Self-care involves maintenance (e.g., diet, exercise, tobacco cessation, sleep habits), monitoring (e.g., recognizing signs and symptoms, listening to body), and managing (e.g., taking medication, calling the healthcare provider). However, self-care is often poor in patients with heart failure (HF).
While patient education is necessary to discuss self-care, it is not always sufficient, said Barbara Riegel, PhD, RN, FAAN, of the University of Pennsylvania, who discussed this topic during a session titled, “Self-Care in HF: Where the Emphasis Needs to Lie” at the American College of Cardiology Annual Scientific Session. Ninety-nine percent of self-care is managed by the patients and their caregivers, not the doctors, said Dr. Riegel. Self-care can improve outcomes, so why don’t patients perform self-care?
“We’ve learned that there are a lot of factors that are impairing patients’ abilities to perform self-care,” said Dr. Riegel. Most patients with HF (98%) have two or more coexisting chronic conditions. In addition, treatment regimens are often complex. Other symptoms may thwart self-care goals, such as impaired cognition, physical limitations, low energy, depression, and anxiety. Patients may also have inadequate knowledge and skills, as well as economic constraints and poor access to healthcare.
Studies have found that self-care declines as the level of comorbidity rises, probably because of a decrease in self-efficacy. Attitudes drive the priority given by patients to various self-care behaviors, and fragmented self-care instruction leads to poor integration of self-care and self-care skill deficits, she said.
Patients with HF take, on average, 10 medications per day, most of which require multiple doses. Approximately three-quarters of older adults with multiple chronic conditions are at risk of therapeutic competition—a treatment recommended for one condition that may adversely compete with another condition, according to a 2014 study by Lorgunpai et al. Physicians should also recognize that they contribute to poor patient self-care, said Dr. Riegel.
“We have incredibly high expectations of our patients. We ask them to develop a level of knowledge that is not common in the general population,” she said. “We put them on a regimen that they don’t want to partake in [and] they aren’t familiar with.” Patients also face fragmented instructions from multiple providers, as well as polypharmacy and therapeutic competition.
Next, Dr. Riegel discussed symptom perception. Patients were asked about their experience with certain symptoms: 80% experienced fatigue, but just 48% recognized it had something to do with their HF condition. In addition, 93% of patients experienced shortness of breath, but 59% recognized it as related to HF.
“They can’t manage their symptoms because they’re not even interpreting [them] correctly,” she said.
Dr. Riegel suggested that for patients with HF, physicians consider de-prescribing their regimen. Ask patients how quickly they recognize their symptoms and what they do to manage them, then assess symptom pattern characteristics to identify potential problems. Promote self-care early, before the window of opportunity closes, she concluded.