By Kate Jacobson | January 11, 2021
Those who suffer cardiac and pulmonary events and chronic diseases often are saddled with more than just the physical repercussions of their illness. They’re also battling declines in cognitive functions—and that can have a major impact on program adherence.
Diann Gaalema, PhD, associate professor at the University of Vermont, said those working in the cardiac and pulmonary rehabilitation space need to start thinking about how the cognitive functions of patients may be stunting their progress. And, more importantly, what they can do as staff to break down cognitive barriers that make people less adherent.
“Managing a chronic disease is a very cognitively challenging thing,” she said. “And we see that cognitive challenges are predicting non-adherence to disease management. But we also know that if we can get people into rehab and support these patients, we can help them overcome the deficits.”
Cognition is a very broad term that encompasses how people think and acquire knowledge about things. All of us are able to develop information about ourselves and the world around us by using our senses and experiences. For some, though, top-down cognitive processes and memory are impacted by chronic illnesses.
Gaalema said in her research, patients with chronic pulmonary and cardiovascular diseases, such as COPD and coronary artery disease, are more likely to suffer cognitive impairment as a result of their illness. If that isn’t difficult enough, after being diagnosed with these types of disease, many patients are asked to change fundamental habits in their life: what they eat, how they exercise, quitting smoking and taking medication.
“These new behaviors may be incongruent with what they’ve been doing for the last 60 years,” she said. “You have decades of experience behaving in one way, and you’re being told you need to change everything you’ve been doing. That is going to be incredibly cognitively challenging.”
When patients are struggling with these issues, their adherence to the overall program struggles as well. In a study she conducted, Gaalema found that those who scored lower on cognitive flexibility tests—which measure one’s ability to change what they’re doing in response to new information—had a 45% program completion rate. Compare that to the 65% completion rate for those who scored higher.
Those who had higher rates of impulsivity—or those who place a higher emphasis on what’s happening now vs. what could happen in the future—also had lower adherence rates. Only about a third of those patients completed the program, compared to two thirds completion rate of those with less impulsivity.
“There are high rates of these impairments in this population, and they’re predicting how patients interact with care,” she said. “These are important things we need to keep an eye out for.”
Gaalema said CR and PR professionals need to understand that all patients are at risk for suffering cognitive impairment. And because they might not be presenting as “severe” symptoms, like those associated with dementia, they should be taken very seriously. Even a slight impairment of someone’s cognitive ability might make it hard for them to remember to go to appointments or take their medications correctly, which overtime can affect the impact of rehabilitation.
So what can those in the field do to combat these cognitive impairments? Gaalema said it’s important to start at the beginning. Ask your patients questions about how they’re feeling mentally, perform simple cognition tests that measure executive function and cognitive flexibility. Examine how patients are dealing with objective and subjective tasks: Are they struggling with simple memory issues? How quickly can they shift their thinking? What’s their ability to manage and maintain goals?
From there, you can help craft a care plan that takes into consideration where they struggle—and create systems to reward patients when they succeed. Clinics themselves can also take down barriers of care. Simple things like automatic appointment reminders, auto-enrollment and scheduling visits that conjunct with other appointments can make the task of rehabilitation less cognitively taxing.
“It can make a difference for someone,” she said. “It may not be obvious why a patient is struggling to get into rehab, so anything we can do to make sure they’re not having trouble is something that contributes to adherence.”
And as a patient is going through the program, it’s important to continue having conversations about cognition. Understanding the support a patient needs and helping them overcome those challenges can help their overall cognitive functions overtime—and get them to adhere to their CR/PR journey.
“Programs should be aware that patients are facing these challenges,” Gaalema said. “If we can get those patients engaged and keep them in care, we can make a difference for them cognitively.”
This presentation originally appeared as part of the AACVPR 35th Annual Meeting.