Longitudinal Transition of Symptom Cluster Profiles Among Community-Dwelling Older Adults With Heart Failure.

BACKGROUND: Older adults with heart failure experience clustered symptoms. However, little is known about how symptom clusters transition over time. OBJECTIVES: This study aimed to (1) identify the longitudinal transition of symptom cluster profiles over 8 years and (2) examine the associations between demographic and clinical factors and the transition between symptom cluster profiles over time. METHODS: We conducted a longitudinal secondary analysis of data from the Health and Retirement Study's 2008, 2012, and 2016 surveys. We included participants with heart failure in the core data sets and their proxy respondents in the exit data sets. We included demographic and clinical variables as well as six symptoms (fatigue, shortness of breath, pain, swelling, depressive symptoms, dizziness) through physical health interviews. We used latent transition analysis and multinominal regressions to determine longitudinal profiles and explored the association between demographic and clinical factors and membership in symptom cluster profiles. RESULTS: Among 690 participants, we found four symptom cluster profiles (high burden, low burden, distressing, and respiratory-depressive distress). Participants in the low burden at baseline had the highest probability of transitioning to the respiratory-depressive distress profile. Participants in the respiratory-depressive distress at 4 years had the highest probability of transitioning to the high burden profile. Male sex, Black/African American race, smoking, and comorbidities were associated with the increased odds of transiting from the low symptom burden to the high symptom burden profile. DISCUSSION: Symptom cluster profile memberships were stable over an 8-year period. However, symptom cluster profiles are changeable and deteriorate over time. Identifying predictive factors enables targeted interventions for those at highest risk.

Daytime symptom trajectories among adults with stable heart failure and insomnia: evidence from a randomised controlled trial of cognitive behavioural therapy for insomnia.

People with heart failure (HF) experience a high symptom burden and prevalent insomnia. However, little is known about daytime symptom trajectories after cognitive behavioural therapy for insomnia (CBT-I). In this study we describe: (1) daytime symptom trajectories among adults with insomnia and stable HF over 1 year, (2) how symptom trajectories differ between CBT-I versus HF self-management interventions, and (3) associations between demographic, clinical, and sleep characteristics, perceived stress, health-related quality of life (HRQoL), functional performance and daytime symptoms trajectories. We retrospectively analysed data from a randomised controlled trial of CBT-I versus HF self-management (NCT0266038). We measured sleep, perceived stress, HRQoL, and functional performance at baseline and symptoms at baseline, 3, 6, and 12 months. We conducted group-based trajectory modelling, analysis of variance, chi-square, and proportional odds models. Among 175 participants (mean [standard deviation] age 63.0 [12.9] years, 57.1% male, 76% White), we found four daytime symptom trajectories: (A) low improving symptoms (38.3%); (B) low psychological symptoms and high improving physical symptoms (22.8%); (C) high improving symptoms (24.0%); and (D) high not improving symptoms (14.9%). The CBT-I versus the HF self-management group had higher odds of belonging to Group A compared to other trajectories after controlling for baseline fatigue (odds ratio = 3.27, 95% confidence interval 1.39-7.68). The difference between the CBT-I and the HF self-management group was not statistically significant after controlling for baseline characteristics. Group D had the highest body mass index, perceived stress, and insomnia severity and the lowest cognitive ability, HRQoL, and functional performance. Research is needed to further evaluate factors contributing to symptom trajectories.

Rest-activity rhythms predict time to hospitalizations and emergency department visits among participants in a randomized control of adults with heart failure and insomnia.

BACKGROUND: We examined the effects of insomnia and diurnal rest-activity rhythms (RARs) on time to hospitalizations and emergency department (ED) visits in a randomized controlled trial of cognitive behavioral therapy for insomnia among people with chronic heart failure (HF) and insomnia. METHODS: Among 168 HF patients, we measured insomnia, CPAP use, sleep, symptoms, and 24-h wrist actigraphy and computed the circadian quotient (strength of the RAR) from wrist actigraphy and computed cox-proportional hazard and frailty models. RESULTS: Eighty-five (50.1%) and ninety-one (54.2%) participants had at least one hospitalization or ED visit, respectively. NYHA class and comorbidity predicted time to hospitalizations and ED visits, while younger age and male sex predicted earlier hospitalizations. Low ejection fraction predicted time to first cardiac event and composite events. Independent of clinical and demographic predictors, a lower circadian quotient and more severe pain significantly predicted earlier hospitalizations. A more robust circadian quotient, more severe insomnia, and fatigue predicted earlier ED visits independent from clinical and demographic factors. Pain and fatigue predicted composite events. CONCLUSION: Insomnia severity and RARs independently predicted hospitalizations and ED visits independent of clinical and demographic variables. Further research is necessary to determine whether improving insomnia and strengthening RARs improves outcomes among people with HF. CLINICAL TRIALS REGISTRATION: NCT02660385.

An Evolutionary Concept Analysis in People With Heart Failure-Symptom Clusters or Symptom Cluster Profiles?

The concept of symptom clusters in heart failure (HF) has been defined and measured inconsistently. We used Rodgers' evolutionary method to review related concepts in the HF literature. Symptom clusters and symptom cluster profiles are characterized by multiple symptoms, a synergistic relationship, and result in a myriad of poor outcomes. Researchers should carefully consider the conceptual differences underpinning symptom clusters and symptom cluster profiles and choose the appropriate concept aligned with their research questions, empirical methods, and target HF population.

Partners' Experience of Informal Caregiving for Patients With Heart Failure: A Meta-ethnography.

BACKGROUND: Individuals with heart failure (HF), a debilitating disease with ongoing adaptation and management, are often cared for by partner caregivers whose needs and voices are overshadowed by the demands of HF management. With multidimensional needs and complex challenges for individuals with HF, partner caregivers have to deal with uncertainty and need guidance. Given the vital role of partners, attention should be drawn toward understanding the experience of HF partner caregivers. OBJECTIVE: The aim of this study was to synthesize existing qualitative evidence related to caregivers' views and experiences of caring for their partners with HF. This knowledge would assist healthcare providers to better meet the demand of partners and provide them with effective guidance. METHODS: A meta-ethnography of qualitative evidence was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations for reporting systematic reviews. A comprehensive search of PubMed, Scopus, ISI Web of Science, CINAHL, PsycINFO, and EMBASE, as well as hand searches of the reference lists from included articles, was conducted. A combination of subject terms including MeSH and keywords related to HF, partner experience, and qualitative methods was used to identify studies. Studies were included if they were published in English between January 2000 and December 2020 and examined caregivers' experiences in providing care for their partner with HF by using qualitative methods. RESULTS: Ten articles were included, with 178 participants, and most partners were female. Five studies were conducted in the United States, and 4 studies were conducted in Sweden. Five studies reported partners' health problems; 8 of the studies delineated the inclusion and exclusion criteria for partners. Five overarching themes emerged: shouldering the responsibility, being overloaded, bearing emotional burdens, staying positive, and "left in the dark," craving support from others. CONCLUSIONS AND CLINICAL IMPLICATIONS: Given the complex roles in caring for individuals with HF, more qualitative research is strongly warranted to enhance caregivers' support and education. A deeper and more comprehensive understanding of the experiences of caregivers for partners with HF is essential for developing tailored interventions. Healthcare providers should be aware of the importance of ongoing assessment and evaluate partner caregivers' needs and assist them in providing more information and formulating coping strategies as required.

The association between psychological factors and self-care in patients with heart failure: an integrative review.

AIMS: This integrative review aims to describe the current evidence concerning the relationship between a broad range of psychological factors (depression, depressive symptoms, anxiety, stress, and type-D personality) and self-care in patients with heart failure. METHODS AND RESULTS: Six electronic databases were searched and keywords were used to identify potential eligible studies published within the last 10 years. To be eligible, individuals with heart failure aged 18 years or older and who were included in any type of observational study that examined the association between psychological factors and self-care were considered. Twenty articles were included, and 16 of them reported that depression/depressive symptoms were associated with poorer self-care, after controlling for age, sex, education level, cardiac history, or comorbidities. Five studies found that self-care confidence/self-efficacy mediates the relationship between depression/depressive symptoms and self-care. The association between depression/depressive symptoms and self-care varied in assessment methods and statistical approaches. Seven studies showed an inverse association between anxiety and self-care. Four studies found a stronger association between self-care and depression compared with the relationship between self-care and other psychological factors. Stress and type-D personality were both associated with self-care in four studies. CONCLUSION: Depression/depressive symptoms and anxiety were found to be inversely associated with self-care in patients with heart failure. Depression exhibited a stronger impact on self-care than other psychological factors. Limited studies assessed stress and type-D personality; the results should be considered with caution. Further studies are warranted on different psychological factors and their underlying mechanisms in individuals with heart failure.

Nurses' knowledge of heart failure assessment and management: A cross-sectional survey.

BACKGROUND: Nurses' knowledge of heart failure (HF) is highly variable, ranging from expert to poor, potentially leading to inadequate self-care. OBJECTIVES: (1) document the knowledge variation of HF assessment and management among specialist and generalist nurses; (2) determine factors that may be associated with nurses' knowledge; and (3) describe nurses' views of knowledge deficits and ways to improve nurses' knowledge to better meet the needs educational interventions. METHOD: Members of the American Association of Heart Failure Nurses and Registered Nurses were invited to participate in a cross-sectional survey. Independent samples t-test, chi-square, and linear regression were used for quantitative analysis. Text analysis was applied to analyze the themes of qualitative comments. RESULTS: A total of 918 nurses completed the survey. Specialist nurses had higher scores than generalist nurses with statistically significant F-test for diet, fluid, signs/symptoms, medication, and exercise. Both specialist and generalist nurses were least knowledgeable about dry weight, asymptomatic hypotension, and transient dizziness. Being a specialist nurse was associated with higher level of knowledge scores. Years of experience and race were significant factors associated with knowledge scores in generalist nurses. Confidence level and race were significant predictors for specialist nurses. Three themes emerged regarding the cause of nurses' insufficient knowledge and several approaches were provided. CONCLUSIONS: Specialist nurses are not only knowledgeable, but their knowledge levels are less variable compared to generalist nurses. There is a need to identify additional factors that may potentially influence nurses' knowledge, contributing to the effectiveness of interventions.

Preoperative Cognitive Assessment Recommendations for the Older Adult.

PURPOSE: The purpose of this project was to identify the need for and to improve the preoperative cognitive assessment of the older adult. DESIGN: A retrospective chart review was used to explore the incidence of postoperative delirium (PD) and characteristics associated with it. METHODS: A retrospective chart review was used to identify the incidence of PD in a community hospital. The data were analyzed using descriptive statistics for trends in demographic and physiological characteristics of older adults undergoing elective hip or knee surgery. FINDINGS: The incidence of PD was found to be 11%. Older adults with PD had an increased mean age and comorbid conditions. PD was associated with a mean increase in hospital stay, postoperative complications, and 30-day readmission. CONCLUSIONS: Preoperative cognitive assessment can identify high-risk patients, stratify care, medically optimize the older adult before surgery, and improve perioperative outcomes.

Symptom Distress: Implementation of Palliative Care Guidelines to Improve Pain, Fatigue, and Anxiety in Patients With Advanced Cancer.

BACKGROUND: The integration of palliative care into standard oncology care is supported by research to improve quality of life and symptom distress in patients with advanced cancer. In 2016, the American Society of Clinical Oncology (ASCO) released practice guidelines for oncology palliative care that emphasized interprofessional assessment and management of this patient population. OBJECTIVES: The purpose of this study was to evaluate the effect of clinical guidelines on symptom distress in patients with advanced cancer. METHODS: In two oncology palliative care clinics, the Edmonton Symptom Assessment Scale (ESAS) scores for pain, fatigue, and anxiety were measured prior to consultation (T1) and at two subsequent visits (T2 and T3). A standardized documentation template was used to measure fidelity for key guideline components. FINDINGS: Pain, fatigue, and anxiety ESAS scores were statistically lower from T1 to T3. The frequency of patients having a decrease of 2 or more points for all symptoms increased compared to baseline data. There was 100% compliance to the documentation template during the guideline implementation.

Preparing Clinicians for Transitioning Patients Across Care Settings and Into the Home Through Simulation.

Assuring home care staff competencies through simulation has the potential to improve care transitions and clinical outcomes. Recreating a home environment can be used for orientation of home care staff and to meet other learning needs. Lessons learned from the use of simulation in a geriatric nursing course in a prelicensure program can be used to prepare clinicians for transitioning patients across care settings. With simulation, learners can identify challenges in patient safety, pain management, and management of patients' cognitive decline as well as learn how to communicate with patients, family members, and the healthcare team. Simulation, as an interactive pedagogy, provides opportunities for learners to practice assessment, monitoring, and patient care in a controlled, safe, risk-free environment. Following participation in a simulation, learners are given the opportunity to reflect on ways to improve patient care when transitioning from acute to home care settings. Simulations described in this article can be used for orientation of staff to a home healthcare agency because they allow clinicians to hone the skills necessary for patient care in the home. Staff educators can also use simulation to validate staff competencies in caring for patients at home.

Frailty determinants in two long-term care settings: Assistant living facilities and home and community-based programs.

There is limited knowledge on differences in frailty among residents in assisted living facilities (ALF) and home and community-based services (HCBS). This study used a retrospective cross-sectional design to compare frailty determinants in two long-term care settings. The HCBS setting had a greater proportion of positive responses to 9 of 14 frailty indicators. The ALF setting had a greater proportion to only 2 of the 14 frailty indicators. The finding that the HCBS setting had a significantly greater proportion of participants with positive frailty indicators as compared to the ALF setting suggests the degree of frailty risk is different by health care setting.

Frailty in older adults: an evolutionary concept analysis.

The term frailty is often used to describe a subset of the older population with complex health issues. It is associated with dependence, disability, increased health care use, and mortality. An emergent problem is the lack of consensus as to the etiology and definition of frailty. The purpose of this concept analysis is to clarify the concept of frailty in the context of older adults and propose a definition of frailty that may be relevant to identification of frail older adults. The results from this analysis conclude frailty in older adults is a tenuous state of health that is the result of the complex interplay of physiological, psychosocial, and environmental stressors that increases an older adult's susceptibility to adverse health outcomes.

Multidisciplinary Specialty Teams: A Self-Management Program for Patients With Advanced Cancer.

Self-management has been shown to be an effective intervention to enable and empower patients with chronic illness to manage their health. Taking Early Action to Manage Self (TEAMS) is such an intervention, providing education and support to patients with advanced solid tumors to develop self-management skills. We conducted a study and surveyed health-care providers about their perceptions of multidisciplinary teams on the outcomes of this TEAMS intervention as well as factors that may influence its adoption into practice. The majority of respondents reported that the TEAMS program was feasible to practice and well suited to their patient population. In this article, the full results of this survey are presented, along with the emerging themes of empowerment and improved communication between patients and providers. In addition, facilitators and barriers to its adoption are explored. Although providers supported the adoption of the TEAMS program, provider resources to implement and maintain it need to be addressed prior to its widespread adoption.

Development of a frailty measure for older adults: the frailty index for elders.

BACKGROUND AND PURPOSE: Frailty is a significant challenge for health care. Therefore, it is important to identify frail individuals. Theoretical Framework: The Vulnerability/Risk/Human Response/Care Model. The purpose of this study was to develop and validate a measure to identify frail older adults. METHODS: Instrument development encompassed the following: delineation of content domains, item generation, content validity, quantitative content validity analysis, and psychometric analysis. RESULTS: Findings indicated the following: (a) Frailty is a complex concept, (b) the Frailty Index for Elders (FIFE) is composed of 10 items, (c) FIFE was able to predict depression, and (d) FIFE was able to differentiate differences in demographic profiles by social support environment. CONCLUSIONS: FIFE is a valid instrument. FIFE can be used to study the relationships among frailty determinants, provide standardized measurement, and develop and measure interventional studies.

Validity and reliability of the geriatric sexuality inventory.

Effective health care for older adults requires that providers assess and manage sexual health needs with high priority. This assessment begins with an effective sexuality assessment tool. A two-step, research approach was undertaken to develop and test the Geriatric Sexuality Inventory (GSI). Literature and expert review resulted in a 34-item instrument that was initially completed by 34 older adults ages 60 to 91 (mean age = 75). The testing was repeated in 19 of the original participants. The sample was 75% women, and 88% Caucasian with 9% single, 27% married, 18% divorced, and 46% widowed participants. Internal consistency reliability was run on all 53 responses and revealed adequate reliability (alpha = 0.74). Test-retest analysis also revealed good initial instrument reliability (r = 0.78; p < 0.001). Responses to open-ended questions regarding sexual information and care needs supported evidence gathered from the literature. Initial testing of the GSI revealed content validity and good internal consistency and test-retest reliability.

The use of comorbidities among adults experiencing care transitions: a systematic review and evolutionary analysis of empirical literature.

OBJECTIVE: To systematically review how comorbidities are employed in the empirical literature for adults coping with multiple chronic conditions during common episodes of acute illness that resulted in transition across health care setting. METHODS: Evolutionary concept analysis inductively identifies current consensus regarding the usage of a concept and results in exploring attributes and clarification of the concept. Sixty studies from 1965 to 2009 identified from MEDLINE, CINAHL, PsychINFO, and ISI Web of Science databases were analysed. RESULTS: Comorbidities were used heterogeneously among reviewed studies with most controlling for their presence (n=33) and lacking robust measurement (n=37). The designation of index or principal condition was equally heterogeneous with approximately half (n=26) representing the main disease or diagnosis of interest to the researcher. In this study comorbidities were associated with personal, disease or system level antecedents and consequences. A conceptual framework is proposed. DISCUSSION: The impact of comorbidities on the care and outcomes of adults coping with multiple chronic conditions is limited by heterogeneous and ambiguous usage. While analytic techniques have become more sophisticated, continued lack of meaningful conceptualization and instrument use has limited maturation of this important concept for research, practice and policy purposes.