Changes in health care have resulted in shorter hospital stays for older adults, with convalescence and rehabilitation occurring in other settings. Many elderly individuals recovering from serious illnesses or surgery continue their rehabilitation in subacute units or skilled care units (Levenson, 1998). The transfer to these facilities may occur quickly following 3 to 4 days of hospitalization, and is fueled by the payment system. In most cases, the older adult feels weak, is uncomfortable, and has little or no appetite. Yet, because of the importance of restoration of functional status, the older adult must participate in rigorous physical and occupational therapy.
In a recent study, fatigue was identified as the greatest complaint of patients recovering in a subacute unit. These elderly individuals stated they were often overwhelmed with fatigue and sometimes refused their afternoon session of therapy (Robinson, 1999). Refusal of therapy slows progress and also may jeopardize insurance payment for care.
Several factors, including pain, sleep deprivation, and the stress of illness or surgery could contribute to the fatigue experienced by these patients. Pain contributes to fatigue by increasing heart rate, blood pressure, respiratory rate, muscle tone, and oxygen consumption. Sleep deprivation results in limited non-rapid eye movement (NREM) phase of sleep, decline in protein synthesis, and a slower rate of healing (McDowell, Mion, Lydon, & Inouye, 1998). For those recovering from surgery, the surgical experience creates a state of stress. The body releases hormones resulting in decreased glucose utilization, decreased protein synthesis, and increased protein catabolism (Grindel, 1994).
Additionally, the energy requirement for rehabilitation greatly contributes to fatigue. Patients with lower extremity injury, surgery, or weakness must learn to ambulate with the support of walkers. For those with restricted weight bearing, the arms must support the body weight. Mechanical work performed by the unaffected limb is increased, and the energy cost of walking may approach maximum consumption (Gussoni, Margonato, Ventura, & Veiosteinas, 1990). The purpose of this study was to examine the influence of a fatigue reduction program on the level of fatigue experienced by older adults convalescing in a subacute unit following lower extremity injury, surgery, or weakness.
Fatigue is extremely complex and difficult to define. Fatigue has both physiological and psychological components influenced by social and cultural factors. Fatigue occurs when the demand for activity is too great, or when the mechanisms that help the individual restore a sense of balance are disturbed (Aaronson et al., 1999).
Although studies focusing on the older population are few, clinical evidence shows that fatigue accompanies surgery, acute illness, and exacerbation of chronic illness. Researchers have correlated fatigue with a number of factors, including nutritional states, pain, energy expenditure regimens, and age, providing evidence to the complexity of fatigue.
One of these factors is nutrition. In studies of patients recovering from surgery, fatigue was associated with measures of poor nutrition including weight loss, decreased triceps fold skin measurements, decreased serum transferrin, and decreased protein synthesis (Christensen, Hougard, & Kehlet 1985; Christensen & Kehlet, 1984; Keele, Bray, Emery, Duncan, & Silk, 1997; Petersson, Wernerman, Waller, von der Decken, & Vinnars, 1990; Yamamoto et al., 1997).
Another factor correlated with fatigue is increased cardiovascular effort associated with the rehabilitation process. MoI and Baker (1991) identified cardiovascular signs and symptoms of activity intolerance in elderly individuals participating in intense rehabilitation following cerebral vascular accident (CVA). Along with the complaint of fatigue, patients demonstrated an increased diastolic blood pressure, dyspnea, and an irregular heart rate. Similar signs were noted in patients participating in rehabilitation following heart surgery. Signs associated with fatigue were rapid heart rate, low ejection fraction, and dyspnea (Christensen, Bendix, & Kehlet, 1982; Christensen, Stage, Galbo, Christensen, & Kehlet, 1989; Gortner & Rankin, 1988; Gregersen, 1988; Schaefer, 1990). Activities included in rehabilitation, such as walking with a walker or sponge bathing from a basin of water, require additional upper body effort and increased cardiovascular exertion. This cardiovascular effort may add to the fatigue level.
Pain and sleep deprivation also have been correlated with fatigue and have implications for elderly patients convalescing in an institutional environment. Crosby (1991) reported moderately strong correlations between fatigue and pain (r = .62) and between fatigue and fragmented sleep (r = .42). In a study of acute episodes of back pain, Feuerstein, Carter, and Papciak (1987) reported that fatigue progressed significantly throughout the day as the pain worsened. Schroeder, Gillanders, Mahr, and Hill (1991) reported that pain, sleep quality, and functional status accounted for 42% of the variance in fatigue among post-operauve patients.
Researchers disagree on the degree to which advancing age contributes to fatigue. Schaefer and Potylycki (1993) reported a low to moderate correlation between age and fatigue (r = .39), and Christensen et al. (1985) reported no correlation in a small sample of elderly patients after abdominal surgery. Advancing age, along with being female and well educated, accounted for 14% of the variation in the fatigue of elderly participants experiencing acute episodes of rheumatoid arthritis. However, age alone did not contribute significantly (Belza, Henke, Yelin, Epstein, & Gilliss, 1993).
Although limited research tests the effectiveness of interventions to reduce fatigue, fatigue reduction interventions have been proposed. Nutritional interventions emphasizing increasing protein and carbohydrates have been suggested (Christensen & Kehlet, 1984; Petersson et al., 1990). Techniques for energy conservation, such as frequent rest periods and allowing others to assist with home management activities, cleaning, shopping, and meal preparation, have also been suggested (Rhodes, Watson, & Hansen, 1988; Schaefer, 1990). Pain management through medications, distraction, diversional activities, and spiritual activities may also help reduce fatigue (Crosby, 1991; Schaefer, 1990; Schaefer & Potylycki, 1993). Labyak and Metzger (1997) determined 3-minute back rubs were associated with relaxation and maximum reductions in heart rate and respiratory rate. Participants reported quicker sleep onset, better sleep quality, and less fatigue during the day. Oberle, Allen, and Lynkowski (1994) discussed the importance of patient teaching (i.e., explaining to patients that fatigue may accompany an illness).
Intervention studies specific to the elderly adult population that measure the multidimensionality of fatigue are needed. The following areas seem to be the most promising: modulating activity and rest to conserve energy; managing symptoms such as alterations in nutrition, oxygenation, and pain; modulation of environmental factors to reduce disruption of sleep-wake cycle; and patient teaching to reduce anxiety.
The model developed by Piper (1989) helps explain the concept of fatigue. Piper identified the following stressor patterns that contribute to fatigue: changes in energy substrate pattern or altered nutrition; changes in activity and rest patterns; changes in sleep- wake patterns; treatment patterns; symptom patterns (e.g., pain); and psychological patterns (e.g., anxiety and depression). All of these factors could conceivably contribute to increased fatigue among elderly individuals convalescing in subacute units. Additionally, Piper explained that fatigue can be manifested in three dimensions:
* Subjective - the older adult perceives greater fatigue.
* Physical - the older adult may not have the energy or endurance to participate to the maximum level in therapy.
* Cognitive - the older adult may have difficulty with such cognitive functions as attention and recall.
Based on this conceptualization of fatigue, a program of interventions designed to reduce the stressor patterns should be more effective than a single intervention. Additionally, the model indicates fatigue should be assessed by measuring all three dimensions (i.e., physical, cognitive, and subjective fatigue).
It was within this context that the fatigue reduction program and the measurements of fatigue for this study were developed. For this study, fatigue was defined as a state of increased tiredness and decreased capability for physical activity and mental concentration.
Setting and Sample
This study took place in the subacute units of two midwestern longterm care facilities. The units had a total of 52 beds. Eligibility criteria were any patient who:
* Was 70 or older.
* Had experienced a lower extremity fracture, lower extremity joint surgery, or weakness of one lower extremity related to a recent CVA.
* Was learning to ambulate with a walker with limited weight bearing on one extremity.
* On entry to the study, scored at least 24 on the Mini-Mental State Exam (MMSE) (Folstein, Folstein, & McHugh, 1975).
Learning to ambulate with a walker was chosen as a criterion because upper body exertion required for use of a walker increases cardiovascular effort and conceivably contributes to the level of fatigue. Patients who scored lower than 24 on the MMSE or who were on caloric or protein restriction were excluded from the study. All participants took part in rehabilitation sessions twice daily.
The sample consisted of 50 participants - 25 patients in the control group and 25 patients in the experimental group. The experimental group received a fatigue reduction program (Sidebar), and the control group received no specific intervention for fatigue. Each participant's level of fatigue was measured the day after admission and again 1 week later. Alweek interval for measurements was necessary because the length of stay for major joint surgery patients was 10.2 days. Participants were assigned alternately to the two groups. The mean age for the patients was 81 (SD = 4.45), with the ages ranging from 70 to 89.
The institutional review board of the local university approved the study. Participants were approached the first day after admission to the subacute unit. Written informed consent was obtained from each participant. Instruction about the fatigue reduction program was provided to those in the experimental group. The researchers requested each patient rest 30 minutes after bathing and 45 minutes after therapy. It was explained that these two activities contributed to fatigue. Participants were told that a small amount (2 ounces) of a high-protein, high-carbohydrate liquid supplement would be brought to them four times a day. Participants were shown the can of supplement and approximately how much they would receive. Each participant was encouraged to ask for pain medication at bedtime, even if they did not feel too uncomfortable. They were told a 3-minute back rub would be provided at bedtime.
Each patient in the experimental group was given a copy of the fatigue reduction program in large print to help ensure that the interventions were provided. A copy of the fatigue program, printed on bright yellow paper, was placed in the interdisciplinary plan of care and on the clipboard outside the patient's door. The orders for the liquid supplement were placed on the medication record.
No specific interventions were provided to the control group. They received the routine care without the supplements, defined rest periods, or back rub. They had contact with the investigator initially and 1 week later when fatigue measures were obtained.
To introduce the fatigue program and to encourage adherence, educational programs were provided to the nurses on the unit Day and evening shift staff nurses attended a 1-hour inservice. A brief description of the program was printed and placed in every staff member's mailbox. Several new staff were hired during the study, and they were provided with an individual session. The licensed practical nurses on the unit conducted the interventions. As each new patient was recruited, the investigator reviewed the program with the nurse who was working at the time.
COMPARISON OF PATIENTS IN THE CONTROL AND EXPERIMENTAL GROUPS*
Using Piper's conceptualization to guide measurement of fatigue, instruments were selected to measure fatigue in the subjective, cognitive, and physiologic dimension. In selecting instruments, consideration was given to the brevity of the instrument to avoid tiring the elderly individual. The Visual Analogue Scale (VAS) was used to measure the subjective component of fatigue (Piper, 1993). The VAS was a 100 mm vertical line with "no fatigue" at the bottom and "the most fatigue I have ever felt" at the top. The VAS has been correlated with the Modified Fatigue Symptom Checklist (.76, p < .0001) and has a reliability of .87 to .95 (Pugh, 1993). Tack (1990) reported the VAS was correlated with the Profile of Mood States Fatigue Subscale (.71, p < .01). Because the participants in this study were elderly individuals, a vertical version was used for this study as recommended by Herr and Mobily (1993). Participants were asked to place marks on the line to reflect the severity of their fatigue.
The MMSE was selected to measure cognitive fatigue. Piper (1993) recommended measuring attention and concentration when assessing the cognitive dimension of fatigue. Pugh (1993) used the digit span of the Wechsler Adult Intelligence Test, which measured attention and concentration in adults (Wechsler, 1945). Although the MMSE has not been used to measure fatigue, it has components that measure attention and concentration in older adults, and its psychometric properties have been widely studied with elderly individuals. Internal consistency in various studies ranged from .65 to .96, and the test-retest reliability ranged from .79 to .96 with various populations (Tombaugh & Mclntyre, 1992).
A hand-held dynamometer was used to measure physical fatigue. Pugh (1993) reported a significant, but low, correlation of the dynamometer with VAS (r = -.19, p < .05) and the Modified Fatigue Symptom Checklist (r = -.21, p < .05) (Pugh, 1993). Buxton, Frizelle, Parry, Pettigrew, and Hopkins (1992) reported that grip strength fatigue was moderately correlated with Profile of Mood States Fatigue Subscale (r = .49) in adults who had undergone abdominal surgery (McNair, Lorr, & Droppleman, 1981). Crosby (1991) reported fatigue levels were positively correlated with scores on the dynamometer for adults (r = .52).
Prior to beginning the study, interrater reliability was determined. Three researchers evaluated each of nine participants using the instruments. Each patient was asked to complete the VAS and the MMSE and squeeze the dynamometer. The researchers then scored each result independently. Percent agreement was as follows: VAS = 100%, MMSE = 100%, and handheld bulb dynamometer - 93%.
A total of 61 patients were approached to participate in the study. Two patients scored below 24 on the MMSE, and 9 others declined to participate, leaving 50 participants. Table 1 displays the characteristics of the participants in the control group compared with the experimental group. Group comparisons on demographic variables were conducted using t test statistics for continuous variables and chi-square statistics for categorical variables. No significant differences existed between the control and experimental groups on any demographic variables. The most common diagnosis in each group was hip fracture repaired by hip pinning (14 in the control group and 12 in the experimental group).
Outcome Measures and Results
To test the hypothesis that elderly participants who participate in a fatigue reduction program will experience less fatigue than those who do not participate, the change between the initial scores on the three measures of fatigue and the scores 1 week later were determined. The researchers anticipated some improvement by both groups as they began to recover. To determine if there was a significant difference, the change in the scores of the control group was compared to the change in the scores of the experimental group. The group statistics on the change in the three measures of fatigue are displayed in Table 2. The differences between the change scores (i.e., pretest and post-test scores) of the two groups were analyzed using the t test and were significant in all three measures of fatigue, with the experimental group exhibiting a significantly greater reduction in fatigue.
CHANGE IN FATIGUE MEASURES BY INTERVENTION AND CONTROL GROUP
With regard to the cognitive scores, the change reflected an increase in MMSE scores. This indicated a significant decrease in cognitive fatigue. The difference in the means of the experimental group change and the control group change in cognitive fatigue was 1.36.
The visual analogue score changes for the experimental group were in the negative direction, thus reflecting a lower subjective rating of fatigue. However, the control group's VAS scores increased, reflecting an increase in their perception of fatigue. The difference in the means of the experimental group change and control group change was 15.12.
The scores on the hand-held dynamometer were in the positive direction (greater pounds per square inch), representing a decrease in level of physical fatigue. The difference in the means of the experimental group change and the control group change in physical fatigue was 2.91.
The results of this study indicate a program of simple nursing interventions can make a difference in the fatigue experienced by elderly patients convalescing in subacute units after lower extremity injury, weakness, or injury. The older adult's level of fatigue was reduced as measured in the cognitive, subjective, and physical dimensions of fatigue.
In the cognitive dimension, one might expect relocation would result in a lower score on the MMSE, and an improvement in the scores would be expected with time. Both groups did improve in cognitive scores with time, but the group receiving the fatigue reduction program improved to a greater degree. The areas of change on die MMSE occurred in orientation to place, the recall items (e.g., ball, flag, tree), and the attention items (e.g., spelling "world" backwards). This supports Pugh's use of attention and recall as measurements offatigue(Pugh,1993).
Likewise, one also would expect the physical fatigue score measured with a hand-held dynamometer to improve as the older adult gained strength. The instrument is primarily used to measure upper body strength and may not have been measuring fatigue. All of these participants were learning to ambulate with walkers and were also receiving exercises for upper body strengthening. One would expect patients to attain a higher score after a week. As expected, the physical fatigue scores did improve for both groups, but the improvement was much greater in the group receiving the fatigue reduction program. Receiving rest and proper nutrition may allow older adults to participate to a greater degree in their therapy sessions, thus affecting physical strength.
Because of the normal aging changes in nighttime sleep quantity, most healthy elderly individuals nap during the day, some may nap midmorning and mid-afternoon. However, in a subacute unit where several sessions of physical and occupational therapy are provided daily, opportunity for naps are limited. Nursing staff often assist the patient with morning care and then help them up to the chair, where they remain until after supper. The day is nearly filled with meals and therapy and little time to rest. This study indicates the value of short rest periods in bed for the patient. This is additional work for the staff in transferring, but these transfers can be used as teaching sessions to enable further independence.
In general, the program was well received by staff and patients alike. Only two of the 25 patients in the experimental group did not like the taste of the nutritional supplement and did not take it every time it was offered.
This study has several important limitations. First, interventions for fatigue should be measured during a longer period of time. However, the length of stay for major joint surgery patients in these units was 10.2 days, allowing a limited amount of time to intervene and measure fatigue. It is important for the nurse who discharges a patient from subacute care to reinforce the importance of nutrition, alternating periods of activity and rest, and promotion of good sleep hygiene.
An additional limitation is that the researchers were not blinded to the group assignment. They provided the patients in the experimental group with a description of the program and, thus, created a potential bias favoring the intervention group.
At the time of the post-test, the researchers asked the participants if they had received the rest periods and the back rubs at the requested time. The patients had received the back rubs and rest periods an average of 6 of the 7 days, or 85% of the time. Several reported they had to remind the caregiver they were participating in the fatigue reduction program. The medication record reflected the nutritional supplement was provided 100% of the time. Ideally, it would have been best if the same person could have provided the back rub to each person in the experimental group. Despite the initial in-service, there was high staff turnover and it is certain the proficiency in administration of the program varied among different caregivers. However, in reality, no two nurses perform the back rub exactly the same, and the study implies that the actual technique may not be as important as the length of time.
Aaronson et al. (1999) described the difficulty in measuring fatigue and stated there is no "gold standard" with which to measure fatigue. Based on their recent work, these authors suggested using several instruments to measure each aspect of fatigue and key biological parameters. Suggested instruments included:
* Visual Analogue Scale for Fatigue (Lee, Hicks, & Nino-Murcia, 1991).
* Multidimensional Assessment of Fatigue (Belza et al., 1993).
* Symptom Distress Scale (McCorkle & Young, 1978). Laboratory studies, including hemoglobin and hematocrit, white cell counts, thyroids function, and chemistry profiles might have provided additional useful data.
Aaronson et al. (1999) also suggested measuring depression in relation to fatigue. Considering the effect on functional status and sudden loss of independence in this study population, depression could be related to fatigue. One participant told the researcher that his fatigue made him feel very depressed.
In considering the results of the study, one must also consider the power of suggestion and the effect of human contact. That patients knew caregivers were trying to help them reduce their level of fatigue may, in itself, have helped the patient rest better. Additionally, patients participating in the fatigue reduction program experienced more contact with caregivers. A nutritional supplement was delivered four times a day, caregivers assisted patients back to bed and up again at additional times, and a caregiver was present to provide a 3-minute back rub. Three participants said being in the study and having the interaction with the researcher gave them "a boost," just to know someone cared. The effect of the additional act of human caring cannot be underestimated.
The outcomes of this study reinforce the value of the simple nursing interventions that have been an integral component of nursing care from its roots - the provision of adequate nutrition, alteration of activity and rest, and promotion of relaxation. Similarly, McDowell et al. (1998) validated the value of a program of nursing interventions in the promotion of sleep. Using the nursing interventions of a back rub, warm drink, and relaxation tapes, these researchers were able to improve sleep quality. These researchers kept data on whether each of the interventions was actually provided to the patient and demonstrated a steadily rising correlation in sleep quality as the number of parts of the protocol increased. This study also supported the value of multiple interventions to target nursing problems. In a highly technical nursing care environment, the profession of nursing must continue to value these nursing measures so integral to nursing.
The implications for these simple nursing interventions for any older patient recovering from illness of surgery are considerable. Functional status could be measured and associated with the level of fatigue to determine if reduction of fatigue improved functional status. The number of elderly patients receiving care in a subacute care or skilled care unit will rise as the population ages. As technology continues to advance in these types of units, nurses must closely examine what really makes the difference in outcomes for these older adults. Increased emphasis and valuing of these simple nursing interventions holds many potential benefits for convalescing older adults.
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COMPARISON OF PATIENTS IN THE CONTROL AND EXPERIMENTAL GROUPS*
CHANGE IN FATIGUE MEASURES BY INTERVENTION AND CONTROL GROUP