Evidence-Based Practice Corner: Understanding the Needs of Heart Failure Patients

Heart failure is a serious and growing problem, especially for older adults. It’s the only major cardiovascular disease that’s increasing in prevalence, and is the most common diagnosis for hospital patients age 65 and older.

Good follow-up care, including taking medications properly, making healthy diet choices and monitoring changes in condition, is necessary to manage this deadly chronic illness. But what happens if heart failure patients aren’t able to follow care instructions—and their healthcare providers (and sometimes the patients themselves) don’t realize that they can’t?

Lisa BratzkeThat was what Lisa Bratzke, PhD, RN, ANP-BC, began suspecting, while working as a nurse practitioner in a cardiology clinic.

“No matter how much time we spent teaching our heart failure patients and giving them materials to help them at home about how to manage their disease, they were still frequently back in the office or hospitalized,” remembers Bratzke, who’s now an assistant professor at the University of Wisconsin–Madison School of Nursing.

Yet “they seemed like they wanted to genuinely not be in the hospital and not be seeing me. They just weren’t able to carry through when they got home.”

Through her research, Bratzke identified the problem: nearly half of heart failure patients living in the community suffer cognitive impairment. While the condition may not be apparent, delayed memory and decision making are especially impacted—and both are essential to follow-up care.

For example, a heart failure patient with cognitive impairment may easily relay back care instructions in the clinic, a common strategy to ensure that the patient understands. But after a 20 minute car ride home, the patient probably won’t be able to remember that information, due to difficulties with delayed memory.

When heart failure patients notice changes in their condition, their decision-making skills are key. Cognitive impairment may make it difficult or impossible for them to judge whether they should adjust their medications or call their care provider in response.

What can health care providers do to better support heart failure patients?

The first step is to be aware of the high prevalence of cognitive impairment among heart failure patients. It’s also important to realize that many patients attribute their cognitive changes to normal aging or are afraid to share that they’re experiencing difficulties. Rather than admitting that they’re struggling with balancing their checkbook, making a shopping list or planning meals, they may say that they no longer like to do those things.

People with heart failure have one of the highest 90-day hospital readmission rates, compared to other chronic illnesses. “Interventions where we have advanced practice or heart failure-trained nurses who follow patients at home initially, after hospitalization … calling them frequently or seeing them at home” are effective at keeping patients out of the hospital, Bratzke says. A similar approach may help cognitively impaired patients by effectively “taking over the brain function that’s lost.”

Heath care providers should consider heart failure patients’ support systems, including family members and caregivers. “We send a lot of information out and assume that the caregiver can take over,” but sometimes caregivers have their own health challenges, cautions Bratzke. “We can’t assume that the patient’s going to remember anything at all, so that puts a lot of extra burden on the caregiver.”

As more is understood about the cognitive impairment experienced by many heart failure patients, better health interventions can be developed. Major questions remain, including: When and how is the brain affected? Do cognitive abilities keep declining over time? Can brain function be restored?

The last question is of particular interest to Lisa Bratzke. Any intervention that boosts cognitive abilities will help patients manage their cardiovascular health, while improving their quality of life.

Exercise can restore cognitive function, but even low-impact exercise may not be a viable option for people with heart failure. Instead, Bratzke will explore whether meditation or other mindfulness practices benefit heart failure patients with cognitive impairment.

With “a little closer follow up and a little more frequent appointment schedules,” heart failure patients with cognitive impairment could not only stay out of the hospital, but see health improvements. “Acknowledging that cognitive impairment exists is half the battle,” says Bratzke.

–Diane Farsetta
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