The non-medical needs of heart failure patients

Patients who are terminally ill and their caregivers get the so-called palliative care which focuses on reducing the suffering of the patients and easing the burden off caregivers and family members. This type of care, however, is not provided to less severe (but nonetheless life-threatening) chronically ill patients and their families. However, there is a general feeling that some of their needs - especially non-medical needs - aren’t given the attention they deserve, according to a research study reported at the American Heart Association’s 10th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke. This is especially true in patients with heart failure (and their caregivers), who expressed distress over the following:

not knowing what to expect

being unable to relieve symptoms

a lack of communication with medical staff

Researchers at the University of Colorado Denver School of Medicine conducted in-depth interviews with 33 outpatients with heart failure and 20 caregivers. The interviewees were asked what the following in relation to the situation of having heart failure:

• What causes them distress?
• What would they find most helpful?
• What are the unmet needs with regards to symptom management, psychosocial care and planning?

The results of the interviews indicate that

Uncertainty causes a lot of distress.

Patients and their caregivers want to know more about what to expect about the disease, its management, and prognosis.

Patients also need more help with symptom relief.

Finally, patients and carers expressed their desire for more communication with their health care providers.

According to lead researcher Dr. David Bekelman

“Most teams treating heart failure are medically focused. There is little guidance on the emotional, financial, spiritual and social impact of heart failure. This study helps define a role for palliative care in addressing the needs of heart failure patients and their caregivers.”

It seems that chronically ill patients such as those with heart failure have unmet needs that go beyond just mere medical care. There is a need for psychological and social support for these patients and their caregivers. Previous studies have shown that heart patients are prone to depression that can affect their overall quality of life. Their caregivers are affected as well.

Dr. Bekelman continues:

“There are unmet needs in the management of this disease. People need to know what to expect in the future of the illness and require help in adjusting to the limitations of heart failure by learning what steps they can take to improve the quality of their lives.”

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Heart over head: cognitive problems in patients with chronic heart failure

Heart failure and cognitive decline - is there a link? This is the question that researchers from the University of California Davis Medical Center wanted to answer.

It may not be evident but heart health and brain health are closely linked. The UC Davis  study was conducted by comparing 50 heart failure patients with 50 controls (participants without heart failure). The demographics of the two groups (age, gender and estimated intelligence quotient) were very similar. The total of 100 participants were then assessed using 19 neurophysiological tests that asses the following:

• orientation
• attention
• memory
• executive function
• motor speed
• reaction times

The tests have been showed to be effective in measuring specific cognitive functions. The results of the assessments show that heart failure patients performed poorly compared to the control group in the majority of the tests. Other key results are:

• Heart failure patients had lower scores in 14 out of 19 test measures.
• 23% of heart failure patients had shown “mild to severe deficits in one or more aspects of memory, learning, attention, and/or reaction times.”
• Heart failure patients have a more than 4-fold risk for cognitive impairment than the controls

The severity of these cognitive deficits in this sample of HF patients was associated with several factors, namely depressed learning and previous heart attacks but not to the left ventricular ejection fraction (LVEF), depression, anxiety, or physical functioning, duration or the classification heart failure according to the New York Heart Association( NYHA) classification system.

Data on the link between heart functioning and brain function are very limited and the effects of chronic heart failure on cognitive functions are not fully understood. This study adds valuable data to this rather “underrecognized and underappreciated” issue. The results have some wide-encompassing clinical implications. According to lead author Dr Mary Jane Sauvé

“What it means in clinical practice is that when you give these patients verbal instructions, you also need to provide written materials because of patient difficulties with information requiring attention, learning, and memory functions; that you include the family in the discussion whenever possible; and that patients and families need to have a direct line to call if they are getting into trouble or become confused about the instructions. There is nothing more frustrating than a phone tree, even for people without [cognitive impairment].”

It is a fact that although screening for depression in cardiac patients is highly recommended, screening for cognitive deficits is not routine performed. However, cognitive problems can lead to non-compliance with therapy and medication regimen. Thus, this review paper recommends that

“…future research needs to focus on identifying a simple screening tool that nurses can use to screen for subtle changes in cognition including forgetfulness and delayed recall. Early identification of subtle cognitive changes has the potential to guide healthcare providers to formulate feasible strategies to understand and/or prevent a low cardiac output state before major cognitive impairment becomes evident.”

 

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Why South African heart failure patients are young and female

Young and female - this is the typical demographic profile of heart failure patients in South Africa. “Heart failure patients in Soweto, South Africa, are more likely to be middle-aged and female compared to patients in Western nations.” according to a recent study.

So why the difference compared to Western countries? According to the study, the contributing factors are probably the following:

• increased incidence of hypertension
• heart valve disorders
• increasing urbanization

Urbanization is especially of significance because increase in heart problems has also been observed in urbanized parts of more affluent countries. This suggests that with economic development and affluence come lifestyle changes in the population - e.g. eating more processed less nutritious food and decreased physical activity - that is unfortunately unhealthy. However, unlike in developed countries, the health care system of developing countries like South Africa is not ready to handle the problems. However, there is more to South Africa’s heart problems that initially thought.

The South African report published in Circulation: Journal of the American Heart Association gives the following figures:

Eighty-eight percent of the new heart failure patients were black Africans.

Their average age was 55, and 57 percent were women.

About 90 percent had at least one cardiovascular risk factor - with hypertension being the most common (60 percent).

Twenty-seven percent of patients had right heart failure (reduced pumping ability in the right heart chambers).

The high percentage of isolated right heart failure - 27% - surprised the authors. Usually right heart failure which occurs as a consequence of left heart failure. The incidence of isolated heart failure in the South Africana population studied is 10 times more than what has been observed in western countries where left heart failure is more prevalent. Right heart failure is associated to damage to the lungs and pulmonary vessels usually seem is smokers.The authors speculate that air pollution - both environmental and occupation - may be a major factor. Pollution, of course, especially traffic-generated fine particle pollution, is another price of urbanization.

Another interesting finding of the study is the fac t that new cases of heart failure involved women who were on the average, 3 years younger than men. Most of these women are of reproductive age, thus indicating “pregnancy-related heart failure, as post-partum cardiomyopathy occurs more frequently in black African women.”

The study authors went on to say that is clearly a need for gender-specific programs for prevention, screening and management of heart failure in South Africa.

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The link between heart failure and bone fractures

Depression, poor quality of life, and now, increased risk for bone fractures. Is there no end to the problems facing heart failure patients? Unfortunately, a study by Canadian researchers found a link between heart failure and incidence of bone fractures.

“Patients who are newly diagnosed with heart failure in the emergency department are at least four times as likely to suffer serious bone fractures over the next year compared with patients presenting to the emergency department with other CV disorders.”

The analysis was based on hospital data from over 16,000 patients. 2041 of these patients were just newly diagnosed with heart failure. The remaining 14,253 had other cardiovascular conditions. The incidence of any orthopedic bone fracture among heart failure patients was more than 4 times higher (4.6% vs. 1%) than those without heart failure. The figures did not significantly change when corrected for age, sex, and medications. Of all types of fractures, hip fractures are the most common with more than 6% higher risk among heart failure patients. This is especially disturbing because hip fractures are difficult to heal, cause prolonged disability and increase the risk for thrombosis and lung infections.

The mechanism behind the heart failure - bone fracture link is not clear and requires bigger and more in-depth studies. A possible explanation might be the fact that long term heart failure can cause secondary parathyroidism. Parathyroidism is a condition wherein the parathyroid glands are enlarged. The glands are responsible for controlling the breakdown of calcium in the body. Dysfunction of the parathyroid glands can cause bone loss and high levels of blood calcium. Other factors which can further weaken the bones may be poor nutrition and lack of exercise among elderly depressed heart failure patients.

Heart failure is a chronic disease that worsens over time until the heart completes loses the capacity to pump. According to the American Heart Association, “more than 5 million Americans are living with heart failure, and 550,000 new cases are diagnosed each year.” According to the study, heart failure is also a leading cause of hospitalizations and mortality in Canada. It occurs in 2.2% of the general population and 8.4% in adults older than 75.

The results of the study also highlight a possible link between heart failure and osteoporosis. The incidence of osteoporosis is about 25% in females and 12% in males among adults 50 years old and above.

The study continues to say that

“heart failure and osteoporosis also share common risk factors such as older age, female sex, smoking and type-2 diabetes.”

However, with the proper preventive measures, such as lifestyle changes and knowing the early signs, heart failure need not be a death sentence.

               

There’s no place like home: home monitoring program for cardiovascular patients

Is home monitoring by patients with heart disease and/or hypertension a feasible alternative? According to experts and results of recent studies, there’s actually no place like home for monitoring cardiovascular patients.

 

Hypertension patients

In a recent joint scientific statement by the American Heart Association (AHA), American Society of Hypertension (ASH), and Preventive Cardiovascular Nurses Association (PCNA), experts push for more home monitoring programs of hypertension patients.

“Given the amount of accumulated evidence about the value of home blood-pressure monitoring (HBPM), it is time to make HBPM a part of routine management of hypertensive patients, especially those with diabetes, coronary heart disease, chronic kidney disease, substantial nonadherence, or a substantial white-coat effect.”

according Dr Thomas Pickering, who is a member of the scientific committee who write the statement, as quoted by heartwire.

HBPM is recommended to be a routine part of the management of hypertension, be it known or suspected. It is also recommended for those with the so-called “white-coat hypertension” because routine monitoring may detect “masked hypertension” before it becomes critical.

The committee notes that regular use of home monitoring will improve the quality as lower the cost of health care to the 72 million people with some form of hypertension. It urges the reimbursement of HBPM costs by health insurance.

The use of HBPM has gained popularity in recent years as people’s health literacy improved. According to a recent Gallup poll:

The number of patients monitoring their BP at home has increased steadily over the past 5 years, being 38% in 2000 and 55% in 2005, an increase of 17%. 

The proportion of patients owning a monitor has increased from 49% in 2000 to 64% in 2005.

Of patients who do not own monitors, 14% said that expense was the reason.

Heart failure patients

According to another study, home monitoring programs of heart failure patients may actually be more beneficial than initially thought, Health Day News reports

110 patients at the Massachusetts General Hospital in Boston were randomly divided into 2 groups. One group of 68 patients received the usual follow-up care for heart failure patients. Another group of 42 patients were monitored remotely while they stayed at home. The patients in the remote care group had remote monitoring equipment attached that measured vital signs such as heart rate, pulse and blood pressure. They also measured their weight daily and answered a questionnaire about their general well-being. When any of the remote care patients show abnormal values, a health care professional makes a house visit to make a proper assessment. The remote care program is called the Connected Cardiac Care program and was conducted by the Center for Connected Health.

After 3 months of follow-up, patients in the remote care group had much lower hospital readmission rates (31%) compared to the control group (38%). The remote care group also had lower incidence of heart-failure related admissions and emergency room visits.

In a future resource post, I will go into detail about different home monitoring programs available.

Source:

Pickering TG, Houston-Miller N, Ogedegbe G, et al. Call to action on use and reimbursement for home blood pressure monitoring. Hypertension 2008.

Health Day News, 1 May 2008

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Depression in heart patients: exercise plus psychological therapy work best

In a previous post, I touched on the beneficial effects of laughter and positive emotions on our heart and vascular system. It is very common however, that heart patients, especially those above 60, suffer from depression, thereby further worsening their underlying heart conditions. However, a recent study conducted by researchers at Emory University in Atlanta, Georgia may just have found a rehabilitation program that seems to greatly benefit heart patients physically as well as psychologically.

The researchers studied 74 patients who had heart failure and have been diagnosed with depression. The patients were split 4 groups, with each group receiving a different type of home-based rehabilitation program for 3 months, as described below:

• exercise and psychological counselling
• psychological counselling only
• exercise only
• no interventions

Physical exercise consisted of walking for at least 30 minutes three times a week, with low-to-moderate intensity. Patients involved in exercise had heart rate monitors installed. They were taught how to self-monitor their physical exertion levels, and recognize the point when they have to stop exercise.

The type of psychological counselling used in the study was known as cognitive behavioural therapy. The counselling sessions were conducted one-to-one at the patients’ homes by psychiatric nurse specialists. “These sessions were designed to encourage patients to think positively and ‘reformat’ their beliefs about their illness and activity limitations.”

The results of the study after 3 months show that the group assigned to the exercise plus psychological counselling program performed significantly better in terms of physical recovery and overcoming depression compared to the other group. They also experienced better improvement in quality of life. The group assigned to psychological counselling only also improved in overcoming depressive symptoms but not as well as the first group. As expected, the group which did not have any rehabilitation program performed the worst.

There are several reasons why heart patients are depressed. Disability, loss of productivity, disturbed sleeping patterns, as well as financial worries are just a few.

In another related study by Swedish researchers, fear of death seems to be a major factor that causes heart patients to be depressive.

“Elderly patients with heart failure had a lot of thoughts about death. Higher levels of anxiety/depression were correlated to fear of death. Many expressed death as a natural relief from suffering, others were afraid of pain, loss of independence and dignity.”

It seems that a two-pronged approach to rehabilitation, one that caters to the body as well as to the soul, is the best way to help heart patients get back on their feet again.

“Heart failure patients who suffer from depression may benefit from exercise combined with psychological therapy to improve their physical function, reduce their depressive symptoms and enhance quality of life.”

Photo credit

               

There’s no place like home: home monitoring program for cardiovascular patients

Is home monitoring by patients with heart disease and/or hypertension a feasible alternative? According to experts and results of recent studies, there’s actually no place like home for monitoring cardiovascular patients.

Hypertension patients

In a recent joint scientific statement by the American Heart Association (AHA), American Society of Hypertension (ASH), and Preventive Cardiovascular Nurses Association (PCNA), experts push for more home monitoring programs of hypertension patients.

“Given the amount of accumulated evidence about the value of home blood-pressure monitoring (HBPM), it is time to make HBPM a part of routine management of hypertensive patients, especially those with diabetes, coronary heart disease, chronic kidney disease, substantial nonadherence, or a substantial white-coat effect.”

according Dr Thomas Pickering, who is a member of the scientific committee who write the statement, as quoted by heartwire.

HBPM is recommended to be a routine part of the management of hypertension, be it known or suspected. It is also recommended for those with the so-called “white-coat hypertension” because routine monitoring may detect “masked hypertension” before it becomes critical.

The committee notes that regular use of home monitoring will improve the quality as lower the cost of health care to the 72 million people with some form of hypertension. It urges for the reimbursement of HBPM costs by health insurance.

The use of HBPM has gained popularity in recent years as people’s health literacy improved. According to a recent Gallup poll:

The number of patients monitoring their BP at home has increased steadily over the past 5 years, being 38% in 2000 and 55% in 2005, an increase of 17%.

The proportion of patients owning a monitor has increased from 49% in 2000 to 64% in 2005.

Of patients who do not own monitors, 14% said that expense was the reason

Heart failure patients

According to another study, home monitoring programs of heart failure patients may actually be more beneficial than previously thought, Health Day News reports.

110 patients at the Massachusetts General Hospital in Boston were randomly divided into 2 groups. One group of 68 patients received the usual follow-up clinic-based care for heart failure patients. Another group of 42 patients were monitored remotely while they stayed at home. The patients in the remote care group had remote monitoring equipment attached that measured vital signs such as heart rate, pulse and blood pressure. They also measured their weight daily and answered a questionnaire about their general well-being. When any of the remote care patients show abnormal values, a health care professional makes a house visit to make a proper assessment. The remote care program is called the Connected Cardiac Care program and was conducted by the Center for Connected Health.

After 3 months of follow-up, patients in the remote care group had much lower hospital readmission rates (31%) compared to the control group (38%). The remote care group also had lower incidence of heart-failure related admissions and emergency room visits.

In a future resource post, I will go into detail about different home monitoring programs available.

Source:

Pickering TG, Houston-Miller N, Ogedegbe G, et al. Call to action on use and reimbursement for home blood pressure monitoring. Hypertension 2008.

Health Day News, 1 May 2008

 

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