Introduction Approximately 1-2% of the adult population in developed countries suffer from heart failure (HF), with the prevalence rising to more than 10% among patients 80 years of age or older. The HF syndrome is associated with elevated mortality and morbidity, and decreased quality of life. Cognitive dysfunction has been reported in patients suffering from a variety of cardiovascular disorders. However, few studies have systematically assessed cognitive performance in HF patients, its prevalence and other factors influencing cognition in HF patients. Further, it is of great interest to understand the relationship between self-care in HF and cognition. It may be important to screen for cognitive dysfunction as it may influence HF patients’ ability to perform self-care, e.g. make lifestyle changes, adhere to medical treatment and monitor, evaluate and treat symptoms of deterioration. Aim The overall aim of this thesis was to explore cognitive function in elderly patients with chronic heart failure with focus on prevalence, risk factors, sleep and self-care. Design and method This thesis is based on four quantitative studies. The data from study I and II were collected in a prospective longitudinal design, including Swedish same-sex twin pairs born in 1913 or earlier in Sweden. The study was conducted 1991-2002 and a total of 702 individuals aged 80 and older were included. Study III and IV had a cross- sectional design and included stable HF patients, median 72 years of age, living in the community in the south of Sweden. Data were collected between 2009 and 2012. Study III included a total of 137 patients and Study IV included 142 patients. Results Study I found that  octogenarians with HF had significantly poorer spatial performance and episodic memory, and that the episodic memory declined more over time compared to a non-HF population of the same ages. Study II showed that octogenarians with HF had a significantly higher prevalence of vascular dementia, 16% vs. 6%, and all types of dementia, 40% vs. 30%, than those not diagnosed with HF. Factors related to dementia in individuals with HF were depression, hypertension and increased levels of homocysteine. Diabetes was associated with an increased risk for vascular dementia. In study III we found that  HF patients with sleep disordered breathing (SDB) (apnoea-hypopnoea index >15) had significantly higher saturation time < 90%, more difficulties maintaining sleep and lower levels of daytime sleepiness compared to those in the non-SDB group. Cognitive function did not differ between the SDB and the non-SDB-group. Only insomnia was associated with a decreased global cognititive function measured with the Mini Mental State Examination instrument. Finally, in study IV, the relationship between self-care and different dimensions of cognitive function was explored. Psycho- and visuomotor function (speed and attention) was the only dimension of cognitive function associated with self-care. Conclusion Octogenarians suffering from HF have a decreased performance in spatial and episodic memory and they also have a higher risk for developing dementia. Cognitive dysfunction as well as higher prevalence of dementia can contribute to decreased adherence to prescribed therapy and self-care management, and lead to other socio-behavioural problems.   Self-care was found to be associated with psychomotor speed. This may influence sustained attention negatively and the ability to carry out more than one task at the same time. This may lead to decreased attention for receiving and understanding information on self-care. / Thesis

Population aging in Canada is associated with a rising burden of heart failure (HF), a condition associated with substantial morbidity, mortality and health service use. HF management involves pharmacotherapy, exercise, dietary restrictions and symptom monitoring. First-line combination pharmacotherapy for HF consists of an angiotensin converting enzyme inhibitor (ACE inhibitor) or angiotensin receptor blocker (ARB) in conjunction with a β-adrenergic receptor blocker (β-blocker). This combination therapy can reduce mortality, improve symptoms and reduce health service use. However, evidence about the benefits of these therapies has been derived from randomized controlled trials in younger patients from acute care and specialty clinic settings. Little work has explored outcomes among older individuals and those in the community setting. In purposely studying an older cohort of individuals with HF, the goals of this research were three-fold: to comprehensively describe their sociodemographic, clinical and service use characteristics; to describe rates of usage of first-line HF pharmacotherapy and correlates of non-use; and to examine the outcomes of mortality, long-term care (LTC) admission, long-stay hospitalization, admission, new cognitive decline and new functional decline as well as predictors of these outcomes. To achieve these aims, this work made use of the extensive data available through the Resident Assessment Instrument – Home Care (RAI-HC) database in Ontario. The RAI-HC is mandated for use in Ontario to assess all long-stay home care clients (those expected to receive home care service for at least 60 days). This assessment contains over 300 items about sociodemographic and clinical characteristics, diagnoses, service use and geriatric conditions, such as functional abilities and cognition. The study samples included long-stay home care clients older than 65 years of age. The descriptive analyses (N=264,030) demonstrated that older home care clients with HF are a more complex group than home care clients without HF, with more comorbidity and higher use of medications and health care services. From the analyses examining pharmacotherapy use (N=176,860), rates of use of first-line pharmacotherapy were low, with only 30% of clients with HF receiving recommended combination first-line therapies, a similar proportion receiving no therapies and the remainder receiving at least one therapy. The multivariate analyses revealed that hypertension and diabetes mellitus diagnoses affect first-line therapy use. Regardless of clinical subgroup, use of these therapies was less likely among older clients and those with functional impairment, airway disease or behavioural symptoms. Longitudinal analyses were done using Cox proportional hazards regression modeling (N=9,283) in which individuals were followed for nine months after each RAI-HC assessment. Results from these analyses showed that female gender and living alone reduced the risk of all outcomes except LTC admission, while age over 85 years generally increased the risk of all examined outcomes. Comprehensive clinical indicators, the Changes in Health, End-stage disease, Signs and Symptoms (CHESS) scale and Method for Assigning Priority Level (MAPLe) algorithm, increased the risk of all outcomes except new cognitive decline. ACE inhibitor use was protective of LTC admission and functional decline, but not mortality, long-stay hospitalizations or cognitive decline. The complexity of older individuals with HF could impair self-care abilities and points to the need for initiatives to help such individuals manage their care at home with appropriate support and services. The low rates of use of first-line pharmacotherapy among older home care clients with HF highlights the need for better understanding of which factors affect prescribing practices. Better evidence, that is more applicable to older individuals with HF, is needed about the therapeutic benefits of first-line therapies to help enhance the evidence base and improve patient care.

Background: Chronic heart failure (CHF) is a complex clinical condition. The higher survival rate after heart attack and other heart diseases, plus aging population, has led to more CHF patients. Symptoms can have negative impact on exercise capacity, ability to perform activities of daily living and quality of life. Heart failure clinics have been established to help better quality of life. Helping to stabilize and maintain patients´ health can reduce the need of hospital admission. Nurses´ role is to promote health, treat and relieve symptoms that can lead to better quality of life and self-care. Aim: To describe specialist nurses´ experiences of promoting health for patients with heart failure. Method: A qualitative inductive approach was used to interview six specialist nurses with competence in heart failure caring. The interviews were analyzed by using qualitative content analysis where the interpretation of the text formed eight categories. Results: Categories revealed that each nurse had her own strategy of caring for, supporting and strengthening both patients and kin, such as through communication, medication management, managing self-care, working interdisciplinary. At times the patients' decisions had to be accepted, even if this led to death. Conclusion: Nurses´ caring, supporting and informing roll along with availability was of great importance to the well being of patients and kin. Creating a good relationship was the foundation of a well functioning co-operation between nurse, patient and next of kin which led to a feeling of security for patients. Most important factor was the patient experiencing health at present.

För många närstående förändras livet radikalt när  en anhörig diagnostiseras med hjärtsvikt. Att leva med hjärtsvikt är som att "knacka på dödens dörr och aldrig veta vad som är att vänta av morgondagen". Att stanna hemma och vårda en en anhörig under palliativ fas innebär stora påfrestningar i närståendes liv. Syfte: Att belysa närståendes upplevelser när anhörig med hjärtsvikt vårdas palliativt i hemmet. Metod: Studien utfördes som en allmän litteraturstudie. Tolv kvalitativa och tre kvantitatva vetenskapliga artiklar ingick. Resultat:  Närstående som vårdade en anhörig palliativt i hemmet upplevde social isolering, stress och ångest och krav på att vara en "stöttepelare". Närstående upplevde också att informationen om tillstånd och prognos var bristfällig. Upplevelsen av att känna stöd från vårdpersonal varierade och närstående ville vara delaktiga i vården. Slutsats: Det är klarlagt att hjärtsvikt har en betydande påverkan på närståendes liv. Närståendes situation behöver studeras vidare och då speciellt när det gäller palliativ hemsjukvård. / For many next of kin important changes took place when heart failure was diagnosed. Meanings of living with heart failure emerged as "knocking on death's door" yet surviving and never knowing what to expect of tomorrow. Staying at home in the palliative phase of life brings multiple complex issues for next of kin who is subject to stress during a along period of time. The aim of the study was: To illuminate next of kin's experiences when a partner with heart failure is taken care of in palliative home care setting. Method: A general litterature review based on twelve qualitative and three quantitative scientific articles. Findings: Next of kin in palliative home care setting described situations of being restricted, they experienced stress and anxiety, and took on the role of being "a pillar of strength". Next of kin also described how they lacked adequate medical information. Som next of kin experienced  that they received support from healthcare personnel but some lacked concrete support. Next of kin also felt it important to have influence on decisions. Conclusion: It is clear that heart failure seriously affects the lives of next of kin. This group need to be further investigated, especially when it comes to palliative care at home.

Bakgrund: Hjärtsvikt är symtom på en bakomliggande sjukdom. För att ange svårighetsgraden indelas den i fyra funktionsklasser utifrån symtomens svårighetsgrad. Vi skriver om hjärtsviktspatienter med grad III och IV. Lidandet beskrivs utifrån Katie Erikssons omvårdnadsteori. Känsla av sammanhang i livet och döendet beskrivs utifrån Aaron Antonovskys sammanhang i tillvaron och den egna sorgen inför döden beskrivs utifrån Elisabeth Kubler-Ross faser mot acceptans. Syfte: Syftet är beskriva hur hjärtsviktspatienter talar om döendet och döden. Metod: Detta är en systematisk litteraturstudie som resulterade i nio artiklar varav åtta artiklar är utförda med kvalitativ metod och en är utförd med kvantitativ metod. De kvalitativa artiklarna analyserades med hjälp av kvalitativ innehållsanalys. Resultat: Efter analys och kodning framkom kategorierna att brist på autonomi gav ett lidande. Hopp om livet trots hot om en försämring. Det förberedande samtalen inför döden och förberedelse inför döden. Insikt om dödens närvaro gav acceptans. Slutsats: Leva med hjärtsvikt handlade om att leva nära döden och vara medveten om hur instabilt livet tedde sig i en kamp mellan hopp och förtvivlan. Det var viktigt för patienten att bli bekräftade och bemötta med respekt av sjuksköterskan.

Bakgrund: Forskning har visat att träning förbättrar den fysiska förmågan och höjer livskvaliteten hos personer med hjärtsvikt. Trots detta är det många personer med hjärtsvikt som inte deltar i gruppträning. Syfte: Syftet med denna studie var att beskriva vilka faktorer som personer med hjärtsvikt, som inte deltar i hjärtsviktsgrupp, upplever som hinder respektive möjligheter när de ska ta beslut om att delta i gruppträning. Design: Studien var en kvalitativ studie med deskriptiv design som utfördes genom semistrukturerade intervjuer med fem informanter. Resultat och slutsats: Resultaten, som tolkades utifrån beteendeförändringsmodellen Health Action Process Approach (HAPA), av denna studie visade att informanterna upplever olika hinder för träningen som har med prioritet, otrygghet, psykisk ohälsa, transportproblem och bristande information att göra. I vissa fall väljs träningen också bort på grund av att informanterna istället tränar i hemmet. Det största hindret enligt studiens resultat var bristen på information. Framförallt har informanterna bristande kunskap om träning som en del av behandlingen vid hjärtsvikt, NYHA II-III, och de effekter som träningen ger. Detta medför att informanterna inte uppfattar vilka möjligheter som träning i hjärtsviktsgrupp ger. De faktorer som uppfattas som positiva med träning har att göra med att informanterna uppskattar träningen, att de känner samhörighet med andra i träningsgruppen och att de upplever en förbättrad hälsa. / Background: Research has shown that exercise improves the physical ability and improves the quality of life for people with heart failure. Despite this, many people with heart failure does not participate in group training. Aim: The purpose of this study was to describe what factors that people with heart failure, who do not participate in heart failure group, perceived as barriers and opportunities when they will take the decision to participate in training in heart failure group. Design: The study was a qualitative study with descriptive design and was done by semi-structured interviews with five informants. Results and conclusion: The results of this study, which were interpreted by the behavior change model, Health Action Process Approach (HAPA), showed that the informants perceive different barriers to training which are about priority, insecurity, mental illness, transportation problems and inadequate information. In some cases the informants choose home training instead of group training. The biggest barrier according to the results of this study was lack of information. In particular, informants lack of knowledge about exercise as a part of treatment for heart failure, NYHA II-III, and the effects of the training. This means that the informants do not perceive the opportunities that training in heart failure group can give. The factors that are perceived as positive with training have to do with informants appreciate the training, that they feel connected with others in the training group and that they experience a health improvement.

Syftet var att utifrån aktuell vetenskaplig litteratur beskriva människors upplevelser av att leva med hjärtsvikt. Sjuksköterskans uppgifter är att planera, genomföra och utvärdera omvårdnaden kring hjärtsviktspatienten. En systematisk litteraturstudie gjordes för att belysa aktuell forskning inom ämnet. Artikelsökningarna gjordes i databaserna PubMed, Blackwell Synergy och Cinahl. För att säkra studiens kvalitet användes kvalitativa och kvantitativa granskningsmallar. Resultatet visade att patienter med hjärtsvikt upplevde oro och stress kring sina symtom. Flertalet beskrev en inre turbulens och en förlorad självständighet. Upplevelserna skilde sig bland könen. De flesta kände sig fysiskt begränsade på grund av tröttheten, vilket ledde till en känsla av social isolering. Stödet från omgivningen varierade. Studierna visade att behovet av omvårdande insatser var stort. Flertalet av patienterna hade försämrad aptit och led av oöverkomlig törst. Många drabbades av andnöd och sömnstörningar som gav konsekvenser i det dagliga livet. Kommunikationsproblem mellan sjukvårdspersonal och patienter förekom. Sjuksköterskan kan genom sina omvårdande insatser och sitt engagemang förbättra patientens situation. Litteraturstudien ger ökad förståelse för livssituationen hos patienter med hjärtsvikt.

Research Objectives Heart failure (HF) is a common condition in persons older than 65 years. Existing literature indicated that hospital readmission rates after discharge for heart failure patients are immensely high. However, previous studies showed that almost half of the early hospital readmissions could be prevented. Moreover, Angiotensin-converting enzyme (ACE) inhibitor and Angiotensin receptor blocker (ARB) are the commonly used medications for heart failure patients to control blood pressure. Nevertheless, studies indicated that these two medications could also cause the risk of hospital readmission. Little studies examined the associations of medication use and hospital readmission of heart failure patients in Taiwan. This study aims to investigate the influence factors of hospital readmissions among heart failure patients in Taiwan. Study Design We collected the data from National Health Insurance (NHI) database during the period from year 2000 to 2006. Based on the rule of Bureau of National Health Insurance in Taiwan, the 14-day readmission is considered as a poor quality indicator. We categorized readmissions into 4 groups (14-day, 30-day, 180-day and over 180-day) and evaluated each group¡¦s demographic, hospital characteristics, medical resource utilization, Charlson Comorbidity Index and medication utilizations of ACE inhibitor and ARB. We conducted descriptive analyses by using chi-square and t tests and applied multivariate logistic regression analyses to estimate the probabilities of hospital readmissions of heart failure patients. Population Studied Patients aged 50 or older with heart failure were identified based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Principle Findings Among 1920 heart failure patients, 19.9% of them were readmitted within 14 days, 7.6% were readmitted within 30 days and 26% were readmitted within 180 days. The medical resource utilizations such as average inpatients cost per patient, average outpatients cost per patient, total medical cost, average of inpatients times per patient and average of outpatients times per patient were significantly higher in patients with readmissions than those without readmission. Age, Charlson Comorbidity Index, patients who had been treated with ACE inhibitors and patients who had been treated with ARB were significantly affected the probabilities of readmissions. Conclusion The heart failure patients with readmissions had significantly higher medical resource utilizations than those without readmission. The medication uses of ACE inhibitors or ARB were significantly affected the probabilities of hospital readmissions. By understanding more about the influence factors of readmissions among heart failure patients, we may provide continue improvements of quality of care and reduce unnecessary medical costs. This study results provide useful reference for policy-makers to establish effective disease management program and appropriate health care financing arrangement in the future.

<p>Ventricular Assist Devices (VADs) are mechanical pumps used to off-load a deceased heart, primarily in late stage congestive heart failure patients. VAD employment may facilitate cardiac recovery, but most often provides time before a suitable heart transplant can be found. Lately, long term use VAD systems have been introduced as an alternative to a heart transplant.</p><p>Traditionally, design of VADs has employed either displacement based pump technologies or radial-flow pumps, also known as rotodynamic pumps. A displacement pump induces a mechanical force on a fluid contained within a defined space, hence giving it motion. Radial-flow pumps impart momentum to a fluid, most often by placing a rotating device in the fluid.</p><p>This thesis introduces a novel pumping concept, combining features from both displacement and radial-flow pumps. A first prototype, the Vivicor^TM pump, has been designed, fabricated and evaluated In Vitro, the results reported in this thesis.</p><p>The In Vitro evaluation of the Vivicor^TM pump provides evidence of a pump with mechanical self-regulation based on pump pre-load level, much like a displacement pump. The Vivicor^TM pump also displays pulsating outflow in combination with an inflow both during pump systole and diastole. The latter provides potential advantages over traditional displacement pumps as smaller cannulae or catheters can be used, facilitating miniaturization. Continuos filling throughout the pumping cycle also require less pressure to be exerted on the fluid, compared to displacement pumps, limiting the risk of mechanical damage to the pumped fluid. The In Vitro evaluation has also provided further insights on necessary design modifications in the second-generation Vivicor^TM prototype, currently planned. The Vivicor^TMpumping technology is highly interesting for further development and evaluation for use in ventricular assist applications.</p>

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