Abstract: Self Care Behaviors (SCB) is one of the most important challenges in controlling readmission and improving the elderly patients outcomes. The aims of this study were to describe the SCB among elderly with heart failure and to assess relationships between SCB, demographic characteristics, age-related characteristics and clinical characteristics. In this cross sectional study, 184 elderly (age = 60) with heart failure were selected with convenience sampling from 4 teaching hospitals. To assess SCB, the European Heart Failure Self Care Behavior Scale was used. Its validity and reliability were confirmed (CVI = 0.97 and α = 0.74). Data was collected from patients’ medical record and by interviews. The highest percentage of behaviors not performing properly (score>2), were related to self reported exercise (96.2%), receiving a flu shot (89.7%) and weight monitoring (80.5%), respectively. There was significant relationship between SCB and cognitive impairment (p<0.001), serum sodium level (p<0.001), charlson co-morbidity Index (p = 0.001), ejection fraction (p = 0.002), visual impairment (p = 0.002), sleep disorders (p = 0.003), poly-pharmacy (p = 0.004), hearing impairment (p = 0.012) and systolic blood pressure (p = 0.049). Significant relationship between SCB and age-related characteristics suggests the need to design both supportive and preventive programs among elderly with heart failure.
INTRODUTION
Chronic Heart Failure (CHF) is a world-wild health problem that is associated with significant morbidity and mortality. Its prevalence is rising to ≥10% among 70 years of age or older persons (McMurray et al., 2012) and the overall cost of managing heart failure is estimated at least 1-2% total health care expenditure (Stewart, 2005).
The constellation of symptoms associated with CHF can impact on individuals’ ability in performing every day activities of daily living and contribute to the challenge of living with the syndrome (Stromberg, 2005). The results of several studies shows that patients’ self care, abilities are often far from optimal (Jaarsma et al., 1993, 2013) and early readmission of older patients with high heart failure symptoms (Yu et al., 2006). Non-compliance in patients with heart failure rates ranging 42-64% (Cline et al., 1999) and contribute to worsening heart failure symptoms and may lead to hospitalization (Van der Wal et al., 2005, 2006).
Self care behaviors among older people with heart failure are further complicated due to an increasing number of co-existing co-morbidities (Van der Wal and Jaarsma, 2008; De Geest et al., 2004), age related impairment such as hearing, visual and cognitive impairment and demographic characteristics such as illiteracy (De Geest et al., 2004). With adequately performing self care behaviors, up to 50% readmissions of patients will be prevented (Jaarsma et al., 1993; Yu et al., 2006).
Although, some studies were conducted to assess self care abilities in HF patients in our country (Abootalebi et al., 2012; Adib-Hajbaghery et al., 2013; Shojaei et al., 2009), little is known about factors affecting self care behaviors in elderly patients. The aim of this study was to determine the self care behaviors and related factors among older people with chronic heart failure.
METHODOLOGY
This cross-sectional study is a preliminary study that is conducted to determine the predictors of self care behaviors among elderly with heart failure. In this study, 184 patients were selected with convenience sampling from 4 teaching hospitals located in the East, the center and the West of the Mazandaran Province in Iran. Patients were included in this study between October 2013 and January 2014, when they were hospitalized for symptomatic heart failure, confirmed by the cardiologists. Inclusion criteria were the history of at least 6 months involvement with heart failure, age ≥60 and being stable (1-2 days after admission). Exclusion criteria were communication problems such as severe hearing impairment with no hearing aids, speech problems and severe cognitive impairment with Abbreviated Mental Test (AMT) scores<4 (Hodkinson, 1972).
The variables were collected from patients’ medical records and by interviews. Demographic variables consisted of age, gender and education level.
Age-related variables consisted of hearing, visual and cognitive status, poly-pharmacy (≥5 different drugs) and co-morbidities (Charlson Co-morbidity Index). Cognitive status was measured by using Iranian version of Abbreviated Mental Test (Foroughan et al., 2008). In this 10-item scale, a 1 score is given to each correct answer. Its ideal cut of point has reported 6 and its sensitivity and specificity have identified 85 and 99%, respectively (Foroughan et al., 2008). A score 0-3 indicates severe cognitive impairment and 4-6 indicates moderate cognitive impairment. Hearing and visual impairment obtained by taking history and patients’ medical records. The severity of co-morbid conditions was assessed using the Charlson Co-morbidity Index (Charlson et al., 1987) which classifies co-morbidities based on the number and seriousness of 1 year survival with higher scores indicating greater risk of death. Most diseases are assigned an index of 1 but more severe conditions are given a weight score 2, 3 or 6. All weights are summed to obtain a numeric co-morbidity score for each particular patient. For each decade >40 years of age, a score of 1 is added to that score. Because each study participant had heart failure and at least 60 years of age, the minimum score was 3.
Clinical variables consisted of left ventricular Ejection Fraction (EF), severity of disease (NYHA class), sleep status, blood pressure, Body Mass Index, number of hospitalizations during past 6 months and some biochemical characteristics of the blood. Sleep status was assessed using by participant self report and Iranian version of Epworth Daytime Sleepiness scale and its chronbach's alpha is reported 0.75 (Malakouti et al., 2009). This 8-item scale measures sleepiness on a 4-point likert scale ranging from 0 (never) to 3 (high) and a total score was calculated. The cut of point 9 or more indicates sleepiness (Malakouti et al., 2009).
To assess self care behaviors, the European Heart Failure Self Care Behaviors (EHFSCB) questionnaire was used (Jaarsma et al., 1993). This 12-item scale measures self care behaviors on a 5-point likert scale ranging from 1 (strongly agree) to 5 (strongly disagree). A total score is calculated by summing responses from each item and lower score indicates better self care. Its validity and reliability were confirmed by two studies in Iran (Abootalebi et al., 2012; Shojaei et al., 2009). In this study, its Content Validity Index (CVI) was confirmed by 10 specialist persons (cardiologist and cardiac nurse) with at least 5 years job history in the field (CVI = 0.97). Its reliability was tested by Cronbach’s alpha (α = 0.74).
After taking written informed consent, each patient was interviewed by an independent data collector who was not involved in care for the patient. Data gathering was done in several stages, based on patient’ endurance. This study ethically complies with the Declaration of Helsinki. In our study, Heart Failure Self Care Behaviors (HFSCB) was examined before hospitalization.
Descriptive statistics were used to characterize this sample. For factors that are known to be related to self care behaviors in other studies, univariate analysis were conducted. Normality of continuous variables was assessed by kolmogorov-smirnov test. Independent t test and ANOVA were used for data analysis. All analyses were performed with SPSS version 16.0.
RESULTS
Self care behaviors: The mean of self care scores was 31.86± 8.09 (minimum 13 and maximum 54) and with 95% CI 30.68-33.04. The majority of elderly (56.5%) took care of themselves moderately (scores 29-44), 38% (70) took care well (scores 12-28) and 5.5%(10) took care improperly (scores 45-60).
Table 1 describes the results of the scoring on the separate items. The highest percentage of behaviors not performing properly (score>2) were related to self reported exercise (96.2%), receiving a flu shot (89.7%) and weight monitoring (80.5%), respectively. The highest percentage of behaviors performing well (score 1 and 2) were related to taking medication as prescribed (94.6%), contact their doctor if shortness of breath increases (84.8%) and adherence of low salt diet (83.7%).
| Table 1: | Self care behaviors among elderly with CHF (N = 184) |
| Table 2: | Mean of self care behaviors scores among elderly with CHF related to demographic characteristics (N = 184) |
| Table 3: | Mean of self care behaviors scores among elderly with CHF regarding to age-related characteristics (N = 184) |
| Table 4: | Comparison of bio-chemical characteristics among elderly with good care (12-28 scores) and no good care (29-60 scores) |
| BUN: Blood urea nitrogen, FBS: Fasting blood sugar | |
Demographic characteristics: In this study, 61.4% of participants (113) were female and 38.6% (71) were male. 70% of elderly (128) were in the 60-75 year age group, 29% (54) were in the 75-90 year age group and 1% (2) were in the 90-94 year age group. The mean age in women and men were 70.7±8.35 and 70.01±8.99, respectively (p = 0.595).
The mean of self care scores was lower among younger than older, significantly (p = 0.018). There was not significant relationships between self care scores, gender and education level (Table 2).
Age-related characteristics: Self care behaviors were better among elderly without cognitive impairment (p<0.001) without visual impairment (p = 0.002) and without hearing impairment (p = 0.012). Elderly with poly-pharmacy, who took 5 different drugs or more, took care of themselves better than elderly without (p = 0.004) (Table 3).
Among elderly in the 75-94 year age group, odds ratio of visual impairment was 1.27 (95% CI 0.82-1.96) compared to elderly in the 60-75 year age group (p = 0.275). In addition, odds ratio of hearing impairment was 1.98 (95% CI 1.3-3.02) (p = 0.002) and odds ratio of cognitive impairment was 2.11 (95% CI 1.24-3.57) (p = 0.003).
Clinical characteristics: There was not significant correlation between biochemical characteristics of the blood and self care behaviors scores, except for serum sodium level (p<0.001) (Table 4).
The mean of Charlson co-morbidity index and systolic blood pressure were lower among elderly with good care, compared to no good care, significantly (p = 0.001 and p = 0.049, respectively) (Table 5). In addition, the mean of self care behaviors scores were lower among elderly with ischemic heart disease (p<0.001), elderly with ejection fraction 40% or higher (p = 0.002) and elderly without sleep disorders (p = 0.003), significantly (Table 6).
| Table 5: | Comparison of some characteristics among elderly with good care and no good care |
| Table 6: | Mean of self care behaviors scores among elderly with CHF related to clinical characteristics |
DISCUSSION
Self care behaviors: In this study, the highest percentage of behaviors not performing properly were related to self reported exercise (96.2%), receiving a flu shot (89.7%) and weight monitoring (80.5%), respectively. The results of a study that performed in 15 countries worldwide showed following results; low rates of exercise from 36% in one of the samples in Germany to 90% in of the Italian samples, not getting an annual flu shot in 16-75% patients and not weighting daily in 24% (Australian samples) to 95% patients (Hong Kong samples) (Jaarsma et al., 2013).
Lower rates of exercise among older people in this study may be due to nearly high occurrence of ischemic heart disease (58.5%) among our participants. In addition, a significant part of them (40.2%) was in NYHA class IV. According to the current guidelines, to achieve the modest breathlessness during exertion is advised at least 20 min, minimum of three times a week (Lainscak et al., 2011). Environments that are safe, have walkable spaces or feature age-appropriate exercise equipment and activities that help to facilitate adherence to regular exercise (Rodiek and Schwarz, 2005). Although, access to health promotion activities such as exercise classes is important, access alone will not improve adherence to exercise (Becker et al., 2005). Other factors associated with exercise adherence may include demographics (gender, education), mental health, cognitive status, psychosocial factors such as motivation (Resnick and D’Adamo, 2011).
Lower rates of getting an annual flu shot, in this study, is probably related to their poor literacy and unawareness of the risks of influenza complications or unawareness of the relationship between the flu and deterioration of HF (Jaarsma et al., 2013). In addition, the patients aren’t routinely reminded to get a flu shot by their primary provider (Krum et al., 2011; Li and Liu, 2009).
Demographic characteristics: The results of this study showed no significant relationship between education level and self care behaviors. This finding is consistent with the finding of some studies (Dunlay et al., 2011; Chriss et al., 2004; Huyen et al., 2011), however, in a similarly designed cross sectional studies, other researchers found significant relationship between these variables (Shojaei et al., 2009; Abootalebi et al., 2012; Rockwell and Riegel, 2001; Riegel et al., 2009). Low literacy has been reported in 27-54% patients with HF (Laramee et al., 2007; Morrow et al., 2006; Dewalt et al., 2006). Individuals with inadequate literacy and chronic conditions such as HF may be at increased risk for poor self care (Evangelista et al., 2010; Wolf et al., 2005; Dennison et al., 2011), increased hospital admissions (Baker et al., 2002) and increased mortality (Baker et al., 2007). In our study, the majority of participants (74.5%) were illiterate. The relative low sample size and likely good social support from family members or friends may be contribute in this no relationship between education level and self care behaviors.
The mean of self care scores were lower among men, compared to women but there was not significant relationship. No significant relationship between gender and self care behaviors, in this study, is consistent with some studies (Abootalebi et al., 2012; Huyen et al., 2011; Rockwell and Riegel, 2001; Riegel et al., 2009; Gallagher et al., 2011) and is contrast with the other ones (Shojaei et al., 2009; Dunlay et al., 2011; Chriss et al., 2004). Higher self care scores in women, in this study, may be due to more low education level, more housekeeping activities and less opportunity to carry out appropriate self care.
Age-related characteristics: The results of this study showed that young elderly took care of themselves better than old ones. This finding is consistent with the finding of some studies (Van der Wal and Jaarsma, 2008; Cocchieri et al., 2014) and is contrast with the other ones (Evangelista et al., 2003; Dunlay et al., 2011). Decreased self care ability may be due to increasing visual and hearing impairment with age, loss of depth perception, impaired visual contrast and decreased vision with age, these factors may cause HF self care more difficult. It can affect activities such as reading medication names and learning new materials those are reading based (Moser and Watkins, 2008). Daily weighing is difficult for those with impaired vision and balance (Timiras, 2007). Hearing impairment may also make problems related to communication with health professional and resulted in poor self care (De Geest et al., 2004).
With increasing of age, probability of cognitive impairment is increased. In our study, the mean of self care behaviors scores was better among elderly without cognitive impairment. Chronic HF increases the odds for cognitive impairments two fold after controlling for other known risk factors (Cacciator et al., 1998). Although, further studies are needed to explore the potential mechanisms, lowering EF, hypo-oxygenation of brain vessels and factors indirectly link to heart failure such as poly-pharmacy, sleep disorders, nutritional deficiencies and depression could be related to cognitive impairment in HF (Riegel et al., 2002).
Surprisingly, the mean of self care behavior scores was better among elderly with poly-pharmacy than elderly without poly-pharmacy. Poly-pharmacy is a worrisome problem in view of the increased risk for adverse events and non-adherence (De Geest et al., 2004). In this study, the type of taken drugs had not been registered and poly-pharmacy may be related to supplement and minerals consumption.
The mean of Charlson Co-morbidity Index among elderly with good care was lower than elderly without. The presence of co-morbidities, especially if symptoms are similar to those of heart failure, makes difficult the recognition and subsequent management of symptoms (Moser and Watkins, 2008; Macinnes, 2008).
Clinical characteristics: In this study, the mean of systolic blood pressure and serum sodium level were lower among elderly with good care than elderly without. Control of blood pressure is important in prevention of heart failure (Pocock et al., 2006). The hypertension in the very old Trial (HYVET) is the first study that clearly demonstrated the benefits of anti-hypertensive therapy in older patients. In that study, lowering BP in patients with hypertension (mean age 84 years) lowered the risk of both stroke and all-cause mortality (Beckett et al., 2008). Hyponatremia is one the negative prognostic factors in HF (Pocock et al., 2006). Multiple studies have shown that hyponatremia in patients with heart failure is an independent predictor of mortality and repeated hospitalizations for de-compensation (Klein et al., 2005; Gheorghiade et al., 2007; Aronson et al., 2014). The results of a large study among 6,55,493 patients with non-dialysis-dependent chronic kidney disease showed the association of serum sodium level with mortality was U-shaped and the lowest mortality was seen in patients with sodium level of 140 mEq L-1 and both lower and higher levels showed significant associations with increased mortality (Kovesdy et al., 2012). In our study, although the mean of serum sodium level was within the normal range, it was lower 140 mEq L-1 among elderly with good care. This may be due to consumption of diuretics or strict dietary sodium restriction. Sodium determines body fluid volume and therefore sodium restriction might be beneficial (Lainscak et al., 2011). But strict sodium restriction can be harmful through hypovolemia and increased neuro-hormonal activities (Konerman and Hummel, 2014).
There was significant difference between ejection fraction among elderly with and without good care. But there was not significant difference between NYHA class among elderly with and without good care. This finding is consistent with the findings of some studies (Chriss et al., 2004; Gallagher et al., 2011) and is contrast with the other ones (Rockwell and Riegel, 2001; Riegel et al., 2009). In a large study, among 7599 patients with HF left ventricular ejection was more powerful predictor than NYHA class, for CV death/HF hospitalization (Pocock et al., 2006).
In this study, the mean of self care behaviors scores was lower among elderly with ischemic heart disease than elderly without. But the mean of self care behaviors scores was higher among elderly with hypertension and anemia than elderly without. Although, presence of co-morbidities makes the recognition and subsequent management of symptoms difficult, the results of some studies showed that they correlate with good care (Artinian et al., 2002; Riegel et al., 2007). Occurrence of chest pain and fear of myocardial infarction may be resulted in better self care behaviors among elderly with ischemic heart disease.
CONCLUSION
In this study, some clinical and age-related characteristics had a negative effect on self care behaviors. Interventions to improve self care behaviors among elderly with heart failure should target both clinical and age-related characteristics, as the synergistic effects of these factors may lead to greater health risks in this population. Following suggestions may be resulted in better SCB among elderly with heart failure:
| • | Regularly assessment of hearing, visual and cognitive status of older people with heart failure |
| • | Using of teaching material with bigger font size, speaking slower and repeating several times |
| • | Development of enriched environment in order to stimulate all of the sensory organs |
| • | Motivational interviewing in order to persuade regularly physical activity and proper nutrition |
| • | Supervision and control of cardiovascular risk factors such as hypertension |
| • | Social support both behalf of family members and professional health care |
ACKNOWLEDGMENT
The authors are thankful to the dear elderly with CHF for their kind co-operation and the cardiologists and cardiac nurse colleagues of the Mazandaran university of Medical Sciences for their support and collaboration. This study was conducted in line with PhD thesis No. ETH- 1155 and was supported by the University of Social Welfare and Rehabilitation Sciences, Tehran, Iran and the Mazandaran University of Medical Sciences, Sari, Iran.