Age and gender differences in heart failure symptom cluster profiles Kristen A. Sethares, PhD, RN, CNE College of Nursing University of Massachusetts

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1 Age and gender differences in heart failure symptom cluster profiles Kristen A. Sethares, PhD, RN, CNE College of Nursing University of Massachusetts Dartmouth, No. Dartmouth, Ma.

2 Heart Failure Affects close to 6 million people in the United States today (Mozaffarian et al., 2016). Responsible for more than 1 million hospital admissions and 15 million physician visits a year (Mozafarrian et al., 2016). The leading cause of hospitalization ti in those over the age of 65, costing Medicare $17 billion per year (CMMS, 2016). Close to 30% of persons discharged from the hospital will be readmitted within 30 days (CMMS, 2016). Major symptoms of the condition include shortness of breath, fluid retention, ti and tiredness (HFSA, 2016). These symptoms affect the person s quality of life, ability to perform daily activities and mood (Carlson & Riegel, 2001).

3 Background HF symptoms are important early indicators of impending decompensation. Most HF hospitalizations are for management of distressing symptoms, especially dyspnea yp and fatigue, with to close to 80% of patients reporting anywhere from 3-7 symptoms at the time of admission (Gallagher et al., 2012). The presence of a number of symptoms can contribute to difficulty with symptom interpretation especially in older adults (Jurgens, 2006). HF self-care management is one of the least frequently performed self-care behaviors due to failure to recognize symptoms and lack of knowledge about what to do when symptoms occur. Those who perform adequate ate self-care management have improved outcomes including survival (Lee et al., 2010). Previous HF symptom cluster research has described 2 to 3 clusters (Hertzog et al., 2010; Jurgens et al., 2009; Song et al., 2010; Lee et al., 2010). However, comparisons of age, length of time with HF and gender differences between cluster groups have not been previously described. Before educational interventions designed to promote self-care management can be implemented, it is important to understand differences in symptom clusters.

4 Riegel & Dickson, 2008 Self Care of Heart Failure Model

5 Purpose The purpose of this study was: 1. To describe HF symptom clusters. 2. To determine if there were differences in symptom clusters by age, gender and length of time with HF.

6 Methods This exploratory, cross sectional study recruited adults recently hospitalized with an acute exacerbation of HF at a local hospital. IRB approval was received at the university of the investigator and the hospital where subjects were enrolled. Informed consent and HIPPA forms were completed during enrollment. Surveys were completed by interview and sociodemographic characteristics were verified by medical record review.

7 Instruments Heart Failure Somatic Awareness Scale 18 item scale that measures awareness of and distress with 18 common heart failure symptoms on a 0-5 scale. Higher scores on an item indicate greater distress. A score of 0 means the person did not have the symptom. Cronbach s alpha in this study 0.83 (Jurgens, 2006) Demographics Age, gender, length of time with HF, educational level, marital status, income, NYHA class, living situation

8 Data analysis Data were entered into SPSS 23 and assumptions were checked. Descriptive statistics were computed on all variables. Hierarchical agglomerative clustering was used to determine symptom clusters. Chi square was done to determine differences in symptom clusters by gender. ANOVA was used to determine differences in symptom clusters by age and length of time with HF. Post hoc analysis was computed with LSD. Reliability analysis was computed on the study instrument.

9 Sample Variable Total sample (N =133) Age (years) 77.1 (11.3) Length of time with HF (years) 3.2 (3.8) Number of HF symptoms 12.2 (3.2) Educational level l (years) 10.7 (3.2) Proportion of total sample Male gender 54.2 % Portuguese immigrants 34.4% Married 45% Live alone 39.2% NYHA class 3 90% Income < $20,000 year 68%

10 Results 1 3 2

11 Results Variable Cluster 1 (N = 44) Cluster 2 (N = 49) Cluster 3 (N = 40) cardiac respiratory edema M (SD) M (SD) M (SD) Age 79.1 (9.7) 79 (9.8) 71.8 (13.5) p.003 Length of 4.3 (4.2) 2.3 (4.9) 3.3 (4.0).038 time with HF N (%) N (%) N (%) Female 25 (41) 23 (38.3) 12 (20) Male 19(26) 26 (35.6) 28 (38.4).045

12 Discussion Three unique physical symptom clusters were identified similar to previous research. Cardiac Symptom Survey and Minnesota Living i with HF Survey used previously. 2-3 symptom clusters identified in previous studies of HF patients. This is the first study that reports differences in symptom clusters by age, gender and length of time with HF. Significant age and gender differences exist in the symptom experience of older adults with HF. Women in this study tended to be older than male participants. Older adults were more likely to report cardiac and respiratory symptoms than edema. Men more often reported edema symptoms than women. Those who had HF the longest more often reported cardiac symptoms.

13 Implications for practice Clinicians need to assess unique symptom profiles when performing assessments and patient education related to timely treatment for HF exacerbation. Consider age and gender in assessment and treatment of symptoms. Consider using valid and reliable e symptom assessment tools in the clinical setting to assess unique symptom patterns.

14 References Carlson B, Riegel B, Moser DK. Self-care abilities of patients with heart failure. Heart and Lung. 2001;30(5): Centers for Medicaid and Medicare Services. Retrieved from: for reduction program.html on 2/11/16. Gallagher R, Sullivan A, Hales S, Gillies G, Burke R, Tofler G. Symptom patterns, duration and responses in newly diagnosed patients with heart failure. International journal of nursing practice. Apr 2012;18(2): Hertzog, M. A., Pozehl, B., & Duncan, K. (2010). Cluster analysis of symptom occurrence to identify subgroups of heart failure patients: a pilot study. J Cardiovasc Nurs, 25(4), doi: /JCN.0b013e3181cfbb6c Jurgens C.,Fain, J., & Riegel, B. (2006). Psychometric Testing of the HF Somatic Awareness Scale, Journal of Cardiovascular Nursing, 21, Jurgens, C. Y., Moser, D. K., Armola, R., Carlson, B., Sethares, K., Riegel, B., & Heart Failure Quality of Life Trialist, C. (2009). Symptom clusters of heart failure. Res Nurs Health, 32(5), doi: /nur Lee, C. S., Moser, D. K., Lennie, T. A., & Riegel, B. (2011). Event-free survival in adults with heart failure who engage in self-care management. Heart Lung, 40(1), doi: /j.hrtlng /j Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman, M.,... Stroke Statistics, S. (2016). Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation, 133(4), e38-e360. doi: /CIR Song M, Ratcliffe SJ, Tkacs NC, Riegel B. Self-care and health outcomes of diabetes mellitus. Clinical Nursing Research. Aug 2012;21(3):