Feasibility and Effectiveness of E-Therapy on Fatigue Management in Home-Based Older Adults With Congestive Heart Fail

1. Feasibility and Effectiveness of E-Therapy on Fatigue Management in Home-Based Older Adults With Congestive Heart Failure Bin-Min Tsai, MS, OTR Department of Rehabilitation Science University at Buffalo Presented at NYSOTA Conference Buffalo, NY September 27-29, 2007

2. Introduction • Fatigue in CHF • Fatigue: a significant predictor for developing severe CHF (Ekman, et al., 2005) • Fatigue intervention requires attention • Currently CHF patients may receive fatigue management education before discharge but they may not have opportunity to access the education after going home.

3. Introduction • Community-based program for other chronic conditions: • Multiple sessions; in a face-to-face group format • Low adherence rate (Lamb, et al., 2005) • Traveling was challenging (Cox, 2004) • Internet - based program: • Can increase access to healthcare service • May be as effective as a community-based education program • (Tomita, Sewall, & Tsai; 2005)

4. Purpose of the Study • To create a supportive environmentvia the internet for home-based older adults with CHF and test the feasibility & effectiveness of “e-therapy” on fatigue management

5. Literature Review: Impacts of Fatigue • Difficulties in carrying out ADL/IADL tasks(Warner, 2001) • Functional status • Impaired physical, cognitive, social functioning (Mathiowetz et al., 2001; 2005; Vanage, Gilbertson, & Mathiowetz, 2003) • Current health and health- related quality of life (Warner, 2001; Mathiowetz et al., 2001; 2005; Vanage et al, 2003) • Decreased satisfaction with life(Stephen, 2000)

6. The Energy Conservation Education • Effects: • Increase in use of energy conservation strategies • Reduction in fatigue severity and impact • Improving sense of self-efficacy for managing fatigue • Improving health-related qualify of life. (Mathiowetz et al., 2001; 2005; Vanage, Gilbertson, & Mathiowetz, 2003) • Challenges: • Only less than a half of participants were able to attend all sessions. (Lamb, et al., 2005; Mathiowetz et al., 2005)

7. Internet-based Energy Conservation Education • “In order for the energy conservation strategies to be most effective, the environment needs to support people who would like to learn and use the strategies” (Matuska et al., 2007)

8. Development of the E-Therapy Program • Application of e-health method in Wellness Network study (Tomita & Naughton, 2004) • The principle investigator (PI) developed the e-therapy program providing three types of support: • Informational support : Created energy conservationonline education material for CHF-related fatigue management 2. Instrumental support: provided means to self-mange fatigue in a secure web site called daily log to record daily activity level & use of energy conservation strategies. 3. Emotional support: developed 6 discussion topics and led discussions in an online support group

9. Research Questions • RQ1: Does the e-therapy group use the e-therapy program and implement the energy conservation strategies instructed in the program? • RQ2 : Does the e-therapy group increases knowledge of fatigue management in CHF? • RQ 3: Does e-therapy group have higher physical, cognitive & social functions than the control group after the intervention?

10. Research Questions • RQ 4: Does e-therapy group have less fatigue using Global Fatigue Index than the control group after the intervention? • RQ 5: Does e-therapy group have higher overall and individual activity levels than the control group? • RQ 6: What energy conservation strategies are perceived as the most beneficial?

11. Method: Research Design • Quasi-experimental two group mixed design 2-wk 12 weeks 6 weeks Baseline Pretest Posttest Follow-Up T O1 X O2 (X) O3 C O1 O2 O3 - O: Observation - X: Active intervention with both e-therapy technology and a therapist - (X): Passive intervention with technology only

12. Method: Participants • CHF patients in the Wellness Network study (Tomita & Naughton, 2004) • ≥ 55 years old • CHF: New York Heart Association (NYHA) Functional Classification level II or III • Slight or marked limitations in physical activities • Ordinary or less than physical activities could contribute to shortness of breath, fatigue, or palpitation • MMSE: 24 or higher • Living in their own home

13. Method: Procedures Obtaining HSIRB Approval Recruitment of participants (n=31) Pilot study (n=5) 2- week baseline Initial Interview (n=31) 12-week active Intervention 12th week interview (n=31) 6-week passive intervention 18th week interview (n=29)

14. E-Therapy Program: 12-week active intervention 1. Use of a daily health log 2.Access to online education for fatigue management in CHF patients(www.agingresearch.buffalo.edu) • CHF-related fatigue • 14 energy conservation strategies & their applications in daily lives 3.Participation in online support group(www.agingresearch.buffalo.edu) • With peer and professional support • Facilitated by an rehab professional • Discussion topics: • Diet and nutrition • CHF • Helpful tips for health management • Exercise • Computer use • Fatigue management

15. Energy Conservation Strategies • Make sure your work is at the proper height • Keep your work within easy range • Use adaptive equipment, gadgets, or energy-saving devices • Use proper posture and body mechanics throughout your day • Eliminate part or all of an activity to conserve energy • Delegate part or all of an activity to another person • Communicate need for assistance to family members or others • Modify standards by changing the frequency or expected outcome of an activity • Adjust priorities by choosing how to spend available energy • Simplify activities so they require less energy • Plan your day and week to balance work and rest times • Change the time of day that you do an activity to reduce fatigue • Include rest periods in the day, or rest at least one hour/day • Rest during tiring activities that take 30 minutes or longer

16. E-Therapy Program: 6-week passive intervention • No rehab professional support • Emotional support • Online Support Group (Peer support only) • Informational & Instrumental support • Online Education Material (www.agingresearch.buffalo.edu) • Daily log (http://dailyheathlog.info/)

17. Method: Measurements • Process measures • Daily log record (activity level & energy conservation strategies used) • Outcome measures 1. Knowledge about fatigue management in CHF 2. The Energy Conservation Strategies Survey 3. The Modified Fatigue Impact scale 4. The Multidimensional Assessment of Fatigue scale 5. Activity Level Measure 6. The Short-Form Health Survey 7. Evaluation Form

18. Method: Outcome Measures 1. Knowledge about fatigue management in CHF - 20 multiple-choice questions - to test how much they learned from the online education 2. The Energy Conservation Strategies Survey(Mallik et al., 2005) -14 strategies - Ask what strategies were implemented?

19. Method: Outcome Measures 3. The Modified Fatigue Impact scale (MFIS) - 3 subscales (Physical, Cognitive, & Psychosocial Functioning) - 21 items -- Ex. Because of my fatigue, I have limited my physical activities. - Scoring: three subscale score and a total score - Higher scores indicate a greater impact of fatigue - High internal consistency: Cronbach's alpha of .91, .95, & .81

20. Method: Outcome Measures 4. The Multidimensional Assessment of Fatigue (MAF) scale (Belza, 1995) - 5 dimensions of fatigue: degree, severity, distress, interference with daily activities, and frequency. - Rating scale: 10-point rating scales (1: no fatigue; 10: extreme fatigue), - Total of 5 dimensions called Global fatigue index (GFI): range from 1 to 50. - High test-retest reliability (.73) & concurrent validity (.64)

21. Method: Outcome Measures 5. Activity Level Measure - 13 activity items (ADL and IADLs) - 5 point rating: Q: To what degree did you complete each daily activity? 5 –Complete 100% without any limitation 4 –Mildly-adapted completeness 3 –Moderately adapted completeness 2 – Complete 50% and more at a time 1 – Complete less than 50% at a time 0 – Complete 0% or I do not do this activity. - Internal Consistency: Chronbach’s α=.89 - Test-retest reliability: .94 - Construct validity: factor analysis yielding 2 factors (mild and moderate activity), accounting for 65.9% of the total variances.

22. Method: Outcome Measures 6. The Short-Form Health Survey (SF-36) (Ware, et al., 1993) - Health-related quality of life - Measure 6 dimensions: 1. Physical Functioning 2. Role-Physical (limitation in physical activities), 3. Role-Emotional (accomplished less than would like), 4. Social Functioning 5. Vitality 6. Mental Health - Scoring: transformed to a 0 -100 score - Internal consistency: .80 -.92 - Test-retest reliability: .60 - .81 - Validity was established.

23. Method: Outcome Measures 7. Evaluation of the program - Asks treatment group participants to rate the e-therapy program, including satisfaction, & the most beneficial feature, and strategies learned from the program. - Use both close-ended and open-ended questions

24. Results:Demographics & Health characteristics • 29 participants (14 treatment, 15 control) • Age: 75 years (T: 73, C: 77) • Gender: 20 (69%) F, 9 (31%) M • Race: 24 (82%) Caucasian, 5 (27%) minority • Education: 13 (45 %) middle or high school, 16 (55%) some college or higher • Marital Status: 13 (45%) married, 12 (42%) widowed, 4 (14%) single or separated • Living status: 11 (38%) lived alone, 18 (62%) with someone • # of chronic illnesses: 10 • # of medications taken: 8 • No group differences

25. Amount of exercise Note. Total minutes of aerobic exercise (walking and biking) during the previous week of the time of pretest, posttest, and follow-up

26. Results: Use of the Program • Online education materials: 14 (100 % ) • Daily log: 13 (93 %) used 78 % of 12 weeks (active intervention period) and 64% of 6 weeks (passive intervention period). • Online support group: 8 (57%) participated

27. Results:Implement of Energy Conservation Strategies

28. Results:The Most Beneficial Strategies

29. Results:Knowledge

30. Results: Modified Fatigue Impact ScaleTotal Score

31. Results: Multidimensional Assessment of Fatigue ScaleSeverity

32. Results: Multidimensional Assessment of Fatigue ScaleOverall Figure Impact on Daily Activities

33. Results: Fatigue interference with Individual Daily Activities • At follow-up: More fatigue during cooking, showering, during dressing socializing & shopping in the control group while the treatment maintained the same level.

34. Result: Overall Activity Level

35. Result: Individual Activity Level • At posttest, the treatment group had higher activity level of lunch (p=.012) and dinner preparation (p=.04) • Control group decrease activity level of showering (pretest to follow-up) & light housework (pretest to posttest, pretest to follow-up)

36. Result: Participants’ Perceptions • All (100%) satisfied with the program • All (100%) like to recommend it to other people • 13 (93%) perceived e-therapy very informative and helpful • 9 (64%) perceived e-therapy helped with managing fatigue & improving their energy level • 8 (57%) perceived e-therapy improved their quality of life while 6 (23%) felt the same • The most helpful features: • Daily log & energy conservation online education

37. Discussion: Feasibility • Overall, patients with CHF had a high level of use of e-therapy especially when they felt the feature was easy to use and helpful. • Online education materials: 100 % of patients • Daily log: 93 % of patients • However, the level of online support group use was lower (57%) due to: • lack of interest • fear of communicating with strangers • fear of providing wrong information to others • not understanding how to operate it • These characteristics may be dissipate when older adults become more computer literate in the future.

38. Discussion: Patterns of use of energy conservation strategies • Participants learned and used the strategy of how to pace themselves in daily life more than other strategies because of its immediate result. • The strategy to take more time to implement was least applied. • Use of assistive devices became common strategies • contradictory to other studies using younger patients • because the study participants were older and were more disabled

39. Clinical Implications • The use of a client-centered approach to OT practice has developed rapidly during the last decade • E-therapy is an application of client-centered practice • Make services available to the client at the time of greatest need • Allow clients more flexibility in their daily schedule • The therapist as a facilitator enable the client to generate strategies of coping • Therapists can efficiently deliver therapy through the internet after the initial personal evaluation and training with the clients.

40. Conclusion • The e-therapy program is feasible and effective in maintainingfatigue severity, overall fatigue impact on functions, level of activities & mental healthamong older adults with CHF, if they were motivated, have means, and skills. In this technology age, e-therapy may be actualized in the near future. • The further study is strongly needed to provide clear evidence of effectiveness of e-therapy including cost effectiveness.