Cognitive Function in Cardiac Patients: Exploring the Occupational Therapy Role in Lifestyle Medicine

Abstract

Patients with cardiac dysfunction are at increased risk of mild cognitive impairment, which can affect their ability to successfully engage in daily activities important for home and community safety and in maintaining health and well-being. This risk increases in accordance with the number of cardiac conditions and cardiovascular risk factors or comorbidities. Occupational therapy has a role in chronic disease management in assessing and improving functional abilities affected by physical, emotional, and cognitive domains. With a holistic and client-centered approach, occupational therapy can complement lifestyle medicine principles through promotion and enablement of engagement in purposeful activity and self-management practices. It is suggested that the clinical management of patients with cardiac dysfunction expands beyond the traditional physical aspects of care to encompass cognitive considerations and incorporate occupational therapy in practice.

‘Hypoxic brain injury to the frontal and temporal lobes subsequent to cardiac arrest can result in global cognitive impairment, triggering memory deficits. . . .’

According to the World Health Organization (WHO), cardiovascular disease (CVD) is the leading cause of death globally, with 7.4 million deaths annually caused by heart disease.¹ Worldwide, CVD accounts for approximately 30% of deaths from chronic illnesses and for 10% of disability and burden of disease.^1,2

There are known correlations between cardiac dysfunction and the incidence of cognitive impairment, with some studies estimating its presence in more than 17% of cardiac patients, potentially increasing to around 75% of patients with heart failure.^3,4 Although the range of cognitive deficit varies, impairment is often classified as mild among cardiac patient groups, meaning that there is a cognitive deterioration greater than expected for the person’s age and education level, which may affect their ability to engage in more complex activities and behaviours.^4,5

While the ability to independently complete basic activities of daily living remains intact, the capacity to engage in more complex activities requiring a higher level of cognitive function may be compromised, resulting in increased difficulty completing instrumental activities of daily living (IADL), completing work activities, and engaging in self-management behaviours.^4,6,7 IADLs are more cognitively demanding task behaviors that are required for independent living and include activities such as shopping, meal preparation, driving, and managing finances.⁷ Self-management covers the daily requirements to be undertaken by the individual in order to maintain their health and well-being, which in the context of chronic disease includes activities such as medication adherence and lifestyle modifications.^8-10 Both appropriate self-management and active engagement in IADLs are required for functional independence, home safety, and health maintenance.

Cardiac-Related Cognitive Impairment

Cardiac-related cognitive impairment can be a consequence of cerebral hypoxia and ischemic brain injury attributable to the presence of microembolisms, cerebral hypoperfusion, and impaired cerebral vessel function.^2,10-13 These are related to cardiac dysfunctions, including arrhythmias, blockages from atherosclerosis, and poor cardiac output.^11-14 Table 1 provides an overview of the patterns of impairment reported across a variety of cardiac diagnoses and comorbidities.

Table 1.

Patterns of Cognitive Domain Deficit by Cardiac Diagnosis or Comorbidity as Noted in the Published Literature.

Diagnosis	Cognitive Domain
	Attention	Memory	Executive Function	Psychomotor	Visuospatial	Language	Global
Heart failure2,3,11-14	×	×	×	×		×	×
Coronary artery disease14,18,20		×	×	×	×		×
Arrhythmia and/or ICD17		×	×	×			×
Coronary artery bypass graft14,20			×	×
Atrial fibrillation14,25		×	×				×
Anxiety27	×	×	×
Diabetes33-35	×		×	×
Hypertension35	×	×	×
Obesity35,39			×				×

Abbreviations: ICD, implantable cardioverter-defibrillator.

Systematic reviews of observational studies note a relationship between lower cardiac output and reduced cognitive function.^13,15 Poor symptom awareness, difficulty with information retention, and limited understanding of the relevance of clinical information can be indicators of cognitive impairment, which may predict delays in seeking appropriate care or assistance.^9,15 There are estimations that approximately 50% of readmissions for heart failure are related to a lack of knowledge of or adherence to medical recommendations, with the presence of cognitive dysfunction also being correlated with an increased risk of mortality.^9,15,16

Cognitive compromise can occur with life-threatening arrhythmias, with indications that patients requiring device implantation are vulnerable to irreversible cognitive decline.¹⁷ Some estimates indicate that 75% of patients experience mild to severe short-term impairment post–cardiac arrest, with roughly 33% of these expected to sustain impairment at 6 months.¹⁷ The likelihood of persistent cognitive dysfunction is thought to be related to the duration of arrhythmia-related hypoxia.¹⁷ Hypoxic brain injury to the frontal and temporal lobes subsequent to cardiac arrest can result in global cognitive impairment, triggering memory deficits, impaired information processing, poor insight, lack of initiation, and cognitive inflexibility.

Observational studies suggest that coronary artery disease (CAD) affects global cognition and executive functions consequent to subclinical cerebrovascular disease.^14,18 Patients may, therefore, undergo coronary artery bypass graft (CABG) surgery with preexisting cognitive decline.^19,20 This deterioration may persist postsurgery, with indications that up to 65% of CABG patients experience postoperative cognitive decline.¹⁹ Some of this is attributable to elevated stress levels associated with surgery and the effects of anaesthesia.¹⁹ However, although many of these patients demonstrate improved cognitive function above their presurgical baseline, cognitive function often remains below the population norms in this patient group.^19,20 There is also evidence that the presence of CAD-related presurgical cognitive decline is indicative of both functional deterioration post-CABG and increased incidence of postoperative delirium.^21-24

Cognitive decline is also reported in patients with atrial fibrillation.¹⁴ The promotion of blood clots results in patients demonstrating poorer performance with memory and executive functions, particularly in relation to cognitive flexibility.^14,25

Comorbidities and Cognition

It is recognized that numerous cardiac comorbidities and risk factors, such as obesity, diabetes, smoking, and mood disorders, independently contribute to cognitive impairment. It is recognized that 90% of adult Australians have at least 1 risk factor for heart disease, with 25% having 3 or more risk factors.²⁶

Mood disorders are known to be associated with poorer cognitive performance, particularly with attention, memory, and executive functions.^9,27,28 The prevalence of depression is high among patients with heart disease, particularly among those with heart failure.^28,29 Anxiety disorders are also common, reported to be present in around 80% of patients who have experienced an acute cardiac event and persisting in approximately 25% of these longer term.³⁰ Patients suffering from anxiety or emotional distress following cardiac events have been found to have increased difficulty adhering to lifestyle modification behaviors and be less likely to attend or complete cardiac rehabilitation programs.^30,31 The presence of mood disorders degrades processing efficiency and working memory, contributing to functional difficulties, slower rates of return to work, and poorer quality of life.^27,30

Diabetes, hypertension and smoking are also noted to be predictive of lower cognitive performance.³² Diabetes is understood to negatively affect the domains of attention, working memory, and executive functions and increase the risk of dementia as a result of metabolic abnormalities.^33-35 Deficits with memory, attention, and executive functions are also described in patients with hypertension, with higher blood pressure noted to be associated with a steeper decline.³⁵ Smoking increases the incidence of cerebral atrophy and hypoperfusion, which is associated with reduced psychomotor speed and cognitive flexibility and an increased risk of dementia, particularly when combined with other cardiovascular risk factors.^32,35

Once considered to be problematic in more affluent countries, obesity is now a global issue, doubling worldwide since 1980.³⁶ In 2015, the WHO reported that globally, more than 1.9 billion adults are overweight, with 600 million of these being obese, as measured by a body mass index (BMI) ≥30 kg/m².³⁶ Between 33% and 66% of adults from modern western countries are classified as overweight or obese, with obesity a known risk factor for CVD and increased mortality and morbidity.^37,38 A review by Smith et al³⁹ in 2011 recognized that increased adiposity is associated with decreased global cognitive function, particularly executive functions. It is also noted that executive dysfunction is a risk factor for an increase in BMI, suggesting a bidirectional relationship.³⁹

Cognition, Function, and Health Literacy

Cognitive performance is related to functional abilities and the capacity to successfully participate in self-management behaviors. The presence of cardiac-related cognitive impairments, complicated by the presence of risk factors and comorbidities, increases the risk of poor adherence with self-management requirements, difficulty with implementing behavior change, and decreased ability to engage in functional activities important to independent living.⁴ This places these patients at risk of poorer health outcomes, increased hospitalization, and greater burden of disease.¹⁶

Throughout the literature, the cognitive domains noted to be most frequently compromised across cardiac patient groups are memory and executive functions. Executive functions are higher-order abilities associated with the frontal lobe of the brain, including speed of processing, working memory, abstract reasoning, and planning.^2,3,7,40,41 They are involved in the regulation, assimilation, and coordination of other cognitive processes, and are linked to both functional performance and the ability to successfully engage in self-management behaviors.^{3,6,7,9,40,41}

Executive dysfunction can be considered to be an occupational performance issue where impairment results in a breakdown of performing the required complex behavioral procedures involved in task execution, with a subsequent decline in functional trajectory.^6,42 Manifestations of these impairments may be observed when patients need to adapt activities to compensate for physical limitations. In clinical practice, this could be seen in post-CABG patients, who need to learn and apply relevant activity limitations as part of their recovery process such as restrictions to upper-limb weight bearing to avoid postoperative sternal separation. Their ability to develop new ideas or problem solve a situation may be affected, resulting in difficulty with the practical application of such precautions, potentially leading to poor adherence and deconditioning, with an inability to fully participate in their rehabilitation.

There is evidence for both memory and executive function correlates to IADLs, with those experiencing multidomain cognitive impairment experiencing greater functional restriction.^43-46 The presence of mild cognitive impairment (MCI) can be associated with increased difficulty with daily functioning and loss of independence.^43-45 Elderly patients with cardiac-associated cognitive impairment are reported to have a high incidence of functional decline, with the probability of needing help in the home doubling with the presence of each additional CVD or related risk factor.⁴ Alosco et al⁴⁷ indicate that the combination of executive dysfunction with impaired attention and psychomotor speed is related to poorer driving performance. MCI has also been shown to be of influence in engagement with outpatient heart failure and cardiac rehabilitation programs.^3,48

As an integral component of chronic disease care, self-management is the ability of the individual to take ownership of their health and invest in their well-being through daily lifestyle choices.⁴⁹ It entails appropriate engagement and participation in medical and lifestyle recommendations while processing and adapting to the associated changes in life roles.⁴⁹ Adhering to recommended treatments is complex and requires skill and ability of the individual to monitor their symptoms, then implement effective cognitive and behavioral responses to maintain health and well-being.^3,9,50,51 Subsequently, when cognitive performance is compromised, poor self-management can eventuate.^3,9 Poor engagement in such self-management behaviors is linked with increased rates of rehospitalization, poorer lifestyle choices, and worse health outcomes across cardiac patient groups.^9,10

When patients experience an acute cardiac event, self-management recommendations are made around increasing physical activity, medication adherence, and dietary requirements.⁴⁰ The individual’s response is influenced by their cognitive abilities to not only retain and recall the treatment information but to recognize and appropriately act on symptoms as they arise.^9,10,40 Furthermore, the requirements of self-management increase in complexity with more chronic conditions such as heart failure because consideration for fluid management and symptom recognition of acute decompensation become pertinent. Clinicians are potentially expecting these patients to engage in complex behaviors at a time when their capacity to do so may be compromised. From a functional perspective, these same patients commonly experience physical symptoms that limit their ability to engage in daily activities. Without the appropriate problem solving, planning, and organizational cognitive skills, these patients may experience difficulty with initiating and adhering to task adaptation or energy conservation strategies for symptom management. Consequently, patients may feel increasingly overwhelmed and disengage from the task as it becomes too difficult. Without greater support to make the appropriate behavior changes, an increased risk of loss of independence and greater burden of disease may occur.

A link also exists between cognitive function and health literacy. Health literacy can be defined as the ability of an individual to appraise and comprehend health-related information for the purposes of making an informed decision and implementing appropriate health behaviors.^52-54 This includes knowing when and how to access services, having the ability to effectively converse with health care providers, and knowing how to assimilate relevant health information into the context of everyday life.⁵⁵ It has a direct relationship to health, with those experiencing low levels of health literacy being more likely to be hospitalized or have greater burden of disease when compared to those with adequate skills.^53,56,57 While many factors affect health literacy levels, cognition is thought to have a direct influence through executive functions—namely, processing speed, verbal fluency, and working memory.^52-54

Williams et al in 2002 note that patients with low health literacy are more easily overwhelmed by medical information and frequently ask fewer questions than more literate counterparts.⁵⁶ It has been reported that around 60% of Australian adults lack the skills required to comprehend and utilize health-related information, with increasing prevalence in both elderly and chronic disease populations.^56,58 It is suggested that such patients may not always comprehend the detail, context or implications of their diagnosis, health recommendations, or written education materials, thereby affecting the individual’s capacity to engage and adhere.^56,58 Lower health literacy is consequently associated with poorer health status, poor self-care ability, reduced use of preventive services, and increased hospitalization and health care costs.^56,57

The Role of Occupational Therapy

Occupational Therapy offers an invaluable role to cardiac rehabilitation services and chronic disease management by promoting health and quality-of-life outcomes through occupational engagement.⁵⁹ The Australian Cardiac Rehabilitation Association has produced guidelines outlining key components for ensuring quality, evidence-based service delivery.⁶⁰ Core occupational therapy business complements a number of these key principles, primarily facilitating baseline everyday functioning and IADL, including employment, with the aim of maintaining function long term.⁶⁰ Occupational therapy also supports and promotes the principle of tailored education and skill development to motivate and enable self-management and engagement in positive lifestyle changes.⁶⁰

Occupational therapy places the patient at the center of their care while promoting quality of life through engagement in occupations that are meaningful to the individual. Occupations are broadly defined to encompass daily activities that are relevant to personal care and an ability to live an independent and meaningful life, including instrumental activities such as driving, shopping and meal preparation, leisure pursuits, work responsibilities, and life roles. Occupational science lends support to occupational therapy practice by recognizing that occupation is more than the actual activity, rather exploring the impact of illness or disability on the type, scope, and balance of activities in which people participate.⁶¹ It considers the physical, cognitive, and emotional capacities of the individual to support targeted assessment and skill development to manage challenges and barriers to activities and quality of life.^61-63 This fundamental link between the occupations in which people engage and their consequent health outcomes lies at the core of occupational therapy practice.⁶² Furthermore, occupational therapists are aware that cognitive abilities influence activity participation and can be viewed within task performance as guiding the interaction between motor ability, activity demands, and environmental context.⁶⁴ Referred to as functional cognition, this observable process is considered to be an indicator of an individual’s ability to perform daily activities relevant to safe and independent living and improved well-being.^64,65

The facilitation of occupational engagement and health is achieved by occupational therapists through modifying either the activity or environment to better align with the individual’s needs or by adapting the individual’s abilities to support engagement in the desired activity.⁶⁶ Interventions that promote personal goals and tailored interventions to facilitate goal attainment are acknowledged to have positive outcomes in patients experiencing cognitive deficit.^67-69 In clinical areas such as brain injury rehabilitation and pediatrics, this engagement in targeted and meaningful activity within appropriate environmental context is believed to have a positive impact on neuroplasticity.⁷⁰ Additionally, occupational therapy interventions of a cognitive and behavioral nature have been shown via randomized controlled trials (RCTs) to improve function and lessen carer burden in patients with mild to moderate dementia, above that of medication and psychosocial input within the community setting.⁷¹

Occupational therapists have the ability to determine and utilize context to promote more effective and meaningful skill development. The clinical model where learning and retention of skills can be best accomplished during actual activity engagement enables the individual to develop and transition skills to their own environment, which facilitates the generalization of skills between the home and medical environments.^72,73 Activity-based observations of the individual within their personal context also provides valuable insight into functional capacity and barriers to change.^42,63 Stewart et al⁷⁴ note that home-based interventions with heart failure patients are associated with decreased hospital length of stay and consequently lower health care costs when compared with center-based service delivery. Such studies may offer support for greater occupational therapy involvement in the management of cardiac and chronic disease patient groups.

Occupations are closely linked with chronic disease self-management because individuals choose whether they will participate in positive lifestyle activities.⁷⁵ As already noted, chronic disease self-management is a dynamic process requiring ongoing adaptation of responses to manage complications and comorbidities over the course of an illness.⁴⁹ It needs to be considered in the holistic context of the person’s abilities and skillset, their environment, and available resources.⁴⁹ A professional focus on how people engage in activities and interact with their environment and the consequent impact on health and well-being places occupational therapists in an ideal position to influence self-management engagement.⁶² Occupational therapists can promote self-management and positive health behaviors through occupational performance coaching to overcome cognitive, physical, and emotional barriers to the practical integration of health recommendations into their lives.⁶²

Occupational therapy can serve to bridge the knowledge and practice gap between clinical and home environments.⁷³ Through purposeful activity and promoting functional capacity, occupational therapists can build self-efficacy and progress health behavior change for improved self-management. With an emphasis on patient enablement, occupational therapy provides assistance to the individual in finding meaning in clinical information, problem solving to determine how it applies to their situation, and strategizing to practically apply these recommendations in their daily activities and routines. Furthermore, the profession offers a unique combination of environmental and behavioral strategies to compensate for cognitive difficulties while enabling engagement in activities and behaviors conducive to improved health and well-being.⁷³ These contributions can assist with patient management and discharge planning processes through targeted allocation of education and support services, ideally reducing complexities with health conditions and the risk of rehospitalization.⁷²

Occupational therapy thereby has an important role in lifestyle medicine, with expertise in optimizing occupational performance and facilitating a return to life roles, recognizing that physical, cognitive, and emotional skills are critical in influencing a patient’s ability to not only function in regard to daily activities, but also effectively engage in chronic disease self-management.^72,76,77

Strategies in Practice

There are approaches that can be implemented by occupational therapists and other health professionals to assist in managing the impact of cognitive deficit on function and self-management abilities. Table 2 provides examples that consider the domains of memory and executive functions to reflect the reported patterns of impairment in this population group.

Table 2.

Examples of Practical Strategies for Managing Cognitive Deficit.

Functional Performance	Health Literacy52,53,55,56,58,78	General
Refer for more specialist assessment and intervention regarding functional capabilities—ie, occupational therapy	Reduce the cognitive load of resources and educational materials	Incorporate appropriate cognitive screening/assessment for high-risk patients
Consider in-home and community support services	Allow increased time for patients to process information and reach decisions	Refer on to appropriate services as needed—eg, neuropsychologist, geriatrician
Provide practical and transitional support between the hospital and home environments	Use paraphrasing and “teach back” approach to establish understanding and further education needs	Consider distractions in environment and potential impact on patient comprehension
Utilize self-management aids—eg, fluid allowance table, chart for daily weights	Allow for repetition and delivery of information over a number of sessions	Consider proactive service engagement, particularly if patient lacks initiative or insight
Use of memory aids—eg, medication adherence packaging, calendars, appointment reminders	Avoid jargon	Involve family and caregivers in education, recommendations, and care plans

Given the associations between cognitive and functional performance, patients may benefit from the engagement of home and community services, which may incorporate domestic task assistance, transport, and community access, and this should be considered both at discharge from hospital or at a change of health status. Referral to occupational therapy for more comprehensive assessment can allow greater identification of areas of deficit and the functional impact as well as enable specific interventions for home safety and independence. Involving family or caregivers can promote greater retention and comprehension and encourage improved adherence. Education and provision of templates for daily weights and fluid allowances may assist with adherence rates in heart failure. For the more chronically unwell or unstable patients, a proactive approach in service engagement may assist with symptom monitoring, appropriate management, and more timely access to supports and services. This could potentially involve a case management style approach or regular appointed face-to-face appointments and phone calls to assist with goal progression and support needs.

The combination of perceived pressure for shortened hospital admissions and increased caseloads in community settings is reflected in demand for clinicians to be more effective and efficient in their service delivery. The consequent perception of being time poor can result in increased reliance on written information for patient support and education.⁵⁷ The presence of cognitive dysfunction exacerbates the gap between the clinical education demands and the patients’ health literacy, resulting in the patient showing less knowledge of their chronic disease, its treatment, and fewer skills in self-management.⁵⁷ It should, therefore, be considered that for health information to successfully reach its target audience, it should be written at a level accessible to that population group and be designed to compensate for limited cognitive skills.^{52,53,56,58,78} It is suggested that patient information resources be pitched at a level of someone aged 10 to 11 years, with integration of pictorials where possible.^56,58 Involvement of consumer focus groups in reviewing written resources can assist in increasing the readability for the target audience and can be a suitable strategy to gauge the appropriateness of the information.⁵⁶ Disseminating education over a number of sessions and via both verbal and written modes may further improve comprehension and retention while limiting the risk of information overload.^55,56

Cognitive screening can be an option for objective evaluation of cognitive status and may be useful in the process of identifying patients with a deficit. Appropriate cognitive screening can allow the establishment of baseline and detection of changes, particularly when self-report is known to have limited reliability in those with impaired cognition. Selection of a screening tool should consider the cognitive domains that it reviews, its design and validation within the targeted population group, and impact and benefit to the patient. A standardized global screening tool that includes assessment of executive function is suggested to reflect the patterns of impairment arising from vascular pathology.^5,79 Those performing below the cutoff scores, thereby indicating potential deficit, may benefit from further testing to determine impacts on self-management and functional abilities.⁸⁰ Caution should be applied with interpretation of screening results because their general purpose is not to diagnose but to provide an overview of cognitive performance.⁸¹ Cognitive screening is best used as part of a broader assessment to identify the need for further investigation, with consideration of the context of the individual and potential confounding issues.⁷⁷ When cognitive concerns are identified, a referral to neuropsychology can be an option to provide a more comprehensive assessment to establish and clarify the cognitive domains that may be affected, assist in the diagnostic process, and review expectations for progression.

A referral for a functional cognitive assessment by occupational therapy can provide insight and accuracy regarding the individuals’ functional abilities in a real-world context with respect to the underlying physical, emotional, and cognitive domains. This evaluation of actual task execution within context appraises one’s ability to safely perform daily living activities in the home and community as relevant to the individual and assists in determining if and when patients will require further support or input to maintain independence and well-being.^40,77 Tailored strategies and interventions can then be developed and integrated into the individual’s unique circumstances, capacities, and resources.⁸²

Such cognitive-related strategies are generally facilitated through remedial or adaptive approaches.⁷³ The remedial approach is based on neuroplasticity concepts and aims to improve function by retraining cognitive abilities through repeated targeted practice of tasks.^73,83 It is a restorative approach aiming to build on existing strengths and abilities through developing supportive techniques to promote new learning or relearning.⁸⁴ Alternatively, adaptive or compensatory approaches accept the presence of a deficit and utilize a range of external adaptations or aids to support function and overcome limitations to minimize the impact of deficits.^73,83,84 A combination of approaches is often used by occupational therapists to promote and transition functional skill engagement in the individual’s environmental context.^67,73

With chronic disease self-management, there is evidence that education alone does not improve health outcomes.⁷⁵ Although traditional didactic educational approaches increase knowledge around health issues, they are generally less successful in changing behaviors or improving outcomes.⁸⁵ There is subsequent recognition of the need to shift focus from patient knowledge of illness and its treatment, to boosting confidence and skills in managing their condition while promoting wellness.⁸⁵ Part of this is to link the individual with community resources to reduce dependence on medical services and promote coping strategies and self-efficacy for long-term behavior change.^75,85,86 Self-efficacy refers to individuals’ confidence in their ability to engage in and complete specific behaviors and is an essential component in successful and sustainable behavior change.⁸⁷ It promotes individual responsibility and internal motivation and can be clinically fostered through collaborative goal setting guided by patient-defined problems.⁸⁷ Collaborative goal setting can also assist in reducing therapeutic barriers by acknowledging and recognizing the patient perspective and priorities.⁷⁵ This empowers patients to take responsibility to manage their own condition and enables assisted problem solving with support from health professionals.⁷⁵

The maintenance of life roles and redefining personal identity within the context of chronic disease can promote wellness and be facilitated through encouraging the individual to identify and prioritize their concerns and goals as applicable to both their health and life circumstances.^75,88 Such an approach promotes the individual at the center of their care and considers internal motivations and goals as essential to sustainable health behavior changes.⁷⁵ This aligns with occupational therapy practice and the profession’s ability to promote care from a client-centered perspective with consideration of the link between occupation and health. The ability of occupational therapy to promote patient-defined goals and building self-efficacy can, therefore, be an effective component in multidisciplinary care for improved chronic disease management.⁶²

Further Considerations

Further investigation of the links between cognition and functional outcomes in cardiac patients is still required. As noted by Royall et al in 2007, there is debate regarding the strength of correlation between cognitive performance and functional abilities, with some neuropsychological studies indicating that the associations are only quite modest.⁸¹ Many studies addressing these links are observational in design, which indicates association only, not causation. Additionally, there is poor representation of occupational therapy in the literature regarding the functional impact of cardiac-related cognitive impairment, with most studies utilizing either a paper-based IADL assessment or reports from the patient or their carers when establishing the functional impacts. This approach lacks the depth and detail of assessment that may be provided through the unique skill set of occupational therapy in assessing functional task performance. It should also be noted that there is limited published literature on the role of occupational therapy and the profession’s clinical contributions in cardiology and lifestyle-related chronic disease practice.

Summary

Consideration of cognitive deficit in patients with cardiac dysfunction should be considered in clinical practice, particularly as the severity of cardiac dysfunction and presence of comorbidities increases. Cardiac-related cognitive impairments are thought to have an independent influence on occupational performance in functional abilities, chronic disease self-management, and health literacy. Consequently, patients are at risk of poorer health outcomes, increased hospitalization, and greater burden of disease because they are less likely to demonstrate initiative, identify the need to seek assistance, or be able to appropriately translate education into practice. As such, patients may require more time-intensive clinical input and support to make informed health decisions, across both the hospital and community settings, particularly in relation to lifestyle behavior change. Appropriate cognitive screening can be important in detecting those with potential deficits and can allow clinicians to identify those who may benefit from referral for further assessment to determine the extent of the deficit and functional impact.

Occupational therapy provides a comprehensive client-centered service with consideration of the physical, cognitive, and emotional domains of an individual and their consequent impact on occupational performance. Complementing a holistic, lifestyle medicine approach to patient treatment and recovery through supporting patients in identifying and solving problems in self-management and IADLs, occupational therapy can assist in developing client-centered strategies to encourage and enable successful engagement. Scope of practice in cardiac rehabilitation and chronic disease management should be encouraged to expand beyond the traditional physical aspects of care to include the cognitive considerations for recovery and inclusion of occupational therapy in practice.