Seongkum Heo

Comparison of prevalence of symptoms of depression, anxiety, and hostility in elderly patients with heart failure, myocardial infarction, and a coronary artery bypass graft.

OBJECTIVE This study sought to compare the prevalence of anxiety, depression, and hostility among 3 clinically diverse elderly cardiac patient cohorts and a reference group of healthy elders. METHODS This was a multicenter, comparative study. A total of 1167 individuals participated: 260 healthy elders, and 907 elderly cardiac patients who were at least 3 months past a hospitalization (478 heart-failure patients, 298 postmyocardial infarction patients, and 131 postcoronary artery bypass graft patients). Symptoms of anxiety, depression, and hostility were measured using the Multiple Affect Adjective Checklist. RESULTS The prevalence of anxiety, depression, and hostility was higher in patients in each of the cardiac patient groups than in the group of healthy elders. Almost three quarters of patients with heart failure reported experiencing symptoms of depression, and the heart-failure group manifested the greatest percentage of patients with depressive symptoms. CONCLUSIONS The high levels of emotional distress common in cardiac patients are not a function of aging, because healthy elders exhibit low levels of anxiety, depression, and hostility.

Testing the Psychometric Properties of the Minnesota Living With Heart Failure Questionnaire

BackgroundHealth-related quality of life (HRQOL) is an important outcome in patients with heart failure. One of the most commonly used instruments to measure HRQOL in this population is the Minnesota Living With Heart Failure Questionnaire (LHFQ). Although the psychometric properties of the LHFQ have been tested, the results do not definitively support the psychometric soundness of the instrument. ObjectiveTo examine the psychometric properties of the LHFQ. MethodData from 638 patients with heart failure were used to assess the reliability, homogeneity, representativeness, discriminative ability, and construct validity of the LHFQ before and after deletion of 5 items that showed lack of representativeness and contributed to inadequate factor structure. ResultsCronbachs alphas for the LHFQ Total and subscales were greater than .80. Interitem correlation coefficients in 17 of the 21 items, item–total correlation coefficients in 20 items, and discriminative ability in all items were acceptable. The total and both subscales of the LHFQ differentiated New York Heart Association functional groups. The Physical subscale was moderately related to the physical measures (the Specific Activity Scale and symptom status), whereas the emotional subscale was weakly related to the measures. The results of item p level testing and factor analysis demonstrated that 7 items were consistently problematic and 5 items were recommended to be deleted. The results of the reliability, homogeneity, and construct validity after deletion of these items demonstrated that the psychometric properties of the LHFQ were improved as a result. DiscussionThe initial results provided additional support for the reliability and substantial evidence for the validity of the LHFQ. However, the results of item and factor analyses did not fully support the psychometric soundness of several items. The psychometric properties of the LHFQ after deleting these items were improved. These results could provide researchers and clinicians a more useful measure of HRQOL.

Gender differences in and factors related to self-care behaviors: A cross-sectional, correlational study of patients with heart failure

BACKGROUND Although self-care may reduce exacerbations of heart failure, reported rates of effective self-care in patients with heart failure are low. Modifiable factors, including psychosocial status, knowledge, and physical factors, are thought to influence heart failure self-care, but little is known about their combined impact on self-care. OBJECTIVES The objective of this study was to identify factors related to self-care behaviors in patients with heart failure. DESIGN A cross-sectional, correlational study design was used. PARTICIPANTS AND SETTINGS One hundred twenty-two patients (77 men and 45 women, mean age 60+/-12 years old, 66% New York Heart Association functional class III/IV) were recruited from the outpatient clinics of an academic medical center and two community hospitals. METHODS Data on self-care behaviors (Self-Care of Heart Failure Index), depressive symptoms, perceived control, self-care confidence, knowledge, functional status, and social support were collected. Factors related to self-care were examined using hierarchical multiple regression. RESULTS Mean self-care behavior scores were less than 70 indicating the majority of men and women with HF did not consistently engage in self-care behaviors. Higher self-care confidence and perceived control and better heart failure management knowledge were associated with better self-care (r2=.25, p<.001). Higher perceived control and better knowledge were related to better self-care behaviors in men (r2=.18, p=.001), while higher self-care confidence and poorer functional status were related to better self-care behaviors in women (r2=.35, p<.001). CONCLUSION This study demonstrates the substantial impact of modifiable factors such as confidence in ones self-care abilities, perceived control, and knowledge on self-care behaviors. This study demonstrates that there are gender differences in factors affecting self-care, even though at baseline men and women have similar knowledge levels, physical, psychological, and behavioral status. Effective interventions focusing on modifiable factors and the unique characteristics of men and women should be provided to improve self-care behaviors in patients with heart failure.

Factors influencing medication adherence in patients with heart failure

BACKGROUND The purpose of this study was to explore factors influencing adherence to the prescribed medical regimen in patients with heart failure (HF). METHODS A convenience sample of 7 women and 9 men with HF participated in in-depth interviews. The interviews were audio-taped, transcribed, and checked for accuracy. Content analysis strategies were used to analyze the data. RESULTS The desire to be healthy was the primary motivator in the decision to take medications as prescribed. The process of making connections enhanced medication adherence. Participants connected knowledge of their illness and their symptoms with their medications effectiveness in decreasing these symptoms. Connections to a health care provider and family enhanced treatment adherence. Participants relied on environmental cues as reminders to take their medications, resulting in a habit of daily medication use. CONCLUSIONS Education that helps clients understand their illness, particular symptoms and how medications help them may be beneficial in promoting adherence. A positive working relationship with the health care provider may result in improved adherence.

The Control Attitudes Scale-Revised: psychometric evaluation in three groups of patients with cardiac illness.

Background: Perceived control is a construct with important theoretical and clinical implications for healthcare providers, yet practical application of the construct in research and clinical practice awaits development of an easily administered instrument to measure perceived control with evidence of reliability and validity. Objective: To test the psychometric properties of the Control Attitudes Scale-Revised (CAS-R) using a sample of 3,396 individuals with coronary heart disease, 513 patients with acute myocardial infarction, and 146 patients with heart failure. Methods: Analyses were done separately in each patient group. Reliability was assessed using Cronbachs alpha to determine internal consistency, and item homogeneity was assessed using item-total and interitem correlations. Validity was examined using principal component analysis and testing hypotheses about known associations. Results: Cronbachs alpha values for the CAS-R in patients with coronary heart disease, acute myocardial infarction, and heart failure were all greater than .70. Item-total and interitem correlation coefficients for all items were acceptable in the groups. In factor analyses, the same single factor was extracted in all groups, and all items were loaded moderately or strongly to the factor in each group. As hypothesized in the final construct validity test, in all groups, patients with higher levels of perceived control had less depression and less anxiety compared with those of patients who had lower levels of perceived control. Conclusion: This study provides evidence of the reliability and validity of the 8-item CAS-R as a measure of perceived control in patients with cardiac illness and provides important insight into a key patient construct.

Gender Differences in the Effects of Physical and Emotional Symptoms on Health-Related Quality of Life in Patients with Heart Failure

Background: Physical and emotional symptoms are common in heart failure. These symptoms are theorized to affect health-related quality of life (HRQOL), but their impact is likely mediated by variables not yet explored. Moreover, gender may affect these relationships. Aim: To determine gender differences in the effects of physical and emotional symptom status on HRQOL. Methods and results: Data from 51 men and 47 women with heart failure were analyzed using regression analyses. There were no gender differences in physical or emotional symptom status, or HRQOL, but there were differences in the dynamic relationships among the variables. In bivariate analyses, physical and emotional symptom status was related to HRQOL in both men and women. However, in women, physical symptom status was related to HRQOL, while in men depression affected HRQOL in multivariate analyses (p < .001, r 2 = .27; p < .001, r 2 = .40, respectively). Functional status measured by the New York Heart Association functional class mediated the effects of anxiety and depression on HRQOL only in women. Conclusion: There were gender differences in the dynamic relationships among variables related to HRQOL. These results demonstrate the need for individualized, comprehensive evaluation of patients HRQOL and symptom status in order to appropriately target interventions.

From Novice to Expert: Confidence and Activity Status Determine Heart Failure Self-care Performance.

Background:In a previous, small, mixed-methods study, heart failure patients were described as novice, expert, or inconsistent in self-care. In that study, self-care types differed in experience, confidence, attitudes, and skill. Objectives:The aims of this study were to validate the novice-to-expert self-care typology and to identify determinants of the heart failure self-care types. Methods:A cross-sectional descriptive study was performed using data from 689 adults with heart failure (61 ± 2.5 years; 36% female, 50% New York Heart Association class III). Two-step likelihood cluster analysis was used to classify patients into groups using all items in the maintenance and management scales of the Self-care of Heart Failure Index. Multinomial regression was used to identify the determinants of each self-care cluster, testing the influence of age, gender, left ventricular ejection fraction, body mass index, depression, anxiety, hostility, perceived control, social support, activity status (Duke Activity Status Index), and self-care confidence. Results:Self-care behaviors clustered best into three types: novice (n = 185, 26.9%), expert (n = 229, 33.2%), and inconsistent (n = 275, 39.9%). The model predicting self-care cluster membership was significant (&khgr;2 = 88.67, p < .001); Duke Activity Status Index score and Self-care of Heart Failure Index confidence score were the only significant individual factors. Higher activity status increased the odds that patients would be inconsistent (odds ratio [OR] = 1.02-1.09) or novice (OR = 1.02-1.10) in self-care. Higher self-care confidence increased the odds of being an expert (OR = 1.05-1.09) or inconsistent (OR = 1.01-1.05) in self-care. Discussion:The three-level typology of heart failure self-care was confirmed. Patients who have fewer limitations to daily activities may not be driven adequately to engage in heart failure self-care and may need extra assistance in developing expertise.

Factors influencing food intake in patients with heart failure: a comparison with healthy elders.

Background and research objective: Promoting adequate nutritional intake of patients with heart failure (HF) is an essential component of comprehensive management. This goal can be hampered by decreased appetite, as well as psychological, social, and HF-related factors that can affect food intake. Factors related to aging may also affect food intake in older patients. The purpose of this study was to compare patients with HF to healthy elders regarding the extent to which they perceived how appetite and hunger, emotional and social, and illness factors affected the amount of food they ate in the previous week. Subjects and methods: Sixty-seven patients with HF were recruited from 3 Midwestern HF clinics. As part of a larger study examining nutrition in HF, patients filled out the Food Eating Experiences and Diet (FEED) questionnaire, an instrument designed to assess factors affecting appetite and hunger. Patients were asked to rate their hunger and appetite on a visual analog scale. On Likert-type scales, they rated the extent to which appetite/hunger, emotional/social, and illness factors affected the amount of food intake. Sixty-eight healthy elders were recruited from 2 Midwestern senior citizen centers. As part of a study collecting a large data set for comparison with HF patients, healthy elders provided demographic and health information and filled out the FEED questionnaire. Results and conclusions: Factors rated as affecting food intake most often by patients with HF were decreased hunger sensations, diet restrictions, fatigue, shortness of breath, nausea, anxiety, and sadness. Factors rated most often by healthy elders as affecting food intake were diminished hunger sensations, early satiety, eating alone, and decreased senses of taste and smell. Among patients with HF, many factors unique from those present due to age were reported to affect food intake.

Symptom clusters in men and women with heart failure and their impact on cardiac event-free survival

Background:Because patients with heart failure (HF) experience multiple symptoms simultaneously, it is necessary to explore symptom clusters rather than individual symptoms to determine their impact on outcomes. Given gender differences in symptom experience, examination of potential gender differences in clusters is reasonable. Objective:The objective of the study was to compare symptom clusters between men and women with HF, differences in patient characteristics among symptom clusters, and the impact of symptom clusters on cardiac event-free survival. Methods:A total of 331 patients with HF recruited from HF clinics were included (35% were female and 62% were of New York Heart Association classes III/IV). Cluster analysis was used to identify symptom clusters between men and women based on ratings of distress related to 7 symptoms. Analysis of variance or &khgr;2 test was used to compare characteristics of patient groups that were divided by the median split of total distress scores of each cluster. Cox proportional hazards regression was used to determine whether total scores of symptom distress in symptom clusters predicted time to first cardiac event. Results:Two identical symptom clusters were identified in men and women: a physical symptom cluster composed of dyspnea, fatigue/increased need to rest, fatigue/low energy, and sleep disturbances and an emotional/cognitive symptom cluster composed of worrying, feeling depressed, and cognitive problems. Patients with higher distress from the physical symptom cluster were primarily females and of New York Heart Association classes III and IV (P < .05). Patients with higher distress from the emotional/cognitive symptom cluster were younger than those with lower distress (P < .05). The total symptom distress score in the emotional/cognitive cluster, but not the physical cluster, was an independent predictor of cardiac event-free survival (hazard ratio, 1.18; 95% confidence interval, 1.03-1.37). Conclusion:Although distress for individual symptoms may differ between men and women, they both experienced identical symptom clusters. Only the emotional/cognitive cluster predicted a higher risk for a cardiac event. These results suggested that interventions should be developed that consider symptom clusters. Targeting patients who have high distress from emotional/cognitive symptoms may be particularly important as they may be most vulnerable for adverse outcomes.

Psychometrics of the PHQ-9 as a measure of depressive symptoms in patients with heart failure

Background Depression in patients with heart failure commonly goes undiagnosed and untreated. The Patient Health Questionnaire-9 (PHQ-9) is a simple, valid measure of depressive symptoms that may facilitate clinical assessment. It has not been validated in patients with heart failure. Aims To test the reliability, and concurrent and construct validity of the PHQ-9 in patients with heart failure. Methods A total of 322 heart failure patients (32% female, 61 ± 12 years, 56% New York Heart Association class III/IV) completed the PHQ-9, the Beck Depression Inventory-II (BDI-II), and the Control Attitudes Scale (CAS). Results Cronbach’s alpha of .83 supported the internal consistency reliability of the PHQ-9 in this sample. Inter-item correlations (range .22–.66) and item-total correlation (except item 9) supported homogeneity of the PHQ-9. Spearman’s rho of .80, (p < .001) between the PHQ-9 and the BDI-II supported the concurrent validity as did the agreement between the PHQ-9 and the BDI-II (Kappa = 0.64, p < .001). At cut-off score of 10, the PHQ-9 was 70% sensitive and 92% specific in identifying depressive symptoms, using the BDI-II scores as the criterion for comparison. Differences in PHQ-9 scores by level of perceived control measured by CAS (t318 = −5.05, p < .001) supported construct validity. Conclusion The PHQ-9 is a reliable, valid measure of depressive symptoms in patients with heart failure.