DAMOCLES project show that cognitive function is a strong determinant of the influence of self-care behavior on health-related quality of life in patients with heart failure
Authors: Jose-Bazan N , Jimenez-Marrero S , Ramos-Polo R , Enjuanes-Grau C , Alcoberro L , Hidalgo-Quiros E , Ras M , Calero-Molina E , Ruiz-Munoz M , Yun-Viladomat S , Garay A , Moliner P , Garcimartin P , Calvo E , Comin-Colet J 
Published: October 2022

Abstract

Background
Poor self-care is associated with a poorer outcomes in patients with heart failure (HF). Psycho-social factors are determinants of patient-reported outcomes (PROMs) such as health-realted quality of life (QoL). However, little is known about the interplay between self-care and psychosocial factors such as cognitive function on PROMs in patients with HF.

Purpose
Describe the effect of self-care on QoL across cognitive function and explore whether the interaction between self-care and cognitive function may account for this effect.

Methods
1120 patients with chronic HF from DAMOCLES study were analyzed. We used the modified European Heart Failure Self-care Behaviour Scale 9-item version (EHFSCBS-9) to measure self-care (inverted and standardised: higher scores indicate better self-care). To assess QoL, we used Minnesota Living with Heart Failure Questionnaire (MLHFQ) (higher scores indicate worse QoL). Cognitive function was evaluated using Mini-Mental State Examination (MMSE) and Short Portable Mental State Questionnaire (SPMSQ) Tests. Cognitive impairment was defined as abnormal age-and-literacy-adjusted scores. General linear models (GLM) were constructed to explore the interaction between cognitive function and poor self-care (defined as EHFSCBS-9 ≤lower tertile) on adjusted MLHFQ scores. To determine the impact self-care, multivariate linear regressions models to predict QoL were constructed stratified according to cognitive function. All models were adjusted by determinants of HF severity.

Results
Mean age was 72±11 years, 43% were women and mean LVEF was 45±17%. Lower MMSE scores (β=−0,163; p-value &lt;0.001) and &gt;3 errors in the SPMSQ indicating cognitive impairment (β=0.071; p-value = 0.023) were associated with higher scores in the MLHFQ. These associations were confirmed in multivariare linear regression models (β=0.062; p-value = 0.038). In adjusted GLM, poor global self-care (F=4.8; p-value = 0.029) was an independent predictor of higher adjusted scores in the MLHFQ. Interaction term poor self-care by cognitive impairment was significantly associated with MLHFQ scores (F=6.0; p-value=0.014; Figure 1). Multivariate linear regresion models (Table 1) stratified according the absence (panel A) or the presence (panel B) of cognitive impairment showed that cognitive function modulates the association between self-care behaviour and QoL. This effect was only seen in patients without cognitive impairment. In patients with cognitive dysfunction, self-care behaviour did not longer influence self-perceived health status in patients with HF.

Conclusions
Self-care behaviour is an independent predictor of PROMs in HF regardless cognitive disfunction. Cognitive function modulates 1) influence of global self-care and each one of its dimensions on emotional QoL and 2) impact of global self-care and consulting behaviour on global and social QoL.

Funding Acknowledgement
Type of funding sources: None.