English)In: Journal of Cardiovascular Nursing, ISSN 0889-4655, E-ISSN 1550-5049, Vol. 29, no 1, 82-90 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND AND RESEARCH OBJECTIVE:: An increasing body of evidence shows that individuals diagnosed with congestive heart failure (CHF) are at a higher risk for dementia. However, the prevalence rate of dementia among persons with CHF in very old individuals has not been previously reported, and little is known about the comorbidities that place old persons with CHF at a higher risk for dementia. The aim of this study was to compare the prevalence of dementia in individuals 80 years or older who have CHF with that in individuals without CHF and to identify factors related to dementia in individuals diagnosed with CHF.

METHODS:: A total of 702 participants from a Swedish population-based longitudinal study (Octogenerian Twin) were included. The group consisted of same-sex twin pairs, age 80 years or older, and 138 participants had CHF. Dementia was diagnosed according to criteria in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. Generalized estimating equations including gender, age and educational level, waist circumference, diabetes, hypertension, smoking, depression, and blood values were used in a case-control analysis.

RESULTS:: Individuals with CHF had a significantly higher prevalence of vascular dementia, 16% vs 6% (P < 0.001), and of all types of dementia, 40% vs 30% (P < 0.01), than those not diagnosed with CHF. The generalized estimating equation models showed that depression, hypertension, and/or increased levels of homocysteine were all associated with a higher risk for dementia in individuals with CHF. Diabetes was specifically associated with an increased risk for vascular dementia.

CONCLUSIONS:: The prevalence of dementia was higher among individuals with CHF than in those without CHF. Diabetes, depression, and hypertension in patients with CHF require special attention from healthcare professionals because these conditions are associated with an elevated risk for dementia. Higher levels of homocysteine were also found to be a marker of dementia in patients with CHF. Further research is needed to identify the factors related to dementia in individuals 80 years or older diagnosed with CHF.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-96804 (URN)10.1097/JCN.0b013e318275543d (DOI)000328934000013 ()23369853 (PubMedID)
Available from: 2013-08-27 Created: 2013-08-27 Last updated: 2017-12-06Bibliographically approved
3. Association between sleep-disordered breathing, sleep–wake pattern, and cognitive impairment among patients with chronic heart failure
Open this publication in new window or tab >>Association between sleep-disordered breathing, sleep–wake pattern, and cognitive impairment among patients with chronic heart failure
2013 (English)In: European Journal of Heart Failure, ISSN 1388-9842, E-ISSN 1879-0844, Vol. 15, no 5, 496-504 p.Article in journal (Refereed) Published
Abstract [en]

Aims Chronic heart failure (CHF) and sleep-disordered breathing (SDB) are often co-existing problems among the elderly. Apnoeic events may cause cognitive impairment. The aim of the study was to compare sleep and wake patterns, insomnia, daytime sleepiness, and cognitive function in community-dwelling CHF patients, with and without SDB, and to investigate the association between sleep-related factors and cognitive dysfunction.

Methods and results In this cross-sectional observational study, SDB was measured with an ApneaLink device and defined as an apnoea–hypopnoea index (AHI) ≥15/h of sleep. Sleep and wake patterns were measured with actigraphy for 1 week. Insomnia was measured with the Minimal Insomnia Symptom Scale, daytime sleepiness with the Epworth Sleepiness Scale, and cognitive function with a neuropsychological test battery. A total of 137 patients (68% male, median age 72 years, 58% NYHA functional class II) were consecutively included. Forty-four per cent had SDB (AHI ≥15). The SDB group had significantly higher saturation time below 90%, more difficulties maintaining sleep, and lower levels of daytime sleepiness compared with the non-SDB group. Cognitive function and sleep and wake patterns did not differ between the SDB and the non-SDB group. Insomnia was associated with decreased global cognition.

Conclusion The prevalence of cognitive dysfunction was low in this population with predominantly mild to moderate CHF. This might have influenced the lack of associations between cognitive function and SDB. Insomnia was the only sleep-related factor significantly influencing cognition.

Place, publisher, year, edition, pages
Oxford University Press (OUP): Policy B, 2013
Keyword
Chronic heart failure, Cognitive dysfunction, Sleep-disordered breathing, Sleepwake pattern, Insomnia
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-93967 (URN)10.1093/eurjhf/hft014 (DOI)000318552200004 ()
Note

Funding Agencies|Research Council in South-East Sweden (FORSS)||Heart-Lung Foundation||Ostergotland County Council||Linkoping University||Linkoping University Hospital, Sweden||

Available from: 2013-06-13 Created: 2013-06-13 Last updated: 2017-12-06Bibliographically approved
4. The association between self-care and cognitive dysfunction in patients with chronic heart failure
Open this publication in new window or tab >>The association between self-care and cognitive dysfunction in patients with chronic heart failure
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2015 (English)In: Heart & Lung, ISSN 0147-9563, E-ISSN 1527-3288, Vol. 44, no 4, 113-119 p.Article in journal (Refereed) Published
Abstract [en]

Aim: To test the relationship between cognitive function and self-care in patients with heart failure after adjusting for the contribution of age, education, functional status, myocardial stress, sleep and depression. Further, the relationship between cognitive function and self-care was explored with depression and sleep as moderators.

Background: Self-care can significantly impact functional capacity, well-being, morbidity, and prognosis in patients with heart failure (HF). However, self-care requires the cognitive ability to learn, perceive, interpret and respond. The influence of demographics and clinical symptoms on the relationship between cognition and self-care needs to be further understood.

Design: Descriptive, cross-sectional study.

Methods: The study included 142 patients with chronic HF (68% male, median age 72 years, 61% in NYHA II). Self-care was measured with the European Heart Failure Self-Care Behavior Scale. Cognitive function was evaluated with neuropsychological tests measuring global cognitive dysfunction, psychomotor speed, executive function, visual-spatial perception/construct, spatial performance, semantic and episodic memory.

Findings: Psychomotor function (speed and attention) measured with the Trail Making A was the only dimension of cognitive function significantly associated with self-care. Neither depressive symptoms, nor sleep disturbances  moderated the relation between cognitive function and selfcare.

Conclusion: Deficits in psychomotor speed have implications for how patients should be educated and supported to perform self-care. A decrease in sustained attention and ability to carry out more than one task at a same time could lead to difficulties in self-care. Screening for psychomotor speed is therefore advocated for patients with HF.

Place, publisher, year, edition, pages
New York: Elsevier, 2015
Keyword
Aging, Brain natriuretic peptides, Cognitive function, Depression, Heart failure, Nursing, Psychomotor speed, Patient education, Self-care, Sleep disordered breathing, Trail-making test
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-96805 (URN)10.1016/j.hrting.2014.12.003 (DOI)000351027400007 ()
Available from: 2013-08-27 Created: 2013-08-27 Last updated: 2017-12-06Bibliographically approved

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