Australian Occupational Therapy
Journal
Australian Occupational Therapy Journal (2010) 57, 34–41
Research Article
Impact of fatigue on everyday life among older people
with chronic heart failure
Eva-Britt Norberg,1,2 Kurt Boman3 and Britta Löfgren1
1Department of Community Medicine and Rehabilitation, Occupational Therapy, Umeå University, Umeå, 2Skellefteå
County Hospital, Skellefteå, Sweden, and 3Department of Medicine, Skellefteå County Hospital, Skellefteå, and Department
of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
Aim: To explore the relationship between fatigue and per-
formance of activities of daily living (ADL), use of assis-
tive devices, home-help service and community mobility
services in older clients with chronic heart failure.
Methods: A cross-sectional descriptive study of 40
patients was performed using the Multidimensional Fati-
gue Inventory, the Staircase of ADL, Assessment of Motor
and Process Skills and a demographic checklist.
Results: We found high levels of general fatigue, physical
fatigue and reduced activity. Greater fatigue was associ-
ated significantly with increased dependence and decreased
quality of ADL, but not for shopping. Use of community
mobility services and assistive devices was frequent and
home help less frequent. Use of assistive devices and home
help were associated significantly with greater fatigue, but
not the use of community mobility services.
Conclusions: Fatigue had a negative impact on ADL
mainly from physical rather than from mental causes.
Improved energy conservation strategies to reduce the con-
sequences of fatigue are needed.
KEY WORDS activities of daily living, ageing, fatigue,
occupational performance, primary health care.
Introduction
Little is known about fatigue among older people with
chronic heart failure (CHF) from an occupational per-
spective. But the phenomenon is commonly seen in occu-
Eva-Britt Norberg Reg OT, MSc. Kurt Boman; Professor,
Chief Physician, Consultant in Cardiology and Internal
Medicine. Britta Löfgren Reg OT, PhD; Assistant
Professor.
Correspondence: Eva-Britt Norberg, Lindegårdsvägen 3,
931 91 Skellefteå, Sweden. Email: evabritt.norberg@
gmail.com
Accepted for publication 6 September 2009.
C 2010 The Authors
Journal compilation
C 2010 Australian Association of Pattenden, Roberts & Lewin, 2007), using assistive
Occupational Therapists
doi: 10.1111/j.1440-1630.2009.00847.x
pational therapy practice within the context of activities
of daily living (ADL), and interventions such as the use
of energy conservation techniques and equipment to con-
serve energy have been studied and evaluated for other
populations (Matuska, Mathiowetz & Finlayson, 2007).
CHF occurs primarily among older people and is charac-
terised by symptoms such as fatigue and breathlessness
(Dickstein et al., 2008). Although there is no widely
accepted definition of fatigue at present within occupa-
tional therapy, Piper (1993) describes it as a whole body
tiredness that is rare, abnormal or extreme and, in addi-
tion, out of proportion to, or unrelated to, activity or
effort. Research findings indicate that fatigue, as a multi-
dimensional symptom among people with CHF, involves
an individual’s body, emotions and cognitive abilities,
which may result in physical restrictions and emotional
discomfort (Falk, Swedberg, Gaston-Johansson & Ekman,
2007).
Older people with CHF receiving primary health care
appear to retain a strong desire to live as independently
as possible in their own homes (Barnes et al., 2006; Falk,
Wahn & Lidell, 2007). Although, Norberg, Boman and
Löfgren (2008) found that older people in primary health
care with CHF self-reported a high degree of dependence
and perceived strain during performance of ADL. Initial
knowledge about the relationship between experienced
symptoms and the performance of physical activities in a
group of older frail community-living people with coro-
nary heart disease (CHD) has been reported by Mithal,
Mann and Granger (2001). The results indicated a mild to
moderate relationship between the symptoms and perfor-
mance of physical activities. Fatigue was the most com-
monly reported symptom followed by shortness of
breath and chest pain. The authors recommend use of
occupational therapy interventions such as assistive
devices and energy conservation techniques.
The need for compensatory interventions to cope with
the loss in functional capacity has also been noted in
some qualitative studies of older people with CHF, such
as modifying physical environments (S. Falk et al., 2007;
devices (Barnes et al., 2006; Brännström, Ekman, Norberg,
FATIGUE IN EVERYDAY LIFE IN CHRONIC HEART FAILURE
Boman & Strandberg, 2006) and community mobility ser-
vices (S. Falk et al.). However, little is known about the
current frequency of use. Other compensatory interven-
tions in rehabilitation not previously discussed might
include, for example, modifying the way activities are
performed, or modifying the activities themselves.
There is limited published literature about the rehabili-
tation of older people with CHF, many of whom suffer
from multiple diseases, although this group of patients is
becoming increasingly common in the community. In
spite of the fact that the impact of symptoms on ADL
among older people with CHF has been described, a fati-
gue assessment to distinguish the multifactorial nature of
fatigue and an assessment with a specific occupational
therapy instrument would be valuable. More information
is needed on the association between fatigue, ADL and
the use of common compensatory interventions for this
group to facilitate the development of activity-based
rehabilitation programmes.
Overall, this study aimed to explore the impact of fati-
gue among older people with CHF through associations
with performance in ADL, use of assistive devices, home
help and community mobility services.
Materials and methods
Participants
All participants were consecutively recruited from one
primary health-care centre according to symptoms,
mainly dyspnoea and fatigue, and were diagnosed with
heart failure (Olofsson, Edebro & Boman, 2007). A total of
63 persons (Norberg et al., 2008) were found to be eligible
for the present study, among whom 40 participated. Of
the original 63 eligible, three died during the inclusion
period, 11 declined to participate and nine were excluded
for the reasons of dementia, terminal illness, inability to
speak Swedish, a move to another city or travelling
abroad (Norberg et al.).
Instruments
A structured questionnaire was used to collect data con-
cerning demographics, use of assistive devices and local
government support such as home help and mobility ser-
vices. The Swedish version (Fürst & Åhsberg, 2001) of the
Multidimensional Fatigue Inventory, MFI-20 (Smets,
Garssen, Bonke & De Haes, 1995), was used to measure
self-reported fatigue over the last few days (Smets et al.).
This can be more valuable than the current fatigue, as
some variation in the intensity of fatigue can occur over
shorter timeframes. Fatigue is described in five dimen-
sions: general fatigue, physical fatigue, reduced activity,
reduced motivation and mental fatigue. The instrument
consists of 20 statements, where participant responses are
measured on a five-point scale. Higher scores indicate a
higher degree of fatigue, with four as a minimum and 20
as a maximum score.
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35
The participant’s perceived ADL ability was identified
by the Staircase of ADL (Sonn & Hulter Åsberg, 1991).
According to the present ICF version, urinary continence
is classified as a body function (WHO, 2001) and there-
fore this item was excluded from this study. Conse-
quently, the assessment incorporates five personal
activities of daily living (PADL), that is, bathing, dress-
ing, toileting, transfers and feeding, as well as four instru-
mental activities of daily living (IADL), that is, cooking,
transportation, shopping and cleaning. The performance
of each activity was assessed using a three-point categori-
cal scale: independent, partly dependent or dependent,
and the ratings were dichotomised (Sonn & Hulter
Åsberg) into independent or dependent. Independent can
include the use of assistive devices and dependent is
defined as dependence on another person. The number of
participants rated as dependent in each PADL item was
small. The items feeding, transfers, toileting, dressing
and bathing were consequently transformed into an inde-
pendent group in all PADL activities and a dependent
group in one or more PADL activities.
The occupational performance of PADL and ⁄ or IADL
was observed and evaluated by a trained and calibrated
occupational therapist using the Assessment of Motor and
Process Skills, AMPS (Fisher, 2003). The AMPS manual
includes 83 standardised ADL activities from which the
client, during an AMPS interview, chooses two challeng-
ing, meaningful and relevant activities to perform. During
the assessment the client is evaluated in 16 ADL motor
skills and 20 ADL process skills according to the AMPS
manual using a four-point ordinal scale. The AMPS motor
skills evaluates the person’s performance of ADL tasks
involving the movement of one’s self or objects, for exam-
ple, walking, lifting and endurance. The 20 ADL process
skills evaluate actions, how these are organised over time,
the selection and use of appropriate tools and materials
and adapting ADL performance to problems as they
appear. Results below the AMPS ADL motor skill scale
cut-off of 2.0 logits indicate a client’s increased level of
effort during the performance, and results below the
AMPS ADL process skill scale cut-off of 1.0 indicate
decreased efficiency, safety and independence. Several
studies support the reliability and validity of AMPS for
assessing persons across a range of ages (Fisher).
Procedure
People recruited for this study received an information
letter outlining the aim of the study, assessments and the
procedure to be followed, and were contacted after one to
two weeks by telephone. After obtaining their consent to
participate in the study, they were interviewed using the
questionnaire and the Staircase of ADL. At the end of the
telephonic conversation, the AMPS interview was con-
ducted and a preliminary contract was made containing
two tasks that the client wished to perform at his or her
home. The occupational therapist visited the participants
in their homes during the following week and MFI was
36 E.-B. NORBERG ET AL.

conducted. The AMPS interview and the preliminary task TABLE 2: Multidimentional Fatigue Inventory values for
contract were confirmed and the AMPS assessments per- older people with chronic heart failure. Higher fatigue scores
formed. Furthermore, the use of assistive devices was indicate a higher degree of fatigue
examined.
% %
Statistics Median Q1–Q3 min max
Medians, quartiles, mean values, standard deviations,
percentiles and ranges were calculated. Significance was General fatigue 17.0 11.25–19.00 0.0 17.5
tested using chi-square, Fischer’s exact test for small Physical fatigue 15.5 11.25–19.75 0.0 25.0
groups and Mann–Whitney’s U-test; P £ 0.05 was Reduced activity 15.5 11.25–18.75 0.0 12.5
regarded as statistically significant. Age was dichoto-
Reduced motivation 9.0 7.25–12.0 5.0 0.0
mised into £80 and ‡81 years, and PADL was dichoto-
Mental fatigue 9.5 5.0–13.0 20.0 2.5
mised into dependent in one or more PADL activities or
independent in PADL activities.
% min indicates the percentage of participants with
Further analyses involved the calculation of odds ratios
minimum possible score 4; % max indicates the percentage
(ORs) at 95% confidence intervals (CIs). The estimated
of participants with maximum possible score 20.
ORs indicate the odds of significantly different fatigue
scales for participants dependent in PADL, cooking,
transport, cleaning and AMPS ADL motor skill measures more other diagnoses, of which musculoskeletal disor-
below the cut-off and is adjusted for £81 years of age by ders were most frequent. There were no differences
univariate logistic regression. SPSS v.12.0.1 was used to between the participants (40) and the non-participants
analyse data (SPSS Inc., Chicago, IL, USA). (23) with respect to age and gender variables.
The participant’s experience of fatigue is described in
Ethical approval Table 2. General fatigue (mean 15.48, SD 3.97), physical
This study was approved by the Ethical Committee of the fatigue (mean 15.10, SD 4.41) and reduced activity (mean
Medical Faculty of Umeå University. 14.7, SD 4.29) were the subscales with the highest scores,
followed by reduced motivation (mean 9.0, SD 3.02) and
mental fatigue (mean 9.5, SD 4.48). A quarter of the par-
Results ticipants self-reported maximum scores for physical fati-
Table 1 shows the basic characteristics of the 40 partici- gue.
pants, 24 women and 16 men aged between 66 and Table 3 shows associations between fatigue and the
91 years (mean 80.6, SD 6.3). Apart from cardiovascular Staircase of ADL. Persons categorised into the dependent
disease, most participants, 39 (98%), reported one or group in one or more PADL activities reported the high-
est possible median scores for physical fatigue and
reduced activity closely followed by general fatigue.
TABLE 1: Participants’ characteristics, n = 40 Scores on all MFI dimensions were significantly higher
among dependent participants (Table 3), but only
reduced activity remained significant, when adjusted for
Total, n (%)
age (OR: 1.62,CI 1.03–2.56, P = 0.038).
Participants dependent in cooking, transportation and
Women 24 (60)
cleaning reported significantly higher MFI values in
Men 16 (40)
general fatigue, physical fatigue and reduced activity
Single 20 (50)
compared with those rated as independent (Table 3).
Housing
The association remained after adjustment for age in
Own house ⁄ apartment 36 (90) cooking for reduced activity (OR: 1.38, CI: 1.04–1.83,
Residential care 4 (10) P = 0.025) and for transportation for general fatigue
Used assistive device 27 (68) (OR: 1.29, CI 1.04–1.61, P = 0.019), physical fatigue (OR:
Used home-help service 8 (20) 1.25, CI 1.03–1.52, P = 0.023) and reduced activity (OR:
Used community mobility services 17 (43) 1.31, CI 1.05–1.63, P = 0.015). For cleaning, the associa-
Self-reported diseases other than 39 (97.5) tion remained after adjusting for age in general fatigue
cardiovascular disease (OR: 1.25, CI 1.02–1.53, P = 0.032), physical fatigue (OR:
Musculoskeletal disorders 23 (57.5) 1.32, CI 1.07–1.64, P = 0.009) and reduced activity (OR:
Visual disorders 12 (30) 1.39, CI 1.09–1.77, P = 0.008). Reduced motivation was
Orthopaedic 10 (25) also found to be significantly higher among participants
Stroke 6 (15) dependent in cooking, but did not remain after adjust-
Respiratory disease 6 (15) ing for age (OR: 1.194, CI: 0.908–1.570, P = 0.204).
No significant difference in fatigue was found between

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FATIGUE IN EVERYDAY LIFE IN CHRONIC HEART FAILURE 37

TABLE 3: Associations between fatigue and dependency in activities of daily living (ADLs) for older people with chronic heart failure
(n = 40). Fatigue scores range from 4 to 20, where higher scores indicate a higher degree of fatigue

n General fatigue Physical fatigue Reduced activity Reduced motivation Mental fatigue

PADL
Independent 32 16.0 (11.00–18.00) 14.0 (11.00–18.75) 15.00 (10.25–16.75) 9.0 (7.00–11.00) 7.5 (4.25–12.75)
Dependent 8 19.5 (16.25–20.00) 20.00 (17.00–20.00) 20.00 (19.00–20.00) 12.0 (9.50–13.00) 12.0 (11.00–14.00)
P-value 0.033 0.005 <0.001 0.030 0.022
IADL
Cooking
Independent 24 14.0 (11.00–18.00) 14.0 (10.25–17.50) 14.5 (9.25–16.00) 9.0 (7.00–10.00) 8.0 (4.00–11.75)
Dependent 16 18.0 (16.25–19.75) 19.0 (14.50–20.00) 19.0 (15.00–20.00) 11.0 (8.25–13.00) 12.0 (4.25–12.75)
P-value 0.033 0.013 0.001 0.039 0.062
Transport
Independent 21 14.0 (10.00–17.50) 13.0 (9.00–17.00) 14.0 (9.50–16.00) 9.0 (8.00–10.50) 8.0 (6.00–12.50)
Dependent 19 18.0 (16.00–20.00) 19.0 (14.00–20.00) 18.00 (15.00–20.00) 11.0 (7.00–13.00) 11.0 (4.00–11.75)
P-value 0.005 0.004 0.001 0.270 0.520
Shopping
Independent 15 16.0 (11.00–18.00) 14.0 (11.00–18.00) 16.0 (11.00–17.00) 9.0 (7.00–12.00) 8.0 (4.00–13.00)
Dependent 25 17.0 (12.00–19.00) 17.0 (11.50–20.00) 15.0 (11.00–19.00) 9.0 (7.50–12.00) 10.00 (6.00–12.50)
P-value 0.543 0.083 0.543 0.804 0.740
Cleaning
Independent 21 14.0 (11.00–17.50) 12.0 (9.00–17.00) 14.0 (9.00–16.00) 9.0 (5.50–10.50) 8.0 (4.00–12.50)
Dependent 19 18.0 (16.00–20.00) 19.0 (15.00–20.00) 18.0 (15.00–20.00) 11.0 (8.00–13.00) 11.0 (7.00–14.00)
P-value 0.005 0.001 <0.001 0.054 0.145
AMPS ADL motor ability
Above cut-off 16 13.0 (11.00–16.75) 12.0 (8.75–15.75) 13.5 (13.50–15.00) 9.0 (7.25–10.25) 6.0 (4.00–8.00)
Below cut-off 24 18.0 (16.00–20.00) 18.5 (14.00–20.00) 17.0 (14.25–19.00) 9.5 (7.25–12.75) 11.0 (8.25–14.00)
P-value 0.001 0.003 0.001 0.436 0.002
AMPS ADL process ability
Above cut-off 25 16.0 (11.00–19.00) 14.0 (11.00–19.50) 15.0 (10.00–20.00) 9.0 (7.00–13.00) 8.0 (5.00–14.00)
Below cut-off 15 17.0 (11.00–19.00) 17.00 (11.00–19.50) 17.0 (11.50–16.50) 9.0 (7.50–10.50) 11.0 (5.00–14.00)
P-value 0.422 0.472 0.164 0.164 0.391

In the fatigue scores, values without brackets are medians and the ranges within brackets indicate Q1–Q3.
AMPS, Assessment of Motor and Process Skills; IADL, instrumental ADL; PADL, personal ADL.

participants dependent or not dependent in shopping
(Table 3).
Table 3 also shows the relation between fatigue and
occupational performance. Participants assessed under
AMPS motor ability cut-off reported significantly higher
fatigue scores when adjusted for age for general fatigue
(OR: 1.26,CI 1.03–1.55, P = 0.028), reduced activity (OR:
1.26,CI 1.02–1.56, P = 0.029) and mental fatigue (OR:
1.31,CI 1.04–1.66, P = 0.023). No significant difference
was found for reduced motivation and physical fatigue
when adjusted for age or for AMPS process scores
(Table 3).
More than two-thirds (68%) of the participants used
assistive devices in their homes (Table 1), and they
reported a significantly higher level of general fatigue,
physical fatigue and reduced activity (Table 4). However,
the association did not remain when adjusted for age.
Common assistive devices included bath ⁄ shower devices
(18; 45%), walking frames (17; 42.5%), raised toilet seats
(11; 27.5%), raising blocks ⁄ cushions (9; 22.5%) and elec-
tric manoeuvrable bed ⁄ backrests (6; 15.0%). Less com-
mon devices were wheelchairs (4; 10.0%), work-chairs (4;
10.0%), canes ⁄ crutches (3; 7.5%) and, for example, stock-
ing aids and bath-tub handles.
One-fifth (20%) of the participants used community
home help (Table 1) and were estimated to have higher
physical fatigue and reduced activity than non-users
(Table 4). However, the association did not remain when
adjusted for age. Local government support for commu-
nity mobility service was granted for 17 persons (43%)
(Table 1) and no significant differences for self-reported
fatigue were found (Table 4).

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38 E.-B. NORBERG ET AL.

TABLE 4: Association between fatigue and use of assistive devices, home help and mobility service for older people with chronic heart
failure (n = 40). Fatigue scores range from 4 to 20, where higher scores indicate a higher degree of fatigue

n General fatigue Physical fatigue Reduced activity Reduced motivation Mental fatigue

Use of assistive devices

No 14.0 (10.00–17.00) 12.0 (7.50–16.00) 12.0 (8.50–15.50) 9.0 (7.00–10.00) 8.0 (4.00–12.00)
Yes 18.0 (14.00–20.00) 17.0 (14.00–20.00) 17.0 (14.00–19.00) 10.0 (8.00–13.00) 11.0 (5.00–14.00)
P-value 0.036 0.007 0.005 0.127 0.051
Use of home-help service
No 16.0 (11.25–18.00) 14.5 (11.00–18.75) 15.0 (10.25–17.00) 9.0 (7.00–11.00) 8.0 (4.25–12.75)
Yes 19.5 (12.50–20.00) 20.0 (15.50–20.00) 19.5 (16.00–20.00) 11.5 (8.25–12.75) 12.0 (10.25–14.00)
P-value 0.109 0.011 0.005 0.222 0.051
Use of community mobility services
No 17.0 (12.00–18.00) 16.0 (11.00–19.00) 15.0 (12.00–17.00) 9.0 (8.00–11.00) 8.0 (5.00–13.00)
Yes 17 (11.00–19.50) 15.0 (11.50–20.00) 17.0 (10.00–19.50) 10.0 (7.00–12.50) 11.0 (4.00–14.00)
P-value 0.685 0.871 0.265 0.607 0.685

In the fatigue scores, values without brackets are medians and the ranges within brackets indicate Q1–Q3.

Participants dependent in one or more PADL activities

Discussion
The main findings in this study were participants’ high
level of reported general fatigue, physical fatigue and
reduced activity. There was an association between these
dimensions of fatigue and participants’ dependence and
decreased quality of performance in several ADLs. No
association between shopping and fatigue was found.
Use of assistive devices was frequent, home help was less
frequent and both were associated with fatigue. No asso-
ciation between the use of community mobility services
and fatigue was found.
For older people with CHF, fatigue seems to be a phys-
ical rather than a mental experience. In this study we
found that general fatigue, physical fatigue and reduced
activity were the dimensions with the highest mean
scores of fatigue, and that fatigue was more strongly
related to physical and functional limitations than to psy-
chological variables such as reduced motivation and
mental fatigue. These results seem to confirm those of
previous studies (K. Falk et al., 2007) of older people with
CHF. Of note was the high percentage of participants
with maximum scores for physical fatigue and general
fatigue and minimum scores for mental fatigue. As
expected, our participants had higher scores compared
with elderly groups in general Danish (Watt et al., 2000)
and German (Schwaz, Krauss & Hinz, 2003) populations,
especially for general fatigue, physical fatigue and
reduced activity.
Age had some impact on results and seems sometimes
to be a confounding variable. However, we found that all
associations between reduced activity, items of the
Staircase of ADL and AMPS ADL motor ability remained
significant when adjusted for age. This tells us how
radical the impact of fatigue is for the performance of
ADL among older people with CHF.
exhibited significantly more fatigue in all dimensions
compared with participants rated as independent. These
results indicated that fatigue might be increased in all
fatigue dimensions, even psychological variables, such as
reduced motivation and mental fatigue, before older peo-
ple with CHF give up their independence in PADL activi-
ties.
Many participants in this study were dependent in
cooking, and the association with most dimensions of
fatigue was strong. In a previous study, Lennie, Moser,
Heo, Chung and Zambroski (2006) described patients’
problems with food intake, such as insufficient energy to
cook, to eat and to buy food, as well as how experiences
of diet restrictions, nausea, lack of hunger, anxiety and
sadness could affect food intake. From this viewpoint, it
is important that health professionals recognise the need
of interventions to support cooking before malnutrition
occurs.
Dependency in transportation, in this case the use of
buses, was associated with general fatigue, physical fati-
gue and reduced activity. In a previous study (Norberg
et al., 2008), many of the participants declared that they
never used public transportation as there were no buses
available. A literature review (Broome, McKenna, Flem-
ing & Worrall, 2009) pointed out a wide range of barriers
for the use of public buses by older people. Frequent bar-
riers included limited scheduling of buses and long dis-
tances from the home or destination to bus stops (Broome
et al.), issues experienced also for older people with CHF
(S. Falk et al., 2007). Providing community mobility ser-
vices, as in Sweden, which is organised and financed by
the local government, serves to compensate for this trans-
port disadvantage. No associations between the use of
community mobility services and participants’ experi-
ence of fatigue were found in this study, possibly because

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FATIGUE IN EVERYDAY LIFE IN CHRONIC HEART FAILURE
of a lack of fatigue assessment in the community mobility
service eligibility criteria. A collaboration between local
government employees and health professionals could
review the impact of fatigue and elaborate on criteria for
granting community mobility services.
No significant association was found between partici-
pants’ dependency in shopping and their experience of
fatigue, although a previous study with the participant
group (Norberg et al., 2008) pointed to shopping as the
activity with the most dependent participants. There may
be a variety of reasons for this lack of association between
shopping and fatigue. Shopping is a complex activity and
therefore more knowledge about this important activity
is required as the prevalence of dependency is so sub-
stantial.
Participants dependent in cleaning experienced signifi-
cantly higher general fatigue, physical fatigue and
reduced activity than those rated as independent. Clean-
ing is the hardest item to perform in the cumulative order
of the Staircase of ADL (Sonn & Hulter Åsberg, 1991).
Despite this, in a previous study (Norberg et al., 2008), it
was found that many participants performed the activity
independently with less or more strain. Based on clinical
experience, persons with CHF commonly use energy con-
servation techniques, such as resting during fatiguing
activities, eliminating part of the activity or changing the
locations of equipment to maintain independence despite
fatigue.
Use of assistive devices as a part of a compensatory
approach is a common occupational therapy intervention
to support clients’ performance of ADL (Fisher, 1998). In
this study, the use of assistive devices was extensive and
energy conservation techniques like sitting in the bath ⁄
shower or on a work-chair in the kitchen seemed to have
been used. Many participants used walking frames, prob-
ably to compensate for loss of balance, dizziness or diffi-
culties in standing or walking, symptoms also found in
previous studies of people with CHF (Brännström et al.,
2006; Pattenden et al., 2007). The use of walking frames
can increase security and enable persons with CHF to be
active and to exercise outdoors. None of the participants
used motorised mobility aids like scooters or electric
wheelchairs, although many were dependent in transpor-
tation and shopping and could possibly benefit from
these. Symptoms such as breathlessness at night (Patten-
den et al.) and shortness of breath, especially when lying
down in the bed (Brännström et al.), are common symp-
toms for persons with CHF, and previous studies
reported that between 28% and 58% of participants
needed to sleep with many pillows or sitting up in a chair
at night because of shortness of breath (Barnes et al., 2006;
Zambroski, Moser, Bhat & Ziegler, 2005). Difficulty in
sleeping is also the symptom reported to be the most bur-
densome not only for this group of clients, but also for
their carers (Zambroski et al.), and can increase the feel-
ing of other symptoms, such as fatigue (Pattenden et al.).
In this study, 15% of the participants used an electric
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39
manoeuvrable bed ⁄ backrest, a surprisingly low figure.
No previous study has, to our knowledge, evaluated the
effects of this assistive device, although it has been in
clinical use as an intervention by occupational therapists
for many years. An intervention study on the effects of
electric manoeuvrable beds or backrests is, therefore, rec-
ommended to explore evidence for this intervention.
Some participants used community home help, mostly
for PADL, and higher age seemed to influence the eligi-
bility of community home help. As there were more par-
ticipants dependent in one or more IADL activities than
those receiving home help, these results indicate that
many participants were assisted by people other than
home help personnel in their IADL activities.
The research findings concerning the relationship
between age and fatigue are somewhat divergent. Ties-
inga, Dassen, Halfens and van den Heuvel (1999) found
an association between higher ages and decreasing
fatigue scores, but Schwaz et al. (2003) found increasing
fatigue scores for older people. According to Watt et al.
(2000), both age and chronic diseases are important fac-
tors contributing to the amount of fatigue in a Danish
population, as non-diseased persons reported a decrease
with age on most fatigue scales, whereas on the contrary,
an increase with age in the diseased group. In this study,
we found some effect of age on associations between fati-
gue and dependency in ADL activities, but most signifi-
cance did remain after adjustment for age.
Although this study contributes to the understanding
of fatigue, there are some limitations to be considered.
The small number of participants in this study makes it
difficult to generalise from the results, and the high
amount of comorbidity must also be taken into consid-
eration as it can affect fatigue. However, the strength of
this study is the valuable description of an ordinary
group of elderly persons with comorbidities and a con-
firmed diagnosis of CHF, treated in a primary health-
care centre.
Clinical implications
This study contributes to the understanding of fatigue. At
the same time, it raises new questions about the impact of
fatigue on ADLs in a group of elderly people with CHF.
It is important for the occupational therapist to identify
persons at risk for severe fatigue, and those over 80 years
may be more likely to be at risk. Smets et al. (1995) recom-
mend general fatigue as a short form of MFI-20, when a
short instrument is required, for example, in everyday
clinical practice. However, there is some uncertainty
about the validity and reliability of this short instrument.
However, for this population, physical fatigue and
reduced activity seem more valid as a short instrument
for occupational therapy evaluation, because of their
stronger associations with occupational performance. An
effective first step for rehabilitation and local government
employees could be to simply ask the client about the nat-
ure of their fatigue.
40
Given the range of dependency with ADLs and occu-
pational performance issues, there appears to be a need
for rehabilitation among persons with CHF in primary
health care. A study by Pattenden et al. (2007) described
the need for a more integrated health and social care,
education and self-management, rehabilitation and tech-
niques of chronic disease management. They found that
only a few clients had been given any specific advice on
how to remain active, and that some participants volun-
tarily limited their activity levels to feel safer. They also
found that persons with fewer socioeconomic resources
were even more vulnerable, as they could not afford
adaptations in their homes. Instead, these researchers
wanted to see rehabilitation and psycho-social support
for both clients and carers with a focus on what the cli-
ents can do rather than what they cannot do. An appro-
priate service model for older people with CHF may
involve a team, including both primary health-care and
local government personnel cooperating in supporting
ADL. This coordinated team could, for example, improve
bases for the assessment of granting mobility services, as
there presently seems to be a lack of association between
fatigue and eligibility for using these services.
No studies of occupational therapy interventions to
decrease fatigue and improve ADL performance for older
people with CHF were found in our literature review.
Some guidance can perhaps be given by results from a
small study by Fisher, Atler and Potts (2007) who found
that short-term, occupation-based occupational therapy
interventions guided by the Occupational Therapy Inter-
vention Process Model, OTIPM (Fisher, 2009), improved
performance of frail, community-living older adults. The
improvement was documented in relation to accom-
plished goals and increased AMPS ADL motor skills, and
use of compensatory interventions were common.
Developing and evaluating various interventions that
may reduce fatigue and its impact on ADL is a logical
research direction. This study showed that many partici-
pants used assistive devices, probably to compensate for
physical fatigue, but little is known about additional con-
ceivable interventions. Examples of interventions may
include decision-making trees for prescribing assistive
devices, energy conservation strategies or ways to sup-
port physical activity. Findings from previous occupa-
tional therapy intervention studies among other groups
of clients where energy conservation strategies for man-
aging daily activities were used (Matuska et al., 2007)
may be beneficial to guide further research.
Conclusion
In conclusion, fatigue had a negative impact on ADL
mainly from physical rather than mental causes. There-
fore, we suggest that persons with CHF using a
compensatory approach may benefit from learning
more about how to use energy conservation strategies
in managing ADL. Such strategies might improve inde-
C 2010 The Authors
Journal compilation
E.-B. NORBERG ET AL.
pendence and may increase the quality of occupational
performance.
Acknowledgements
The authors thank all the participants in this study and in
particular Mona Olofsson who selected and diagnosed
the participants and Gary Webster for linguistic assis-
tance. They also thank the HeartNetCentre, an
EU-funded structural funds project, Objective 1, Äldre-
centrum Umeå, the Swedish Heart and Lung Association,
the Swedish Association of Occupational Therapists, the
Foundation of Medical Research in Skellefteå and
Research Grants for Västerbotten County Council for
funding this study.
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