Cognitive and self-care changes in patients with heart failure in the Amazon Region

Heart failure is characterized as the lack of blood pumping capacity performed by the heart, which is considered a public health problem worldwide. Due to HF, the individual can Research, Society and Development, v. 9, n. 6, e98963321, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i6.3321 3 develop clinical aspects that impact cognitive function and, consequently, self-care. Therefore, this study aimed to investigate cognitive changes and self-care in patients affected by HF and compare it with the cognitive and self-care changes of healthy participants. This is a quantitative, epidemiological, cross-sectional case-control study carried out at an institution in the city of Belém, Pará, Brazil. The following tests were used for data collection: Montreal Cognitive Assessment, Digit Symbol Substitution Test, European Heart Failure Self-care Behavior Scale (EHFScBS). Data were tabulated in Microsoft Excel 2010 and statistically treated by Epi Info version 3.5.2 with a 5% significance level and considering a 95% confidence interval in all analyzes. It was observed that patients with HF have slightly better self-care compared to patients without HF with scores obtained by EHFScBS equal to 29.7 ± 6.9 and 31.8 ± 8.2, respectively. Additionally, patients with HF showed impairments in the three cognitive domains, and women with HF demonstrated greater cognitive impairment compared to the other participants. The present study provides data to help build new approaches to interventions by the multidisciplinary team to promote better self-care and avoid cognitive impairments in patients with HF.

develop clinical aspects that impact cognitive function and, consequently, self-care.
Therefore, this study aimed to investigate cognitive changes and self-care in patients affected by HF and compare it with the cognitive and self-care changes of healthy participants. This is a quantitative, epidemiological, cross-sectional case-control study carried out at an institution in the city of Belém, Pará, Brazil. The following tests were used for data collection: Montreal Cognitive Assessment, Digit Symbol Substitution Test, European Heart Failure Self-care Behavior Scale (EHFScBS). Data were tabulated in Microsoft Excel 2010 and statistically treated by Epi Info version 3.5.2 with a 5% significance level and considering a 95% confidence interval in all analyzes. It was observed that patients with HF have slightly better self-care compared to patients without HF with scores obtained by EHFScBS equal to 29.7 ± 6.9 and 31.8 ± 8.2, respectively. Additionally, patients with HF showed impairments in the three cognitive domains, and women with HF demonstrated greater cognitive impairment compared to the other participants. The present study provides data to help build new approaches to interventions by the multidisciplinary team to promote better self-care and avoid cognitive impairments in patients with HF.

Resumen
La insuficiencia cardíaca se caracteriza por la falta de capacidad de bombeo de sangre realizada por el corazón, que se considera un problema de salud pública en todo el mundo.

Introduction
Heart failure (HF) is defined as an inability of the heart to pump blood effectively (CCDIC, 2018).This is considered a worldwide public health problem, being the main cause of hospitalization and mortality (Albuquerque et al., 2015;Boisvert, Proulx-Belhumeur, Gonçalve, Francoeur, & Gallani, 2015). In 2017, there were 27,461 deaths from HF in Brazil, representing16.7% of 567,370 hospital admissions in the first half of 2019 alone (Brazil, 2019a;Brazil, 2019b).
HF self-care refers to behavioral actions to maintain health and autonomy in decisionmaking during the worsening symptoms (management of self-care). Several clinical, physical, psychological, situational, and social aspects can affect self-care, requiring individual behavioral changes to deal with the disease and the treatment (Ferreira et al., 2015).
Cognition is considered to have the main influence on self-care maintenance, especially in older adults, resulting in greater adherence to treatment and lower readmissions (Uchmanowicz, Polańska, Mazur & Froelicher, 2017).
Given the above mentioned issues, the indispensability of conducting an investigation about the cognitive alterations and their impact on the self-care of the patient with HF and, consequently, the harmful interference that these alterations may cause in the treatment and quality of life of the patient was verified. This study aimed to investigate cognitive and selfcare changes in patients with HF and to compare these changes with those in healthy participants.

Materials and Methods
This is a prospective case-control study. It was developed in the emergency room of the cardiology and medical clinic of the Hospital de Clinicas Gaspar Viana Foundation (FHCGV) in Belém, Pará, Brazil. Research, Society andDevelopment, v. 9, n. 6, e98963321, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i6.3321 To compose the case group, the following patients were considered eligible: (i) patients diagnosed with HF; (ii) patients admitted within 72 hours; (iii) patients aged ≥ 50 years; (iv) patients without myocardial revascularization in the last month; (v) patients without signs of secondary HF and/or sepsis. All participants read and agreed to participate in the study by signing the informed consent form (ICF). Those who did not meet the inclusion criteria and those who did not agree to sign the consent form were considered ineligible.
In the control group, the following individuals participated in the study: (i) individuals aged ≥ 50 years; (ii) individuals without evidence of cardiovascular disease, kidney disease, or other chronic degenerative diseases; (iii) individuals who showed interest in participating in the study by signing the consent form. The study did not include those who did not meet the inclusion criteria and those who did not agree to sign the informed consent form.
Data collection was performed over a period of 6 months (October 2016 to March 2017). In the case group, data were collected from 30 patients diagnosed with HF, obtained by random sampling, while in the control group, 30 participants with spontaneous demand for intuition for other causes not related to cardiovascular diseases were enrolled in the study.
Data collection was made using standardized tests such as the Montreal Cognitive Assessment (MoCA) (Nasreddine et al., 2005;Simões et al., 2008) and the Digit Symbol Substitution Test (DSST) (Rosano et al., 2016). A total of 8 cognitive domains were evaluated using the first test, while response processing speed, sustained attention, and visual and spatial skills were evaluated using the second test. Both tests were used in the case and control groups.
To assess self-care in the case group, the European Heart Failure Self-Care Behavior Scale (EHFScBS) instrument was employed, which is composed of 12 questions about the recognition of the signs and symptoms of decompensation HF and decision-making in the presence of these. The test result can be satisfactory self-care (12 points) or unsatisfactory self-care (60 points) (Jaarsma, Strömberg, Martensson & Dracup, 2003). Alternatively, in the control group, the self-care assessment instrument was adapted by the authors, using the EHFScBS as the basic instrument and removing specific questions about HF. It also consists of 12 questions related to self-care behaviors.
Statistical analysis was performed according to the nature of the variables, with initial execution of descriptive analysis, informing the percentage values of the results of the categorical variables; in addition, means and standard deviations of numerical variables were obtained. Research, Society and Development, v. 9, n. 6, e98963321, 2020 (CC BY 4. The analysis of significance of categorical data was performed using chi-square or Fisher's exact statistical tests. For comparison of numerical data and normal distribution, the analysis of variance (ANOVA) was performed. The database and the tables and graphs were formatted in Microsoft Excel 2010. All analyses were performed using the Epi Info version 3.5.2 statistical software. The level of statistical significance adopted was 5% (p-value <0.05), considering a 95% confidence interval in all analyses.
This study was submitted and approved by the Research Ethics Committee -CEP of FHCGV, with CAAE: 55063716.2.0000.0016. After obtaining the approval, the study was initiated following all ethical and legal precepts, provided in Resolution No. 466/12 of the National Health Council, in all stages of the study.

Results
The case group consisted of 30 patients with HF who were treated at the cardiac emergency department of the referral center in Pará. The sample consisted mostly of male patients (66.7%), with a mean age of 68.4 years ± 8.04 (Table 1).

Family income
Less than 1 minimum wage 11 36,6 --Greater than 1 and less than 2l 14 46,6 --Greater than 2 and less than or equal to 5 4 13,3 --Greater than 5 and less than or equal to 10 ----Greater than 10 minimum wages 1 3,3 --  For self-care assessment, EHFScBS was used, with the results obtained from the participants' assessment, the arithmetic mean and standard deviation were calculated (Table   3). It is noteworthy that the present study identified a minimum score of 19 points and a maximum of 49 points.

Schooling
Research, Society and Development, v. 9, n. 6, e98963321, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i6.3321 Regarding the self-care score obtained using the EHFScBS in the case and control groups, it was noticed that patients with HF had slightly better self-care, with a mean score of 29.7 ± 6.9, while healthy participants obtained a mean score of 31.8 ± 8.2, both with regular self-care classification.
When correlating cognitive impairment with the sociodemographic profile of HF patients, it was observed that female patients had greater impairment in memory, processing speed, and executive function domains, without statistical significance, with an average of 2.5 ± 0.7 (Table 4).
Research, Society and Development, v. 9, n. 6, e98963321, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i6.3321 Additionally, age over 70 years was found to be associated with higher cognitive impairment (p = 0.00065). Followed by patients from other municipalities with an average of 2.6 ± 0.5, with an income of less than 1 minimum wage with an average of 2.5 ± 0.8 and patients who declared themselves not literate with an average of 2.6 ± 0.5, although not statistically significant.
There was no significant relationship between sociodemographic and self-care profiles, although self-care in the case group was slightly better than that in the control group.
It is noteworthy that the best HF patient scores through the EHFScBS were obtained by Research, Society andDevelopment, v. 9, n. 6, e98963321, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i6.3321 female patients with a mean score of 29.4 ± 5.7; patients included in the age group ≥80 with a mean of 27.6 ± 10; patients from the municipality of Belém with an average of 29.2 ± 5.9; white patients(27.7 ± 6.4); patients with family income less than one minimum wage with an average of 27.6 ± 6.1; and patients with incomplete elementary schooling (27 ± 4.7).

Discussion
Regarding the participants' gender, the present study corroborates the findings of the study conducted by Sousa et al. (2018), according to which 61% of the patients with HF were male. The mean age identified in this study was 68.4 ± 8.04 years, similar to the national standard of 64.1 ± 15.9 years (Albuquerque et al., 2015). There was a predominance of brown race, followed by white and then black; such data are in line with those obtained by Medeiros & Medeiros (2017), who found values of 63.2%, 28.1%, and 8.8% for brown, white, and black populations, respectively. Margoto, Colombo & Gallani (2009) demonstrated in their study, conducted in a university hospital in the interior of São Paulo, the prevalence of HF cases among males (54.1%), with an average age of 58 years, low level of education, and informed average monthly of 1 to 2 minimum wages, showing similarity with the data found in our study. The prevalence of HF in males was also identified by Nascimento (2012), in a study carried out at the clinical hospital of the Medical School of São Paulo, in which 120 patients participated in the study, of which 65% were male.
Compared to the control group, the case group had a higher number of participants with cognitive impairment, all with statistical significance. These data are in line with those of international studies, which point out that cognitive impairments in patients with HF in the domains related to memory, attention, psychomotor speed, and executive function may affect the self-care decision-making capacity and the ability of the patient to comply with treatment and to recognize and manage worsening symptoms (Ferreira et al., 2015;Riegel, Lee, & Dickson 2011). In the study by Sauvé, Lewis, Blanklenbiller, Rickabaugh & Pressler (2009), the authors recruited 50 HF patients, who were compared with 50 control/healthy individuals, and they found that patients had significantly lower scores than controls, and this was evaluated using specific tests. This corroborates the findings of our study, in which there was statistical Research, Society andDevelopment, v. 9, n. 6, e98963321, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i6.3321 13 significance when comparing cognitive changes between the case and control groups in the three domains evaluated.
Studies have demonstrated that memory impairment in HF patients may influence the effective performance of self-care in several ways. This memory impairment may impede learning and retention of information necessary to maintain disease stability, such as remembering the dosage and timing of medications or remembering to monitor weight daily.
These patients may have difficulty recognizing the main symptoms of disease decompensation and taking early actions that prevent readmission (Hajduk et al., 2013;Kim & Shin, 2012). In the present study, there was greater impairment in processing speed in individuals with HF, which may influence rapid decision-making, symptom identification, and seeking medical care, impairing self-care.
Studies conducted by Parissis et al. (2013) and Carvalho (2014) show a prevalence of cognitive impairment in female HF patients, as they present more negative feelings, loss of hope, reduced perception of family and social support, and, especially, development of depressive conditions, which may be related to the high rates of cognitive impairment.
Although done discreetly, the present study revealed a prevalence of cognitive impairment in females, but without statistical significance.
Although the case group presented alterations in all the evaluated domains of cognition, such data do not indicate that this is irreversible damage. Studies show that most cognitive impairments are reversible and point out that aerobic physical activity can contribute to the improvement of cognition, especially the domain of executive functions, and to improved quality of life of these patients. Thus, it is essential that physical activity is included as an element of treatment for patients (Galioto, Fedor & Gunstad, 2015;Rêgo, Cabral & Fontes, 2018).
In the self-care assessment, the score obtained in the case group was slightly lower than that in the control group, thus indicating better self-care in individuals with HF; however, there was no statistical significance. In the study by Sousa et al. (2018) at a cardiology outpatient clinic in João Pessoa, Paraíba, Brazil, 100 patients with HF were evaluated. With regard to self-care analysis, similar data were obtained with a mean score of 35.17 ± 7.87, ranging from 15 to 54 points.
It is believed that obtaining better self-care scores in the case group is related to patients' knowledge about their disease and the factors associated with it. Studies indicate that part of the success of the HF treatment is associated with patients' knowledge of its pathology, contributing to an adequate perception of their health status (Bonin et al., 2016).
In a study by Rockwell & Riegel (2001) on 209 HF patients in six American hospitals, seven variables were analyzed and only two were predictors of self-care: education (p = 0.009) and symptom severity (p = 0.046); thus, the study points out that understanding and performing adequate self-care reduces the risk of worsening of the disease and, consequently, of readmissions and deaths of patients with HF.
In contrast, the data obtained here contradict the findings in other national studies that show that the higher the educational level, the lower the scores, resulting in better self-care. In the case group, participants with lower educational level had lower scores than participants with higher education level (Conceição, Santos, Santos & Cruz, 2015;Ferreira et al., 2015;Rockwell & Riegel 2014;Sousa et al., 2018).
A study by Hajduk et al. (2013) shows that cognitive impairment has been identified in older patients with low educational attainment.
The findings of this study are similar to ours, where we noticed the difficulties the study population faced when performing cognitive tests, which may be somewhat impaired by the lack of knowledge and understanding due to the factors of age and education, and this interferes with the test results. This indicates that the impairment of cognitive factors may not be linked only to HF.

Final Considerations
In this study, impairment was observed in three cognitive domains, with processing speed being the most impaired domain. There was a significant correlation between cognitive changes and age. However, self-care was similar for all participants.
There was a significant correlation between case and control groups when comparing cognitive changes, however, when self-care was evaluated, there was no significant relationship between the groups. Given these results, it is clear that cognitive impairment is not shown to have an isolated influence on self-care, considering that it presented differently.
However, the cognitive changes of the patients in the case group showed greater impairment. Research, Society andDevelopment, v. 9, n. 6, e98963321, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i6.3321 15 The present results helped in the construction and development of multidisciplinary team interventions that seek to promote and improve self-care in patients with HF, taking into account their profile and the degree of cognitive impairment, an aggravating factor identified among most patients affected by HF. We emphasize the need for further studies that show ways to improve self-care and prevent cognitive changes in patients with HF, aiming at a better quality of life.
A limitation of this study is the use of self-reported self-care scales, in addition to the cross-sectional design of the study, which makes it impossible to assess long-term behavior and interference of casualties and factors that affect self-care.
Cognition is a key factor in self-care, treatment adherence and health maintenance in the elderly population in chronic conditions. Therefore, it is suggested here additional studies that can reinforce the importance of this individual before public health policies and his role in the readjustment of lifestyle, especially in limiting conditions such as heart failure.