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Chronic Heart Failure (CHF) is known to have a substantial impact on activities of daily living (ADL) and symptoms such as breathlessness and fatigue are characteristic. Despite this, research in occupational therapy concerning people with CHF is rare. The overall aim of this thesis was to increase the knowledge of ADL ability and fatigue among those with CHF, to describe experiences of limitations in occupational performance and the strategies that these elderly people use to manage their daily activities and also to describe a programme including energy conservation for clients with CHF in primary healthcare.

Method Three groups of older people with a verified diagnosis of CHF and one group of occupational therapists (OTs), all recruited from primary healthcare, were analyzed. The ADL ability of 40 participants was described, with reference to dependence on others, perceived strain and quality of occupational performance. The association between ADL ability and the New York Heart Association Classification (NYHA), a functional classification for people with CHF, was analyzed. Fatigue and its association to ADL ability, use of assistive devices and community support were also analyzed. Ten respondents were then interviewed and asked to describe the strategies they used to manage ADL. The interview results were combined with the current body of research and CHF guidelines to form a base for the development of an intervention programme, including energy conservation, for people with CHF. The programme, based on the Occupational Therapy Intervention Process Model (OTIPM), was used by OTs in primary healthcare, and the clients’ ADL, goal achievements and use of energy conservation strategies were described, as well as the five clients’ and two OTs’ experiences of the program.

Results Most participants were independent in personal ADL activities (PADL). A majority was dependent in one or more instrumental ADL activities (IADL) and perceived strain when performing the activities independently. The Assessment of Motor and Process Skills (AMPS) showed a reduced quality of occupational performance compared with healthy people of the same age. Age had a significant impact on ADL performance. Despite this, participants in NYHA III/IV showed significantly increased effort (under motor cutoff) when performing ADL tasks compared with those in NYHA I/II. Fatigue was common and greater fatigue was associated significant with increased dependence and decreased quality of occupational performance, with the exception of shopping. Participants who used assistive devices and home care estimated higher physical fatigue, but no correlation was found with community mobility services. Comorbidities, which can affect occupational performance, were common in all the studies.

The participants experiences of limitations in occupational performance and the strategies that they used to manage their daily activities were described as redefining an active life, aware of one’s impaired body and planning activities and balancing the degree of effort.

During the interventions according to the programme the clients’ increased their participation and independence in daily activities, consciously gave up what were less meaningful activities for them and deteriorated because of the progression of the CHF. Most goals were achieved and many energy conservation strategies were used by the clients. The clients’ experiences were described as working in collaboration to manage daily activities and using professional support from OTs to enhance their activities. The OTs’ experiences of the programme were described as being supported with specific knowledge and a structured way of working and finding clinical benefits from working according to the program, but doubt the possibilitiy of using it, due to constraints in clinical practice.

Discussion The participants' physical fatigue and breathlessness had a negative impact on their ADL-ability. Age affected ADL performance, but the impact of a more severe CHF remained adjusted for age. An ongoing process of occupational adaptation due to periodical physical decline and fluctuating day-to-day ability was described. Many of the strategies used by the participants to handle daily activities could be described as energy conservation strategies, an indication that occupational therapy interventions including energy conservation management would be beneficial for clients with CHF. Both the OTs and the clients described that the specialized programme provided structure for the OTs’ work, knowledge about CHF and about valuable energy conservation strategies. The programme seemed to support the OTs to work in a more comprehensive client-centered way.

Conclusion The work with this thesis has increased the limited existing knowledge about elderly people with CHF and their ADL ability, fatigue and the adaptation of occupational performance that they use to manage their daily activities. The experiences indicated that a specialized programme including energy conservation for occupational therapy in primary healthcare seemed to support the OTs work in a more comprehensive client-centered way. The programme needs to be further evaluated.