JinShil Kim

Cognitive Deficits in Chronic Heart Failure

Background:Patients with heart failure (HF) have been found to have cognitive deficits, but it remains unclear whether these deficits are associated with HF or with aging or comorbid conditions common in HF. Objectives:The purpose of this study was (a) to determine the types, the frequency, and the severity of cognitive deficits among patients with chronic HF compared with age- and education-matched healthy participants and participants with major medical conditions other than HF, and (b) to evaluate the relationships between HF severity, age, and comorbidities and cognitive deficits. Methods:A sample of 414 participants completed the study (249 HF patients, 63 healthy and 102 medical participants). The HF patients completed measures of HF severity, comorbidity (multiple comorbidity, depressive symptoms), and neuropsychological functioning. Blood pressure and oxygen saturation were assessed at interview; clinical variables were abstracted from records. Participants in the comparison groups completed the same measures as the HF patients except those specific to HF. Results:Compared with the healthy and medical participants, HF patients had poorer memory, psychomotor speed, and executive function. Significantly more HF patients (24%) had deficits in three or more domains. Higher (worse) HF severity was associated with more cognitive deficits; HF severity interacted with age to explain deficits in executive function. Surprisingly, men with HF had poorer memory, psychomotor speed, and visuospatial recall ability than women. Multiple comorbidity, hypertension, depressive symptoms, and medications were not associated with cognitive deficits in this sample. Discussion:HF results in losses in memory, psychomotor speed, and executive function in almost one fourth of patients. Patients with more severe HF are at risk for cognitive deficits. Older patients with more severe HF may have more problems in executive function, and men with HF may be at increased risk for cognitive deficits. Studies are urgently needed to identify the mechanisms for the cognitive deficits in HF and to test innovative interventions to prevent cognitive loss and decline.

Memory dysfunction, psychomotor slowing, and decreased executive function predict mortality in patients with heart failure and low ejection fraction

BACKGROUND The purpose of this study was to evaluate whether dysfunction of specific cognitive abilities is a predictor of impending mortality in adults with systolic heart failure (HF). METHODS A total of 166 stable outpatients with HF completed cognitive function evaluation in language, working memory, memory, visuospatial ability, psychomotor speed, and executive function using a neuropsychological test battery. Demographic and clinical variables, comorbidity, depressive symptoms, and health-related quality of life were also measured. Patients were followed for 12 months to determine all-cause mortality. RESULTS There were 145 survivors and 21 deaths. In logistic regression analyses, significant predictors of mortality were lower left ventricular ejection fraction (LVEF) and poorer scores on measures of global congnitive function Mini-Mental State Examination [MMSE], working memory, memory, psychomotor speed, and executive function. Memory loss was the most predictive cognitive function variable (overall chi(2) = 17.97, df = 2, P < .001; Nagelkerke R(2) = 0.20). Gender was a significant covariate in 2 models, with men more likely to die. Age, comorbidity, depressive symptoms, and health-related quality of life were not significant predictors. In further analyses, significant predictors of mortality were lower systolic blood pressure and poorer global cognitive function, working memory, memory, psychomotor speed, and executive function, with memory being the most predictive. CONCLUSIONS As hypothesized, lower LVEF and memory dysfunction predicted mortality. Poorer global cognitive score as determined by the MMSE, working memory, psychomotor speed, and executive function were also significant predictors. LVEF or systolic blood pressure had similar predictive values. Interventions are urgently needed to prevent and manage memory loss in HF.

Measuring Depressive Symptoms in Heart Failure: Validity and Reliability of the Patient Health Questionnaire–8

BACKGROUND Depressive symptoms are common in patients with heart failure, but few investigators have reported the validity and reliability of measures of depressive symptoms among these patients. OBJECTIVES To evaluate the validity and reliability of a measure of depressive symptoms, the Patient Health Questionnaire-8 (PHQ-8), among 249 patients with chronic heart failure. METHODS As part of a larger study, patients completed the PHQ-8 and the Living With Heart Failure Questionnaire. New York Heart Association class was assessed as a measure of the severity of heart failure. Construct validity of the PHQ-8 was evaluated by confirmatory factor analysis, Pearson correlation coefficients, and analysis of variance. Internal consistency reliability was estimated by using the Cronbach α. RESULTS The sample was 63% men, with a mean age of 63 years, and 67% reported their race as white. Construct validity of the PHQ-8 was supported. The confirmatory factor analysis model reflected the emotional and somatic dimensions of depressive symptoms and displayed a good fit with the data. The χ(2) value of the PHQ-8 was 24.75 with 18 degrees of freedom (P =.13) and the goodness-of-fit index was 0.98. The PHQ-8 was significantly correlated with the total and subscale scores on the Living With Heart Failure Questionnaire (P <.001 for all correlations). Differences in the PHQ-8 scores were found among New York Heart Association classes (F=20.4, P<.001). The PHQ-8 internal consistency reliability (Cronbach α) was 0.82. CONCLUSIONS The PHQ-8 demonstrated satisfactory validity and reliability; these results support its use to measure depressive symptoms in patients with heart failure.

Gender- and age-specific prevalence of metabolic syndrome among Korean adults: analysis of the fifth Korean National Health and Nutrition Examination Survey.

Background:Despite the growing prevalence of metabolic syndrome (MetS) in Korea, information is lacking on gender- and age-specific patterns in prevalence of MetS among Korean adults. Aims:The aims of this study were to examine (1) gender-specific prevalence of MetS by its component abnormalities, (2) the prevalence of MetS and its component abnormalities by gender and 10-year age groups, and (3) gender-specific lifestyle risk factors for MetS presentation among Korean adults. Methods:A secondary data analysis was performed using the most recent national survey. A sample group of 5760 adults (mean age, 44.6 ± 0.46 years; 43.5% men) completed household interviews to provide blood (for high-density lipoprotein cholesterol, triglyceride, and glucose) and anthropometric measurements (ie, waist circumference, weight, and height) to define MetS, as well as data on lifestyle risk factors. Results:Approximately 1 in 4 Korean adults met the MetS diagnostic criteria. Given each component abnormality, MetS was the most prevalent in men with low high-density lipoprotein cholesterol (63.4%), followed by abdominal obesity (62.3%). In women, it was most prevalent in those with hypertriglyceridemia (73.2%), followed by hyperglycemia (69.7%). Metabolic syndrome showed an association with advanced age for both men and women (P < .001 for both), with greater prevalence of MetS in young and middle-aged men than in women (6.7%–39.9% vs 3.3%–36.4%); these patterns were reversed in people 60 years or older (34.0%–40.5% vs 55.2%–64.1%). Gender-specific lifestyle risk factors for MetS presentation showed a significant association with heavy alcohol drinking and obesity for both men (odds ratio, 1.65 and 5.26, respectively; P < .001 for both) and women (odds ratio, 1.96 and 5.94; P < .042 and < .001, respectively). Conclusions:Metabolic syndrome is prevalent in a representative sample of Korean adults, with gender- and age-specific patterns. These results are helpful in identification of vulnerable subgroups at high risk for MetS, providing a basis for promotion of cardiovascular health and risk management of MetS.

Dose-dependent relationship of physical and depressive symptoms with health-related quality of life in patients with heart failure

Background: Patients with heart failure (HF) have poor health-related quality of life (HRQOL). The vast majority of patients have physical symptoms, and about 30–40% have depressive symptoms. The combined effects of physical and depressive symptoms on HRQOL have not been examined fully in HF. Purposes: To examine the combined effects of physical and depressive symptoms on HRQOL using repeated measures, controlling for covariates (i.e. age, education level, New York Heart Association (NYHA) functional class, financial status, and health perception). Methods: Patients (N = 224, 62 ± 12 years old, 67% male, 38% NYHA functional class III/IV) provided data on physical (Symptom Status Questionnaire) and depressive symptoms (Beck Depression Inventory II) at baseline and HRQOL (Minnesota Living with Heart Failure Questionnaire) at baseline and 12 months. Patients were divided into three groups based on presence of physical and depressive symptoms: a) no symptom group, b) one symptom group (dyspnea or fatigue), and c) two symptom group (physical and depressive symptoms). Repeated measures ANOVA was used to analyze the data. Results: The least squares mean scores of baseline and 12-month HRQOL differed significantly in the three groups after controlling for the covariates (26.4 vs. 36.6 vs. 53.1, respectively, all pairwise p values < 0.001). There was no time-by-group interaction or time main effect. Conclusion: Physical and depressive symptoms have a dose–response relationship with HRQOL. Further research is needed to provide effective interventions to improve physical and depressive symptoms, in turn, HRQOL.

Communication for end-of-life care planning among Korean patients with terminal cancer: A context-oriented model.

OBJECTIVE In Korea, patients with terminal cancer are often caught out of the loop in end-of-life (EoL) care discussions. Healthcare professionals also have difficulty engaging in such communication in a variety of healthcare contexts. Therefore, the objective of our study was to develop a communication model for EoL care decision making compatible with the clinical environment in Korea. METHODS Using focus-group interview methodology, participants included eight doctors and five nurses who provide EoL care for terminal cancer patients in acute hospital settings or hospice care facilities in various provinces of Korea. RESULTS Five themes emerged regarding EoL care discussion, which included: (1) timing, (2) responsible professionals, (3) disclosure of bad news, (4) content areas of EoL care discussion, and (5) implementing strategies for EoL care discussions. These themes were based on development of a communication algorithm for EoL discussion among patients with terminal cancer. A structural communication step for delivery of a terminal prognosis was specified at the phase of disclosure of bad news: beginning with determination of a patients decision-making capability, followed by a patients perception of his/her condition, a patients wish to know, family dynamics, and a patients and/or familys readiness for EoL discussions. SIGNIFICANCE OF RESULTS The proposed context-oriented communication algorithm could provide a helpful guideline for EoL communication and, accordingly, facilitate meaningful improvements in EoL care in Korean clinical practice. The feasibility of this algorithm has not yet been determined, and its validation in a larger sample of patients with terminal cancers, using a quantitative research methodology, is a priority of research.

Change in cognitive function over 12 months among patients with an implantable cardioverter-defibrillator.

Background:Patients with implantable cardioverter-defibrillators (ICDs) have decreased cognitive function associated with arrhythmic and/or cardiac disorders, such as ischemic cardiomyopathy. Little is known about changes in cognitive function over time among ICD patients. Aims:The aim of this study was to evaluate baseline-to-12-month changes in cognitive function in memory (total recall and delayed recall), psychomotor speed, and executive function among ICD patients. Methods:In this prospective study, 115 (mean [SD] age, 64.83 [9.06] years, 75% mean) and 77 ICD patients completed baseline and 12-month face-to-face interviews, respectively, which included neuropsychological tests to evaluate cognitive function. Results:Patients who completed baseline and 12-month testing had decreased total and delayed recall memory (all P < .05). No significant changes from baseline to 12 months were observed in psychomotor speed (t = 0.33; P = .74) and executive function (t = −1.12; P = .27). Using 1.0 standard deviation or below the mean as a cutoff criterion, 12% to 22% of ICD patients had poor cognitive function over time. Particularly, at baseline, 17 (15%) and 15 (13%) of the 115 patients had poor memory in total and delayed recall, respectively. At 12 months, 12 (16%) and 9 (12%) of the 77 patients had poor memory in total and delayed recall, respectively. Conclusions:In this sample of patients with ICDs, memory was poor at baseline and decreased over 12 months. Future studies are indicated to determine how this change in memory influences outcomes such as medication adherence.

Cluster dyads of risk factors and symptoms are associated with major adverse cardiac events in patients with acute myocardial infarction.

The purpose of this study was to examine the cluster dyads of risk factors and symptoms and their impact on the incidence of 12 month major adverse cardiac events (MACEs) among patients with first-time myocardial infarction (MI). In a descriptive study, a total of 522 patients completed semi-structured interviews for data on risk factors and symptoms. Patients were followed for 12 months to determine MACEs. Latent class cluster analysis was performed to identify risk factor clusters and symptom clusters. Logistic regression analysis was performed to determine the impact of cluster dyads on 12 month MACEs. There were 436 event-free survivors and 86 patients with MACEs for 12 months. Ten risk factors and 14 symptoms were clustered into two (dyslipidemia/smoking, hypertension/diabetes dominant) and three (typical, multiple, atypical) memberships, respectively. Six cluster dyads which were generated based on the association between risk factors and symptom clusters were a significant predictor of 12 month MACEs, with the incidence occurring three times higher in a dyad of hypertension/diabetes-and-atypical symptoms than a dyad of dyslipidemia/smoking-and-typical symptoms (odds ratio = 3.10, P = 0.01), after adjustment for age, gender and a type of MI diagnosis. The information on cluster dyads suggests that health-care providers need to consider both risk factors and symptoms at hospital presentation for risk stratification to prevent adverse outcomes.The purpose of this study was to examine the cluster dyads of risk factors and symptoms and their impact on the incidence of 12 month major adverse cardiac events (MACEs) among patients with first-time myocardial infarction (MI). In a descriptive study, a total of 522 patients completed semi-structured interviews for data on risk factors and symptoms. Patients were followed for 12 months to determine MACEs. Latent class cluster analysis was performed to identify risk factor clusters and symptom clusters. Logistic regression analysis was performed to determine the impact of cluster dyads on 12 month MACEs. There were 436 event-free survivors and 86 patients with MACEs for 12 months. Ten risk factors and 14 symptoms were clustered into two (dyslipidemia/smoking, hypertension/diabetes dominant) and three (typical, multiple, atypical) memberships, respectively. Six cluster dyads which were generated based on the association between risk factors and symptom clusters were a significant predictor of 12 month MACEs, with the incidence occurring three times higher in a dyad of hypertension/diabetes-and-atypical symptoms than a dyad of dyslipidemia/smoking-and-typical symptoms (odds ratio = 3.10, P = 0.01), after adjustment for age, gender and a type of MI diagnosis. The information on cluster dyads suggests that health-care providers need to consider both risk factors and symptoms at hospital presentation for risk stratification to prevent adverse outcomes.

Professional Opinions on Advance Directives in Korea

A Korean advance directive (K-AD) draft was developed for establishment of a unified and evidence-based form of AD in Korea. Yet, it remains unknown whether this K-AD is culturally and practically compatible for employment in a clinical environment. Therefore, the aim of this study was to solicit professional opinions regarding this K-AD draft. Using a panel of experts in hospice and end-of-life (EOL) care, a 3-round Delphi study was conducted for evaluation of K-AD, composed of 16 specifics in 5 components, including introduction, a value statement, treatment options, proxy appointment, and stakeholders’ signatures. A consensus was determined: An item scored as important (≥4 on a 5-point Likert scale) among 75% of experts or content validity ratio of 0.59 or greater. Forty experts, 35% (n = 14) and 79% (n = 11) of previous-round participants, completed each round. Item evaluation did not differ across 3 rounds (Friedman &khgr;2 = 0.00-6.00, P = .05-1.00). Experts reached a consensus on 5 K-AD components, all-encompassing. Among EOL treatment options, cardiopulmonary resuscitation, artificial ventilation, artificial feeding, and hospice care were determined for inclusion of the K-AD. Important-item content validity ratios ranged from 0.64 to 1.00. In conclusion, K-AD could be used as a vehicle to facilitate the decision-making process for EOL care.

Facilitators and Barriers to Use of Advance Directives in Korea

Few studies assessing professional opinions regarding facilitators and barriers to use of advance directives (ADs) in Korea have been reported. The aims of this study were to (1) identify facilitators and barriers to use of ADs and (2) evaluate their importance in clinical practice. To address the aims of the study, a panel of experts in end-of-life care was invited and their opinions regarding facilitators and barriers to use of ADs were solicited using a semistructured survey (round 1). The relative importance of facilitators and barriers that emerged from the survey was evaluated on a 10-point Likert scale (round 2). Forty experts participated in round 1; 38% of them completed round 2. Five facilitators were identified with regard to knowledge, legal system, patient-provider paradigm shift, public and professional education, and cultural understanding. Seven barriers emerged, including negative attitudes, lack of a legal system, Korean Confucian belief, limited support, professional incompetence, and advances in medical therapy. Knowledge and negative attitudes were the most important facilitator and barrier for successful implementation of ADs, respectively. In conclusion, public and professional education is believed to be critical to increasing knowledge and enhancing positive attitudes toward ADs and professional competence in end-of-life care. A legal model of ADs that is compatible with Korean culture is also needed.