# Quality Care Alleviates Behavioral Cognitive Impairment and Reduces Complications in Elderly Patients with Cardiovascular and Cerebrovascular Diseases

Authors: Xiaomei Li; Fangning Wang; Rongfen Li; Hongyan Tian
Journal: Journal of Healthcare Engineering
 (2022)

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## Abstract

Objective. Cardiovascular and cerebrovascular disease (CCVD) remains the most common factor of death around the world. Nursing care plays a key role in the recovery of patients with CCVD. This study was to explore the application of quality care in aged patients with CCVD. Methods. Totally, 74 aged CCVD patients admitted from June 2018 to June 2019 in Dongying People’s Hospital were randomly assigned in 2 groups with the same treatment. The control group was treated with routine care intervention, and the observation group was treated with quality care intervention for 12 weeks. Meanwhile, the frequency of agitation behaviors and cognitive ability were assessed, and complication was counted. Results. The observation group showed decreased Cohen-Mansfield Agitation Inventory (CAMI) scores from 47.31 ± 8.27 to 38.73 ± 6.94, raised Mini-Mental State Examination (MMSE) scores from 15.01 ± 3.9 to 19.34 ± 3.15 and Montreal Cognitive Assessment (MoCA) scores from 16.92 ± 5.48 to 20.37 ± 4.16, and reduced complications after quality care intervention. Conclusion. Quality care intervention exerted a better application effect on aged CCVD patients, along with reduction of agitation, improvement of mental condition and behavioral cognitive function, and reduced complications.


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## Body

## 1. Introduction

Cardiovascular and cerebrovascular disease (CCVD) is a fatal disease with multifactorial pathogenesis [1]. The risk factors for CCVD comprise bad habits such as smoking and alcohol-drinking, high blood pressure, obesity, hypercholesterolemia, and diabetes mellitus [2]. Although extensive research studies have been conducted to improve the early diagnosis and treatment of CCVD, the survival rate of patients with CCVD remains surprisingly low [3]. Besides this, its features of high incidence, mortality, and disability pose huge burdens on the family and society [4]. Close association among cognitive impairment, CCVD, and mortality has been documented in a previous study [5], as well as the crucial role of aging in CCVD and neurodegenerative disorders [6]. Therefore, it necessitates the attenuation of cognitive impairment in elderly CCVD patients in clinical application.High-quality nursing care has been reported to exert considerable effects on patients with chronic heart failure in the respect of psychological outcomes [7]. Generally speaking, patients with cerebrovascular diseases such as ischemic stroke require prioritizing nursing and intensive care to improve outcomes and reduce the chances of disability [8]. The mental comfort care is positively correlated with the improvement in cognitive conditions in elderly patients [9]. Nursing care including preoperative and postoperative education is indispensable to the prevention and management of ostomy complications [10]. However, the clinical application of quality care in elderly patients with CCVD is rarely investigated, and the effect of quality care on cognitive impairment and complications in elderly patients with CCVD requires attention. The present study aimed to clarify the beneficial contributions of quality care to the attenuation of cognitive impairment and decrease in complication rates in elderly patients with CCVD by comparing the frequency of agitation behavior and cognitive impairment degree in patients receiving different nursing interventions, with the expectation to offer a new idea in accelerating postoperative recovery from nursing angle.


## 2. Materials and Methods

### 2.1. Ethics Statement

The present study was conducted under the approval of the Medical Ethics Committee of Dongying People’s Hospital. All patients and their families were informed of the study and signed the informed consent (approval no. DYYX.2021.072).


### 2.2. General Data

Totally, 74 aged patients with chronic heart failure admitted in Dongying People’s Hospital from June 2018 to June 2019 were enrolled and randomized to 2 groups (N = 37): the control group (20 males and 17 females; aged 65–80 years; average age: 70.35 ± 5.64) and the observation group (21 males and 16 females; aged 60–81 years; average age: 70.39 ± 5.78). The basic data between the two groups showed no statistical difference p>0.05. The inclusion criteria were as follows: patients diagnosed with chronic heart failure in accordance with related criteria in guidelines for the diagnosis and treatment of chronic heart failure (2019), patients were 60 years old or above, patients were conscious and able to communicate, patients were at II-III stages of NYHA cardiac function, with ≤40% left ventricular ejection fraction (LVEF), patients and their families were informed of the study and signed the informed consent, and the study was conducted under the approval of the Medical Ethics Committee of Dongying People’s Hospital. The exclusion criteria were as follows: patients with mental and intellectual disabilities, patients with primary diseases or dysfunctions in important organs such as the brain, liver, and kidney, and patients with missing basic information.


### 2.3. Intervention Methods

The patients in the control group were given routine nursing care, including routine health education, more communication with patients, psychological counseling, and routine discharge guidance.Patients in the observation group were given quality care on the basis of routine nursing care, which consisted of 6 aspects. (1) Cognitive assessment: the related nursing intervention group was established based on the medical history of patients after admission. The psychological and physiological state and cardiac function stages of patients were evaluated by the primary nurse, and the cognition of the disease and nursing needs were well-known in the form of language communication and question and answer. (2) Harmonious nurse-patient relationship: harmonious nurse-patient relationship was established on the basis of frequent communication in a peaceful tone, active listening to the patients, and answering the patients’ questions to ensure trust and intimacy. (3) Enhancement of guidance for patients’ self-management ability: within 48 h of admission, patients were given systematic education about the cognitive intervention path. Patients with higher level of education were guided to read related books, while patients with lower level of education were orally educated. Patients were acknowledged with the inducing factors so as to do a good job of self-protection in health education. Patients were taught the methods of mental balance, progressive relaxation training method, methods of judging the aggravation of heart failure, and methods of cough and expectoration. Patients were in the sitting position, lying position on high pillows, and fowler position to breathe easily. An appropriate amount of exercise was determined according to the cardiac function. In the 6-min walking test, the lower the grade, the worse the cardiac function. (4) Behavior reconstruction: patients were guided to have a regular routine, sufficient sleep, and healthy diet, with a decreased sodium and calorie intake, limited access to drinking water, multiple-meal-with-small-amount-for-each, and prohibition of smoking and alcohol. The bodyweight was measured twice a day. The disease progressed once the bodyweight increased by more than 1 kg per day along with the manifestations of nausea and vomiting, lower limbs edema, dyspnea, and low urine output. (5) Family support intervention: the family members were informed to urge patients to use drugs strictly following the doctor’s advice without medication reduction, change of medication, or medication withdrawal without counseling. The family members were guided to observe disease status changes such as respiratory rate, presence of dyspnea, cyanosis, ability of independent and effective expectoration, and changes of complexion, pulse, and limb temperature. The frequency of defecation was observed. The family members were informed of diet plans to prevent constipation and cautioned against exertion in defecation for patients. The family members of patients required prolonged bed rest were informed to regularly assist body position transformation and keep the sheets clean. The family members were taught to assist effective expectoration by clap on the back or turning over. The family members were encouraged to visit more to improve communication and offer family affection. (6) Follow-up visit after discharge: the 1st follow-up visit was conducted after 1 week of discharge to offer guidance about medication and diet. Follow-up visits were conducted twice within the 1st month, followed by 1 follow-up visit per month for half a year. Family visits and rehabilitation guidance were carried out after 2 months of discharge (30–40 min/visit) to observe patients’ status, impart healthcare-related knowledge, and teach patients and their families some skills of home nursing.


### 2.4. Evaluation Indexes

First, the frequency of agitation in these two groups before and after care intervention was evaluated using the Chinese version of Cohen-Mansfield Agitation Inventory (CMAI) which was composed of 3 dimension (29 items), including physical aggressive behavior (12 items), physical nonaggressive behavior (9 items), and language agitation behavior (8 items). Each item ranks from 1 to 7 points based on the frequency of agitation, and the total score was 29–203 points, with higher scores indicative of higher frequency of agitation. Second, the cognitive function of patients in these two groups was assessed using the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). MMSE consisted of 20 questions (30 items) with a total score of 30 points, with higher scores suggestive of higher cognitive ability; while, MoCA consisted of 11 items in 8 cognitive dimensions with a total score of 30 points, with ≥26 points indicative of normal and higher scores indicative of higher cognitive ability. To reduce errors of cognitive ability caused by level of education, patients who received education for more than 12 years were given 1 extra point.


### 2.5. Statistical Analysis

Data were recorded using the Excel spreadsheets. Data were statistically analyzed using SPSS 25.0 software. All the scores were presented as mean ± standard deviation (x ± s). Data were analyzed using the X2 test and t-test. The value of p<0.05 was indicative of significant difference.


## 2.1. Ethics Statement

The present study was conducted under the approval of the Medical Ethics Committee of Dongying People’s Hospital. All patients and their families were informed of the study and signed the informed consent (approval no. DYYX.2021.072).


## 2.2. General Data

Totally, 74 aged patients with chronic heart failure admitted in Dongying People’s Hospital from June 2018 to June 2019 were enrolled and randomized to 2 groups (N = 37): the control group (20 males and 17 females; aged 65–80 years; average age: 70.35 ± 5.64) and the observation group (21 males and 16 females; aged 60–81 years; average age: 70.39 ± 5.78). The basic data between the two groups showed no statistical difference p>0.05. The inclusion criteria were as follows: patients diagnosed with chronic heart failure in accordance with related criteria in guidelines for the diagnosis and treatment of chronic heart failure (2019), patients were 60 years old or above, patients were conscious and able to communicate, patients were at II-III stages of NYHA cardiac function, with ≤40% left ventricular ejection fraction (LVEF), patients and their families were informed of the study and signed the informed consent, and the study was conducted under the approval of the Medical Ethics Committee of Dongying People’s Hospital. The exclusion criteria were as follows: patients with mental and intellectual disabilities, patients with primary diseases or dysfunctions in important organs such as the brain, liver, and kidney, and patients with missing basic information.


## 2.3. Intervention Methods

The patients in the control group were given routine nursing care, including routine health education, more communication with patients, psychological counseling, and routine discharge guidance.Patients in the observation group were given quality care on the basis of routine nursing care, which consisted of 6 aspects. (1) Cognitive assessment: the related nursing intervention group was established based on the medical history of patients after admission. The psychological and physiological state and cardiac function stages of patients were evaluated by the primary nurse, and the cognition of the disease and nursing needs were well-known in the form of language communication and question and answer. (2) Harmonious nurse-patient relationship: harmonious nurse-patient relationship was established on the basis of frequent communication in a peaceful tone, active listening to the patients, and answering the patients’ questions to ensure trust and intimacy. (3) Enhancement of guidance for patients’ self-management ability: within 48 h of admission, patients were given systematic education about the cognitive intervention path. Patients with higher level of education were guided to read related books, while patients with lower level of education were orally educated. Patients were acknowledged with the inducing factors so as to do a good job of self-protection in health education. Patients were taught the methods of mental balance, progressive relaxation training method, methods of judging the aggravation of heart failure, and methods of cough and expectoration. Patients were in the sitting position, lying position on high pillows, and fowler position to breathe easily. An appropriate amount of exercise was determined according to the cardiac function. In the 6-min walking test, the lower the grade, the worse the cardiac function. (4) Behavior reconstruction: patients were guided to have a regular routine, sufficient sleep, and healthy diet, with a decreased sodium and calorie intake, limited access to drinking water, multiple-meal-with-small-amount-for-each, and prohibition of smoking and alcohol. The bodyweight was measured twice a day. The disease progressed once the bodyweight increased by more than 1 kg per day along with the manifestations of nausea and vomiting, lower limbs edema, dyspnea, and low urine output. (5) Family support intervention: the family members were informed to urge patients to use drugs strictly following the doctor’s advice without medication reduction, change of medication, or medication withdrawal without counseling. The family members were guided to observe disease status changes such as respiratory rate, presence of dyspnea, cyanosis, ability of independent and effective expectoration, and changes of complexion, pulse, and limb temperature. The frequency of defecation was observed. The family members were informed of diet plans to prevent constipation and cautioned against exertion in defecation for patients. The family members of patients required prolonged bed rest were informed to regularly assist body position transformation and keep the sheets clean. The family members were taught to assist effective expectoration by clap on the back or turning over. The family members were encouraged to visit more to improve communication and offer family affection. (6) Follow-up visit after discharge: the 1st follow-up visit was conducted after 1 week of discharge to offer guidance about medication and diet. Follow-up visits were conducted twice within the 1st month, followed by 1 follow-up visit per month for half a year. Family visits and rehabilitation guidance were carried out after 2 months of discharge (30–40 min/visit) to observe patients’ status, impart healthcare-related knowledge, and teach patients and their families some skills of home nursing.


## 2.4. Evaluation Indexes

First, the frequency of agitation in these two groups before and after care intervention was evaluated using the Chinese version of Cohen-Mansfield Agitation Inventory (CMAI) which was composed of 3 dimension (29 items), including physical aggressive behavior (12 items), physical nonaggressive behavior (9 items), and language agitation behavior (8 items). Each item ranks from 1 to 7 points based on the frequency of agitation, and the total score was 29–203 points, with higher scores indicative of higher frequency of agitation. Second, the cognitive function of patients in these two groups was assessed using the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). MMSE consisted of 20 questions (30 items) with a total score of 30 points, with higher scores suggestive of higher cognitive ability; while, MoCA consisted of 11 items in 8 cognitive dimensions with a total score of 30 points, with ≥26 points indicative of normal and higher scores indicative of higher cognitive ability. To reduce errors of cognitive ability caused by level of education, patients who received education for more than 12 years were given 1 extra point.


## 2.5. Statistical Analysis

Data were recorded using the Excel spreadsheets. Data were statistically analyzed using SPSS 25.0 software. All the scores were presented as mean ± standard deviation (x ± s). Data were analyzed using the X2 test and t-test. The value of p<0.05 was indicative of significant difference.


## 3. Results

### 3.1. Comparisons of CAMI Agitation in Two Groups before and after Intervention

There was no statistical significance in agitation scores between the two groups before quality care interventionp>0.05. After quality care intervention, the observation group exhibited decreased scores of physical aggressive behavior, physical nonaggressive behavior, language agitation behavior, and total scores of CMAI, which were significantly lower than the control group (p<0.05, Table 1).Table 1
Comparisons of CAMI agitation in two groups before and after intervention.
Physical nonaggressive behaviorPhysical aggressive behaviorLanguage agitation behaviorTotal scoresBeforeAfterBeforeAfterBeforeAfterBeforeAfterObservation group38.47 ± 3.5031.62 ± 3.4934.72 ± 4.0928.48 ± 3.7537.67 ± 3.9231.34 ± 3.18110.23 ± 14.3390.47 ± 13.23Control group38.52 ± 3.4828.34 ± 3.7734.70 ± 4.0824.72 ± 3.2737.64 ± 3.9028.57 ± 2.83110.12 ± 14.2983.01 ± 12.48P value0.935<0.0010.978<0.0010.965<0.0010.9650.001t value2.361.978.440.846.260.711.491.66


### 3.2. Comparisons of Cognitive Ability in Two Groups before and after Intervention

There was no statistical difference in MMSE and MoCA scores between the two groups before quality care interventionp>0.05. After quality care intervention, the observation group showed increased MMSE and MoCA scores compared to the control group (p<0.05, Table 2).Table 2
Comparisons of MMSE and MoCA scores in two groups before and after intervention.
MMSEMoCAGroupsBeforeAfterBeforeAfterObservation group18.18 ± 5.1624.30 ± 5.3716.90 ± 5.6724.16 ± 4.41Control group18.16 ± 5.3221.26 ± 5.0917.00 ± 5.5122.10 ± 5.46P value0.9720.0110.9350.047t value1.822.642.172.84


### 3.3. Comparisons of Complications in Two Groups before and after Intervention

During the nursing intervention, the incidence of complications in the control group was 29.72% (11/37), including 4 patients with arrhythmia, 3 patients with stroke, and 4 patients with increased serum creatinine; in the observation group, the incidence of complications was 10.81% (4/37), including 1 patient with arrhythmia, 1 patient with stroke, and 2 patients with elevated serum creatinine (Table3).Table 3
Comparisons of complications in two groups before and after intervention.
GroupsArrhythmiaStrokeIncreased serum creatinineTotal incidenceControl group(n = 37)43411 (29.72)Observation group (n = 37)1124 (10.81)P value<0.05<0.05<0.05<0.05t value3.413.794.225.14


## 3.1. Comparisons of CAMI Agitation in Two Groups before and after Intervention

There was no statistical significance in agitation scores between the two groups before quality care interventionp>0.05. After quality care intervention, the observation group exhibited decreased scores of physical aggressive behavior, physical nonaggressive behavior, language agitation behavior, and total scores of CMAI, which were significantly lower than the control group (p<0.05, Table 1).Table 1
Comparisons of CAMI agitation in two groups before and after intervention.
Physical nonaggressive behaviorPhysical aggressive behaviorLanguage agitation behaviorTotal scoresBeforeAfterBeforeAfterBeforeAfterBeforeAfterObservation group38.47 ± 3.5031.62 ± 3.4934.72 ± 4.0928.48 ± 3.7537.67 ± 3.9231.34 ± 3.18110.23 ± 14.3390.47 ± 13.23Control group38.52 ± 3.4828.34 ± 3.7734.70 ± 4.0824.72 ± 3.2737.64 ± 3.9028.57 ± 2.83110.12 ± 14.2983.01 ± 12.48P value0.935<0.0010.978<0.0010.965<0.0010.9650.001t value2.361.978.440.846.260.711.491.66


## 3.2. Comparisons of Cognitive Ability in Two Groups before and after Intervention

There was no statistical difference in MMSE and MoCA scores between the two groups before quality care interventionp>0.05. After quality care intervention, the observation group showed increased MMSE and MoCA scores compared to the control group (p<0.05, Table 2).Table 2
Comparisons of MMSE and MoCA scores in two groups before and after intervention.
MMSEMoCAGroupsBeforeAfterBeforeAfterObservation group18.18 ± 5.1624.30 ± 5.3716.90 ± 5.6724.16 ± 4.41Control group18.16 ± 5.3221.26 ± 5.0917.00 ± 5.5122.10 ± 5.46P value0.9720.0110.9350.047t value1.822.642.172.84


## 3.3. Comparisons of Complications in Two Groups before and after Intervention

During the nursing intervention, the incidence of complications in the control group was 29.72% (11/37), including 4 patients with arrhythmia, 3 patients with stroke, and 4 patients with increased serum creatinine; in the observation group, the incidence of complications was 10.81% (4/37), including 1 patient with arrhythmia, 1 patient with stroke, and 2 patients with elevated serum creatinine (Table3).Table 3
Comparisons of complications in two groups before and after intervention.
GroupsArrhythmiaStrokeIncreased serum creatinineTotal incidenceControl group(n = 37)43411 (29.72)Observation group (n = 37)1124 (10.81)P value<0.05<0.05<0.05<0.05t value3.413.794.225.14


## 4. Discussion

CCVD remains a main contributor to mortality and morbidity [11]. The hard-done work of our peers has highlighted that cognitive impairment frequently occurs in elderly CCVD patients [12–14]. The pivotal role of primary care has been identified in treating CCVD patients [15]. The present study focused on the clinical application of quality care on elderly patients with CCVD and revealed the improving effects of quality care on ameliorating cognitive impairment and complication reduction in elderly CCVD patients.Agitation is commonly seen in the intensive care unit [16], and sometimes, it is so severe that the patients may hurt themselves or the nursing staff [17]. Previous studies have documented that CCVD patients may present agitation and aggression [18]. In our study, patients treated with quality care exhibited decreased total scores of CMAI and scores of subthemes including physical aggressive behavior, physical nonaggressive behavior, and language agitation behavior relative to those treated with routine care intervention. Adequate control of agitation is essential to prevent adverse events such as removal of endotracheal tubes, increased duration of mechanical ventilation, and increased resource utilization [19, 20]. Effective individualized care helps minimize agitation in patients recovering from traumatic brain injury [21]. Consistently, our study suggested that quality care reduced agitation in elderly CCVD patients.One of the most challenging neuropsychological diseases in the elderly population is cognitive impairment, defined as a decline in intellectual function, ranging from mild amnesia to severe and debilitating dementia [22]. Cognitive impairment represents a possible risk factor for mortality in patients with CCVD [5]. MMSE and MoCA are two commonly used tools for cognitive screening [23]. Our study showed an increase in MMSE and MoCA scores in patient receiving quality care intervention compared to those receiving routine care intervention. The dementia day care MAKS intervention could stabilize cognitive ability [24]. A recent randomized trial suggested that biopsychosocial holistic care can improve the cognitive function and quality of life of elderly patients with mild cognitive impairment [25]. Similarly, our study demonstrated that quality care improved cognitive function in elderly CCVD patients.Transient ischemic attack, arrhythmia, and angina pectoris are common complications of acute CCVDs [26, 27]. The recurrence of complications is an indicator for assessing the quality of care, which, instead, suggests that the effect of quality care could at least partly be determined by observation of complication occurrence [28]. According to our results, the complication rates of the patients treated with quality care were significantly decreased compared to those with routine care intervention. Comprehensive quality care improves the postoperative complications in gallstone patients [29]. Similarly, the online home nursing care could reduce complication and improve the quality of life of patients with traumatic spinal cord injury [30]. Taken together, quality care reduced complication rates in elderly CCVD patients.


## 5. Conclusion

In conclusion, this study emphasizes that quality care can reduce cognitive impairment and decrease agitation and complications in elderly patients with CCVD. However, our study still has some limitations with a small sample size and insufficient evaluation parameters of cognitive function. Future studies should use larger sample sizes and more evaluation parameters in order to provide stronger reliability for clinical services.



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*Source: 8958099-2022-03-30.xml*