Search

Background The relationship between inadequate sleep duration and hypertension risk has been established in the general population, but there is a gap in the literature on predictors of habitual sleep duration in adults with hypertension. This study examined factors associated with habitual sleep duration among adults with hypertension in the United States (US). Methods Data of 5660 adults with hypertension were obtained by combining the 2015–2018 cycles of the National Health and Nutrition Examination Survey (NHANES). Survey weighted multinomial logistic regression models were fit to examine factors associated with short ( 9 h) sleep duration with adequate sleep duration (7–9 h) as the reference. Results The prevalence of self-reported adequate sleep duration was 65.7%, while short sleep duration was 23.6%, and long sleep duration 10.7%. Short sleep duration (compared to adequate sleep duration) was positively associated with history of seeking help for sleeping difficulties (relative risk ratio [RRR], 1.25; 95% confidence interval [CI], 1.02–1.53), Non-Hispanic Black race/ethnicity (RRR, 2.08; 95% CI, 1.61–2.67), working ≥45 h/week (RRR, 1.81; 95% CI, 1.32–2.48), and negatively associated with older age ≥ 65 years (RRR, 0.63; 95% CI, 0.45–0.91) and female gender (RRR, 0.70; 95% CI, 0.56–0.88). Long sleep duration was positively associated with female gender (RRR, 1.24; 95% CI, 1.001–1.54), chronic kidney disease (RRR, 1.48; 95% CI, 1.14–1.92), moderate depressive symptoms (RRR, 1.62; 95% CI, 1.08–2.44), moderately severe to severe depressive symptoms (RRR, 1.89; 95% CI, 1.05–3.43), being in retirement (RRR, 3.46; 95% CI, 2.18–5.49), and not working due to health reasons (RRR, 4.87; 95% CI, 2.89–8.22) or other reasons (RRR, 3.29; 95% CI, 1.84–5.88). Conclusion This population-based study identified factors independently associated with habitual sleep duration in adults with hypertension. These included help-seeking for sleeping difficulty, gender, age, chronic kidney disease, depressive symptoms, race/ethnicity, and employment status. These findings can help in the development of tailored approaches for promoting adequate sleep duration in adults with hypertension.

Social and economic inequality are chronic stressors that continually erode the mental and physical health of marginalized groups, undermining overall societal resilience. In this comprehensive review, we synthesize evidence of greater increases in mental health symptoms during the COVID-19 pandemic among socially or economically marginalized groups in the United States, including (a) people who are low income or experiencing homelessness, (b) racial and ethnic minorities, (c) women and lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) communities, (d) immigrants and migrants, (e) children and people with a history of childhood adversity, and (f) the socially isolated and lonely. Based on this evidence, we propose that reducing social and economic inequality would promote population mental health and societal resilience to future crises. Specifically, we propose concrete, actionable recommendations for policy, intervention, and practice that would bolster five “pillars” of societal resilience: (1) economic safety and equity, (2) accessible healthcare, including mental health services, (3) combating racial injustice and promoting respect for diversity, equity, and inclusion, (4) child and family protection services, and (5) social cohesion. Although the recent pandemic exposed and accentuated steep inequalities within our society, efforts to rebuild offer the opportunity to re-envision societal resilience and policy to reduce multiple forms of inequality for our collective benefit.

Aims Caregivers of persons living with ventricular assist devices (VADs) are integrally involved in both medical and non-medical care. We sought to understand tasks caregivers perform after surgical recovery, ways the home is adapted for those tasks, and presence of home safety hazards. Methods and results We conducted semi-structured interviews with persons living with a VAD and their caregivers. Pictures were taken of areas in the home where: (i) caregiving activities occurred, (ii) VAD or medical supplies were kept, and (iii) home adaptations were made for VAD care. Pictures were described in written detail and analysed. A qualitative descriptive approach was used for analysis. The sample consisted of 10 dyads, with mostly spousal relationships (60%) between male patients (60%) and female caregivers (80%). Three themes were identified: (i) Evolution of Caregiving and Support: Patients gain independence, but caregivers are still needed, (ii) Adapting the Home Environment: Changes are focused on functional needs, and (iii) Hidden Dangers: Illumination of safety concerns by photographs. Assistance with bathing, driveline care, and medication management were common caregiving tasks. Most home adaptations occurred in the bathroom and bedroom including sleeping recliners, shower chairs, removable shower heads, and hanging hooks to hold VAD equipment. Safety hazards included minimal space for safe ambulation, infection risk, and home-made adaptations to the environment. Conclusions These findings describe key home caregiving tasks, home adaptations, and safety concerns that require further education and support. Utilizing pictures may be a feasible method for assessing VAD teaching, caregiving needs, and identifying potential risks.

BackgroundVital components of communicating goals of care and preferences include eliciting the patient and caregiver's definition of quality of life, understanding meaningful activities and relationships, and exploring wishes for care at the end of life. Although current literature suggests framing conversations regarding end of life through the lens of meaning and quality of life, there is limited literature exploring dyadic congruence surrounding these important constructs among patients with ventricular assist devices (VADs) and their caregivers.ObjectivesThe purpose of this study was to explore congruence of VAD patient and caregiver perspectives regarding end of life, definitions of quality of life, and meaning in life while managing the uncertainty of living with a VAD.MethodsWe used thematic analysis to analyze semistructured qualitative interviews of 10 patient-caregiver dyads 3 to 12 months after VAD implantation.ResultsThree major themes were identified: (1) differing trajectories of uncertainty and worry, (2) a spectrum of end-of-life perspectives, and (3) enjoying everyday moments and independence. Overall, patients and caregivers had differing perspectives regarding uncertainty and end of life. Within-dyad congruence was most evident as dyads discussed definitions of meaning or quality of life.ConclusionsDyadic perspectives on end of life, meaning in life, and quality of life can inform how palliative care and VAD teams approach conversations about planning for the end of life. Findings from this study can inform future shared decision-making interventions for patients living with VADs and their caregivers.

Background Management of heart failure (HF) involves complex self-care recommendations. Many patients have difficulty adhering to these recommendations, and mechanisms that support behavior change are poorly understood. Objective The objective of this study was to explore the perceptions and motivations of individuals with HF who became adherent to HF treatment recommendations after being non-adherent. Methods This was a qualitative descriptive study. Participants were recruited from cardiology clinics and completed a semi-structured interview on their experiences and motivations for self-care behavior change. Data was analyzed using thematic analysis. The sample size (n = 8) was sufficient to achieve saturation. Results Five themes were identified: experiencing mortality, optimism and hope, making connections between behavior and health, self–efficacy, and the role of the clinician. The temporal chronological sequence of these themes across participants varied. Conclusions This study adds to our current understanding of HF self-care by suggesting mechanisms that may enhance existing self-care interventions, and demonstrating the important role of the clinician.

The number of older adults living with functional decline and serious illness is growing exponentially at a time when availability of both family and professional caregivers is strained. Achieving optimal outcomes for this vulnerable population involves advancing the knowledge needed to improve the quality of care delivered by families, health professionals, and community programs. Recent reports from National Institute of Health and the National Academy of Science, Engineering and Medicine have called for the identification of gaps in key areas of family caregiving intervention research. In March 2018, the Family Caregiving Institute at UC Davis convened an invitational meeting of over 50 thought leaders in family caregiving—representing service agencies, funding organizations, and academia—to participate in the Research Priorities in Caregiving Summit: Advancing Family-Centered Care across the Trajectory of Serious Illness. Using an iterative process, attendees identified the top 10 research priorities and created research priority statements that incorporated a definition of the priority topic, rationale for the priority; problem(s) to address; priority population(s); and example research topics. The research priority statements serve as a roadmap for research development that will address the most significant gaps in the caregiving field.

Everlyne G Ogugu,1 Sheryl L Catz,1 Janice F Bell,1 Christiana Drake,2 Julie T Bidwell,1 James E Gangwisch3 1Betty Irene Moore School of Nursing, University of California Davis, Sacramento, CA, USA; 2Department of Statistics, University of California Davis, Davis, CA, USA; 3Department of Psychiatry, Columbia University, New York City, NY, USACorrespondence: Everlyne G Ogugu, Betty Irene Moore School of Nursing, University of California Davis 2570 48th Street Sacramento, Sacramento, CA, 95817, USA, Email egogugu@ucdavis.eduPurpose: This study examined the relationship between habitual sleep duration and blood pressure (BP) control in adults with hypertension.Methods: This cross-sectional study used data of 5163 adults with hypertension obtained from the 2015– 2018 National Health and Nutrition Examination Survey (NHANES). Multivariable logistic regression was used to analyze the association between habitual sleep duration and BP control. Habitual sleep duration was self-reported and defined as the amount of sleep usually obtained in a night or main sleep period during weekdays or workdays. It was categorized as < 6, 6 - < 7, 7– 9, and > 9 hours. BP control was defined as average systolic BP < 130mmHg and diastolic BP < 80mmHg.Results: Results from the fully adjusted models show that among all adults with hypertension, habitual sleep duration of < 6 hours night/main sleep period was associated with reduced odds of BP control (OR = 0.53, 95% CI: 0ss.37– 0.76, P = 0.001) when compared to 7– 9 hours. In the subpopulation of adults who were on antihypertensive medication, those with a sleep duration of < 6 hours had lower odds of BP control than those with a sleep duration of 7– 9 hours (OR = 0.53, 95% CI: 0.36– 0.77, P = 0.002). No significant differences were noted in all adults with hypertension and in the subpopulation of those on antihypertensive medication in BP control between the reference sleep duration group (7– 9 hours) and the 6 - < 7 or > 9 hours groups. There were no significant differences across age groups or gender in the relationship between habitual sleep duration and BP control.Conclusion: Sleep duration of < 6 hours is associated with reduced odds of hypertension control. These significant findings indicate that interventions to support adequate habitual sleep duration may be a promising addition to the current hypertension management guidelines.Keywords: hypertension, blood pressure control, hypertension control, sleep, sleep duration

Background Mothers and their children demonstrate dyadic synchrony of hypothalamic–pituitary–adrenal (HPA) axis function, likely influenced by shared genetic or environmental factors. Although evidence has shown that chronic stress exposure has physiologic consequences for individuals—including on the HPA axis—minimal research has explored how unmet social needs such as food and housing instability may be associated with chronic stress and HPA axis synchrony in mother–child dyads. Methods We conducted a secondary analysis of data from 364 mother–child dyads with low-income recruited during a randomized trial conducted in an urban pediatric clinic. We used latent profile analysis (LPA) to identify subgroups based on naturally occurring patterns of within-dyad hair cortisol concentration (HCC). A logistic regression model predicted dyadic HCC profile membership as a function of summative count of survey-reported unmet social needs, controlling for demographic and health covariates. Results LPA of HCC data from dyads revealed a 2-profile model as the best fit. Comparisons of log HCC for mothers and children in each profile group resulted in significantly “higher dyadic HCC” versus “lower dyadic HCC” profiles (median log HCC for mothers: 4.64 vs 1.58; children: 5.92 vs 2.79, respectively; P Conclusion Mother–child dyads experience synchronous patterns of physiologic stress, and an increasing number of unmet social needs is associated with a profile of higher dyadic HCC. Interventions aimed at decreasing family-level unmet social needs or maternal stress are, therefore, likely to affect pediatric stress and related health inequities; efforts to address pediatric stress similarly may affect maternal stress and related health inequities. Future research should explore the measures and methods needed to understand the impact of unmet social needs and stress on family dyads.

Stress is a significant part of daily life, and systemic social inequities, such as racism and discrimination, are well-established contributors of chronic stress for African Americans. Added exposure to the stress of caregiving may exacerbate adverse health outcomes. This secondary analysis describes subjective and objective stress in African American family caregivers, and relationships of subjective and objective stress to health outcomes. Baseline data from 142 African American dementia family caregivers from the “Great Village” study were described using means and frequencies; regression models and Pearson’s correlation were used to examine associations between demographics, social determinants of health, and health outcomes. Mixed models were used to examine change and change variation in cortisol. Most caregivers had moderate degrees of stress. Stress was associated with sleep disruption and depressive symptoms, and discrimination appeared to be an independent contributor to depressive symptoms. This work provides a foundation for interpreting subjective and objective indicators of stress to tailor existing multicomponent interventions.

Background: Heart failure (HF) caregivers (CGs) may experience stress due to unpredictable patient disease trajectory. Interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hs-CRP) are reported to be elevated in dementia CGs, but less is known about HF CGs response to stress or relationships with social determinants of health such as education and race. Objective: To determine if social factors (race, education) modify the relationship between patient disease severity trajectory (NYHA class) and CG stress as measured by inflammatory biomarkers of IL-6 and hs-CRP among HF CGs. Methods: A secondary analysis was conducted using baseline data from Caregiver Opportunities for Optimizing Lifestyle (COOL) trial. Education was dichotomized into technical/high school or less versus college or post-graduate degree. Race was dichotomized as African American (AA) or White/Asian due to the low number of Asian CGs. Two-way analysis of variance tests were conducted for IL-6 and hs-CRP to test interaction effects between CG perceived NYHA class and education or race. Results: Participants (n=127) were predominantly female (n=117, 92.1%), AA (n=74, 58.3 %), and the majority (70.1%) reported a college or post-graduate education. Perceived NYHA class were reported as: I (n=32, 25.6%), II (n=31, 24.8%), III (n= 47, 37.6%), and IV (n=15, 12.0%). For hs-CRP, there was a significant interaction between race and NYHA class (p=.013). Higher hs-CRP levels were noted in class II, compared to class I or class III for AA CGs (p=.004). White/Asian CGs did not have significant hs-CRP differences between NYHA classes (p=.634). While similar trends were observed for IL-6 between race and NYHA class, it did not reach statistical significance. In the model for education and perceived disease severity, NYHA class was significant (p=.038) for hs-CRP. In the post hoc test for NYHA class, hs-CRP was highest among NYHA class II (p Conclusions: Our findings suggest that CGs of AA race and/or lower education may experience higher stress earlier in the HF disease trajectory and may therefore benefit from targeted CG support interventions.

Greater family caregiver exposure to uncontrolled patient symptoms is predictive of greater caregiver psychological and physiological stress in dementia and other chronic illnesses, but these phenomena have not been well-studied in heart failure (HF) - a disease with high symptom burden. The purpose of this study was to test the hypothesis that worse patient functional status (as reflected by increasing HF symptoms) would be associated with elevated psychological and physiological stress for the caregiver. This was a secondary analysis of data from 125 HF caregivers in the Caregiver Opportunities for Optimizing Lifestyle (COOL) study. Psychological stress was measured on four dimensions: care-related strain/burden (Oberst Caregiving Burden Scale), depression (Center for Epidemiological Studies Depression Scale), anxiety (State-Trait Anxiety Index), and general stress (Perceived Stress Scale). Physiological stress was measured by markers of HPA axis function (elevated cortisol awakening response [CAR]), endothelial dysfunction (increased PAI-1), and inflammation (increased IL-6, hsCRP). HF patient functional status was quantified by caregiver assessment of New York Heart Association (NYHA) Class. Generalized linear models were used to test associations between patient NYHA Class and stress (one model per indicator). NYHA Class (ordinal) was backwards difference coded in each model to examine caregiver stress in relation to increasing levels of HF severity. Caregivers were mostly female and in their mid-fifties, with a slight majority of the sample being African American and the patient's spouse. Overall, patient functional status was associated with greater caregiver psychological and physiological stress. In terms of psychological stress, higher NYHA Class was significantly associated with greater caregiver anxiety and general stress, but not with caregiver burden or depression. In terms of physiological stress, higher NYHA Class was associated with elevated markers in all models (elevated CAR and higher IL-6, hsCRP, and PAI-1). Across models, most associations between NYHA Class and stress were present at relatively early stages of functional limitation (i.e. Class II), while others emerged when functional limitations became more severe. To inform timing and mechanisms for much-needed caregiver interventions, research is needed to determine which aspects of HF symptomatology are most stressful for caregivers across the HF trajectory.

Background: Adherence to a heart-healthy diet is foundational for the prevention, management, and treatment of cardiovascular disease (CVD). Despite the fact that adhering to dietary guidelines may be challenging in the context of food insecurity, little is known about the likelihood of food insecurity in persons with CVD. Hypothesis: We hypothesized that persons with CVD (hypertension, coronary artery disease, heart failure, or stroke) would have significantly higher odds of food insecurity. Methods: This was an analysis of data from the National Health and Nutrition Examination Survey (NHANES), a nationally representative, cross-sectional study of health in the United States. All adults aged 19 years or older with food insecurity data were included across 3 cycles of NHANES (2011-2016). Food insecurity was measured using the 10-item Food Security Scale. CVD diagnosis was measured by self-report. Risk for food insecurity by CVD diagnosis was examined using multivariable logistic regression models, incorporating NHANES sample and person weights, and controlling for common sociodemographic confounders (age, gender, race/ethnicity, education, marital status). Results: The sample consisted of 17,175 persons (weighted study N =229,247,659). Slightly more than half were male (51.9%), and most were non-Hispanic white (65.1%). Just under half (45.6%) were in early adulthood (19-44 years), 35.3% were in middle adulthood (45-64 years), and 18.6% were in late adulthood (≥65 years). One quarter (25.9%) were food insecure. Consistent with our hypothesis, diagnosis of any CVD (stroke, heart failure, coronary artery disease, or hypertension) was significantly associated with higher likelihood for food insecurity (stroke: OR=2.18; 95% CI 1.83-2.60; p Conclusions: Diagnoses of hypertension, stroke, coronary artery disease, and heart failure were all significantly associated with higher risk for food insecurity. Given the necessity of dietary modification in CVD, further efforts to study food insecurity in CVD alongside other social determinants of health are urgently needed.

Many individuals living with heart failure (HF) rely on unpaid support from their partners, family members, friends, or neighbors as caregivers to help manage their chronic disease. Given the advancements in treatments and devices for patients with HF, caregiving responsibilities have expanded in recent decades to include more intensive care for increasingly precarious patients with HF—tasks that would previously have been undertaken by healthcare professionals in clinical settings. The specific tasks of caregivers of patients with HF vary widely based on the patient’s symptoms and comorbidities, the relationship between patient and caregiver, and the complexity of the treatment regimen. Effects of caregiving on the caregiver and patient range from physical and psychological to financial. Therefore, it is critically important to understand the needs of caregivers to support the increasingly complex medical care they provide to patients living with HF. This scientific statement synthesizes the evidence pertaining to caregiving of adult individuals with HF in order to (1) characterize the HF caregiving role and how it changes with illness trajectory; (2) describe the financial, health, and well-being implications of caregiving in HF; (3) evaluate HF caregiving interventions to support caregiver and patient outcomes; (4) summarize existing policies and resources that support HF caregivers; and (5) identify knowledge gaps and future directions for providers, investigators, health systems, and policymakers.

Background: In chronic illness caregiving, greater family caregiver exposure to patient symptoms is predictive of greater caregiver psychological and physiological stress. Although heart failure (HF) carries high symptom burden, this phenomena is not well-studied in HF caregivers. Objective: To test the hypothesis that caregiver perception of patient HF symptoms is associated with elevated caregiver psychological and physiological stress. Methods: This was a secondary analysis of baseline data from 125 HF caregivers in the Caregiver Opportunities for Optimizing Lifestyle (COOL) study. Psychological stress was measured by caregiver report of care-related strain (Oberst Caregiving Burden Scale), depression (Center for Epidemiological Studies Depression), anxiety (State-Trait Anxiety Index), and general stress (Perceived Stress Scale). Physiological stress was quantified by markers of HPA axis dysfunction (elevated cortisol awakening response [CAR]), endothelial dysfunction (increased PAI-1), and inflammation (increased IL-6, hsCRP). HF symptoms were quantified by caregiver assessment of New York Heart Association (NYHA) Class, dichotomized as asymptomatic [Class I] versus symptomatic [Class II-IV]. Generalized linear models were used to test relationships between symptoms and stress (one model per indicator). IL-6, hsCRP, and PAI-1 were natural log transformed, and CAR was dichotomized based on a cutoff for elevated stress response (>75% increase). All models controlled for sociodemographic confounders (age, gender, race, education, caregiving relationship), with biomarker-specific confounders (comorbidity, adiposity, medications) added to physiological stress models. Results: Caregivers were mostly female (n=115, 92.0%), in their mid-fifties (55.4±11.5), African American (n=72, 57.6%), and the patient’s spouse (n=68, 54.4%) or adult child (n=30, 24.0%). One quarter perceived the patient to be asymptomatic (Class I: n=31, 24.8%; II: n=31, 24.8%; III: n=47, 37.6%; IV: n=15, 12.0%). Symptomatic HF was significantly associated with greater caregiver depression, anxiety, and general stress (β=4.0±1.9, p=0.04; β=3.9±1.4, p Conclusions: Overall, patient HF symptoms were associated with greater caregiver psychological and physiological stress. To inform timing and mechanisms for much-needed caregiver interventions, research is needed to determine which aspects of HF symptomatology are most stressful for caregivers across the HF trajectory.

Background The relationship between physical and affective symptom clusters in heart failure (HF) is unclear. Objectives To identify associations between physical and affective symptom clusters in HF and to quantify outcomes and determinants of symptom subgroups. Methods This was a secondary analysis of data from two cohort studies among adults with HF. Physical and affective symptom clusters were compared using cross-classification modeling. Cox proportional hazards modeling and multinomial logistic regression were used to identify outcomes and determinants of symptom subgroups, respectively. Results In this young, mostly male sample (n = 274), physical and affective symptom clusters were cross-classified in a model with acceptable fit. Three symptom subgroups were identified: congruent-mild (69.3%), incongruent (13.9%), and congruent-severe (16.8%). Compared to the congruent-mild symptom group, the incongruent symptom group had significantly worse 180-day event-free survival. Conclusion Congruence between physical and affective symptom clusters should be considered when identifying patients at higher risk for poor outcomes.

Background In a study of Italian heart failure patient-caregiver dyads, greater caregiver strain significantly predicted lower patient clinical event risk. Objective The purpose of this secondary analysis was to examine this relationship in a sample from the United States. Methods Data came from 92 dyads who participated in a self-care intervention. Logistic regression was used to test the relationship between baseline strain (Bakas Caregiving Outcomes Scale, divided into tertiles) and patient likelihood of events (heart failure hospitalization/emergency visit or all-cause mortality) over 8 months. Results Nearly half of patients (n = 40, 43.5%) had an event. High (vs low) caregiver strain was associated with a 92.7% event-risk reduction, but with substantial variability around the effect (odds ratio, 0.07; 95% confidence interval, 0.01–0.63; P = .02). Conclusions Although findings were similar to the Italian study, the high degree of variability and contrasting findings to other studies signal a level of complexity that warrants further investigation.

Background: Although we know that the quality of life generally improves after left ventricular assist device (LVAD) implantation, we know little about how symptoms change in response to LVAD. Methods: The purpose of this study was to compare the changes in symptoms between bridge and destination therapy patients as part of a prospective cohort study. Physical (dyspnea and wake disturbances) and affective symptoms (depression and anxiety) were measured before LVAD and at 1, 3, and 6 months after LVAD. Multiphase growth modeling was used to capture the 2 major phases of change: initial improvements between preimplant and 1 month after LVAD and subsequent improvements between 1 and 6 months after LVAD. Results: The sample included 64 bridge and 22 destination therapy patients as the preimplant strategy. Destination patients had worse preimplant dyspnea and wake disturbances, and they experienced greater initial improvements in these symptoms compared with bridge patients (all P < .05); subsequent change in both symptoms were similar between groups (both P > .05). Destination patients had worse preimplant depression (P = .042) but experienced similar initial and subsequent improvements in depression in response to LVAD compared with bridge patients (both P > .05). Destination patients had similar preimplant anxiety (P = .279) but experienced less initial and greater subsequent improvements in anxiety after LVAD compared with bridge patients (both P < .05). Conclusion: There are many differences in the magnitude and timing of change in symptom responses to LVAD between bridge and destination therapy patients. Detailed information on changes in specific symptoms may better inform shared decision-making regarding LVAD.

Background Patient's knowledge about heart failure (HF) contributes to successful HF self-care, but less is known about shared patient-caregiver knowledge. Objectives The purpose of this analysis was to: 1) identify configurations of shared HF knowledge in patient-caregiver dyads; 2) characterize dyads within each configuration by comparing sociodemographic factors, HF characteristics, and psychosocial factors; and 3) quantify the relationship between configurations and patient self-care adherence to managing dietary sodium and HF medications. Methods This was a secondary analysis of cross-sectional data (N = 114 dyads, 53% spousal). Patient and caregiver HF knowledge was measured with the Atlanta Heart Failure Knowledge Test. Patient dietary sodium intake was measured by 3-day food record and 24 h urine sodium. Medication adherence was measured by Medication Events Monitoring System caps. Patient HF-related quality of life was measured by the Minnesota Heart Failure Questionnaire; caregiver health-related quality of life was measured by the Short Form-12 Physical Component Summary. Patient and caregiver depression were measured with the Beck Depression Inventory-II. Patient and caregiver perceptions of caregiver-provided autonomy support to succeed in heart failure self-care were measured by the Family Care Climate Questionnaire. Multilevel and latent class modeling were used to identify dyadic knowledge configurations. T-tests and chi-square tests were used to characterize differences in sociodemographic, clinical, and psychosocial characteristics by configuration. Logistic/linear regression were used to quantify relationships between configurations and patient dietary sodium and medication adherence. Results Two dyadic knowledge configurations were identified: “Knowledgeable Together” (higher dyad knowledge, less incongruence; N = 85, 75%) and “Knowledge Gap” (lower dyad knowledge, greater incongruence; N = 29, 25%). Dyads were more likely to be in the “Knowledgeable Together” group if they were White and more highly educated, if the patient had a higher ejection fraction, fewer depressive symptoms, and better autonomy support, and if the caregiver had better quality of life. In unadjusted comparisons, patients in the “Knowledge Gap” group were less likely to adhere to HF medication and diet. In adjusted models, significance was retained for dietary sodium only. Conclusions Dyads with higher shared HF knowledge are likely more successful with select self-care adherence behaviors.

IMPACT: This study is designed to address a critical gap in our understanding of how aging patients and caregivers recognize and respond to clinically important changes in heart failure symptoms during vulnerable transitions. OBJECTIVES/GOALS: Research on family involvement in heart failure (HF) symptom response is limited. Our objective is to examine HF symptom monitoring processes in couples after HF hospitalization, and quantify how coupled symptom assessments predict symptom response, patient clinical events, care strain, and dyad health during the high-risk post-discharge period. METHODS/STUDY POPULATION: This is an ongoing T2 translational study that employs an intensive longitudinal design. Adults aged ≥65 years hospitalized for HF and their caregiving spouse/partner are enrolled. The target n is 48 dyads. Over 5 weeks of follow-up, dyads complete daily diaries assessing patient HF symptoms. Clinical biomarkers of HF severity (NTproBNP, ST2) are also collected. Primary study endpoints are dyads’ HF symptom response behaviors and caregiver strain; secondary endpoints are dyads’ health status and patient clinical events. Dyadic dynamics of symptom assessment will first be characterized using dyadic autoregressive time series models. Subsequently, we will extract cross-partner effect parameters from the time series models and test whether dyadic effects predict the trajectories of each of our endpoints. RESULTS/ANTICIPATED RESULTS: This study is currently underway. In line with our study hypotheses, we anticipate that couples who assess patient symptoms similarly (dyadic agreement), and whose symptom assessments accurately reflect clinical severity, will be more likely to respond to symptoms appropriately with lower stress to the caregiving partner, and have better trajectories of health (self-reported and clinical). Characterizing dyadic symptom dynamics will provide important insight into the day-to-day process of symptom recognition in couples. Further, quantifying dyadic symptom dynamics in relation to our endpoints will provide information on the clinical value of dyadic symptom agreement, and whether it might be a target for future interventions to support better symptom response and health outcomes for both dyad members. DISCUSSION/SIGNIFICANCE OF FINDINGS: This project innovates on existing paradigms by applying family-level theory and techniques to better understand and support interventions for couples during post-discharge HF transitions - a vulnerable period for older adults that has traditionally been studied almost exclusively at the patient-level, with marginal success.

Purpose Persons living with a ventricular assist device (VAD) and their caregivers experience unique stresses however, caregiver experience is inconsistently assessed, so little is known about caregiver contributions to disease and device management, or the effects they experience. The purpose of this mixed methods study is to describe the context of VAD caregiving and explore burdensome elements of caregiving. Methods We recruited VAD patients and caregivers (N=14, 7 dyads) who had been implanted within the past 3-12 months, or had experienced a recent hospital-to-home transition (within 60 days). We administered surveys and conducted semi-structured qualitative interviews from patient and caregiver perspectives. Analysis includes descriptive statistics and thematic analysis of interviews. Results Mean age of VAD patients and caregivers was 55.7 ± 14.2 years and 53.1± 15.8 years, respectively. Most patients were male (75%) and most caregivers were female (87.5%), and most caregiver-patient dyads were spousal (85.7%). Mean caregiver burden (short-form Zarit Burden Interview) score was 12.4 ± 4.4. From qualitative interviews, the areas of the home most commonly modified to support patient needs or make caregiving tasks easier were bathrooms (i.e. railings, shower chairs) and the bedroom (sleeping arrangements). The most common caregiving tasks reported were 1)“monitoring” (i.e. for complications, anticipating needs), 2) managing medications, equipment and appointments, 3) helping with bathing, and 4) changing the driveline dressing. Even when caregivers reported low burden quantitatively, caregivers expressed that they felt overwhelmed with the complexity and intensity of caregiving responsibilities on themselves and their relationships, like a “ball and chain” or like a “cascade that effects everybody.” Conclusion These preliminary findings provide new data on the changes caregivers and patients make to their home environments, and elucidate a potential mismatch between quantitative and qualitative assessments of care burden. Both of these findings require further investigation. Resources to support home changes and living at home following VAD implant may be insufficient to address needs. It may also be helpful to implement more frequent, formal evaluation of caregiving needs and burden using additional instruments that capture elements of caregiving that are unique to the VAD context.

Patients with a left ventricular assist device (LVAD) commonly experience psychological distress post-implantation, but physiological stress and differences by implant strategy remain unstudied. This study describes indicators of physiological (salivary cortisol, C-reactive protein, sleep quality) and psychological (perceived stress, depression, and fatigue) stress by implant strategy and examines relationships between stress and outcomes (quality of life [QOL] and functional status). Prospective, cross-sectional data were collected from patients ≥3 months post-LVAD implantation (n = 44), and descriptive statistics and logistic regression were used. The study sample was average age 57.7 ± 13 years, mostly male (73%), married (70.5%), and racially diverse. Median LVAD support was 18.2 months. Most had normal cortisol awakening response and fair sleep quality, with moderate psychological stress. There were no differences in stress by implant strategy. Normal cortisol awakening response was correlated with low depressive symptoms. Sleep quality and psychological stress were associated with QOL, whereas cortisol and C-reactive protein levels were associated with functional status. This is the first report of salivary biomarkers and stress in LVAD outpatients. Future research should examine physiological and psychological stress and consider potential clinical implications for stress measurement for tailored approaches to stress management in this population.

Background Although current guidelines emphasize the importance of social support to the success of left ventricular assist device ( LVAD ) therapy, few studies examine the influence of the caregiver on patient outcomes or quantify the impact of LVAD caregiving on caregiver outcomes. The purpose of this analysis was to identify patient and caregiver determinants of patient quality of life ( QOL ) and caregiver strain in response to LVAD therapy. Methods and Results Data on patients receiving LVAD therapy and their caregivers (n=50 dyads) were prospectively collected pre‐implantation and 1, 3, and 6 months post‐implantation. Growth curve modeling was used to describe change in patient QOL (Kansas City Cardiomyopathy Questionnaire) and caregiver strain (Multidimensional Caregiver Strain Index). Patient QOL improved most in the first month (β=23.22±3.76, P P P P QOL (β=0.53±0.19, P P =0.04). Better relationship quality was associated with greater improvement in patient QOL (β=14.39±5.85, P =0.01) and less pre‐implantation caregiver strain (β=−9.31±2.28, P P =0.01), and patients with nonspousal caregivers had less improvement in QOL (β=−3.70±1.62, P =0.02). Conclusions A combination of patient and caregiver characteristics predicts patient and caregiver response to LVAD therapy. Including caregiver factors in future studies may be helpful in developing interventions that improve patient and caregiver outcomes, together.

Background: Preventing hospitalization and improving event-free survival are primary goals of heart failure (HF) treatment according to current European Society of Cardiology guidelines; however, substantial uncertainty remains in our ability to predict risk and improve outcomes. Although caregivers often assist patients to manage their HF, little is known about their influence on clinical outcomes. Aims: To quantify the influence of patient and caregiver characteristics on patient clinical event risk in HF. Methods: This was a secondary analysis of data using a sample of Italian adults with HF and their informal caregivers ( n = 183 patient–caregiver dyads). HF patients were followed over 12 months for the following clinical events: hospitalization for HF, emergency room visit for HF or all-cause mortality. Influence of baseline caregiver- and patient-level factors (patient and caregiver age; dyad relationship type; patient New York Heart Association (NYHA) Class, cognition, and comorbidities; and caregiver strain, mental health status, and contributions to HF self-care) on patient risk of death or hospitalization/emergency room use was quantified using Cox proportional hazards regression. Results: Over the course of follow up, 32.8% of patients died, 19.7% were hospitalized for HF and 10.4% visited the emergency room. Higher caregiver strain, better caregiver mental health status and greater caregiver contributions to HF self-care maintenance were associated with significantly better event-free survival. Worse patient functional class and greater caregiver contributions to patient self-care management were associated with significantly worse patient event-free survival. Conclusion: Considering caregiving factors together with patient factors significantly increases our understanding of patient clinical event risk in HF.

Disease self-management is a critical component of maintaining clinical stability for patients with chronic illness. This is particularly evident in the context of heart failure (HF), which is the leading cause of hospitalization for older adults. HF self-management, commonly known as HF self-care, is often performed with the support of informal caregivers. However, little is known about how a HF dyad manages the patient's care together. The purpose of this study was to identify determinants of patient and caregiver contributions to HF self-care maintenance (daily adherence and symptom monitoring) and management (appropriate recognition and response to symptoms), utilizing an approach that controls for dyadic interdependence. This was a secondary analysis of cross-sectional data from 364 dyads of Italian HF patients and caregivers. Multilevel modeling was used to identify determinants of HF self-care within patient-caregiver dyads. Patients averaged 76.2 (SD = 10.7) years old, and a slight majority (56.9%) was male, whereas caregivers averaged 57.4 (SD = 14.6) years old, and about half (48.1%) were male. Most caregivers were adult children (48.4%) or spouses (32.7%) of patients. Both patients and caregivers reported low levels of HF maintenance and management behaviors. Significant individual and dyadic determinants of self-care maintenance and self-care management included gender, quality of life, comorbid burden, impaired ADLs, cognition, hospitalizations, HF duration, relationship type, relationship quality, and social support. These comprehensive dyadic models assist in elucidating the complex nature of patient-caregiver relationships and their influence on HF self-care, leading to more effective ways to intervene and optimize outcomes.

Background: Heart failure (HF) self-care is important in reducing clinical events (all-cause mortality, emergency room visits and hospitalizations). HF self-care behaviors are multidimensional and include maintenance (i.e. daily adherence behaviors), management (i.e. symptom response behaviors) and consulting behaviors (i.e. contacting a provider when appropriate). Across these dimensions, patterns of successful patient engagement in self-care have been observed (e.g. successful in one dimension but not in others), but no previous studies have linked patterns of HF selfcare to clinical events. Objectives: To identify patterns of self-care behaviors in HF patients and their association with clinical events. Methods: This was a prospective, non-experimental, cohort study. Community-dwelling HF patients (n ¼ 459) were enrolled across Italy, and clinical events were collected one year after enrollment. We measured dimensions of self-care behavior with the Self-Care of HF Index (maintenance, management, and confidence) and the European HF Self-care Behavior Scale (consulting behaviors). We used latent class mixture modeling to identify patterns of HF self-care across dimensions, and Cox proportional hazards modeling to quantify event-free survival over 12 months of follow-up. Results: Patients (mean age 71.8 12.1 years) were mostly males (54.9%). Three patterns of self-care behavior were identified; we labeled each by their most prominent dimensional characteristic: poor symptom response, good symptom response, and maintenance-focused behaviors. Patients with good symptom response behaviors had fewer clinical events compared with those who had poor symptom response behaviors (adjusted hazard ratio ¼ 0.66 [0.46e0.96], p ¼ 0.03). Patients with poor symptom response behaviors had the most frequent clinical events. Patients with poor symptom response and those with maintenance-focused behaviors had a similar frequency of clinical events. Conclusions: Self-care is significantly associated with clinical events. Routine assessment, mitigation of barriers, and interventions targeting self-care are needed to reduce clinical events in HF patients

Background Caregivers are thought to play a major role in helping patients first appraise and then respond to heart failure (HF) symptoms. Aims The aims of this study were to: (a) characterise distinct patterns of HF patient–caregiver dyads with respect to symptom appraisal; and (b) link dyadic symptom appraisal to contributions to self-care and caregiver strain. Methods and results A cross-sectional dyadic descriptive design was used to capture patient and caregiver appraisal of patient HF symptoms (i.e. dyspnoea, fatigue, pain and anxiety). Contributions to self-care were measured using patient and caregiver versions of the Self-Care of Heart Failure Index and the European Heart Failure Self-care Behaviour Scale. Caregiver strain was measured using the Multidimensional Caregiver Strain Index. Multilevel and latent class mixture modelling (LCMM) were used to examine distinct patterns of symptom appraisal. Two patterns of dyadic symptom appraisal were identified: one pattern (n = 24; 38.7%) wherein caregivers appraised patients’ symptoms as being significantly worse than did the patient (labelled as ‘Caregiver > Patient’); and a second pattern (n = 38; 61.3%) wherein patients appraised their symptoms similar to or worse than that as perceived by their caregiver (labelled as ‘Patient ⩾ Caregiver’). Dyads in the Caregiver > Patient pattern of symptom appraisal reported much better contributions to self-care (symptom response behaviours only), but also greater caregiver strain, compared with dyads in the Patient ⩾ Caregiver pattern. Greater patient depression and older caregiver age were significant determinants of fitting the Patient ⩾ Caregiver pattern. Conclusion Differences in how HF patients and caregivers appraise symptoms together must be taken into consideration when examining contributions to HF care and caregiver outcomes.

Background: Patients who receive ventricular assist device (VAD) therapy typically rely on informal caregivers (family members or friends) to assist them in managing their device. Objective: The purpose of this study is to characterize changes in person-oriented outcomes (quality of life [QOL], depression, and anxiety) for VAD patients and their caregivers together from pre-implantation to 3 months post-implantation. Methods: This was a formal interim analysis from an ongoing prospective study of VAD patients and caregivers (n = 41 dyads). Data on person-oriented outcomes (QOL: EuroQol 5 Dimensions Visual Analog Scale; depression: Patient Health Questionnaire-8; anxiety: Brief Symptom Inventory) were collected at 3 time points (just prior to implantation and at 1 and 3 months post-implantation). Trajectories of change for patients and caregivers on each measure were estimated using latent growth modeling with parallel processes. Results: Patients’ QOL improved significantly over time, whereas caregiver QOL worsened. Depression and anxiety also improved significantly among patients but did not change among caregivers. There was substantial variability in change on all outcomes for both patients and their caregivers. Conclusions: This is the first quantitative study of VAD patient-caregiver dyads in modern devices that describes change in person-oriented outcomes from pre-implantation to post-implantation. This work supports the need for future studies that account for the inherent relationships between patient and caregiver outcomes and examine variability in patient and caregiver responses to VAD therapy.

Background: Despite evidence from the broader caregiving literature about the interdependent nature of the caregiving dyad, few studies in heart failure (HF) have examined associations between caregiver and patient characteristics. Objective: The aim of this study is to quantitatively synthesize the relationships between caregiver well-being and patient outcomes. Methods: The MEDLINE, PsycINFO, and CINAHL databases were searched for studies of adult HF patients and informal caregivers that tested the relationship between caregiver well-being (perceived strain and psychological distress) and patient outcomes of interest. Summary effects across studies were estimated using random effects meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: A total of 15 articles meeting inclusion criteria were included in the meta-analysis. Taking into account differences across studies, higher caregiver strain was associated significantly with greater patient symptoms (Fisher z = 0.22, P < .001) and higher caregiver strain was associated significantly with lower patient quality of life (Fisher z = −0.36, P < .001). Relationships between caregiver psychological distress and both patient symptoms and quality of life were not significant. Although individual studies largely found significant relationships between worse caregiver well-being and higher patient clinical event-risk, these studies were not amenable to meta-analysis because of substantial variation in event-risk measures. Conclusions: Clinical management and research approaches that acknowledge the interdependent nature of the caregiving dyad hold great potential to benefit both patients and caregivers.

Background: Unexplained heterogeneity in response to ventricular assist device (VAD) implantation for the management of advanced heart failure impedes our ability to predict favorable outcomes, provide adequate patient and family education, and personalize monitoring and symptom management strategies. The purpose of this article was to describe the background and the design of a study entitled “Profiling Biobehavioral Responses to Mechanical Support in Advanced Heart Failure” (PREMISE). Study Design and Methods: PREMISE is a prospective cohort study designed to (1) identify common and distinct trajectories of change in physical and psychological symptom burden; (2) characterize common trajectories of change in serum biomarkers of myocardial stress, systemic inflammation, and endothelial dysfunction; and (3) quantify associations between symptoms and biomarkers of pathogenesis in adults undergoing VAD implantation. Latent growth mixture modeling, including parallel process and cross-classification modeling, will be used to address the study aims and will entail identifying trajectories, quantifying associations between trajectories and both clinical and quality-of-life outcomes, and identifying predictors of favorable symptom and biomarker responses to VAD implantation. Conclusions: Research findings from the PREMISE study will be used to enhance shared patient and provider decision making and to shape a much-needed new breed of interventions and clinical management strategies that are tailored to differential symptom and pathogenic responses to VAD implantation.

Introduction: Mild cognitive dysfunction is common among adults with heart failure (HF). We hypothesized that mild cognitive dysfunction would be associated with poor HF self-care behaviors, particularly patients’ ability to respond to symptoms. Methods: We analyzed data on 148 participants in an observational study of symptoms in adults with moderate-to-advanced HF. Mild cognitive dysfunction was measured with the Montreal Cognitive Assessment (MoCA; range, 0Y30), using cutoff scores for the general population (26) and for adults with cardiovascular disease (24). Heart failure self-care management (evaluation and response to HF symptoms) was measured with the Self-care of HF Index, and consulting behaviors (calling a provider when symptoms occur) were measured using the European HF Self-care Behavior Scale-9. Generalized linear modeling and hierarchical linear modeling were used to quantify the relationship between MoCA cutoff scores and indices of HF self-care. Results: The mean age of the sample was 57 T 12 years, 61.5% were men, and 58.8% had class III/IV HF; the mean left ventricular ejection fraction was 28% T 12%. Using MoCA scores of 26 and 24, respectively, 33.1% and 14.2% of the sample had mild cognitive dysfunction. Controlling for common confounders, participants with MoCA scores lower than 26 reported self-care comparable with that of participants with MoCA scores of 26 or higher. Participants with MoCA scores lower than 24, however, reported 21.5% worse self-care management (P = 0.014) and 51% worse consulting behaviors (P G 0.001) compared with participants with MoCA scores of 24 or higher. Conclusions: A disease-specific cutoff for mild cognitive dysfunction reveals marked differences patients’ ability to recognize and respond to HF symptoms when they occur. Adults with HF and mild cognitive dysfunction are a vulnerable patient group in great need of interventions that complement HF self-care.

African Americans face a disproportionate burden related to the incidence of end stage renal disease. A literature search was conducted for research articles published between 2006-2015 to synthesize current literature related to non-biological barriers to early stages of the pre-kidney transplant continuum for African Americans in the United States. Twenty-four articles were included in the final sample. Eleven barriers were identified. Barriers were categorized as socioeconomic-based barriers, culture-based barriers, and knowledge-based barriers. Resources to develop educational interventions for both patients and providers may help reduce existing barriers.

Introduction Higher caregiver strain was identified as a predictor of lower patient clinical event-risk in a previous analysis of Italian heart failure (HF) patient-caregiver dyads. The purpose of this analysis was to determine whether this trade-off in patient and caregiver outcomes was culturally bound, or replicable in a North American sample. Hypothesis We hypothesized that, similar to the Italian study, higher strain in North American caregivers would predict lower patient event-risk. Methods This was a secondary analysis of data from a 3-arm (usual care, patient-family education, and family partnership intervention) randomized controlled trial to improve HF self-care. Data collection occurred pre-intervention and 4 and 8 months post-intervention. Caregiver strain was measured pre-intervention using the 15-item Bakas Caregiving Outcomes Survey (BCOS: range 15-105, higher scores indicate more positive outcomes related to caregiving), and tertiles were used to divide caregivers into low, moderate, or high strain for analysis. Generalized linear regression was used to examine caregiver strain as a predictor of the likelihood of having any event (HF hospitalization, HF emergency room visit, or all-cause mortality) over time, controlling for intervention group and recent HF hospitalization (previous 4 months). Results All patients (n=92) were NYHA Class II or III, with the majority being Class II (n=68, 73.9%). Patients and caregivers were in their mid-fifties on average (56.3±10.1 and 53.4±12.4 years, respectively) and racially diverse (n=58, 63.0% and n=59, 64.8% African American, respectively), with most patients being male (n=57, 62.0%) and most caregivers being female (n=75, 84.2%). The most common dyad type was spousal (n=40, 44.0%). Over the 8 months, 28 patients were hospitalized, 6 had an emergency room visit and 6 died. The average BCOS scores for the low, moderate, and high strain groups were 82.9±12.5 (range 66-105), 61.1±1.6 (range 60-65), and 52.1±7.4 (range 31-59), respectively. There was no difference in events by intervention group. High caregiver strain (as compared to low strain) was associated with 91.9% lower likelihood of the patient having an event over 8 months follow-up (OR=0.081, 95%CI=0.008-0.850, p=0.036). There was no significant difference in event-risk by moderate caregiver strain. Conclusions Similar to previous findings in an Italian cohort, higher caregiver strain predicted lower HF patient clinical event-risk in this North American sample. Patient event-risk reductions may come with a cost for the family caregiver - a cost that has known sequelae (morbidity, mortality) and must be assessed and addressed.

Introduction: The impact of ventricular assist device (VAD) therapy on affective symptoms among patients with advanced heart failure (HF) and their informal caregivers is not well understood. Hypothesis: We hypothesized that patients’ affective symptoms would improve post-implant, while caregivers’ affective symptoms would worsen. Methods: Prospective, longitudinal data was collected on patients and their caregivers (n=25 dyads) prior to and at 30 and 90 days after VAD implantation. Depression was measured using the Patient Health Questionnaire-8 (PHQ-8; range 0-24, higher scores indicate worse depressive symptoms), and anxiety was measured using the Anxiety Scale of the Brief Symptom Inventory (BSI-ANX; range 0-4; higher scores indicate worse anxiety) in patients and their caregivers. Pre vs. post VAD comparisons in affective symptoms were examined using paired t-tests. Results: Patients requiring VAD implantation were 54.9±12.5 years of age and mostly male (84.0%), while caregivers were 53.9±11.1 years of age and mostly female (80.0%); a majority (72.0%) of dyads were spouses. Patient depression decreased significantly from pre-implant (9.3±5.6) to 30 days (6.9±5.4; t=2.2, p=0.04) and 90 days post-implant (3.6±3.6; t=5.3, p Conclusions: Although depression and anxiety improved dramatically for patients after VAD implantation, the pre-implant affective symptom burden of caregivers was substantially higher than national norms at baseline and was not ameliorated over time. As patient symptoms improve with VAD therapy, their caregivers may benefit from psychosocial interventions to address protracted symptoms of depression and anxiety.

Introduction: Ventricular Assist Device (VAD) implantation is a therapeutic option for many patients with advanced heart failure (HF). Although patient quality of life (QOL) generally improves after VAD, little is known about changes in QOL among caregivers of patients undergoing VAD implantation. Hypothesis: We hypothesized that patient QOL would improve and caregiver QOL would worsen after VAD implantation. Methods: This was a prospective longitudinal study of patients receiving VAD therapy for advanced HF and their informal caregivers (n=27 dyads). QOL was measured pre- VAD implant and at 30 and 90 days post-implant. For patients, QOL was measured with the Kansas City Cardiomyopathy Questionnaire. For caregivers, QOL was measured with the SF-36. Both measures range from 0-100; higher scores indicate better QOL. Pre vs. post VAD comparisons in QOL were examined using paired t-tests. Results: Caregivers and patients were 54.9±10.3 and 54.3±14.6 years of age, respectively. Most patients (88.9%) were male, and most (63.0%) were receiving a VAD as a bridge to transplant. A majority of caregivers were female (85.2%) and the patients’ spouses (77.8%). Patient QOL improved significantly from baseline (28.4±20.7) to 30 days (50.0±25.3; t=-4.1, p Conclusions: Although VAD therapy is associated with QOL benefit for patients, clinicians and researchers should recognize that caregivers are at risk for significant worsening of QOL post-implant. Caregivers of patients undergoing VAD implantation may benefit from greater anticipatory guidance and ongoing support.

Background Heart failure is a burdensome clinical syndrome, and patients and their caregivers are responsible for the vast majority of heart failure care. Objectives This study aimed to characterize naturally occurring archetypes of patient-caregiver dyads with respect to patient and caregiver contributions to heart failure self-care, and to identify patient-, caregiver- and dyadic-level determinants thereof. Design Dyadic analysis of cross-sectional data on patients and their caregivers. Setting Outpatient heart failure clinics in 28 Italian provinces. Participants 509 Italian heart failure patients and their primary caregivers. Methods Multilevel and mixture modeling were used to generate dyadic averages and incongruence in patient and caregiver contributions to heart failure self-care and identify common dyadic archetypes, respectively. Results Three distinct archetypes were observed. 22.4% of dyads were labeled as novice and complementary because patients and caregivers contributed to different aspects of heart failure self-care that was generally poor; these dyads were predominantly older adults with less severe heart failure and their adult child caregivers. 56.4% of dyads were labeled as inconsistent and compensatory because caregivers reported greater contributions to the areas of self-care most insufficient on the part of the patients; patients in these dyads had the highest prevalence of hospitalizations for heart failure in the past year and the fewest limitations to performing activities of daily living independently. Finally, 21.2% of dyads were labeled as expert and collaborative because of high contributions to all aspects of heart failure self-care, the best relationship quality and lowest caregiver strain compared with the other archetypes; patients in this archetype were likely the sickest because they also had the worst heart failure-related quality of life. Conclusion Three distinct archetypes of dyadic contributions to heart failure care were observed that represent a gradient in the level of contributions to self-care, in addition to different approaches to working together to manage heart failure. Interventions and clinical programs that involve heart failure dyads should tailor strategies to take into consideration these distinct archetypes and their attributes.

Background: The majority of heart failure (HF) self-care research remains focused on patients, despite the important involvement of family caregivers. Although self-care confidence has been found to play an important role in the effectiveness of HF self-care management on patient outcomes, no known research has examined self-care confidence within a dyadic context. Objective: The purpose of this study was to identify individual and dyadic determinants of self-care confidence in HF care dyads. Methods: Multilevel modeling, which controls for the interdependent nature of dyadic data, was used to examine 329 Italian HF dyads (caregivers were either spouses or adult children). Results: Both patients and caregivers reported lower-than-adequate levels of confidence, with caregivers reporting slightly higher confidence than patients. Patient and caregiver levels of confidence were significantly associated with greater patient-reported relationship quality and better caregiver mental health. Patient confidence in self-care was significantly associated with patient female gender, nonspousal care dyads, poor caregiver physical health, and low care strain. Caregiver confidence to contribute to self-care was significantly associated with poor emotional quality of life in patients and greater perceived social support by caregivers. Conclusions: Findings are supportive of the need for a dyadic perspective of HF self-care in practice and research as well as the importance of addressing the needs of both members of the dyad to maximize optimal outcomes for both.

Introduction: Recognition and response to symptoms of heart failure (HF) is critical to reducing the risk of hospitalization and mortality. Although many patients have support from caregivers, little is known about caregivers’ contributions to HF symptom response behaviors. We hypothesized that patient-, caregiver-, and dyad-level factors would be associated with better symptom response behaviors. Methods: This was a secondary analysis of data on 364 Italian HF patient-caregiver dyads. HF symptom response behaviors were measured using patient and caregiver versions of the Self-Care of Heart Failure Index (0-100; higher = better). Health status (SF-12) and relationship quality (single item) were collected from patients and caregivers. Patient cognition and comorbidities were measured using the MMSE and Charlson Index. Caregiver social support was measured with the Carers of Older People in Europe Index. Hospitalizations were abstracted from the medical record. Multilevel modeling was used for all analyses. Results: Patients were older (age 76.3±10.8 years), predominantly male (57.3%) and most had NYHA Class II/III HF (72.2%). Caregivers were younger (age 57.7±14.6 years), and most were female (51.7%) and adult child (53.6%) or spousal (34.0%) caregivers. Symptom response behaviors were poor in patients (49.1±19.6) and caregivers (54.7±18.3). Patient gender (male β=-4.60±1.92, p Conclusions: Combinations of individual and relationship factors were significant determinants of patient and caregiver responses to HF symptoms. Assessment of patient and caregiver as a dyad may be useful in evaluating risk for poor management of HF symptoms.