TY - JOUR
AU - Agar, Meera
AB - Abstract Background The purpose of this systematic review was to (a) examine the effects of interventions delivered by a heart failure professional for mild cognitive impairment and dementia on cognitive function, memory, working memory, instrumental activities of daily living, heart failure knowledge, self-care, quality of life and depression; and (b) identify the successful elements of these strategies for heart failure patients with mild cognitive impairment or dementia. Methods and results During March 2018, an electronic search of databases including CINAHL, MEDLINE, EMBASE and PsycINFO was conducted. All randomised controlled trials, which examined an intervention strategy to help heart failure patients with mild cognitive impairment or dementia cope with self-care, were included. An initial search yielded 1622 citations, six studies were included (N= 595 participants, mean age 68 years). There were no significant improvements in cognitive function and depression. However, significant improvements were seen in memory (p=0.015), working memory (p=0.029) and instrumental activities of daily living (p=0.006). Nurse led interventions improved the patient’s heart failure knowledge (p=0.001), self-care (p<0.05) and quality of life (p=0.029). Key elements of these interventions include brain exercises, for example, syllable stacks, individualised assessment and customised education, personalised self-care schedule development, interactive problem-solving training on scenarios and association techniques to prompt self-care activities. Conclusions Modest evidence for nurse led interventions among heart failure patients with mild cognitive impairment or dementia was identified. These results must be interpreted with caution in light of the limited number of available included studies. Mild cognitive impairment, heart failure, dementia, nurse led interventions Introduction Globally, heart failure is a major public health challenge. Heart failure is the leading cause of hospitalisation in individuals aged over 65 years and is associated with increased length of stay, re-hospitalisations and a high risk of mortality.1 As populations age, the incidence of heart failure continues to rise.2 In addition to the high symptom burden and negative impact on quality of life, individuals with heart failure are at risk of developing mild cognitive impairment (MCI) and dementia.3 Many studies in the last decade have shown a correlation between heart failure and MCI although the exact underlying pathophysiological mechanisms are not well elucidated or understood.4 The prevalence of MCI in patients with heart failure ranges from 50% to 80%.1,3 Those living with multiple comorbidities such as heart failure, MCI or dementia are among the most frequent users of the health system, and there is an urgency for research that addresses the unmet needs in this group as the complexity and increased burden of multimorbidity is recognised.5,6 Health care systems based around increasingly narrow specialist care require careful redesign and innovative interventions that recognise and manage the complex realities faced by older multimorbid patients. Increasingly with rising rates of multimorbidity, the paradigm of one patient one disease no longer exists. It is critical to consider the impact this complex interplay of challenging comorbidities and associated symptom management has on an individual’s ability to self-care.2,7 The significant issues facing older people living with heart failure are compounded when MCI is also present. Individuals with heart failure have been reported to have poorer attention, memory and executive function,8 as well as impairments in cognitive processing speed.9,10 As an individual’s MCI progresses, the risk of morbidity and mortality, hospitalisation, adverse events and receiving conflicting advice and treatment from health care providers also increases.9 Patients may have difficulty addressing self-care activities, including engaging in instrumental activities of daily living and achieving short- and long-term adherence to the typically extensive requirements of optimal heart failure therapy.4 Despite this, there are few intervention programmes tailored to the specific needs of heart failure patients with mild cognitive impairment or dementia in clinical practice. In addition, no routine formal evaluation of the individual’s cognitive status is typically performed. Further, there is no expert consensus on the best method or timing of cognitive assessment.4 This paper (a) systematically examines the effects of interventions delivered by a heart failure professional for MCI and dementia on cognitive function, memory, working memory, instrumental activities of daily living (IADLs), heart failure knowledge, self-care, quality of life and depression, and (b) identifies the successful elements of these strategies for heart failure patients with MCI or dementia. Design and method This systematic review was designed, conducted and reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines11 and registered on PROSPERO (ref.: CRD42019119334), the international prospective register of systematic reviews. Search method Key electronic bibliographic databases search included CINAHL, Medline, EMBASE and PsycINFO. The following search terms were used: (‘heart failure’ OR ‘cardiac failure’) AND (‘cognitive impairment’ OR ‘dementia’) AND (‘intervention’ OR ‘tailored intervention’) OR ‘multidisciplinary intervention’. The reference lists of returned articles were hand searched to snowball for additional studies. The full detailed search strategy applied to identify potential studies in the electronic bibliographic database is represented in Appendix 1. Types of studies Studies included in this review were randomised controlled trials (RCTs) that compared targeted self-care educational programmes with a control condition such as usual heart failure care. The settings of the interventions were inpatients, outpatients/in-community and aged care facilities. Only primary research studies were included. Types of participants Included studies recruited patients with heart failure and concomitant MCI. Patients had confirmed diagnosis of heart failure regardless of severity, scored <26 in the Montreal Cognitive Assessment tool, or ⩽ 23 in the Mini Mental State Examination (MMSE) and were aged 18 years or older. Types of interventions Studies describing any structured programme including team, nurse or multidisciplinary led intervention delivering memory/cognitive training or a self-care management programme were included. The programme was required to be delivered by a heart failure professional (for example a heart failure nurse practitioner) to the patient. Usual care included standard medical care without any form of structured education or counselling. Outcomes The primary outcome observed was cognitive function, including working memory. Secondary outcomes were, IADLs, heart failure knowledge, self-care knowledge, health-related quality of life (HRQoL), depression and hospital admissions. Selection of studies All 1622 studies returned from the search were screened for eligibility by two independent reviewers (SA and LH), who reviewed titles, abstracts and full text. Any disagreements were resolved by discussion and, if necessary, a third reviewer (CF) was consulted to achieve consensus Data extraction and analysis Full text data extraction was performed in Covidence12 by the first reviewer (SA). The extracted data was then reviewed by a second reviewer (LH). Data obtained included general information, study eligibility, population and setting, method, risk of bias assessment, participants, intervention group, outcomes and results. As per study selection two reviewers (LH and SA) worked independently and disagreements were resolved through consensus, or in consultation with a third reviewer (CF). Quality and bias assessment The methodological quality of included studies was assessed using the CONSORT checklist for reporting randomised trials13 and the Template for Intervention Description and Replication (TIDieR) checklist.14 The CONSORT Statement is a 25-item checklist which focuses on reporting how the trial was designed, analysed and interpreted.13 The TIDieR checklist is an extension of the CONSORT Statement which is used in conjunction with the CONSORT checklist.14 Risk of bias was assessed using the Cochrane Collaboration Assessment of bias tool.15 Domains assessed included: sequence generation, allocation concealment, blinding of outcome assessment, incomplete data, selective outcome reporting and other sources of bias, for example, conflict of interest in Covidence.12 Responses on each domain were assessed as ‘low’, ‘unclear’ or ‘high’ risk of bias. Results The initial search yielded 2592 citations. After duplicates were removed, 1622 studies remained. Of these, 1610 were excluded as they did not meet the combined inclusion criteria of a heart failure, MCI and/or dementia population receiving an intervention. Twelve full text articles were reviewed. Of these, six studies were excluded for the following reasons: protocol only (n=2); dissertation or theses (n=1); exercise training interventions (n=2) and did not include cognitively impaired or dementia heart failure patient (n=1). Thus, a total of six studies were included in this systematic review (Figure 1). Figure 1. Open in new tabDownload slide PRISMA flow diagram of included studies Study characteristics The final six studies that met the eligibility criteria included 595 heart failure patients. The mean age of the patients was 68 years and ranged from 58 to 77 years. The study sample sizes ranged from N=27 to N=173 participants. Four of the six studies were conducted in the United States and the other two studies were conducted in Europe. Quality assessment and bias The quality of the studies as assessed by the Consort and TIDieR checklists varied widely. All six studies met 13 of the Consort and TIDieR assessment criteria. Overall, the studies specified the background and objectives of their study, eligibility criteria of participants and sufficient details of the intervention, primary and secondary outcome measures, sample size and statistical methods. In addition, the studies also provided a participant flow diagram, complete baseline data, limitations, generalisability and interpretation of the studies and information on their funding sources. Only three studies described the method of sequence generation and four studies indicated that allocation was concealed. Only one study reported blinding of subjects, personnel or outcome assessors. And, three studies provided a trial registration number. Using the Cochrane Collaboration tool for assessing risk of bias, six studies were assessed as ‘low’ risk of bias on one of the six items: selective reporting (Table 1). Five of the studies were assessed as ‘low’ risk of bias on incomplete outcome data. All six studies were assessed as ‘unclear’ risk of bias for blinding of participants and personnel and five studies were assessed as ‘unclear’ risk of bias for blinding of outcome assessment. The key reasons for this assessment were a lack of detail in describing the method of blinding participants and personnel and outcome assessment. Table 1. Risk of bias assessment of the included randomised controlled trial studies First author (year) . Random sequence generation . Allocation concealment . Blinding of participants and personnel . Blinding of outcome assessment . Incomplete outcome data . Selective outcome reporting . Other bias . Davis (2012) Unclear Unclear Unclear Unclear Low Low Low Del Sindaco (2012) Low Low Unclear Low Low Low Low Karlsson (2005) Low Low Unclear Unclear Low Low Low Pressler (2015) Unclear Unclear Unclear Unclear Low Low Low Pressler (2011) Low Low Unclear Unclear High Low Low Viveiros (2017) Unclear Low Unclear Unclear Low Low Low First author (year) . Random sequence generation . Allocation concealment . Blinding of participants and personnel . Blinding of outcome assessment . Incomplete outcome data . Selective outcome reporting . Other bias . Davis (2012) Unclear Unclear Unclear Unclear Low Low Low Del Sindaco (2012) Low Low Unclear Low Low Low Low Karlsson (2005) Low Low Unclear Unclear Low Low Low Pressler (2015) Unclear Unclear Unclear Unclear Low Low Low Pressler (2011) Low Low Unclear Unclear High Low Low Viveiros (2017) Unclear Low Unclear Unclear Low Low Low Open in new tab Table 1. Risk of bias assessment of the included randomised controlled trial studies First author (year) . Random sequence generation . Allocation concealment . Blinding of participants and personnel . Blinding of outcome assessment . Incomplete outcome data . Selective outcome reporting . Other bias . Davis (2012) Unclear Unclear Unclear Unclear Low Low Low Del Sindaco (2012) Low Low Unclear Low Low Low Low Karlsson (2005) Low Low Unclear Unclear Low Low Low Pressler (2015) Unclear Unclear Unclear Unclear Low Low Low Pressler (2011) Low Low Unclear Unclear High Low Low Viveiros (2017) Unclear Low Unclear Unclear Low Low Low First author (year) . Random sequence generation . Allocation concealment . Blinding of participants and personnel . Blinding of outcome assessment . Incomplete outcome data . Selective outcome reporting . Other bias . Davis (2012) Unclear Unclear Unclear Unclear Low Low Low Del Sindaco (2012) Low Low Unclear Low Low Low Low Karlsson (2005) Low Low Unclear Unclear Low Low Low Pressler (2015) Unclear Unclear Unclear Unclear Low Low Low Pressler (2011) Low Low Unclear Unclear High Low Low Viveiros (2017) Unclear Low Unclear Unclear Low Low Low Open in new tab Types of studies All included studies (N=6) were parallel RCTs comparing an intervention group with a control group. Types of participants The studies included adults with a primary diagnosis of heart failure (Table 2). All six studies reported heart failure disease severity based on the New York Association (NYHA) classification and included persons with mild to severe functional limitations (NYHA grade II–IV). There were no studies that specifically addressed the needs of patients with heart failure and dementia. Table 2. Study characteristics of included studies First author (year), country . Design . Sample and participants . Method . Outcome measures . Key findings . Davis (2012), USA RCT N=125 HF with MCI MoCA score <26 62 control (54 complete) 63 intervention (55 complete) Mean MoCA 21.1 ± 2.4 Mean age 59 ± 13 years Male 80% Mean LVEF 34 ± 19 46% NYHA class II, 47% III Measures at baseline and 30 days post-discharge Intervention – targeted self-care teaching using cognitive training for impairments in memory and executive functioning and improving self-confidence Control – discharge teaching for HF; education booklet – dietary and fluid restrictions, symptom recognition and management, exercise and medication adherence 1. HF knowledge – Self-Care of Heart Failure Index (SCHFI) 2. Self-care behaviour –SCHFI 3. Depression – Geriatric Depression Scale 4. Social Support ENRICHD Social Support 5. Readmission rates Mean HF knowledge scores improved (p = 0.001) Mean change scores for self-care improved (not statistically significant) Over half reported depressive symptoms Perceived Social Support high No difference in readmission rates Del Sindaco (2012), Italy RCT N=173 (86 MP and 87 UC) community-living outpatients with HF 60.7% in NYHA III–IV Mean age 77 ± 6 years Male 52% Mean LVEF 33.4 ± 10.7 MMSE score 42% ⩽24 Phone-based follow-up at one and three months after discharge and then six monthly for two years Intervention – MP included discharge planning, patient and caregiver education, therapy optimisation, improved communication and early attention to signs/symptoms Control – UC received treatments and services ordered by physician and/or cardiologist 1. All cause death 2. All cause admission 3. All cause death or HF admission 4. Total costs of care Cognitive impairment across both groups was associated with all-cause death (HR 3.6 (95% CI 1.5–8.3)), HF deaths (HR 2.0 (95% CI 1.2–3.4)) and HF admissions (HR 2.4 (95% CI 1.4–4.3)) MP group showed significant reduction in HF admissions vs. UC (HR 0.5 (95% CI 0.2–0.9)) p=0.007 Karlsson (2005), Sweden RCT N=146 HF patients (72 intervention 74 control Mean LVEF 34% 63.6% NYHA class II 35.6% NYHA class III Mean age 76 ± 7.5 years Male 60.2% MMSE score 12% < 24 HF knowledge, self-care and cognitive function measured at baseline and six months. Intervention – nurse-based outpatient management programme (medication dose changes, verbal and written HF information), self-care, interactive computerised information programme Control – follow-up by GP and treated according to the local health care plan for HF 1. Knowledge of self-care and HF – structured questionnaire made by investigators 2. Cognitive function – MMSE Increased knowledge of self-care at six months for females in the intervention group (p<0.05) Patients with MMSE <24 (n=18) had lower scores on HF knowledge at baseline (10.1± 3.6) vs. (12.8± 3.4) (p<0.01) but not at six months Pressler (2015), USA RCT N=27 HF patients – 13 Brain Fitness (12 completed) and 14 health education (13 completed) 14.8% in NYHA class II-III (13 intervention, 14 control) Mean age 61 ± 11.9 years Male 78% Mean LVEF 28 ± 13.1 MoCA 26.6 ± 2.2 Memory, working memory, processing speed, verbal fluency, IADL, functional mobility, depressive symptoms and HRQoL measured at baseline, eight and 12 weeks. Serum BDNF measured at baseline and at two weeks. Brain Fitness intervention – computerised cognitive training programme completed in 40 h over eight weeks (1 h daily, 5 days/week) Health education intervention – An active control which involved reading eight issues of Heart Insight over eight weeks (1 h each week) 1. Memory – Hopkins Verbal Learning Test-Revised CogState Health computerised neuropsychologic test battery 2. Working memory – Identification and One Back Accuracy Tasks 3.Working memory detection task 4. IADL – The Everyday Problems Test for Cognitively Challenged 5. Depressive symptoms – Patient Health Questionnaire 6. HRQoL – Minnesota Living with HF Questionnaire No differences were found in memory but a group and a group-by-time interaction effect was found for working memory in the One Back Accuracy Task (p=0.046). Pressler (2011), USA RCT N=40 patients with HF (21 Brain Fitness and health education) Mean age 57.8 ± 13.1 Male 70% Mean LVEF 26.7 ± 10.3 50% in NYHA class II Memory, psychomotor speed, verbal fluency and working memory measured at baseline, 8 and 12 weeks. Self-reported cognitive activity and IADLs assessed at baseline and 12 weeks. Patient satisfaction at 12 weeks Brain Fitness intervention – computerised cognitive training programme completed in 40 h over eight weeks (1 h daily/5 days) Health education intervention – Active control – reading eight issues of Heart Insight over eight weeks (1 h/week) 1. Memory – Hopkins Verbal Learning Test–Revised 2. Working memory – One Back Accuracy Tasks 3. IADL – The Everyday Problems Test for Cognitively Challenged Elderly Significant group-by-time interaction for delayed recall memory (p = 0.032), a time effect for list learning both total (p < 0.001) and delayed (p = 0.015), psychomotor speed (p = 0.029), performance of IADLs (p = 0.006) Viveiros (2017) USA RCT N=84 HF patients (two groups of 42 with MCI yes or MCI no, 21 intervention and 21 control in each) Mean age 71 ± 13 years Male 58% Mean LVEF 48 ± 15, 43% in NYHA class III, 40% class IV Intervention – learning condition of STSTa, 20 min non-related educational activity and test Attention-control – learning condition of SSSSb, 20 min non-related educational activity and then a test. 1. Cognitive impairment – MoCA tool 2. Depression – PHQ-2 3. Memory – HVLT-R No significant differences in memory between intervention and control (67.2 ± 18.8 vs. 61.9 ± 22.3; p=0.24). Age (p=0.018) and education (p=0.006) significant predictors of memory First author (year), country . Design . Sample and participants . Method . Outcome measures . Key findings . Davis (2012), USA RCT N=125 HF with MCI MoCA score <26 62 control (54 complete) 63 intervention (55 complete) Mean MoCA 21.1 ± 2.4 Mean age 59 ± 13 years Male 80% Mean LVEF 34 ± 19 46% NYHA class II, 47% III Measures at baseline and 30 days post-discharge Intervention – targeted self-care teaching using cognitive training for impairments in memory and executive functioning and improving self-confidence Control – discharge teaching for HF; education booklet – dietary and fluid restrictions, symptom recognition and management, exercise and medication adherence 1. HF knowledge – Self-Care of Heart Failure Index (SCHFI) 2. Self-care behaviour –SCHFI 3. Depression – Geriatric Depression Scale 4. Social Support ENRICHD Social Support 5. Readmission rates Mean HF knowledge scores improved (p = 0.001) Mean change scores for self-care improved (not statistically significant) Over half reported depressive symptoms Perceived Social Support high No difference in readmission rates Del Sindaco (2012), Italy RCT N=173 (86 MP and 87 UC) community-living outpatients with HF 60.7% in NYHA III–IV Mean age 77 ± 6 years Male 52% Mean LVEF 33.4 ± 10.7 MMSE score 42% ⩽24 Phone-based follow-up at one and three months after discharge and then six monthly for two years Intervention – MP included discharge planning, patient and caregiver education, therapy optimisation, improved communication and early attention to signs/symptoms Control – UC received treatments and services ordered by physician and/or cardiologist 1. All cause death 2. All cause admission 3. All cause death or HF admission 4. Total costs of care Cognitive impairment across both groups was associated with all-cause death (HR 3.6 (95% CI 1.5–8.3)), HF deaths (HR 2.0 (95% CI 1.2–3.4)) and HF admissions (HR 2.4 (95% CI 1.4–4.3)) MP group showed significant reduction in HF admissions vs. UC (HR 0.5 (95% CI 0.2–0.9)) p=0.007 Karlsson (2005), Sweden RCT N=146 HF patients (72 intervention 74 control Mean LVEF 34% 63.6% NYHA class II 35.6% NYHA class III Mean age 76 ± 7.5 years Male 60.2% MMSE score 12% < 24 HF knowledge, self-care and cognitive function measured at baseline and six months. Intervention – nurse-based outpatient management programme (medication dose changes, verbal and written HF information), self-care, interactive computerised information programme Control – follow-up by GP and treated according to the local health care plan for HF 1. Knowledge of self-care and HF – structured questionnaire made by investigators 2. Cognitive function – MMSE Increased knowledge of self-care at six months for females in the intervention group (p<0.05) Patients with MMSE <24 (n=18) had lower scores on HF knowledge at baseline (10.1± 3.6) vs. (12.8± 3.4) (p<0.01) but not at six months Pressler (2015), USA RCT N=27 HF patients – 13 Brain Fitness (12 completed) and 14 health education (13 completed) 14.8% in NYHA class II-III (13 intervention, 14 control) Mean age 61 ± 11.9 years Male 78% Mean LVEF 28 ± 13.1 MoCA 26.6 ± 2.2 Memory, working memory, processing speed, verbal fluency, IADL, functional mobility, depressive symptoms and HRQoL measured at baseline, eight and 12 weeks. Serum BDNF measured at baseline and at two weeks. Brain Fitness intervention – computerised cognitive training programme completed in 40 h over eight weeks (1 h daily, 5 days/week) Health education intervention – An active control which involved reading eight issues of Heart Insight over eight weeks (1 h each week) 1. Memory – Hopkins Verbal Learning Test-Revised CogState Health computerised neuropsychologic test battery 2. Working memory – Identification and One Back Accuracy Tasks 3.Working memory detection task 4. IADL – The Everyday Problems Test for Cognitively Challenged 5. Depressive symptoms – Patient Health Questionnaire 6. HRQoL – Minnesota Living with HF Questionnaire No differences were found in memory but a group and a group-by-time interaction effect was found for working memory in the One Back Accuracy Task (p=0.046). Pressler (2011), USA RCT N=40 patients with HF (21 Brain Fitness and health education) Mean age 57.8 ± 13.1 Male 70% Mean LVEF 26.7 ± 10.3 50% in NYHA class II Memory, psychomotor speed, verbal fluency and working memory measured at baseline, 8 and 12 weeks. Self-reported cognitive activity and IADLs assessed at baseline and 12 weeks. Patient satisfaction at 12 weeks Brain Fitness intervention – computerised cognitive training programme completed in 40 h over eight weeks (1 h daily/5 days) Health education intervention – Active control – reading eight issues of Heart Insight over eight weeks (1 h/week) 1. Memory – Hopkins Verbal Learning Test–Revised 2. Working memory – One Back Accuracy Tasks 3. IADL – The Everyday Problems Test for Cognitively Challenged Elderly Significant group-by-time interaction for delayed recall memory (p = 0.032), a time effect for list learning both total (p < 0.001) and delayed (p = 0.015), psychomotor speed (p = 0.029), performance of IADLs (p = 0.006) Viveiros (2017) USA RCT N=84 HF patients (two groups of 42 with MCI yes or MCI no, 21 intervention and 21 control in each) Mean age 71 ± 13 years Male 58% Mean LVEF 48 ± 15, 43% in NYHA class III, 40% class IV Intervention – learning condition of STSTa, 20 min non-related educational activity and test Attention-control – learning condition of SSSSb, 20 min non-related educational activity and then a test. 1. Cognitive impairment – MoCA tool 2. Depression – PHQ-2 3. Memory – HVLT-R No significant differences in memory between intervention and control (67.2 ± 18.8 vs. 61.9 ± 22.3; p=0.24). Age (p=0.018) and education (p=0.006) significant predictors of memory a STST: S: participants were given an opportunity to study 16 word pairs (GROUND–COLD) + T, a testing trial during which participants were presented the first word of the pair and tested on the recall of the partnered word, for example GROUND– ________. b SSSS: 16 word pairs were sequentially presented on a computer for 6 s (GROUND–COLD) in four learning cycles. BDNF, brain-derived neurotropic factor; CI, confidence interval; GP, general practitioner; HR, hazard ratio; HRQoL, health-related quality of life; HF, heart failure; HVLT-R, Hopkins Verbal Learning Test – Revised; IADL, instrumental activity of daily living; LVEF, left ventricular ejection fraction; MCI, mild cognitive impairment; MMSE, Mini Mental State Examination; MoCA, Montreal Cognitive Assessment Scale; MP, multidisciplinary programme; NYHA, New York Heart Association; PHQ-2, Patient Health Questionnaire-2; RCT: Randomised controlled trial; UC, usual care; USA, United States of America Open in new tab Table 2. Study characteristics of included studies First author (year), country . Design . Sample and participants . Method . Outcome measures . Key findings . Davis (2012), USA RCT N=125 HF with MCI MoCA score <26 62 control (54 complete) 63 intervention (55 complete) Mean MoCA 21.1 ± 2.4 Mean age 59 ± 13 years Male 80% Mean LVEF 34 ± 19 46% NYHA class II, 47% III Measures at baseline and 30 days post-discharge Intervention – targeted self-care teaching using cognitive training for impairments in memory and executive functioning and improving self-confidence Control – discharge teaching for HF; education booklet – dietary and fluid restrictions, symptom recognition and management, exercise and medication adherence 1. HF knowledge – Self-Care of Heart Failure Index (SCHFI) 2. Self-care behaviour –SCHFI 3. Depression – Geriatric Depression Scale 4. Social Support ENRICHD Social Support 5. Readmission rates Mean HF knowledge scores improved (p = 0.001) Mean change scores for self-care improved (not statistically significant) Over half reported depressive symptoms Perceived Social Support high No difference in readmission rates Del Sindaco (2012), Italy RCT N=173 (86 MP and 87 UC) community-living outpatients with HF 60.7% in NYHA III–IV Mean age 77 ± 6 years Male 52% Mean LVEF 33.4 ± 10.7 MMSE score 42% ⩽24 Phone-based follow-up at one and three months after discharge and then six monthly for two years Intervention – MP included discharge planning, patient and caregiver education, therapy optimisation, improved communication and early attention to signs/symptoms Control – UC received treatments and services ordered by physician and/or cardiologist 1. All cause death 2. All cause admission 3. All cause death or HF admission 4. Total costs of care Cognitive impairment across both groups was associated with all-cause death (HR 3.6 (95% CI 1.5–8.3)), HF deaths (HR 2.0 (95% CI 1.2–3.4)) and HF admissions (HR 2.4 (95% CI 1.4–4.3)) MP group showed significant reduction in HF admissions vs. UC (HR 0.5 (95% CI 0.2–0.9)) p=0.007 Karlsson (2005), Sweden RCT N=146 HF patients (72 intervention 74 control Mean LVEF 34% 63.6% NYHA class II 35.6% NYHA class III Mean age 76 ± 7.5 years Male 60.2% MMSE score 12% < 24 HF knowledge, self-care and cognitive function measured at baseline and six months. Intervention – nurse-based outpatient management programme (medication dose changes, verbal and written HF information), self-care, interactive computerised information programme Control – follow-up by GP and treated according to the local health care plan for HF 1. Knowledge of self-care and HF – structured questionnaire made by investigators 2. Cognitive function – MMSE Increased knowledge of self-care at six months for females in the intervention group (p<0.05) Patients with MMSE <24 (n=18) had lower scores on HF knowledge at baseline (10.1± 3.6) vs. (12.8± 3.4) (p<0.01) but not at six months Pressler (2015), USA RCT N=27 HF patients – 13 Brain Fitness (12 completed) and 14 health education (13 completed) 14.8% in NYHA class II-III (13 intervention, 14 control) Mean age 61 ± 11.9 years Male 78% Mean LVEF 28 ± 13.1 MoCA 26.6 ± 2.2 Memory, working memory, processing speed, verbal fluency, IADL, functional mobility, depressive symptoms and HRQoL measured at baseline, eight and 12 weeks. Serum BDNF measured at baseline and at two weeks. Brain Fitness intervention – computerised cognitive training programme completed in 40 h over eight weeks (1 h daily, 5 days/week) Health education intervention – An active control which involved reading eight issues of Heart Insight over eight weeks (1 h each week) 1. Memory – Hopkins Verbal Learning Test-Revised CogState Health computerised neuropsychologic test battery 2. Working memory – Identification and One Back Accuracy Tasks 3.Working memory detection task 4. IADL – The Everyday Problems Test for Cognitively Challenged 5. Depressive symptoms – Patient Health Questionnaire 6. HRQoL – Minnesota Living with HF Questionnaire No differences were found in memory but a group and a group-by-time interaction effect was found for working memory in the One Back Accuracy Task (p=0.046). Pressler (2011), USA RCT N=40 patients with HF (21 Brain Fitness and health education) Mean age 57.8 ± 13.1 Male 70% Mean LVEF 26.7 ± 10.3 50% in NYHA class II Memory, psychomotor speed, verbal fluency and working memory measured at baseline, 8 and 12 weeks. Self-reported cognitive activity and IADLs assessed at baseline and 12 weeks. Patient satisfaction at 12 weeks Brain Fitness intervention – computerised cognitive training programme completed in 40 h over eight weeks (1 h daily/5 days) Health education intervention – Active control – reading eight issues of Heart Insight over eight weeks (1 h/week) 1. Memory – Hopkins Verbal Learning Test–Revised 2. Working memory – One Back Accuracy Tasks 3. IADL – The Everyday Problems Test for Cognitively Challenged Elderly Significant group-by-time interaction for delayed recall memory (p = 0.032), a time effect for list learning both total (p < 0.001) and delayed (p = 0.015), psychomotor speed (p = 0.029), performance of IADLs (p = 0.006) Viveiros (2017) USA RCT N=84 HF patients (two groups of 42 with MCI yes or MCI no, 21 intervention and 21 control in each) Mean age 71 ± 13 years Male 58% Mean LVEF 48 ± 15, 43% in NYHA class III, 40% class IV Intervention – learning condition of STSTa, 20 min non-related educational activity and test Attention-control – learning condition of SSSSb, 20 min non-related educational activity and then a test. 1. Cognitive impairment – MoCA tool 2. Depression – PHQ-2 3. Memory – HVLT-R No significant differences in memory between intervention and control (67.2 ± 18.8 vs. 61.9 ± 22.3; p=0.24). Age (p=0.018) and education (p=0.006) significant predictors of memory First author (year), country . Design . Sample and participants . Method . Outcome measures . Key findings . Davis (2012), USA RCT N=125 HF with MCI MoCA score <26 62 control (54 complete) 63 intervention (55 complete) Mean MoCA 21.1 ± 2.4 Mean age 59 ± 13 years Male 80% Mean LVEF 34 ± 19 46% NYHA class II, 47% III Measures at baseline and 30 days post-discharge Intervention – targeted self-care teaching using cognitive training for impairments in memory and executive functioning and improving self-confidence Control – discharge teaching for HF; education booklet – dietary and fluid restrictions, symptom recognition and management, exercise and medication adherence 1. HF knowledge – Self-Care of Heart Failure Index (SCHFI) 2. Self-care behaviour –SCHFI 3. Depression – Geriatric Depression Scale 4. Social Support ENRICHD Social Support 5. Readmission rates Mean HF knowledge scores improved (p = 0.001) Mean change scores for self-care improved (not statistically significant) Over half reported depressive symptoms Perceived Social Support high No difference in readmission rates Del Sindaco (2012), Italy RCT N=173 (86 MP and 87 UC) community-living outpatients with HF 60.7% in NYHA III–IV Mean age 77 ± 6 years Male 52% Mean LVEF 33.4 ± 10.7 MMSE score 42% ⩽24 Phone-based follow-up at one and three months after discharge and then six monthly for two years Intervention – MP included discharge planning, patient and caregiver education, therapy optimisation, improved communication and early attention to signs/symptoms Control – UC received treatments and services ordered by physician and/or cardiologist 1. All cause death 2. All cause admission 3. All cause death or HF admission 4. Total costs of care Cognitive impairment across both groups was associated with all-cause death (HR 3.6 (95% CI 1.5–8.3)), HF deaths (HR 2.0 (95% CI 1.2–3.4)) and HF admissions (HR 2.4 (95% CI 1.4–4.3)) MP group showed significant reduction in HF admissions vs. UC (HR 0.5 (95% CI 0.2–0.9)) p=0.007 Karlsson (2005), Sweden RCT N=146 HF patients (72 intervention 74 control Mean LVEF 34% 63.6% NYHA class II 35.6% NYHA class III Mean age 76 ± 7.5 years Male 60.2% MMSE score 12% < 24 HF knowledge, self-care and cognitive function measured at baseline and six months. Intervention – nurse-based outpatient management programme (medication dose changes, verbal and written HF information), self-care, interactive computerised information programme Control – follow-up by GP and treated according to the local health care plan for HF 1. Knowledge of self-care and HF – structured questionnaire made by investigators 2. Cognitive function – MMSE Increased knowledge of self-care at six months for females in the intervention group (p<0.05) Patients with MMSE <24 (n=18) had lower scores on HF knowledge at baseline (10.1± 3.6) vs. (12.8± 3.4) (p<0.01) but not at six months Pressler (2015), USA RCT N=27 HF patients – 13 Brain Fitness (12 completed) and 14 health education (13 completed) 14.8% in NYHA class II-III (13 intervention, 14 control) Mean age 61 ± 11.9 years Male 78% Mean LVEF 28 ± 13.1 MoCA 26.6 ± 2.2 Memory, working memory, processing speed, verbal fluency, IADL, functional mobility, depressive symptoms and HRQoL measured at baseline, eight and 12 weeks. Serum BDNF measured at baseline and at two weeks. Brain Fitness intervention – computerised cognitive training programme completed in 40 h over eight weeks (1 h daily, 5 days/week) Health education intervention – An active control which involved reading eight issues of Heart Insight over eight weeks (1 h each week) 1. Memory – Hopkins Verbal Learning Test-Revised CogState Health computerised neuropsychologic test battery 2. Working memory – Identification and One Back Accuracy Tasks 3.Working memory detection task 4. IADL – The Everyday Problems Test for Cognitively Challenged 5. Depressive symptoms – Patient Health Questionnaire 6. HRQoL – Minnesota Living with HF Questionnaire No differences were found in memory but a group and a group-by-time interaction effect was found for working memory in the One Back Accuracy Task (p=0.046). Pressler (2011), USA RCT N=40 patients with HF (21 Brain Fitness and health education) Mean age 57.8 ± 13.1 Male 70% Mean LVEF 26.7 ± 10.3 50% in NYHA class II Memory, psychomotor speed, verbal fluency and working memory measured at baseline, 8 and 12 weeks. Self-reported cognitive activity and IADLs assessed at baseline and 12 weeks. Patient satisfaction at 12 weeks Brain Fitness intervention – computerised cognitive training programme completed in 40 h over eight weeks (1 h daily/5 days) Health education intervention – Active control – reading eight issues of Heart Insight over eight weeks (1 h/week) 1. Memory – Hopkins Verbal Learning Test–Revised 2. Working memory – One Back Accuracy Tasks 3. IADL – The Everyday Problems Test for Cognitively Challenged Elderly Significant group-by-time interaction for delayed recall memory (p = 0.032), a time effect for list learning both total (p < 0.001) and delayed (p = 0.015), psychomotor speed (p = 0.029), performance of IADLs (p = 0.006) Viveiros (2017) USA RCT N=84 HF patients (two groups of 42 with MCI yes or MCI no, 21 intervention and 21 control in each) Mean age 71 ± 13 years Male 58% Mean LVEF 48 ± 15, 43% in NYHA class III, 40% class IV Intervention – learning condition of STSTa, 20 min non-related educational activity and test Attention-control – learning condition of SSSSb, 20 min non-related educational activity and then a test. 1. Cognitive impairment – MoCA tool 2. Depression – PHQ-2 3. Memory – HVLT-R No significant differences in memory between intervention and control (67.2 ± 18.8 vs. 61.9 ± 22.3; p=0.24). Age (p=0.018) and education (p=0.006) significant predictors of memory a STST: S: participants were given an opportunity to study 16 word pairs (GROUND–COLD) + T, a testing trial during which participants were presented the first word of the pair and tested on the recall of the partnered word, for example GROUND– ________. b SSSS: 16 word pairs were sequentially presented on a computer for 6 s (GROUND–COLD) in four learning cycles. BDNF, brain-derived neurotropic factor; CI, confidence interval; GP, general practitioner; HR, hazard ratio; HRQoL, health-related quality of life; HF, heart failure; HVLT-R, Hopkins Verbal Learning Test – Revised; IADL, instrumental activity of daily living; LVEF, left ventricular ejection fraction; MCI, mild cognitive impairment; MMSE, Mini Mental State Examination; MoCA, Montreal Cognitive Assessment Scale; MP, multidisciplinary programme; NYHA, New York Heart Association; PHQ-2, Patient Health Questionnaire-2; RCT: Randomised controlled trial; UC, usual care; USA, United States of America Open in new tab Delivery of the interventions All the studies delivered the interventions to patients only. One study provided individualised telephone support and education.16 In three studies, the interventions were delivered by nurses,17–19 in one by a multidisciplinary team20 and in another by a case manager.16 The studies reported a range of interventions to support heart failure patients with MCI. Two studies utilised a computerised cognitive training intervention,18,19 one study utilised targeted self-care teaching using principles of cognitive training17 and another was an outpatient management programme (verbal and written information about heart failure and self-care, an interactive computerised information programme or with a video information programme).16 Across the six studies, the duration of the intervention ranged from 72 h to 12 weeks. Comparators All studies compared their interventions with a control group. The description of the comparator arm varied per study. In two studies, the Brain Fitness intervention was compared with an active control group called ‘health education’, which involved reading eight issues of Heart Insight over eight weeks (1 h each week).18,19 Two other studies16,20 had ‘usual care’ as a comparator, which involved follow-up and treatment according to the local health care plan for heart failure or ordered by their general practitioner or cardiologist. In one study,17 the control group received standard discharge teaching for heart failure, which included a verbal review of a heart failure patient education booklet covering symptom recognition and management, exercise, dietary and fluid restrictions and medication adherence. And another study had an ‘attention’ control group, which involved a different learning condition ‘SSSS’, a 20 min non-related educational activity followed by a test.21 Primary outcome Cognitive function Only one study16 examined cognitive function at baseline and again following the intervention using the MMSE. There were no significant differences in MMSE scores at baseline or at follow-up between intervention and control groups. However, the percentage of all participants with scores less than 24 at baseline (12%, n=18) reduced significantly at six month follow-up (4%, number not reported), p<0.00516 (see Table 322). Table 3. Outcomes of included studies Intervention First author (year) . Outcome measures demonstrating significant results . Cognitive function . Memory . Working memory . IADLs . HF knowledge . Self-care behaviour . Quality of life . Depression . Targeted self-care teaching Davis et al. (2012) 1. SCHFI, Dutch Heart Failure Knowledge scale (0–15) – – – 11.27 (1.71) to 11.85 (1.5) p=0.001 Effect size 0.31 – – Multidisciplinary programme Del Sindaco et al. (2012) 1. HF admissions – – – – – – – Nurse-based outpatient management programme Karlsson et al. (2005) 1. Knowledge of Self-Care HF, (15 self-care and four HF questions) – – 9.3 (3.1) to 10.8 (2.9); p<0.05 Effect size=0.51 – Nurse-enhanced memory training Pressler et al. (2011) 1. CogState, One Back Speed – working memory 2. The Everyday Problems Test for cognitively challenged elderly (0–32) –IADLs 3. HVLT-R, delayed recall (0–12) – memory – 3. 6.0 (3.2) to 8.5 (2.7); p=0.015 Effect size=0.71 1. 2.9. (0.1) to 2.9 (0.1); p=0.029 Effect size=0.99 2. 27.0 (2.8) to 29.3 (2.5); p=0.006 Effect size=0.69 – – – – Computerised cognitive training Pressler et al. (2015) 1. One Back Accuracy – working memory 2. Digit symbol subtest – working memory Everyday Problems Test (0–32) – IADLs HVLT-R, delayed recall (0–12) – memory PHQ-8 – depression 3. MLHFQ – quality of life – 8.4 (3.2) to 7.9 (2.3); NS 1. 1.2 (0.2) to 1.3 (0.3); grp time p=0.046 Effect size 1.27 2. 8.5 (2.3) to 6.1 (1.1) time p=<0.001, grp time p=0.048 Effect size 0.598 26.5 (1.8) to 26.8 (3.7); NS – – 39.5 (15.8) to 50.3 (16.7); p=0.029 Effect size 0.48 4.8 (3.8) to 5.8 (4.9); NS Learning condition training and educational activity Viveiros et al. (2017) HVLT-R (0–12) – memory 67.2 (18.8) vs. 61.9 (22.3); NS – – – – – – Intervention First author (year) . Outcome measures demonstrating significant results . Cognitive function . Memory . Working memory . IADLs . HF knowledge . Self-care behaviour . Quality of life . Depression . Targeted self-care teaching Davis et al. (2012) 1. SCHFI, Dutch Heart Failure Knowledge scale (0–15) – – – 11.27 (1.71) to 11.85 (1.5) p=0.001 Effect size 0.31 – – Multidisciplinary programme Del Sindaco et al. (2012) 1. HF admissions – – – – – – – Nurse-based outpatient management programme Karlsson et al. (2005) 1. Knowledge of Self-Care HF, (15 self-care and four HF questions) – – 9.3 (3.1) to 10.8 (2.9); p<0.05 Effect size=0.51 – Nurse-enhanced memory training Pressler et al. (2011) 1. CogState, One Back Speed – working memory 2. The Everyday Problems Test for cognitively challenged elderly (0–32) –IADLs 3. HVLT-R, delayed recall (0–12) – memory – 3. 6.0 (3.2) to 8.5 (2.7); p=0.015 Effect size=0.71 1. 2.9. (0.1) to 2.9 (0.1); p=0.029 Effect size=0.99 2. 27.0 (2.8) to 29.3 (2.5); p=0.006 Effect size=0.69 – – – – Computerised cognitive training Pressler et al. (2015) 1. One Back Accuracy – working memory 2. Digit symbol subtest – working memory Everyday Problems Test (0–32) – IADLs HVLT-R, delayed recall (0–12) – memory PHQ-8 – depression 3. MLHFQ – quality of life – 8.4 (3.2) to 7.9 (2.3); NS 1. 1.2 (0.2) to 1.3 (0.3); grp time p=0.046 Effect size 1.27 2. 8.5 (2.3) to 6.1 (1.1) time p=<0.001, grp time p=0.048 Effect size 0.598 26.5 (1.8) to 26.8 (3.7); NS – – 39.5 (15.8) to 50.3 (16.7); p=0.029 Effect size 0.48 4.8 (3.8) to 5.8 (4.9); NS Learning condition training and educational activity Viveiros et al. (2017) HVLT-R (0–12) – memory 67.2 (18.8) vs. 61.9 (22.3); NS – – – – – – Effect size calculation.22 grp, group; HF, heart failure; HVLT-R, Hopkins Verbal Learning Test – Revised; IADL, instrumental activity of daily living; MLHFQ, Minnesota Living with Heart Failure Questionnaire; NS, not significant; PHQ-8, Patient Health Questionnaire-8; SCHFI, Self-Care Heart Failure Index. Open in new tab Table 3. Outcomes of included studies Intervention First author (year) . Outcome measures demonstrating significant results . Cognitive function . Memory . Working memory . IADLs . HF knowledge . Self-care behaviour . Quality of life . Depression . Targeted self-care teaching Davis et al. (2012) 1. SCHFI, Dutch Heart Failure Knowledge scale (0–15) – – – 11.27 (1.71) to 11.85 (1.5) p=0.001 Effect size 0.31 – – Multidisciplinary programme Del Sindaco et al. (2012) 1. HF admissions – – – – – – – Nurse-based outpatient management programme Karlsson et al. (2005) 1. Knowledge of Self-Care HF, (15 self-care and four HF questions) – – 9.3 (3.1) to 10.8 (2.9); p<0.05 Effect size=0.51 – Nurse-enhanced memory training Pressler et al. (2011) 1. CogState, One Back Speed – working memory 2. The Everyday Problems Test for cognitively challenged elderly (0–32) –IADLs 3. HVLT-R, delayed recall (0–12) – memory – 3. 6.0 (3.2) to 8.5 (2.7); p=0.015 Effect size=0.71 1. 2.9. (0.1) to 2.9 (0.1); p=0.029 Effect size=0.99 2. 27.0 (2.8) to 29.3 (2.5); p=0.006 Effect size=0.69 – – – – Computerised cognitive training Pressler et al. (2015) 1. One Back Accuracy – working memory 2. Digit symbol subtest – working memory Everyday Problems Test (0–32) – IADLs HVLT-R, delayed recall (0–12) – memory PHQ-8 – depression 3. MLHFQ – quality of life – 8.4 (3.2) to 7.9 (2.3); NS 1. 1.2 (0.2) to 1.3 (0.3); grp time p=0.046 Effect size 1.27 2. 8.5 (2.3) to 6.1 (1.1) time p=<0.001, grp time p=0.048 Effect size 0.598 26.5 (1.8) to 26.8 (3.7); NS – – 39.5 (15.8) to 50.3 (16.7); p=0.029 Effect size 0.48 4.8 (3.8) to 5.8 (4.9); NS Learning condition training and educational activity Viveiros et al. (2017) HVLT-R (0–12) – memory 67.2 (18.8) vs. 61.9 (22.3); NS – – – – – – Intervention First author (year) . Outcome measures demonstrating significant results . Cognitive function . Memory . Working memory . IADLs . HF knowledge . Self-care behaviour . Quality of life . Depression . Targeted self-care teaching Davis et al. (2012) 1. SCHFI, Dutch Heart Failure Knowledge scale (0–15) – – – 11.27 (1.71) to 11.85 (1.5) p=0.001 Effect size 0.31 – – Multidisciplinary programme Del Sindaco et al. (2012) 1. HF admissions – – – – – – – Nurse-based outpatient management programme Karlsson et al. (2005) 1. Knowledge of Self-Care HF, (15 self-care and four HF questions) – – 9.3 (3.1) to 10.8 (2.9); p<0.05 Effect size=0.51 – Nurse-enhanced memory training Pressler et al. (2011) 1. CogState, One Back Speed – working memory 2. The Everyday Problems Test for cognitively challenged elderly (0–32) –IADLs 3. HVLT-R, delayed recall (0–12) – memory – 3. 6.0 (3.2) to 8.5 (2.7); p=0.015 Effect size=0.71 1. 2.9. (0.1) to 2.9 (0.1); p=0.029 Effect size=0.99 2. 27.0 (2.8) to 29.3 (2.5); p=0.006 Effect size=0.69 – – – – Computerised cognitive training Pressler et al. (2015) 1. One Back Accuracy – working memory 2. Digit symbol subtest – working memory Everyday Problems Test (0–32) – IADLs HVLT-R, delayed recall (0–12) – memory PHQ-8 – depression 3. MLHFQ – quality of life – 8.4 (3.2) to 7.9 (2.3); NS 1. 1.2 (0.2) to 1.3 (0.3); grp time p=0.046 Effect size 1.27 2. 8.5 (2.3) to 6.1 (1.1) time p=<0.001, grp time p=0.048 Effect size 0.598 26.5 (1.8) to 26.8 (3.7); NS – – 39.5 (15.8) to 50.3 (16.7); p=0.029 Effect size 0.48 4.8 (3.8) to 5.8 (4.9); NS Learning condition training and educational activity Viveiros et al. (2017) HVLT-R (0–12) – memory 67.2 (18.8) vs. 61.9 (22.3); NS – – – – – – Effect size calculation.22 grp, group; HF, heart failure; HVLT-R, Hopkins Verbal Learning Test – Revised; IADL, instrumental activity of daily living; MLHFQ, Minnesota Living with Heart Failure Questionnaire; NS, not significant; PHQ-8, Patient Health Questionnaire-8; SCHFI, Self-Care Heart Failure Index. Open in new tab Memory and working memory In three studies memory was observed18,19,21 but only one found significant improvements.18 Memory was measured using the Hopkins Verbal Learning Test – Revised in all the studies. One study reported that the intervention group had better memory compared with the control group but found no significant differences between the groups.21 Similarly, no differences in memory were observed in the study by Pressler et al.19 In contrast, the earlier study by Pressler et al.19 found that patients who received a Brain Fitness intervention improved more in delayed recall memory over time than patients allocated to health education (Table 3). In terms of working memory, two studies found significant improvements after a memory intervention and a computerised cognitive training programme (Brain Fitness program) at eight weeks.18,19 Working memory was measured using the CogState Health (One Back Accuracy task) in both studies. One study reported a significant time effect (F[2, 65] = 3.75; p=0.029) but non-significant group and group–time interaction effects.18 The other study also found significant group (p=0.044) and group-by-time interaction (p=0.046) effects.19 Scores for those in the Brain Fitness group improved over time compared with the health education group, whose scores declined over time.19 Secondary outcomes IADLs Two studies examined IADLs in participants randomly assigned to the Brain Fitness programme and the health education programme18,19 but only one study found significant improvements.18 To assess performance of IADLs, the Everyday Problems Test was used. Contrasting findings were reported by these two studies. One study found a strong significant time effect (F[1, 30] = 8.62; p=0.006) and non-significant group and group–time interaction effects.18 The other study reported no significant differences in IADLs between the groups.19 Heart failure knowledge Two studies examined heart failure knowledge and found improvements after a targeted self-care teaching intervention using principles of cognitive training17 and attendance at a nurse led outpatient clinic.16 The Dutch Heart Failure Knowledge Scale was used to assess heart failure knowledge in one study and a knowledge of heart failure structured questionnaire was utilised by the other study. In one study, the mean knowledge scores of the intervention group increased but decreased in the control group (p<0.001).17 Participants in the intervention group scored higher in questions related to fluid restriction, causes of worsening heart failure symptoms and the function of the heart compared with the control group.17 The other study also reported significant improvements in the mean scores on the knowledge questionnaire of the intervention group after six months (r=0.68, p<0.001).16 At six month follow-up, the intervention group improved scores on questions concerning what heart failure means (p<0.001) and fluid restriction (p<0.001).12 Heart failure self-care Only one study examined self-care and also found significant improvements.16 In this study, self-care was measured using a heart failure self-care structured questionnaire created by the investigators. The study found that females in the intervention group learned more about self-care than females in the control group between baseline and six months (p<0.05).16 HRQoL Only one study observed HRQoL and found significant results. The Minnesota Living with Heart Failure Questionnaire was used to assess HRQoL in this study. A significant time effect was found in both groups (p=0.029).19 Depression Only one study examined depression and found no improvements in depressive symptoms. The Patient Health Questionnaire-8 was used to measure depression. The study reported no statistically significant difference in depressive symptoms in both groups.19 Hospitalisation Only one study examined heart failure-related hospitalisation and found a reduction. The assignment of patients to the multidisciplinary programme (combined outpatient hospital-based and primary care) was associated with a significant reduction in heart failure hospitalisation compared with usual care (p=0.007).20 Elements of successful interventions Successful elements of the Brain Fitness programme by Pressler et al. 201118 which demonstrated improvements in memory (p=0.015), working memory (p=0.029) and IADLs (p=0.006) include visual and auditory components designed to deliver exercises, scenes and stories to strengthen learning and recall of information. In contrast, core components of the Brain Fitness intervention by Pressler et al. 201519 which also showed improvements in working memory (p=0.046) and quality of life (p=0.029) involved sound sweeps, fine tuning, memory grid, syllable stacks and to-do list training. Improvements in heart failure knowledge (p=0.001) were observed in the study by Davis et al.17 The cognitive training intervention had a focus on environmental manipulations, internalised compensatory approaches, reinforcement and a range of materials to help with symptom management, fluid and sodium restriction adherence and medication adherence. In comparison, Karlsson et al.16 utilised a nurse-based outpatient management approach, which involved optimising drug dosage and assisting patients to recognise and manage signs of worsening heart failure. These elements led to significant improvements in heart failure knowledge (p<0.001) and self-care (p<0.05). For a more detailed description of the components of the successful interventions in each study, refer to Table 4. Table 4. Elements of successful interventions Intervention First author (year) . Focus area . Intervention components . Targeted self-care teaching Davis et al. (2012) • Education/instruction • Environmental manipulations • Alter demands on patient • Provide cues for initiation • Provide external guides for sequencing behaviour • Internalised compensatory approaches • Train patient to use memory and organisational aids • Teach self-regulatory strategies • Reinforcement • Individualised assessment and customised education • Patient participation in personalised self-care schedule development • Training on association techniques to prompt self-care activities • Audiotaping of personalised teaching session • Instruction on use of personal schedule and symptom tracker • Daily weight return demonstration • Medication organiser management return demonstration • Follow-up phone call 24–72 h after discharge from hospital • Symptom management • Fluid and sodium restriction adherence • Medication adherence • Personalised daily schedule and symptom tracker workbook • Audiotape recorder with headphones. Audio cassette of personalised teaching session • Laminated refrigerator card with pictograms and self-care reminders • Digital scale. Measuring cups. Salt substitute samples • Medication organiser/dosette box/pillbox Nurse-based outpatient management programme Karlsson et al. (2005) Health care plan Nurse-based outpatient clinic follow-up • Optimising drug dosage of HF medications, e.g. ACE inhibitors, diuretics • Providing information on how to recognise and manage signs of worsening HF Nurse-enhanced memory training Pressler et al. (2011) Auditory • Sound sweeps: a series of frequency sweeps and structured bursts of sound are presented and the person identifies whether sound is rising or falling. The sweeps and bursts are components of basic speech. The sweeps and bursts are presented more quickly as the person progresses through the exercise. • Fine tuning: a series of phonemes and syllables are presented and the person is asked to choose between two phonemes or syllables that sound similar. Phonemes and syllables are elements of complex speech. • Syllable stacks: the person listens to a series of syllables and repeats the sounds in order by clicking the appropriate computer keys. As the person progresses through the exercise, the number of syllables presented increases, the syllables are presented closer together, and the speech delivery speed of the syllables increases. • To-do list training: the person listens to a set of directions and follows them in the order in which they were presented. The speech used to deliver the directions is slow and exaggerated at first; it increases as the person progresses through the programme. • In the Know: the person listens to original stories and answers questions about them. The person is able to practise discriminating between sounds that are different in a slight way in the story. The person is required to remember more details of the story as the exercise progresses. The person trains at a threshold level that is at the upper limit (85%) of his/her ability. Visual • Memory grid: the person is asked to match syllables associated with cards presented on the screen. The number of syllables increases as the person progresses through the exercise. Computerised cognitive training Pressler at al. (2015) Auditory • Stories of novel events are provided • Progressive training is provided; the exercises become complex • Monitors performance, which ensures individualised training • Information is associated with stronger emotions • Feedback and reward is provided • Intervention adherence is tracked. Intervention First author (year) . Focus area . Intervention components . Targeted self-care teaching Davis et al. (2012) • Education/instruction • Environmental manipulations • Alter demands on patient • Provide cues for initiation • Provide external guides for sequencing behaviour • Internalised compensatory approaches • Train patient to use memory and organisational aids • Teach self-regulatory strategies • Reinforcement • Individualised assessment and customised education • Patient participation in personalised self-care schedule development • Training on association techniques to prompt self-care activities • Audiotaping of personalised teaching session • Instruction on use of personal schedule and symptom tracker • Daily weight return demonstration • Medication organiser management return demonstration • Follow-up phone call 24–72 h after discharge from hospital • Symptom management • Fluid and sodium restriction adherence • Medication adherence • Personalised daily schedule and symptom tracker workbook • Audiotape recorder with headphones. Audio cassette of personalised teaching session • Laminated refrigerator card with pictograms and self-care reminders • Digital scale. Measuring cups. Salt substitute samples • Medication organiser/dosette box/pillbox Nurse-based outpatient management programme Karlsson et al. (2005) Health care plan Nurse-based outpatient clinic follow-up • Optimising drug dosage of HF medications, e.g. ACE inhibitors, diuretics • Providing information on how to recognise and manage signs of worsening HF Nurse-enhanced memory training Pressler et al. (2011) Auditory • Sound sweeps: a series of frequency sweeps and structured bursts of sound are presented and the person identifies whether sound is rising or falling. The sweeps and bursts are components of basic speech. The sweeps and bursts are presented more quickly as the person progresses through the exercise. • Fine tuning: a series of phonemes and syllables are presented and the person is asked to choose between two phonemes or syllables that sound similar. Phonemes and syllables are elements of complex speech. • Syllable stacks: the person listens to a series of syllables and repeats the sounds in order by clicking the appropriate computer keys. As the person progresses through the exercise, the number of syllables presented increases, the syllables are presented closer together, and the speech delivery speed of the syllables increases. • To-do list training: the person listens to a set of directions and follows them in the order in which they were presented. The speech used to deliver the directions is slow and exaggerated at first; it increases as the person progresses through the programme. • In the Know: the person listens to original stories and answers questions about them. The person is able to practise discriminating between sounds that are different in a slight way in the story. The person is required to remember more details of the story as the exercise progresses. The person trains at a threshold level that is at the upper limit (85%) of his/her ability. Visual • Memory grid: the person is asked to match syllables associated with cards presented on the screen. The number of syllables increases as the person progresses through the exercise. Computerised cognitive training Pressler at al. (2015) Auditory • Stories of novel events are provided • Progressive training is provided; the exercises become complex • Monitors performance, which ensures individualised training • Information is associated with stronger emotions • Feedback and reward is provided • Intervention adherence is tracked. ACE, angiotensin-converting enzyme; HF, heart failure. Open in new tab Table 4. Elements of successful interventions Intervention First author (year) . Focus area . Intervention components . Targeted self-care teaching Davis et al. (2012) • Education/instruction • Environmental manipulations • Alter demands on patient • Provide cues for initiation • Provide external guides for sequencing behaviour • Internalised compensatory approaches • Train patient to use memory and organisational aids • Teach self-regulatory strategies • Reinforcement • Individualised assessment and customised education • Patient participation in personalised self-care schedule development • Training on association techniques to prompt self-care activities • Audiotaping of personalised teaching session • Instruction on use of personal schedule and symptom tracker • Daily weight return demonstration • Medication organiser management return demonstration • Follow-up phone call 24–72 h after discharge from hospital • Symptom management • Fluid and sodium restriction adherence • Medication adherence • Personalised daily schedule and symptom tracker workbook • Audiotape recorder with headphones. Audio cassette of personalised teaching session • Laminated refrigerator card with pictograms and self-care reminders • Digital scale. Measuring cups. Salt substitute samples • Medication organiser/dosette box/pillbox Nurse-based outpatient management programme Karlsson et al. (2005) Health care plan Nurse-based outpatient clinic follow-up • Optimising drug dosage of HF medications, e.g. ACE inhibitors, diuretics • Providing information on how to recognise and manage signs of worsening HF Nurse-enhanced memory training Pressler et al. (2011) Auditory • Sound sweeps: a series of frequency sweeps and structured bursts of sound are presented and the person identifies whether sound is rising or falling. The sweeps and bursts are components of basic speech. The sweeps and bursts are presented more quickly as the person progresses through the exercise. • Fine tuning: a series of phonemes and syllables are presented and the person is asked to choose between two phonemes or syllables that sound similar. Phonemes and syllables are elements of complex speech. • Syllable stacks: the person listens to a series of syllables and repeats the sounds in order by clicking the appropriate computer keys. As the person progresses through the exercise, the number of syllables presented increases, the syllables are presented closer together, and the speech delivery speed of the syllables increases. • To-do list training: the person listens to a set of directions and follows them in the order in which they were presented. The speech used to deliver the directions is slow and exaggerated at first; it increases as the person progresses through the programme. • In the Know: the person listens to original stories and answers questions about them. The person is able to practise discriminating between sounds that are different in a slight way in the story. The person is required to remember more details of the story as the exercise progresses. The person trains at a threshold level that is at the upper limit (85%) of his/her ability. Visual • Memory grid: the person is asked to match syllables associated with cards presented on the screen. The number of syllables increases as the person progresses through the exercise. Computerised cognitive training Pressler at al. (2015) Auditory • Stories of novel events are provided • Progressive training is provided; the exercises become complex • Monitors performance, which ensures individualised training • Information is associated with stronger emotions • Feedback and reward is provided • Intervention adherence is tracked. Intervention First author (year) . Focus area . Intervention components . Targeted self-care teaching Davis et al. (2012) • Education/instruction • Environmental manipulations • Alter demands on patient • Provide cues for initiation • Provide external guides for sequencing behaviour • Internalised compensatory approaches • Train patient to use memory and organisational aids • Teach self-regulatory strategies • Reinforcement • Individualised assessment and customised education • Patient participation in personalised self-care schedule development • Training on association techniques to prompt self-care activities • Audiotaping of personalised teaching session • Instruction on use of personal schedule and symptom tracker • Daily weight return demonstration • Medication organiser management return demonstration • Follow-up phone call 24–72 h after discharge from hospital • Symptom management • Fluid and sodium restriction adherence • Medication adherence • Personalised daily schedule and symptom tracker workbook • Audiotape recorder with headphones. Audio cassette of personalised teaching session • Laminated refrigerator card with pictograms and self-care reminders • Digital scale. Measuring cups. Salt substitute samples • Medication organiser/dosette box/pillbox Nurse-based outpatient management programme Karlsson et al. (2005) Health care plan Nurse-based outpatient clinic follow-up • Optimising drug dosage of HF medications, e.g. ACE inhibitors, diuretics • Providing information on how to recognise and manage signs of worsening HF Nurse-enhanced memory training Pressler et al. (2011) Auditory • Sound sweeps: a series of frequency sweeps and structured bursts of sound are presented and the person identifies whether sound is rising or falling. The sweeps and bursts are components of basic speech. The sweeps and bursts are presented more quickly as the person progresses through the exercise. • Fine tuning: a series of phonemes and syllables are presented and the person is asked to choose between two phonemes or syllables that sound similar. Phonemes and syllables are elements of complex speech. • Syllable stacks: the person listens to a series of syllables and repeats the sounds in order by clicking the appropriate computer keys. As the person progresses through the exercise, the number of syllables presented increases, the syllables are presented closer together, and the speech delivery speed of the syllables increases. • To-do list training: the person listens to a set of directions and follows them in the order in which they were presented. The speech used to deliver the directions is slow and exaggerated at first; it increases as the person progresses through the programme. • In the Know: the person listens to original stories and answers questions about them. The person is able to practise discriminating between sounds that are different in a slight way in the story. The person is required to remember more details of the story as the exercise progresses. The person trains at a threshold level that is at the upper limit (85%) of his/her ability. Visual • Memory grid: the person is asked to match syllables associated with cards presented on the screen. The number of syllables increases as the person progresses through the exercise. Computerised cognitive training Pressler at al. (2015) Auditory • Stories of novel events are provided • Progressive training is provided; the exercises become complex • Monitors performance, which ensures individualised training • Information is associated with stronger emotions • Feedback and reward is provided • Intervention adherence is tracked. ACE, angiotensin-converting enzyme; HF, heart failure. Open in new tab Discussion The prevalence of cognitive impairment in heart failure is well-recognised and in spite of the implications for heart failure management there is limited evidence which demonstrates the effectiveness of interventions designed to support this population. Nevertheless, some promising elements of interventions which can be utilised to improve cognitive function and memory of heart failure patients with MCI or dementia have been identified in this review. Computerised cognitive/memory training techniques such as sound sweeps, syllable stacks and memory grid improved memory, working memory, IADLs and HRQoL in heart failure with MCI.18,19 This corresponds with other studies which demonstrated that cognitive training programmes are associated with improvements in cognitive outcomes in those with MCI or dementia.23–26 While promising, it is important to note that these studies have relatively small sample sizes and suffered from various methodological limitations that make interpretation of results more difficult. The review also found that tailored educational–behavioural techniques such as individualised assessment, customised education, association training and reinforcement improved heart failure knowledge but did not affect heart failure self-care. As this was the first study to test tailored educational intervention based on cognitive training principles in heart failure patients who screened positive for MCI, comparison with other studies is challenging. However, this result may be explained by the fact that patients were unable to translate the knowledge gained from the tailored educational intervention into self-care practice. Perhaps the in-hospital teaching and single follow-up teach-back phone call was not enough to reinforce education as shown in previous studies.27,28 Ongoing face to face, telephone or mHealth based follow-up and reinforcement of self-care over a longer period of time is more likely to improve self-care, particularly for those with MCI or dementia. Although this review has identified some promising elements of interventions, important questions remain pertaining to screening, composition of interventions and dosing and duration. Elements of successful interventions identified in this review herald challenges for our healthcare systems and professional bodies as we attempt to identify and resource new models of care. People living with heart failure and cognitive impairment or dementia require care and interventions that address the impact of this co-morbidity on successful disease management. Clinicians should be engaged not only in the treatment of heart failure but also in the identification and the management of cognitive impairment and dementia as this directly affects patients’ outcomes and can significantly change the self-care and support requirements of this population. Cognitive dysfunction is multifactorial and several cardiac variables are associated with it. In addition, it is becoming clear that MCI compounds the prognostic significance of other marker syndromes such as frailty and is more prevalent in frail older people who are again more likely to have concomitant heart failure.29 Unfortunately, there is no consensus to guide optimal methods to identify changes in cognition in patients with heart failure. Given the paucity of evidence to support interventions for cognitive impairment in heart failure patients, there remains a need to develop and evaluate effective interventions in this complex patient population. As part of a chronic disease management programme, it is important to consider the elements of successful programmes and Krumholz and colleagues’ Taxonomy of Disease Management Programs30 provides a useful guide. We have considered the six studies included in this review according to the taxonomy and this has highlighted where further research is required. Further, in an era of the digital health revolution it is important to consider the role of health technology, particularly models of care incorporating mHealth to provide support, monitoring, education and ongoing management. There is evidence to support the use of telemonitoring and structured telephone support for people with heart failure,31 but minimal context for their use in cognitive impairment. The use of mHealth technology for monitoring and educational–behavioural interventions for people with heart failure is an emerging model of care that could enable the tailoring of interventions according to cognitive ability. Last, it is critical to consider the role of the informal family caregiver in the management of individuals with heart failure and concomitant dementia or MCI. Informal caregivers have a critical role in providing family and patient centred care through shared decision making and patient advocacy.32 It is therefore vital to partner with patients and engage caregivers in the co-design and co-creation of any future interventions to ensure that these meet the diverse needs of this complex, vulnerable population. Conclusion This review revealed modest evidence for nurse led interventions, demonstrating effective interventions among heart failure patients with MCI or dementia. In light of the methodological shortcomings of the included studies caution should be used when interpreting these results. Further research is required to identify physiological mechanisms of cognitive impairment and dementia in heart failure, elements of effective interventions and type, delivery and dosing of the intervention. Appendix 1. Detailed search strategy 1. Heart failure 2. Cardiac failure 3. 1 OR 2 4. MH Dementia OR dementia 5. MH Frontotemporal Dementia OR MH Dementia, Multi-Infarct 6. MH Dementia, Vascular OR MH Lewy Body Disease 7. MH Dementia, Senile OR MH AIDS Dementia Complex 8. MH Dementia, Presenile OR MH Kohlschutter-Tonz Syndrome 9. MH Impairment, Health Professional OR MH Delirium, Dementia, Amnestic, Cognitive Disorders 10. MH Cognition Disorders OR MH Cognition OR MH Memory Impairment (Saba CCC) 11. MH Cognitive Orientation (Iowa NOC) OR MH Cognitive Ageing 12. MH Cognitive Ability (Iowa NOC) OR MH International Classification of Functioning, Disability and Health OR cognitive impairment 13. 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 14. Targeted intervention AND/OR nurse-based management AND/OR tailored intervention AND/OR nurse led intervention AND/OR multidisciplinary intervention 15. Community dwelling AND/OR aged care AND/OR nursing homes AND/OR hospital AND/OR inpatients 16. 3 AND 13 17. 16 AND 14 17 AND 15 1. Heart failure 2. Cardiac failure 3. 1 OR 2 4. MH Dementia OR dementia 5. MH Frontotemporal Dementia OR MH Dementia, Multi-Infarct 6. MH Dementia, Vascular OR MH Lewy Body Disease 7. MH Dementia, Senile OR MH AIDS Dementia Complex 8. MH Dementia, Presenile OR MH Kohlschutter-Tonz Syndrome 9. MH Impairment, Health Professional OR MH Delirium, Dementia, Amnestic, Cognitive Disorders 10. MH Cognition Disorders OR MH Cognition OR MH Memory Impairment (Saba CCC) 11. MH Cognitive Orientation (Iowa NOC) OR MH Cognitive Ageing 12. MH Cognitive Ability (Iowa NOC) OR MH International Classification of Functioning, Disability and Health OR cognitive impairment 13. 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 14. Targeted intervention AND/OR nurse-based management AND/OR tailored intervention AND/OR nurse led intervention AND/OR multidisciplinary intervention 15. Community dwelling AND/OR aged care AND/OR nursing homes AND/OR hospital AND/OR inpatients 16. 3 AND 13 17. 16 AND 14 17 AND 15 Open in new tab Appendix 1. Detailed search strategy 1. Heart failure 2. Cardiac failure 3. 1 OR 2 4. MH Dementia OR dementia 5. MH Frontotemporal Dementia OR MH Dementia, Multi-Infarct 6. MH Dementia, Vascular OR MH Lewy Body Disease 7. MH Dementia, Senile OR MH AIDS Dementia Complex 8. MH Dementia, Presenile OR MH Kohlschutter-Tonz Syndrome 9. MH Impairment, Health Professional OR MH Delirium, Dementia, Amnestic, Cognitive Disorders 10. MH Cognition Disorders OR MH Cognition OR MH Memory Impairment (Saba CCC) 11. MH Cognitive Orientation (Iowa NOC) OR MH Cognitive Ageing 12. MH Cognitive Ability (Iowa NOC) OR MH International Classification of Functioning, Disability and Health OR cognitive impairment 13. 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 14. Targeted intervention AND/OR nurse-based management AND/OR tailored intervention AND/OR nurse led intervention AND/OR multidisciplinary intervention 15. Community dwelling AND/OR aged care AND/OR nursing homes AND/OR hospital AND/OR inpatients 16. 3 AND 13 17. 16 AND 14 17 AND 15 1. Heart failure 2. Cardiac failure 3. 1 OR 2 4. MH Dementia OR dementia 5. MH Frontotemporal Dementia OR MH Dementia, Multi-Infarct 6. MH Dementia, Vascular OR MH Lewy Body Disease 7. MH Dementia, Senile OR MH AIDS Dementia Complex 8. MH Dementia, Presenile OR MH Kohlschutter-Tonz Syndrome 9. MH Impairment, Health Professional OR MH Delirium, Dementia, Amnestic, Cognitive Disorders 10. MH Cognition Disorders OR MH Cognition OR MH Memory Impairment (Saba CCC) 11. MH Cognitive Orientation (Iowa NOC) OR MH Cognitive Ageing 12. MH Cognitive Ability (Iowa NOC) OR MH International Classification of Functioning, Disability and Health OR cognitive impairment 13. 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 14. Targeted intervention AND/OR nurse-based management AND/OR tailored intervention AND/OR nurse led intervention AND/OR multidisciplinary intervention 15. Community dwelling AND/OR aged care AND/OR nursing homes AND/OR hospital AND/OR inpatients 16. 3 AND 13 17. 16 AND 14 17 AND 15 Open in new tab Implications for Practice Mild cognitive impairment is common in individuals with heart failure. Cardiovascular nurses may deliver a range of interventions for mild cognitive impairment to patients with heart failure. Key elements of these interventions may include brain exercises, syllable stacks, individualised education, interactive problem-solving scenarios and association techniques. Nurse led interventions can help improve heart failure knowledge, self-care and quality of life. There is scope for the future evaluation of nurse-delivered cognitive interventions for patients with heart failure. Funding Louise Hickman was supported by the University of Technology Sydney Research Equity Fellowship Scheme 2016-2017. Sally C Inglis is a Cardiovascular Life Science Fellow, supported by the New South Wales Cardiovascular Research Network which is supported by the Heart Foundation of Australia and the NSW Office for Health and Medical research (CR 11S 6226). Caleb Ferguson is supported by a 2018 Postdoctoral Research Fellowship (Ref: 102168) from the National Heart Foundation of Australia. Declaration of conflicting interests The authors declare that there is no conflict of interest. References 1 Vidan M T , Sanchez E, Fernandez-Aviles F , et al. . FRAIL-HF, a study to evaluate the clinical complexity of heart failure in nondependent older patients: rationale, methods and baseline characteristics . Clin Cardiol 2014 ; 37 : 725 – 732 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Ambrosy A P , Fonarow G C, Butler J , et al. . 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Google Scholar Crossref Search ADS PubMed WorldCat © The European Society of Cardiology 2019 This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © The European Society of Cardiology 2019
TI - Key elements of interventions for heart failure patients with mild cognitive impairment or dementia: A systematic review
JO - European Journal of Cardiovascular Nursing
DO - 10.1177/1474515119865755
DA - 2020-01-01
UR - https://www.deepdyve.com/lp/oxford-university-press/key-elements-of-interventions-for-heart-failure-patients-with-mild-VNWrG9ckxB
SP - 8
EP - 19
VL - 19
IS - 1
DP - DeepDyve
ER -