Heart to Heart: Occupational Therapy for Individuals Living With Heart ...

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CONTINUING EDUCATION ARTICLE

Heart to Heart: Occupational Therapy for Individuals Living With Heart Failure

Samantha M. Barefoot, OTD, MOT, OTR/L, BCPR Assistant Professor, University of Findlay Findlay, Ohio

Cynthia L. Hayden, DHEd, OTR/L, CHT Associate Professor, Eastern Kentucky University Richmond, Kentucky

ABSTRACT Individuals with heart failure (HF) need guidance from their health care team to ensure the promotion of independence in meaningful occupations. In the United States, the most common diagnosis-related group for hospital admissions is HF (Aguanno & Samson, 2018). Specifically, Shah and colleagues (2018) found that 18% of all HF hospitalizations are readmissions. This is significant as health care systems are advocating for effective disease management with reduction of insurance coverage for readmissions occurring within the first 30 days of discharge (Aguanno & Samson, 2018). A primary goal of HF care is to evaluate the influence the disease may have on patients' lives and their ability to cope with and manage the disease (Norberg et al., 2017). This article explores how occupational therapy (OT) practitioners can demonstrate best practice while considering promotion of health and wellness for individuals living with HF.

LEARNING OBJECTIVES After reading this article, you should be able to: 1. Define and describe the most common types of heart failure (HF) 2. elect appropriate management strategies for individuals with

HF 3. dentify the influence client factors have on the disease process,

including cardiovascular system functions, structures of the cardiovascular system, and psychosocial functions 4. Describe the role of occupational therapy in providing education to individuals with HF to promote health and wellness and disease management

5. dentify strategies for enhancing interprofessional and multidisciplinary education and care, including client and caregivers, when working with the HF population

6. Recognize appropriateness of intervention for non-medical needs of those with HF, including contextual issues, social participation, and community mobility.

INTRODUCTION

The purpose of this article is to provide education and strategies regarding best practice when providing occupational therapy services to individuals with heart failure (HF). In recent years, the diagnosis of HF has increased in prevalence in the United States to approximately 6.2 million adults (Centers for Disease Control and Prevention [CDC], 2020; Zamanzadeh et al., 2013). HF is one of the largest health and social problems affecting individuals and should be managed effectively (Aguanno & Samson, 2018). It is important to understand that management of this disease is complex and multifaceted.

Occupational therapy is well suited to provide interventions related to education strategies regarding occupation, health, and well-being. Occupational therapy (OT) practitioners can enable individuals with HF and their caregivers to acquire habits and behaviors to promote positive disease management (American Occupational Therapy Association [AOTA], 2020; Toole et al., 2013). Consequently, increased disease management can decrease health care costs and indirectly improve quality of life through increased participation in meaningful occupations to those individuals living with HF (Norberg et al., 2014; Toole et al., 2013).

As previously noted, as many as 6.2 million adults are living with HF (CDC, 2020). Additionally, in 2018, 13.4% of death certificates in the United States were attributed to HF (CDC, 2020). Moreover, in the United States, the most common diagnosis-related group for hospital admissions is HF (Aguanno & Samson, 2018). More specifically, 18% of all HF hospitalizations are re-admissions within the first 30 days of discharge (Shah et al., 2018). This is likely attributable to the mismanagement of their disease

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process and poor prognosis, leading to a mortality rate of 50% over 3 years (Aguanno & Samson, 2018).

The main goal of HF care is to evaluate the influence this disease has on patients' lives and their ability to cope with and manage the disease (Gustavsson & Branholm, 2003). Within this population, it is occupational therapy's role to educate the patient, provider, and caregiver, to promote physical function, promote ADL and IADL participation, encourage positive disease management, and assist in reducing unnecessary health care costs (Moyers & Metzler, 2014).

Definition of Heart Failure Bozkurt and colleagues (2021) defined HF as a clinical syndrome with current or prior symptoms caused by structural and/ or functional cardiac abnormalities substantiated by elevated peptide levels and/or cardiogenic or systemic congestion. Additionally, HF is diagnosed through ejection fraction, symptoms, and imaging (American Heart Association [AHA], 2017). Differentiation of the various HFs is depicted in Figure 1.

Classifications of HF Table 1. Classifications and Symptoms of Heart Failure

At Risk for HF Individuals who are at risk for HF but without current or

prior symptoms/signs of HF and without structual or biomarkers that are indicative of heart disease.

Pre-HF Individuals without current or prior symptoms/signs of HF,

but who have evidence of structural heart disease or abnormal cardiac function, or elevated peptide levels.

HF Individuals with current or prior symptoms and/or signs

of HF caused by structural and/or functional cardiac abnormality.

Figure 1. Defining Heart Failure

C

A

B

Note: A: Right-sided HF; B: Left-sided HF; C: Congestive HF As noted in Figure 1B, left-sided HF can be either systolic HF or diastolic HF:

? Systolic HF: The left ventricle loses its ability to effectively contract and cannot push the blood with enough force out to the remainder of the body (AHA, 2017).

? Diastolic HF: The left ventricle loses its ability to relax normally and it cannot fill with adequate blood supply during rest period (AHA, 2017).

Right-sided HF is typically a result of left-sided HF. This is most commonly seen as increased fluid pressure and the retrograde flow of blood back into the lungs, damaging the right side of the heart (see Figure 1A).

Congestive heart failure (CHF) commonly presents when there is dysfunction collectively with both sides of the heart. It is associated with an overall decrease in the heart's ability to effectively provide profusion to both sides and therefore causes congestion in the body's tissues. This type of HF is the most common and is associated with clinical signs of edema in the extremities due to increased fluid pressure (AHA, 2017) as seen in Figure 1C.

Advanced HF Individuals with severe symptoms and/or signs of HF at rest, recurrent hospitalizations despite guideline-directed management and therapy, and requiring advanced therapies such as transplant, mechanical circulatory support, or palliative care.

Note: Adapted from the New York Heart Association, 2018; Bozhurt et al., 2021

MANAGING HEART FAILURE

To understand proper management of HF, classifications of HF and the complexity of the cardiac system must be taken into consideration. Moreover, one must recognize that HF cannot be treated with pharmaceuticals alone and requires a comprehensive treatment regimen. The management of HF is complex and involves several steps. Outpatient treatment for HF can include, but is not limited to, the following factors: initial laboratory evaluations, documented measurement of the left ventricle function, body weight, blood pressure, clinical symptoms of volume overload, evaluation of activity level, educating patients on disease management and health-related changes, and ensuring that patients are treated with evidence-based therapy (Mosalpuria et al., 2014).

The aforementioned clinical steps allow for better disease management and prolonged quality of life for individuals diagnosed and living with HF. There is a need to address poor coordination of services, medical nonadherence, and adequate access to services for those with HF (Shah et al., 2018). Consequently about $17 billion of health care costs may be preventable for this population if the needs are properly addressed (Shah et al., 2018).

To assist with off-setting health care costs, HF can be managed from a primary and/or tertiary care model. Primary care is the basic, first level of contact between individuals and their families with the health system. Tertiary care is defined as a

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specialized consultative health care for inpatients. The patients are admitted into these centers on a referral from primary or secondary health professionals. Tertiary care is provided in a facility that has personnel and facilities for advanced medical investigation and treatment (Torrey, 2018). It should be noted, OT practitioners may provide services at both levels of care based on the educational focus of their intervention. It should be noted, OT practitioners may provide services at both levels of care based on the educational focus of their intervention.

Occupational Therapy's Educational Focus When Providing HF Care As Norberg and colleagues (2008) noted, individuals with HF are more dependent with ADLs and IADLs, based on their ability for self-management of their disease process. Likewise, the authors noted that occupational therapy is well suited to provide education on the importance of ADL/IADL participation and incorporation of energy-conservation techniques. Furthermore, occupational therapy can provide appropriate adaptation of tasks, use of assistive technology, and occupational modifications, for success in clients' ability to manage their disease effectively (Norberg et al., 2008). Norberg and colleagues (2014) further delineated in later research occupational therapy's distinct understanding that individuals with HF have psychological and other influences that contribute to their decreased occupational performance. These include but are not limited to a need to redefine an active life, awareness of one's impaired body, realizing one's limited activity ability, striving to preserve an active life, focusing on meaningful activities, and changing versus not changing habits and roles. More specifically, the ability of individuals with HF to plan activities and balance the degree of effort; limiting, organizing, and rationalizing activities; adjusting activities to the particular day's abilities, and using technology and adapting the environment can improve occupational performance (Norberg et al., 2014). Finally, Norberg and colleagues (2014) concluded that occupational therapy can provide education on adaptations and compensatory strategies for continued independence to facilitate the individual's ability to adapt to the disease as it progresses.

Self-management is one instrument to promote health in the context of chronic disease. Self-management extends from individuals' engagement in medical behaviors to coping with participation restrictions, and the emotional aspects of living with disease (Stern, 2018). Despite the emphasis on the importance of disease management, clinical outcomes remain poor for individuals with chronic conditions, such as HF, due to the lack of communication between health care providers. Health care systems are not well structured to provide disease management education effectively (Leland et al., 2017). OT practitioners can act as facilitators of the care team in the disease management process. This would enhance outcomes from an occupational performance perspective as compared to the typical medical approach (Leland et al, 2017).

Furthermore, early identification and occupational engagement for individuals with chronic conditions can have a positive

effect on the health care system (Roberts & Robinson, 2014). Individuals with conditions that place them at high risk for readmissions are in need of education on early identification of symptoms, along with disease management and risk-reduction (Roberts & Robinson, 2014).

Stress Management and Coping Strategies Stress management is known as the physical and emotional activities that individuals perform to protect the body from known stressors. A stressor is any factor that disturbs homeostasis and then produces stress (Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, 2003). The three most effective techniques to manage stress are positive self-talk, emergency stress-stoppers, and stress busting activities (AHA, 2017).

Positive Self-Talk This stress management technique focuses on changing negative thoughts to those that are positive. Negative self-talk may lead to increased stress and anxiety, whereas positive self-talk is shown to be effective in decreasing stress and the overall management of anxiety (AHA, 2017). If positive self-talk is consistently practiced every day, there is an overall positive effect on an individual's ability to appropriately manage the stressors they experience in their life (AHA, 2017).

Emergency Stress-Stoppers This stress management technique is performed to reduce stress in the moment the stressor is exhibited. These actions are typically situation-based and may differ based on the severity of the stressors. Additionally, this technique may be combined to include more than one action in circumstances that are deemed to have multiples stressors present (AHA, 2017).

Stress-Busting Activities Stress busting activities allow individuals to naturally relieve stress in a healthy way. Many individuals with HF do not have healthy outlets for stress relief. Therefore it is imperative that these individuals be educated on activities to reduce and/or eliminate stressors. It is important to encourage an individual with HF to participate in a meaningful hobby, or in a meaningful occupation that promotes health, when utilizing this stress management technique.

Energy Conservation and Work Simplification (ECWS) Energy conservation is referred to as activities to be completed in a way that decreases muscle fatigue, joint stress, and pain (Duke University, n.d.). It is important that OT practitioners serving this population emphasize ECWS techniques, so as to allow for prolonged independence with participation in meaningful occupations on a daily basis and with disease progression. Incorporating ECWS into daily routines, while performing ADLs and/or IADLs, is something that occupational therapists can successfully accomplish when providing care to individuals with HF. When considering ECWS techniques, it is crucial to understand the basic tenets:

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limit the amount of work it takes to complete the task, plan ahead, organize, use appropriate equipment, use effective biomechanical methods, and rest as needed (Duke University, n.d.).

Within the umbrella of ECWS, it is also important to understand the concept of Metabolic Equivalent (MET) Levels. MET levels are based on the intensity of work and the energy expended to complete that work (Jette et al., 1990; Hobb, 2021). They can be referred to as a rate that equals 3.5ml of oxygen per kilogram of body weight per minute. Moreover, METs are described as the functional capacity or exercise tolerance of an individual's (Hobb, 2021; Jette et al., 1990). Having an understanding of MET levels will allow occupational therapists to successfully educate individuals with HF on how to appropriately incorporate ECWS techniques so as to promote independence in planning their daily routine based on the amount of energy a task takes. Tables 2, 3, and 4 are examples of common occupations, the average MET level associated with that occupation, and the recommended maximum amount of METs according to the stage of HF.

Table 2. Common Occupations and MET Levels

ADLs/IADLs

MET Level

Grooming/Bathing--Seated

1.0?2.5

Bathing--standing

2.0?4.0

Dressing

1.0?4.0

Table 4. Stage of HF and Recommended Maximum MET Level

Class/Stage of HF

Recommended Max MET Level

I II III IV Note: Adapted from AHA, 2017

Max MET 6.5 Max MET 4.5 Max MET 3.0 Max MET 1.5

Lifestyle Modifications As noted in Figure 2, the United States (U.S.) Department of Health and Human Services (2013) recommends individuals with HF mind their "ABCs". This is inclusive of ensuring the lifestyle changes of avoiding tobacco, being more active, and choosing good nutrition to allow for prolonged quality of life when living with a progressive disease. Other positive correlations with incorporating these lifestyle modifications include decreasing the negative repercussions of stress, improving blood pressure, decreasing cholesterol, and decreasing the risk of developing obesity or other comorbidities associated with HF -U.S. Department of Health and Human Services, 2013).

Figure 2. Heart Failure "ABCs"

Cooking

1.0?2.5

House Cleaning Gardening

Making a Bed

2.6?4.0 2.6?4.0 1.0?2.5

Avoid Tobacco

Grocery Shopping

2.0?7.0

Note: Adapted from Hobb, 2021; Jette et al., 1990

Table 3. Sample Physical Activities and MET Levels

Be More Active

Choose Good

Nutrition

Physical Activity

MET Level

Walking (leisurely)

Stationary cycle (moderate effort)

1.0?2.5 6.0?10.0

Walking (moderate effort)

2.6?4.0

Climbing stairs

6.0?10.0 (carrying groceries)

Running (moderate effort)

8.8

Various sports (basketball, baseball, wrestling, swim-

ming, etc.)

8.0?12.0 (Dependent on task analysis and performance of

task)

Note: Adapted from Hobb, 2021; Jette et al., 1990

Medication Regimen When educating individuals with HF, it is important to emphasize the importance of adhering to a medication regimen. Tips that will assist with the success of this adherence include but are not limited to: 1. assessing the individual's ability to use a pill organizer marked

with each day/time to take medications 2. ensuring the individual takes the medication at the same time

every day, for more effective disease management 3. educating the individual to not double the dosage to make up

for missed doses; evaluate whether their ability to self-advocate is intact if they will need to discuss possible side effects of their medication with the physician, to ensure they don't discontinue a medication without physician approval

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4. providing resources and ensuring they discuss financial burden, as applicable, with their physician or pharmacist prior to discontinuing a medication

5. instructing on the importance of medication adherence for improved survival and decreased symptoms of HF.

Caregiver Education It is occupational therapy's role to educate family, friends, and/ or caregivers of individuals with HF about the importance of caregiver burden and the effects of burnout (Zamanzadeh et al., 2013). Training caregivers to recognize signs and symptoms of burnout is a crucial part of occupational therapy intervention. These signs and symptoms include but are not limited to withdrawal from family and friends; frequently acquiring illness; loss of interest in activities they previously enjoyed; feelings of self-harm; feeling irritable, hopeless, and/or helpless; emotional and/or physical exhaustion; changes in appetite, weight, or both; substance use, and changes in sleep patterns. Without a caregiver being able to recognize and address burnout, their ability to provide care will be negatively impacted or even unsustainable. In addition, their own health and well-being will be impacted (Zamanzadeh et al., 2013).

Participation in ADLs/IADLs It is important to maintain independence with ADLs and IADLs to improve quality of life and disease management (Lyon, 2018). Self-care management is an important aspect of HF treatment. Health professionals should encourage and promote nonpharmacological management to all patients with HF (Lainscak et al., 2011). Additionally, improved physical activity among CHF patients through independence with self-care routines can limit signs and symptoms of the disease. Therefore, it is important to encourage clients to independently perform ADLs and IADLs (Smeulders et al., 2009). Moreover, "CHF patients face severe symptoms such as fatigue, shortness of breath, and exercise intolerance due to cardiac dysfunction which affects their quality of life" (Smeulders et al., 2009, p. 609). These studies provide evidence and validation of the importance of maintaining independence with ADLs and IADLs through energy conservation and work simplification techniques to enhance quality of life that is affected with CHF.

Other Areas of Educational Focus When Providing Care to Individuals With HF

Physical Activity/Exercise Developing a daily physical activity routine, through participation in occupations, is important for overall health, wellness, and management of disease processes for individuals with HF (Cleveland Clinic, 2016; AOTA, 2020). Prior to starting a new regimen, the client and OT practitioners should consult with the client's physician or nurse to ensure that the type and level of exercise is appropriate for the client's heart condition. It is also important for an OT practitioner, who may oversee the physical activity routine, to ensure that their knowledge of exercise , as

well as precautions and contraindications is strong as related to the occupational engagement the client is participating in. If the daily exercise routine is outside of the context as incorporated through occupational engagement, a practitioner should seek a referral to a physical therapist or exercise physiologist for the client.

Additionally, providing education on how to effectively incorporate a safe exercise regimen is beneficial for these individuals. Recommended physical activity for individuals with HF should be approximately 40 minutes to include the phases of a warm-up, conditioning, and cool-down (Cleveland Clinic, 2016). According to the Cleveland Clinic (2016) types of exercises appropriate for individuals with HF can fall into the categories of flexibility, cardiovascular/aerobic, and strength training for effective disease management. Flexibility involves slow movements to lengthen muscles to promote balance and joint range of motion such as yoga and tai chi. Cardiovascular aerobic exercise recruits large muscle groups and thus improves the way the body uses oxygen with benefits of lowering blood pressing, heart rate, and improved pulmonary status by reducing work on the heart. Examples of this include jogging, riding a bike, jumping rope, and swimming. Finally, strength training involves and calls for repetitive muscle movements until the muscle grows tired with benefits of weight management, stronger bones, stronger musculature, improved balance and better posture that can be established through weight lifting while engaging in meaningful occupations. Moreover, OT practitioners also analyze ADL and IADL activities to see how these can be used as part of an overall strengthening or flexibility program. For example, putting dishes in cabinets after washing can address movement of shoulders with the resistance of the weight of the dish and the repetitive nature of the task.

Patient Monitoring Incorporating patient monitoring allows for best practice when providing care to individuals with HF. Patient monitoring promotes advocacy in the disease management process, which increases quality of life for promoting engagement in occupation. Appropriate guidance for providing education for promoting patient monitoring includes reviewing educational topics throughout support groups and education on patient monitoring as facilitated by the physician, ensuring performance of occupations and tasks independently and encouraging independence throughout HF exacerbations, continuing a regular exercise regimen, following appropriate diet recommendations throughout life, making appropriate lifestyle changes to reduce exacerbations and slow the disease process, demonstrating adherence to the medication regimen, and monitoring signs and symptoms of depression and notifying one's health care professional as appropriate (AHA, 2017).

Diet Adherence Adhering to dietary recommendations when living with a chronic disease, such as HF, can improve symptoms management and prolong disease progression (AHA, 2017). Dietary

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