International Journal of Nursing Studies 47 (2010) 216–228

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International Journal of Nursing Studies
journal homepage: www.elsevier.com/ijns

Review

Fatigue among older people: A review of the research literature
Doris S.F. Yu *, Diana T.F. Lee 1, Ng Wai Man 2
The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong (Special Administrative Region)

A R T I C L E I N F O A B S T R A C T

Article history: Background: Fatigue is a complex phenomenon associated with multiple antecedents and
Received 25 February 2009 detrimental consequences. Although this symptom is prevalent in the older population, it
Received in revised form 11 May 2009 is not easily recognized by nurses and has been under treated.
Accepted 16 May 2009
Aim: The purpose of this review is to describe the existing research on fatigue on older
adults with focus on the lived experience of fatigue, factors related to such fatigue
Keywords: experience and the impact of fatigue on overall health.
Fatigue
Methods: A systematic search of the literature was undertaken to identify research
Older people
evidence on fatigue among the older population. Three databases (i.e. OvidMedline,
Literature review
Symptom CINAHL and PsycINFO) were searched, resulting in 15 eligible studies. Three aspects about
the fatigue phenomenon in older people were identified: the lived experience of fatigue,
relating factors of fatigue, and impact of fatigue on overall health.
Findings: The key findings suggest that fatigue is an overwhelming experience constrains
physical capacity and the energy reserve required for appropriate functioning and social
participation, as well as worsens their morbidity and mortality outcomes. Yet, its
heterogeneous etiologies and multi-dimensional manifestations pose a huge challenge on
its diagnosis and treatment. Indeed, there was inadequate research-base evidence on
fatigue management for older people. This gap in literature may imply that this problem is
poorly recognized and under-treated in older people.
Conclusions: The findings highlight that fatigue is a substantial problem in older people
that deserves early recognition and prompt treatment. Nurses need to be sensitive to the
risk factors of fatigue in the older population and conduct a comprehensive fatigue
assessment on the high risk case. Although this review only identified limited research-
base evidence, the findings do give directions to the development of interventions for
fatigue management for older people.
ß 2009 Elsevier Ltd. All rights reserved.

What is already known about the topic? depleted reserve to cope with the associated devastating
impacts.
o Fatigue is a complex phenomenon associated with o There is evidence to indicate the under-appreciation and
multiple antecedents and detrimental consequences. under-treatment of fatigue among the older population.
o Fatigue is known to be a prevalent problem in the
older population for whom they would have more What this paper adds

o Reviews international research on fatigue among the
older population.
o Presents a fuller picture about the fatigue phenomenon
* Corresponding author. Tel.: +852 3163 4289; fax: +852 2603 5269.
E-mail address: dyu@cuhk.edu.hk (Doris S.F. Yu).
and its relating factors in the older population.
1
Tel.: +852 2609 6227; fax: +852 2994 2107. o Highlights the needs to develop more research-based
2
Tel.: +852 2609 6208; fax: +852 2603 5269. evidence for improving fatigue among older people.

0020-7489/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2009.05.009

The purpose of this review is to Gibby et al. studies were mainly recruited from community settings. and W. a manual search of the bibliographies difficulties to recognition and management of the condition. Tiesinga et al. Information sional in nature (Ream and Richardson. 1999. Of the remaining 112 articles. Introduction enhance awareness and understanding of this complex and poorly defined phenomenon among nurses and other Fatigue is a universal experience in the population and health care professionals. sample char- fatigued individual may present with a lower physical acteristics. decreased attention and concentration. Reyes. disproportionate to the level of physical exertion and is included clients of other age groups (n = 8) or disease not relieved by rest (Tiesinga et al.. Richardson. 3. The inadequate attention to fatigue management among Relevant research studies were sourced using the the older population may be related to the confusion databases OvidMedline (1997–September 2008). while the others depleted reserves to make up for physical and psycholo.. The prevalence is describe the existing research on fatigue on older adults even higher for those who are residing in long-term care with focus on the lived experience of fatigue. 2005).M.. of retrieved studies was also done. under-appre. Major findings from the motivation to work (Aaronson et al. Trendall. fatigue’. 2003.. Yu et al. Australia (n = 2) and Belgium The devastating consequences of fatigue are especially (n = 1). Indeed. some report in affected by the nature of the disease and less representa- literature characterize fatigue as a protective bodily tive of the age-related changes.. 1996. 2004. Inaccurate assessment. Ream and (n = 16 studies) and another 10 from secondary references. discussion papers. defining attributes. medical. which vary 2008) and the keywords ‘fatigue’.. 1996. 1996. mentary letters or conference proceedings were excluded. groups (n = 16).. ‘troublesome’. PsycINFO (1997–September definitions on fatigue have been formulated. 2002). or (2) were review. CINAHL surrounding the phenomenon of fatigue itself. case studies. unpleasant experience typically described as being ‘odi. 2007). 1999). factors setting (Liao and Ferrell. 1996). Tiesinga et al. (n = 78 studies). com- ous’. poorer coping ability. co-morbidities and energy requirement may community-dwelling older people complain of moderate render fatigue a profoundly different experience for older to severe levels of fatigue (Hellstrom et al.N. although it is generally agreed that fatigue can have excluded. related to such fatigue experience and the impact of fatigue ment has not received adequate attention in gerontological on overall health... Ream and Richardson. included 15 articles. ‘muscle considerably on the proposed causes. Trendall. ciation and under-treatment of this condition in the older while some also recruited institutionalized older people.F. Method population (Tiesinga et al.. on fatigue of older people in specific disease groups was Second. 1996. physical and psychiatric factors. ‘mental fatigue’. 1996. a debilitating The reviewed studies were conducted in Denmark compromise of quality of life. However. 2000). but can also be Two researchers (D. hence.S. editorials. Trendall. All of these inconsistencies may language. 1996. The majority of these studies (n = 13) adopted a detrimental to older people. it is a further exempted after reviewing the abstracts because sustained sense of whole body exhaustion that is they were irrelevant or duplicated articles (n = 52). hence. D. Other exclusion criteria response to prevent overtaxing of functional reserve include studies which: (1) were published in non-English (Tiesinga et al. the USA (n = 6). researched. whelming’ (Ream and Richardson. the age-related changes in func- of this symptom indicated that as many as 27–50% of tional status. were used. or non-research based articles (n = 21). The occurrence of fatigue involves a complex interplay of This review. In addition. 1996. poorer for data synthesis (Table 1). who have more seriously quantitative approach to examine fatigue. reviews. ‘comfortlessness’ and even ‘over. 2000) suggest a need to The sample size for the quantitative studies ranged from . Epidemiology population in general. thought processes.. (n = 6). population (Liao and Ferrell. reduced studies were compared with one another for similarities memory. First. / International Journal of Nursing Studies 47 (2010) 216–228 217 1. extracted data from each eligible paper.Y. Focus was placed on the fatigue nursing practice. CINAHL (n = 37 studies) and PsycINFO enon in subjects (Aaronson et al. people (Poluri et al. diverse (1997–September 2008).) independently strikingly idiopathic. Trendall. 2000). ‘older people’. 2000). 2000). Paper focuses alleviated (Ream and Richardson. 2000). research design. 1996). impaired and differences. abstracts or discussion affect proper assessment of the symptoms and add papers. as compared with the is a common symptom among older people. 2000). Trendall. increased irrit- ability and diminished social functioning (Aaronson et al. Some studies have even indicated that nurses were not able to recognize this symptom among the older 2. The samples in the reviewed gical deconditioning. The overall fatigue experience is. used a qualitative approach. a total of 97 articles were Instead of a normal response to bodily exertion. and a about the study setting. Concept analysis has been conducted so as to clarify the A total of 131 articles were located in OvidMedline defining concept of fatigue and to identify the phenom.. Wijeratne et al. phenomenon associated with aging but not related to a ing or improving this condition have been scarcely specific disease. as such fatigue experience would be more a devastating impact on overall well-being. Findings 1999. Paper whose titles indicated of irrelevance to fatigue in Fatigue has been identified as a subjectively reported very older people or were published in forms of abstracts. fatigue manage.. Its manifestation is multi-dimen. Health care interventions for ameliorat. Studies were included if related factors and how the condition might best be they focused on fatigue among older people. and data collection methods were extracted capacity (Tiesinga et al. 1996).

F. demographic background. next 10 years The predictive effect was also significant Age = 70 years (baseline) Functional activity: for the non-disabled counterpart mobility-help scale No information about the health D. Author(s) Research design Aims and objectives Sample characteristics Data collection methods/key Major findings measurements Avlund Secondary To examine whether N = 734 older people participated Tiredness in mobility: Tiredness in mobility was an independent et al.7%) Various tumors (5.1%) Avlund Secondary To examine whether Baseline data from surveys with Mobility disability: mobility-help After adjusting for the effect of chronic et al. Non-disabled PADL-help scale [ADL disability cognitive function and self-rated is defined as need help in one health.7%) their baseline level of disability 5 years later Cardiovascular disease (20%) and chronic illness Mental and neuro-sensory disorders (10. older people who felt tired in longitudinal age 75 predict the onset and Finland (N = 355) six included activities] their daily activities had a three time survey of disability 5 years later increased risk of developing mobility disability than those without tiredness Age = 75 years (baseline) Disability in daily activity: After adjusting for chronic illness.7% limb T scale .2%) Respiratory disorders (5. (1998) analysis of self-reported tiredness in a comprehensive medical survey mobility-tiredness scale predictor of mortality of older people Denmark data in a in mobility and physical done in the period of 1984–1985 after adjusted for the actual disability longitudinal activities of daily living Tiredness in physical activity: at baseline.6%) Endocrinologic and metabolical disorders (4. Yu et al.S. (2001) analysis of self-reported tiredness survey at their age of 75 and 80 Mobility-tiredness scale significantly predicted the use of Denmark data in a in daily activities at age 75 Age = 75 years (baseline) Lower limb–tiredness scale home-help and hospital service longitudinal predict hospitalization and Health status in older people irrespective of survey use of home services Musculoskeletal disease (28. (2002) analysis of self-reported tiredness random sample from the [mobility disability is defined illness. survey predict mortality in the Male:female = 366:368 lower limb-tiredness self-rated health and smoking habit. feeling tiredness in daily Sample completed follow-up or more of the six daily activities] activities had a double risk of study = 517 becoming disabled in daily activities Health status: 2 chronic illness: 32% Tiredness in daily activities: Lower compared to person without tiredness Depressive symptoms: 27.1%) Digestive disorders (7. 218 Table 1 Summaries on fatigue in older adults studies. / International Journal of Nursing Studies 47 (2010) 216–228 status Dependency in ADL: PADL-H scale Global self-rated health: self-developed items Mortality: retrieved from Central National Register Avlund Secondary To examine whether N = 275 participated in a medical Tiredness in daily activities: Self-reported tiredness in mobility et al. cognitive function and self-rated Denmark data in a in daily activities at population in Demark (N = 480) as need help in one or more of the health.

7% mobility alpha (TNF-a) and heat Chronic obstructive airway shock protein (Hsp) 70 disease = 5. To explore: N = 77 nursing homes residents Fatigue: Older RCH elders with higher level et al.2% (3) the relationship Gastro-intestinal disorder = 16.0) years of Life questionnaire endurance was associated with higher level of inflammatory (2) the relationship Health status: Inflammatory mediators: blood test mediators which involved in the between muscle endurance Dementia: 50.F. (2008) exploratory of muscle endurance reported lower Belgium study (1) the relationship Male:female = 24:53 Visual analogue scale level of perceived fatigue in general between muscle and fatigue during daily activities. / International Journal of Nursing Studies 47 (2010) 216–228 follow up the onset of mobility disability randomized controlled trail who included activities] disability in 1.7) years World Health Organization Quality mobility functions.5 years collection at 1. Yu et al. tumor necrosis factor Hypertension = 37. sustained longitudinal in the preceding 5-year and Finland tiredness: 24% or sustained study period on functional Functional ability: Mob-H scale no tiredness: 40%) decline from age 80–85 Age = 75 years (baseline) Elderly with sustained self-reported tiredness in daily activities from Health status not reported age 75–80 were associated with two times increased risk in having functional decline/death during the subsequent 5 years Avlund Prospective To examine whether N = 1396 non-disabled Mobility disability: mobility-help Tiredness in daily activity was et al.9 (7. Lower muscle Female = 78.S. (2003a) analysis of of change in self-reported prospective longitudinal study Mob-T scale change their perceived tiredness Denmark data in a tiredness in daily activities with subjects recruited in Denmark over the 5 years (i.e.5 year in daily activities predict non-disabled control group of a need help in one of the six risk of developing mobility D.9% between muscle endurance and mobility 219 . (2003b) study with self-reported tiredness [3_TD$IF]community-dwellers from the [mobility disability is defined as associated with 2 time increased Denmark 1. endurance and perceived Age: Mobility-tiredness scale Higher level of muscle endurance also fatigue in general as well associated with better balance and as during daily activities Male = 81.6% Muscle endurance: Martin vigorimeter catabolic process associated with and circulatory inflammatory Depression = 46.Avlund Secondary To determine the impact N = 226 older people from a Tiredness in daily activity: Majority of the subjects did not et al.5 years risk in the female counterpart later Male:female = 648:748 Tiredness in daily activity: mobility-tiredness scale Age = 74–75 years (baseline) Bautmans Quantitative.9% Elderly mobility scale for functional (IL)-6.8 (7.8% Mobility and physical dependence: inflammation mediators including Osteoarthritis = 7.5-year times in among non-disabled elderly completed follow-up data older men and 3 times increased men and women 1.8% Tinetti test for balance and gait circulating interleukin Chronic heart failure = 42.

9% Cognitive function: Mini-mental status To compare the chronic Age = 72. There Obesity: 50. or severe Visual analogue scale between fatigued older depression (GDS > 10) were Sleep disorder and lack of exercise people and those without excluded Data on sleeping habits and level were more common in the fatigued fatigue of physical activity was also collected older people but not in the Health status: non-fatigued counterpart.F. Yu et al.8% Depression: 75. terminal group caffine-containing food condition. sleep disorder.5 years examination Except fibromyalgia. Examine the prevalence N = 173 outpatients from Depression: geriatric depression scale Chronic fatigue was common and Ciocon comparative of chronic fatigue in a multispecialty clinic among community-dwelling (1997) study community-dwelling older Fatigue: Chronic fatigue questionnaire older people with prevalence USA people Male:female = 39:129 as 47.3% groups Neurological disease: 73.1% . were Male: 29.4% Arthritis: 68.9% was no difference in the pattern Hypertension: 68. in turn. use of Older people with severe Pain: between fatigue and non-fatigue medication and chronic illness.S.2% people strongly associated with self-reported physical functioning and self-reported Age = 65–90 years Functional status: role and social functioning Physical Performance battery to Health status measure lower body performance D. of chronic illness was comparable exercise habit. (2002) analysis on fatigue and pain mediate older people who did not have of the Short-Form 36 Survey association between medical USA data of a the effect of medical serious medical conditions that conditions and physical status. which. medical condition was controlled in older adults to moderate physical activity common self-reported medical found moderately associated with trial conditions or syndromes in older symptoms.2% of medication use and caffeine Cardiac disease: 63. prevalence illness.6% consumption between the two Respiratory diseases: 69. randomized conditions on functioning could limit participation in light Medical conditions: sum of eight However. 220 Table 1 (Continued ) Author(s) Research design Aims and objectives Sample characteristics Data collection methods/key Major findings measurements Bennett Secondary To determine whether N = 225 communities-dwelling Symptoms: pain and fatigue scale There was a lack of significant et al. / International Journal of Nursing Studies 47 (2010) 216–228 Arthritis: 59% SF-36 Physical functioning scale Hypertension: 36% SF-36 role physical and social Heart disease: 18% functioning subscales Galindo-Ciocon Quantitative.

Yu et al. To examine prevalence Recruited from a 750-bed Fatigue: modified piper fatigue scale 98% of subjects reported fatigue with Ferrell (2000) cross-sectional of fatigue in older people multilevel long-term care facility 51% as mild. By To examine the subjects’ Katz activities of daily living scale comparing the standard regression perceived sources of coefficients.9 years number of routine medications. To explore the longitudinal N = 178 community-dwellers Data was collected by means of survey After adjust for the socio-demographic et al. D. Such feeling depleted their energy for doing or continuing any activities.0%) Health behaviors (physical activity/stress management): single item indicator 100+ years (30. perspectives hermeneutic Women aged 65 years or above Feeling very tired impaired older peoples’ approach well-being in the physical. more anxious persons.Liao and Quantitative. Even though they wanted to keep going on.F. psychological and social dimensions. (2006) longitudinal influences of personality at baseline and during follow-up variables. / International Journal of Nursing Studies 47 (2010) 216–228 Pain: 7-item pain scale There was no significant relationship between fatigue and demographic Functional performance: Walking tests characteristics Martin Quantitative. the energy and motivation fades and resulted in strong feeling of incompetence and disgraceful. demographic factors Functional status: higher level of pain and lower level of functional performance.8  4. 40% as moderate and USA correlational using the residential Depression: Geriatric depression 7% as severe study care services. N = 199 institutionalized elders scale (GDS) Multivariate analysis indicated that To examine the relationship Male:female = 36:163 Cognitive state: mini-mental state fatigue was independently predicted between fatigue and exam by higher level of depression. USA study and health behaviors on Male:female = 54:124 18 months later for centenarians and those who were less physically changes in fatigue [fatigue and 5 years for non-centenarians action and with higher nutritional risk was regarded as a state Age: were more likely to show increased characterized by a general Personality (anxiety and extraversion): fatigue on subsequent longitudinal lack of energy or vigor] 60–69 years (37. To explore the lived N = 10 community-dwellers Unstructured interviews asking Feeling very tired was described as USA phenomenological experience of feeling very who were volunteers in participants the experience of feeling a devitalizing languor that caused [89_TD$IF]study tired from older adults’ a community projects very tired by engaging too many activities phenomenological. fatigue and their Lawton intermediate activities of the effect of depression was most self-care interventions daily living prominent. Such debilitating feeling also stopped participants from continuing with their social relating activities 221 .S.6%) 16PF personality factor inventory assessment 80–89 years (32.3%) Health behavior (nutritional): nutritional risk measures Fatigue: fatigue scale of the Eight State Questionnaire Parse (2003) Qualitative. greater various clinical and Age = 87.

person N = 33 non-caregiver (control) Snyder-Halpern sleep scale poorer overall health and poorer with Parkinson’s disease N = 30 Alzhimer’s disease patients’ health as compared with 5 years and cancer and those who caregivers Distress symptoms: the symptom ago than the control did not N = 29 Parkinson’s disease patients’ distress scale caregivers There was no significant difference in N = 33 cancer patients’ caregivers Mood disturbance: the profile of the fatigue and sleep difficulty between mood states (short form) the different caregiving groups. self-reported tiredness Cardiovascular disease: 20. However.6% was associated with nine time increase in onset of disability Respiratory disease: 3. / International Journal of Nursing Studies 47 (2010) 216–228 study 5-.F. cognitive 74 years (control group) older American resources and services status and problematic behaviors 72 years (Alzheimer’s disease) scale (OARS) was different between the three 73 years (Parkinson’s disease) caregiving groups. They reported that getting rest made them felt refreshed and could move on vigorously thereafter Schultz-Larsen Secondary To determine the effect of N = 705 community-dwelling Disability: mobility-help scale Self-reported tiredness in daily and Avlund analysis of self-reported tiredness in older people who had activities was an independent (2007) data from daily activities on onset of participated in the longitudinal Tiredness in daily activities: predictor of disability and mortality Denmark a longitudinal disability and mortality in medical survey in Demark mobility-tiredness scale in older people in 5-.6% in 10. Age: the caregiving situation in terms Physical health of the care recipient: of functional impairment. 10.and 15-year D.and 15-year among a times group of community-dwelling Age = 70 years older people After adjusting for gender and Health status: comorbidity.and 15-year. 222 Table 1 (Continued ) Author(s) Research design Aims and objectives Sample characteristics Data collection methods/key Major findings measurements Living with such feeling prompted the participants to introduce repose-revive rhythm in their life.S. All groups reported 70 years (Cancer) Problem behaviour of the care recipient: a relatively high level of perceived problematic behaviors scale social support and there was no Male:female= significant difference Cognitive impairment: cognitive status 16:17 (control) scale 14:16 (Alzheimer’s Disease) 14:15 (Parkinson’s Disease) Perceived social support: expressive 16:17 (Cancer group) social support scale .3% in 5 years and 2 time increase Musculoskeletal disease: 10. 10. caregiver of patients with Sleep pattern: The Verran and The caregiver group also reported Alzheimer’s disease. Yu et al. Tiredness Endocrine disease: 8.5% also doubled the risk for mortality at the three time points Teel and Ex post facto To compare the perceptions Recruited from a neurology Fatigue: The visual analogue scale Caregiver groups reported significantly Press (1999) research design of fatigue between older research clinic at a medical for fatigue greater fatigue and sleep difficulty USA people who were spousal center and a cancer center when compared with control groups.

4% et al.9% was cases comorbid Australia study and its relationship with General Health Questionnaire (GHQ). ‘‘pacing yourself’’. International Statistical Classification of current psychological disorder. ‘Feeling safe and belonging’ mentioned the positive psychological reaction of the participants when they were supported by others at the time of getting fatigue Wijeratne Quantitative. the former diagnosis. To explore and describe N = 12 frail elderly people residing Semi-structure interview was used The findings described more on the et al. / International Journal of Nursing Studies 47 (2010) 216–228 or chronic fatigue syndrome being a burden of others were reported As for the later three themes. The discussion focused on with fatigue and the ways frail study Male:female = 2:10 the way participants felt when fatigued.F. 5 out of 13 non-comorbid fatigue cases also had the symptom resolved at 12 months 223 . worthlessness and D. Diseases.S.5% was cases with fatigue alone.Toye Qualitative. and the other had described the sense of frustration multiple diseases including various with the limitation imposed by from various cardiovascular diseases. diabetes mellitus. mood disorders. in older primary care elders Fatigue symptom: six somatic symptoms and 9. and greater physical illness predicted fatigue. To determine the N = 124 outpatients from medical Psychological symptom: The overall rate of fatigue is 27. respiratory disease. Physical health: Cumulative Illness Rating Scale for Geriatrics By following up the subjects for another year. ‘Pacing yourself’’ referred to the ways clients interspaced their activities with breaks and ‘moving on’ described other strategies participants used to increase energy level and cope with fatigue. older people cope with the feeling.4 years from GHQ By using logistic regression analyses. the way fatigue affected them and the Five major themes emerged including Age = 72–93 years ways to cope with fatigue ‘‘battling on’’. fatigue whereas the latter described musculoskeletal diseases. ‘‘hitting rock bottom’’. to function in day-to-day life. the findings indicated that non-cormobid fatigue cases did not tend to evolve into psychological cases. (2007) correlational characteristics of fatigue clinics 6 anxiety/depression items from the in which 16. Feelings of despair.7% with psychological disorder Mean age = 73. (2006) exploratory the experiences of fatigue in aged care facilities to explore participants’ perceptions psychosocial consequence of living Australia and descriptive of frail older people of fatigue. Fatigue cases with psychological disorder: it was found that female gender. 10th Revision for neurasthenia psychotropic drug use. nor vice versa. fatigue and psychological disorder. eye and the psychological impact of failure hearing problems. psychological disorder Male: 50% 10. they were concerned with the way older people coped with the feelings. Yu et al. ‘‘moving on’’ Health status: One participant with just one single For the first two themes.

both of them something more than the tangible assistance per se. who perceived that there potential factors and consequences of fatigue in older was a ‘natural rhythm’ requiring them to interspersing people. / International Journal of Nursing Studies 47 (2010) 216–228 77 to 734. Liao as a state of energy depletion among older people. hence hinted that fatigue might be an early symptom of Other negative emotions associated with the reduced physical deconditioning or even underlying pathological capacity to function also included feelings of despair. older people also reported a sense of security and 2003. they reported that instilling including: (1) the lived experience of fatigue. this study found typically resulted when fatigue limited certain activities. 2006). The symptom also Galindo-Ciocon and Ciocon. the difference in the coping methods may older people. It also indicates 1997. By collecting the blood sample experience.. As for the two qualitative studies. these studies covered a wide range of factors emerged from the descriptions of the disabling effects of from the physiological. ‘fading’.. non-specificity of the fatigue experience. fatigued older people reported poorer sleep 2006). Although the use of cross-sectional (Parse. exercise than the older people without complaining fatigue. 2003).. down’ (Parse. Bautmans et al. ‘shutting their eyes’. et al. changes in older people. 1999. 2000. activities with breaks in the course of living with fatigue. 2006). The benefit of such support was highlighted as obstructive airway disease and chronic heart failure. Toye et al. By highlighted the devastating impact of fatigue on the comparing the characteristics of older people whose psychological well-being of older people (Toye et al.2. 1997.. the findings still provide important insights into institutionalized older people. The findings of these two studies ‘‘fading when wanting to continue working’’ (Parse. 2000. Wijeratne et al. The lack of a relationship between chronic illness and Indeed. 2006.. attending exercise class. 2003). as the met the criterion of data saturation in sampling (Parse. Teel and that older people are pre-occupied with the debilitating Press. The use of such metaphors reflects the 2007. and (3) impact of fatigue on overall effective means of moving beyond fatigue-related debil- health. As fatigue is a complex consequences. as one on drawing any causal inferences (Bautmans et al. The studies explored different belongingness when support was received to cope with aspects of the fatigue phenomenon in older people and the the fatigue-related physical incapacity. Bautmans et al. . and Ferrell (2000) found that fatigue was independently chosen terms such as ‘stopped them from doing anything’ predicted by poor walking capacity. has a higher Two studies examined the lived experience of fatigue in level of fatigue.1. The lived experience of fatigue among older people difficult to conclude which group of older people.. physical. (2006) used with poorer muscle endurance perceived a higher level of the theme ‘battling on’ to illustrate such self-characterized fatigue in day-to-day life..F. Wijeratne et al. older people. The deliberate pacing of Ciocon and Ciocon (1997) found that fatigue was not activities was the most common accommodative method related to the majority of chronic illnesses in older people. These older people reported that they could move on with renewed strength after resting. there was a feeling of frustration that for circulating inflammatory mediators. Galindo-Ciocon and Ciocon. Toye et al. 2007). incompetency and being a burden to others. As for the com- findings can be categorized into three main areas munity-dwelling older people. behavioral and psycho- fatigue among the community-dwelling older people social perspectives. community (Parse. the institutionalized or community-dwelling. indicate that fatigue in the latter group may be more 2006) and the other in the those who were dwelling in the responsive to periods of physical rest. complaint of fatigue persisted for more than 3 months Older people used various strategies to live with the with those whose complaint did not last this long. and various relaxation therapies. (2) related a ‘repose-revive rhythm’ to daily living was the most factors of fatigue. Instead. the presence of bodily and ‘natural rhythm’ imply older people may have little pain and the use of medication among institutionalized control over fatigue-related debilitation. 2006. Indeed. and ‘organs (bodily organs) are slowing factors related to fatigue among older people (Avlund et al.. 1999. 2008. Toye Martin et al. Yet. Relating factors of fatigue among older people which encompasses physical. Martin et al. Teel and Press. Although it is 3. Galindo- debilitating effects of fatigue. (2006) identified a similar experience in the 2007).S. Liao and Ferrell. They included eating sugary food to gain energy. emotional and social com- ponents. Using the The relationship between physical factors and fatigue theme ‘hitting rock bottom’ to illustrate such emotions was different in the community-dwelling older people. The self. person put it. reported by the institutionalized older people (Toye et al. 2008. (2008) reported similar Older people tend to describe themselves as struggling findings and indicated that institutionalized older people to live with the problem of fatigue. Liao and Ferrell.. one in institutionalized elders (Toye et al. hindered them from participating in social activities. Other coping strategies were more restorative in patterns and were more likely to have no habit of regular nature. Older people reported that fatigue had design in the majority of these studies imposed restrictions stopped them from doing much of anything except.. itation. 2003). Three studies examined the relationship between These findings highlighted the devastating effect of fatigue physical health and fatigue among older people. Older people described fatigue as a ‘heavy Quite a number of the reviewed studies identified feeling’.. The findings in both studies reinforced fatigue being a multi-dimensional phenomenon 3. the term ‘devitalizing languor’ phenomenon. that the low muscle endurance might be the result of low- Such experience was described by the older participants as grade inflammation. Yu et al. social support also acted as an important coping fatigue may be related to the exclusion of all older people resource for the institutionalized older people suffering with debilitating chronic illnesses such as chronic fatigue.224 D. 2003).

it was the perceived role requirement suffering psychological-related fatigue. 3. measured by a validated instrument which asked older the presence of a psychological disorder was found to people the level of tiredness after performing various daily associate with eight times an increased risk of having activities such as transfer. Impact of fatigue on overall health (2006) also included personality factors such as trait anxiety and extraversion as predictors of fatigue in later Not many studies have examined the impact of fatigue life. this points over the subsequent 15 years. (2006) identified a relationship between levels and more sleep disturbances as compared with fatigue and lifestyle factors among the community-dwell. prolonged tiredness after activity. presence of six somatic symptoms. only one of them et al. disease and cancer reported more fatigue. functionings among older people. Another series of studies (2007). Indeed. An optimal nutri. lower energy Martin et al. (2007) pointed out that cantly higher risk of having new onset of mobility among the 27. to be strongly associated with lower levels of self-reported The relationship between psychological factor and physical activity as well as limited role and social fatigue has been further confirmed by Wijeratne et al. the need to from the selected samples of a number of large-scale sleep longer. despite previous studies consistently mortality of older people. Tiredness in the course of daily activities was and poor concentration. 1998. such as walking indoors and fatigue. which contributed to the feeling of fatigue and exhaustion. none of them evolved into an identifiable tiredness also significantly predicted a three times psychological problem in the subsequent year.5% of 2003b). 2006). persistent fatigue in the past year. Martin et al. on the health outcomes.5 years (Avlund et al. There is a possibility that the poor sleep activities.. The older people with medical condition that identified fatigue influence of trait anxiety on fatigue was even more as a mediating factor of poor health (Bennett et al. 1996). 2001. 2002). Such debilitating that fatigue might be better depicted by a model utilizing effects may explain why older people who reported somatic and psychological phenomena in parallel. They found that whereas extraversion showed no on the health of older people. the time of care provided each day nutritional risk as important causative factors of fatigue and the functional as well as cognitive impairment of the in older people. 2007). home-help and hospital services in the subsequent 5 years . Schultz-Larsen anxiety and affective disorder) in the community-dwelling and Avlund. it ing older people (N = 178). this study identified physical inactivity and in the role of a caregiver.4% of older people who identified as having disability in the following 1. approximately 10. As for the increased risk in decline in performance in functional test other 12 older people who only had a psychological among older people in the subsequent 5 years (Avlund disorder but not fatigue at baseline. including the presence In these studies. Wijeratne et al. The authors suggested years (Schultz-Larsen and Avlund. In fact. Such findings may indicate that instead of physically active might improve mood status and prevent the actual caregiving responsibilities draining the energy depression. who determined the characteristics of fatigue and may give greater insight into the health impacts of fatigue its relationship with psychological disorders (including (Avlund et al. it should also be noted that the fatigued older Meeting the role expectations of later life is also a people attributed the poor sleep patterns to various contributing factor to fatigue in older people.F. prominent than that of the previously mentioned lifestyle Fatigue which resulted from medical conditions was found factors.. cognitive impairment and self-rated health. predictive effect. the elderly spousal caregiver was independent of the centenarians) for 5 years and centenarians for a period of 8 caregiving situation in terms of the length of time engaged months. rather tiredness would have significantly higher utilization of than in a hierarchical configuration. service utilization and even Nevertheless. By using these diagnostic criteria. Follow-up assessment than the impact of medical morbidity which only on different health outcomes took place at different time associated with four times the increased risk.S. an important resource for protecting older people from becoming fatigued. 2002. Older people who reported reporting a prominent effect of psychological factors in tiredness in daily activities were associated with signifi- relating to fatigue. Yu et al.3. Such a detrimental effect was far more prominent going outdoors (Avlund et al. hence. Parkinson’s illness and fatigue. the baseline data were mainly obtained of muscle pain or tired muscles after activity. them did not have any comorbid psychological disorder. / International Journal of Nursing Studies 47 (2010) 216–228 225 However. older people with a high level of trait which explored the mechanism of functional decline in anxiety reported more fatigue and less vigor over time. 2000). 2002.. self-reported Indeed.b. The authors explained that keeping oneself care recipients. Health etiology of the fatigue phenomenon. However.. There was only one study. fatigue was defined as a in daily activities on functional and health outcomes of somatic phenomenon and was characterized by the community-dwelling older people. and the effect was sustained for up to 15 reported fatigue at 1-year follow up. 2003a. The findings finding was also reported for older people who were consistently identified the devastating effects of tiredness dwelling in residential care setting (Liao and Ferrell. which in turn protected an individual from from older people. 2007). life-style is. surveys. those who did not have any caregiving duties. tion state was in fact crucial to prevent the development of Such findings further reinforce the complexity in the fatigue-related physical conditions such as anemia. severe leg pain especially relevant to those who are involved in caregiving and arthritic pain. In that study. After controlling for the effects of chronic illness. They examined the effects of tiredness older people. D. Teel and Press (1999) found that older spousal patterns may mediate the relationship between medical caregivers of patients with Alzhimer’s disease. This is physical health problems such as nocturia.. poor sleep. By conducting a longitudinal was interesting that the level of disturbance reported by evaluation of the fatigue level of older people (non.

Such inadequacy of care assessment of this symptom can be conducted in the would definitely pose a threat to the functional capacity of course of care planning. so that further undertreated in older people. 2004) and frequency of disease gical. for specific research purposes. As a once losses have occurred.e. poses challenge to its proper diagnosis and care professionals need to take a more active role in treatment. The findings on the lived higher trait anxiety. 2002).. the vague turn lower their sense of control and eventually weaken nature of fatigue may hinder older people from reporting their sense of purposeful coherence. the lack of consensus in the between the two populations is that patients with chronic definitions of fatigue has led to great variation in the illness usually related the fatigue experience to the disease content and design of these scales. Richardson (1996) gave a similar opinion by defining ‘Compensation’ is a coping strategy characterized by using fatigue as on a continuum. The findings here. The lack of studies on fatigue management assessing fatigue in older people. further reinforce the importance of fatigue with the undesirable performance. 2008. This may suggest that fatigue has quite a and subjective nature of fatigue adds difficulty to its universal manifestation irrespective of its underlying clinical assessment. The situation can get even worse if older this phenomenon. this subjective coping with the fatigue experience. Ream and use ‘compensation’ to adapt to such aging losses. that fatigue is a distressing and overwhelming experience Symptom recognition is a crucial step to help older affecting the overall well-being of older people.. Such finding which examined fatigue in older people. and exercise are regarded as a 4. Getting additional rest during the daytime. has physiolo- perception (Yu et al. of older people in coping with this debilitating condition in enon in later life. other disease. When older people experience result. poorer functional performance. However.. the studies by Avlund and colleagues may imply the fatigue and energy depletion. a key difference in the fatigue experience developed to measure it.. Yu et al. In the current review..F. with the former characterized as a normal As for the older people. this review highlights nurses’ vital role in optimizing the resources provides a comprehensive picture of the fatigue phenom. the daily activities.. Compensation and Optimization Model as et al. the complexity of such experience. and worsen their morbidity and identified a number of factors related to fatigue in older mortality outcomes. 2003). people characterize the fatigue experience as a normal heterogeneous etiologies and multi-dimensional manifes. Patients with chronic complaint even associated with two times increased risk of illness may believe that treatment for the disease could mortality in 10 years time. and the presence of a psychological experience of fatigue in older people are similar to those disorder were more susceptible to this distressing condi- identified in patients with chronic illnesses such as cancer tion. 1999). chronic disease management. Indeed. tiredness has been recognized as one of the proposed by Baltes and Baltes (1990).. However.. The research evidence clearly illustrates day-to-day life. debilitating effect constrains physical capacity and the which suggest fatigue may be an early symptom of energy reserve required for appropriate functioning and physical deconditioning and/or pathology among older social participation. fatigue may be interpreted as a sensation which occurs after exertion and the latter as kind of progressive functional decline. as a majority of and the associated treatment. eating sugary food. Such feelings may in assessment in gerontological care. the ubiquitous et al. we have fatigued older people.S. Although various scales have been causes. Many older people report frustration people. especially in terms of the factors. people. 1998). Yet. ‘pacing’ is used as a possibly of even more devastating effects of fatigue on the compensation strategy to enable them to keep up with health outcomes of older people. This review indicates that fatigue in specific symptoms (Yennurajalingam et al. older people may manifestations of fatigue (Tralongo et al. whereas older people were the instruments have been developed to measure fatigue less likely to mention the cause of fatigue. This requires a good may imply that this problem is poorly recognized and awareness of the high risk group for fatigue. previous studies also indicated that fatigue in criticized as inadequate to providing the comprehensive patients with chronic illness are strongly associated with fatigue assessment needed for thorough care planning the disease severity (Falk et al. and psychosocial manifestations.. Falk As for the assessment of fatigue itself. energy) is generated to cope with the Through a thorough review of the findings from studies fatigue experience (Lang et al. with the milder form being alternative means or resources to maintain a desired state tiredness and the other extreme being exhaustion. Discussion kind of ‘regenerative compensation’ by which an addi- tional resource (i. 2008). 2007). The findings indicate that older people who have Fatigue has been a more common research topic in multiple cormorbidities. They were hence more clinical and life-style factors (Avlund et al. 1998).. / International Journal of Nursing Studies 47 (2010) 216–228 irrespective of their baseline level of disability and population may explain the variation in their ways of comorbidity (Avlund et al. (Aaronson et al. 2007). attention needs to be directed to all of these and congestive heart failure. Such difference very detrimental impact on physical capacity and emo- between patients with chronic illness and the general older tional well-being. Indeed. and has a exacerbation (Baghai-Ravary et al. physical.. likely to resort to more sedentary pursuits so as to prevent Although tiredness has been differentiated from exacerbating fatigue in the disease course. Thus. nurses and other health tations. their content has been Indeed. 2009). physical and psychosocial impact (Fitch et al. in terms of its ubiquitous nature. 2001). fatigue. consequence of aging.226 D. Therefore. It is recommended that capturing such . after controlling for the relevant have a restorative effect on fatigue. health older people is etiologically heterogeneous. According to the an abnormal state of excessive whole body tiredness (Piper Selection.. Its people cope with the fatigue experience.

2008). European Journal of Public Health issues are worth considering in interpreting the findings. exercise therapy may be 5.. care for fatigue management. non-Caucasian population. Cassmeyer. the etiology or consequences of fatigue. a majority of the studies used a cross- factors. Defining and measuring fatigue... Neuberger. K. M. More effort needs to be placed on suggests the use of a narrative approach for symptom developing research-based evidence to improve fatigue management.. 965–973. 2005).. Based on influenced by an individual’s cultural value and belief..F. 2001. tion. Further investigation of the There is compelling evidence to indicate the beneficial cultural influence on fatigue experience would also be effects of exercise on the muscle strength and cardior. along sectional design to examine the relating factors of fatigue. As both of these parameters are crucial to maintain an individual’s physical capacity. Tiredness in daily activities among nondisabled old people as promote an adaptation of older people to their situation determinant of onset of disability. K.T. Based on the above limitations. Yu et al. 1999. Its calming effect on the mind can dimensional manifestation imposes real challenges to prevent those negative emotions which ‘wear people out’. Journal of Clinical Epidemiology 55 (Krishnasamy. tives of examining fatigue in older people. Functional ability scales aspects of fatigue in older people. K. 35–42. 2003a. Journal of Aging and Health 13 (2). value of this method in future investigation of fatigue Avlund. 1996. the current review Fatigue is a known to be a substantial health problem in indicates a significant role for psychological factors in the older population. et al. Besides. Avlund. L. 2007).. G. 2002.. Journal of meaningful discussion with them. Pedersen.T. all the nurses can be understood to play a substantial role in reviewed evidence was derived from the Western popula- relieving the burden of such debilitation on older people. M. The findings of this review provide preliminary relaxation therapy in relieving fatigue among patients with indications on how to assist older people to cope with the chronic illness (Yu et al. 1997). Although this review identifies evidence on various Avlund. D.. the literature fatigue experience. Schroll. S. Such a recount of the fatigue experience facilitates older people developing an awareness of both None. The narrative approach. 267–286... though the current orders or metabolic abnormalities which affect tissue findings would be more generalizable to the broader older oxygenation. and consequences of fatigue. C. Attention needs to be given to the (10). Finally.. Knowing that fatigue is a subjective phenomenon for However. 45–50. The findings would have limited value for understanding In view of the devastating consequences of fatigue. this psychological component of fatigue in older people. Indeed. our findings about the nature of fatigue and its related the findings would have limited generalizability to the factors. to 85: influence of preceding changes in tiredness in daily activities. Conclusion a valuable strategy to reduce fatigue in older people. M.. as well as the associated distressing feelings. fatigue search strategy. Schroll. A validation study. Tiredness as determinant of subsequent use of health and social services among nondisabled management for older people. Indeed. This method involves a gradually evolving management. also be enriched by including more databases into the From the biomedical and physical perspectives. 6. fatigue may be managed from the biomedical.S. the nature of the problem and coping behaviors (Ekman & Skott.. but may also cause future research examining fatigue among the older muscle wasting and further aggravate an existing fatigue population need to clearly define the construct of fatigue problem. L. health professionals in managing this distressing symp- The evidence indeed suggests the beneficial effect of tom. Pallikkathayil. 771–777. the key biological parameters and predisposing conclusion. the study findings may physical and psychological perspectives. indeed. K. in terms of its Relaxation therapy has well-recognized effect in relieving ubiquitous nature. situation so that they are more able to engage in Pierce.S... However. Schultz Larsen. J. M. has been demonstrated to be an effective means to Avlund. R. Teel. elderly people. with limitations on physical activities and social function.S.. V. Damsgaard... This review indicated that it is in fact fatigue. P. Fatigue itself may lead to emotional manifestation. As for the psychological perspective. and multi- psychological distress.. heterogeneous etiologies. our review suggests that there is a lack of which its interpretation and manifestation would be research-based evidence to inform the practice. M. Excluding studies into older people in can be managed by identifying and correcting any specific disease groups also limited research evidence treatable underlying pathology or cause of fatigue such which evaluated strategies to address fatigue in these as chronic inflammatory conditions. majority of them Psychosomatic Medicine 65 (5). / International Journal of Nursing Studies 47 (2010) 216–228 227 complex phenomenon among older people require did not clearly define the fatigue phenomenon. significant to shed light on developing culturally relevant espiratory fitness of older people (Nied and Franklin. several methodological for the elderly. Laukkanen. Nursing Scholarship 31 (1). Besides. Sakari-Rantala. groups (Borneman et al. a devastating condition that compromises the quality of Hence it is important for nurses to make efforts to alleviate life and other health outcomes of older people. This would detailed assessment on characteristics and quantification add difficulty to the data synthesis or lead to biased of fatigue. sleep-related dis.. process by which older people discuss the fatigue experience in the context it is experienced and its impact Conflict of interest on their daily life.. Functional decline from age 80 Despite the reviewed studies shared the common objec.. . Kreiner. 2002). K. the complexity of this phenomenon. Schroll. Damsgaard.B. a common consequence of fatigue. The process also provides nurses with an References opportunity to gain a better understanding of the clients’ Aaronson. A. reduced physical capacity is not only population in general. Managing fatigue hence requires a concerted and adopt a longitudinal approach to depict the etiologies effort to improve the physical capacity of older people.

Rieckmann. Dijkstra. Bishop.W. narrative-based method of interpretation. among community-dwelling old men and women. J.. Wang. 2007. T. Wijeratne.. ality and health behaviors on fatigue in late and very late life. D.T.. The mediating Teel. D.L. D. 1996. Lee.. H.. Palmer. M. 1997. the Behavioral Sciences. Schroll. S. 1990.. B. M. A.R. 124–140. Kayser-Jones... P. International Journal of Palliative Nursing 3 (3). J. 1201–1205. 2002..F. Stewart.M. Predom. Galindo-Ciocon. Woo. European Journal of Car. Journal of Advanced Nursing Yennurajalingam.. Pain Medicine Bautmans. 2003. K.. 129–136.M. 426–430. Woo. Wedzicha.C.. The revised Piper fatigue scale: psychometric evalua- Baghai-Ravary. Paul. H. of Cardiovascular Nursing 6 (2). T. Psychological Sciences and Social Sciences 57 (6).. K. T.. 332–344.J.J.O. Yu. 2007. with heart failure.. S. Y. Hickie. jective measure for the identification of frailty among non-disabled interleukin-6. 2008. 2007. T. 126–131...R. dimensions. 584–593. Ferrell.R. K.). 319– Avlund. Tiredness in daily elderly.. (2). P. B. Koczywas. Yu et al.B.. T.. Effects of relaxation therapy on Lang.S. 83–93. M...J. J. an older primary care sample.. Vass.B. 231–237. Rantanen. Fatigue in frail elderly people. 1998. 44 (1). 48 (6).. and circulating tumor necrosis factor-alpha.A.D. 2002. Factors underlying tiredness in Martin. tion in women with breast cancer. Baltes. Hendriksen. Glaser... L. Respini. 1997.. 2000. F. Successful Aging: Perspectives From Journal of Nursing Studies 33 (5). T. and heat shock protein 70.. S57–S64. 161–166. Poon. Are nurses able to assess fatigue. Nursing Research 51 (4).. Baltes. International Journal of care in lung cancer. D. C. Cleeland. I. and opti.. 51–62... D. G. noncaregiving roles. 1125–1130.. 1126–1131.A. M.. American Geriatrics Society 48 (4). Piper. The role of tired. Dassen.M.228 D. R.. 2005...C. 2003.. 352–360. A. Research in Nursing & Health 27.N.R. Anderson... Clinical Lung Cancer 9 (6). / International Journal of Nursing Studies 47 (2010) 216–228 Avlund. Chronic fatigue in the elderly. 2008. 501–509.. S.F... Bennett. J. 2002. Quality of life and symp. L. C... 2007. Slaughter. International Baltes.. 2008. Fatigue: a summary of 2008.L. Tiredness in daily activities: a sub- perception.N.. R. Nursing Science Quarterly 16 (4). Ferrell. 2005. Respiratory Medicine Poluri... S. R. T.. The characteristics of fatigue in Journal of Clinical Geropsychology 3 (4). 323–333. European Journal International Journal of Palliative Nursing 12 (5). A. J. Mets. Critical Fitch. Journal of the American community-living older adults... Hallberg. types of fatigue in residential home patients? Scandinavian Journal of Falk.. with chronic obstructive pulmonary disease.. pp. Fatigue in 103 (2). Fatigue: a concept analysis.. 1999. Tiredness and subsequent of Gerontology Series B: Psychological Sciences and Social Sciences 61 disability in older adults. Donaldson... K. 419–426... 389–396.. Health related quality of life in elderly Liao.C.. White.G.. R.. A.J. Schultz-Larsen. K. 2009.. 216–223. 2006.S. M. 2004. Supportive Care in Cancer 16 (10). V...S. Bruera. K. Balts. 16–25. C.. Cristian. Fatigue and aging. prevalent and severe symptom associated with uncertainty and sense Toye. A. T. Dibble. Weiss. 202–208. Mendoza. I.. T.S.. New York. M. Yu. Njemini. Promoting and prescribing exercise for the Avlund. Fatigue is a Caring Sciences 16 (2). (Eds. N. Association between fatigue and other cancer-related symptoms in Krishnasamy. 251–256. Fatigue among elders in caregiving and effect of pain and fatigue on level of functioning in older adults.K..J. toms among older people living at home.. Exploring patient experiences and self. In: Ream. C. Poulter.. D.S. Gerontological Medical Science 61A. J. Sun..W. 2003b. Journals Avlund.. Journal of Psychosomatic Research 62 (4). 91–108. Mores.. Ciocon. Gaston-Johansson. M. Avlund. 2000. of coherence in patients with chronic heart failure. Goldring. M.. The lived experience of feeling very tired: a study using years. Psychological perspectives on successful of North America 16 (1). D. D. P. Journal of Clinical Epidemiology 51 (4). Tralongo. initiated strategies for living with cancer-related fatigue.A. Persson. Lee. Determinants and impact of fatigue in patients 677–684. R. 291–298. 427– mization in everyday functioning? Journals of Gerontology Series B: 437. M. Mings. exertion fatigue and diovascular Nursing 4 (3). Canadian Trendall. Age and Ageing 32 (6). C. K. . K. G.. M. E. K. Zhang. Lemper.R. K.C. aging: the model of selective optimization with compensation. ness in daily activities. 99–104.. advanced cancer. Findley. 153–158. Muscle 4 (3). Nursing 32 (5). M. W. T.. Ekman.. Swedberg.. Oncology Nursing Forum 25 (4). Hurst... I. A. 1998. M..G. An interdisciplinary care approach for integration of palliative the definitions. Ekman. E... Aging Clinical and Experimental Research 2007 19. M. The role of walking limitations... Developing clinical knowledge through a Tiesinga.I.J. F.J. Reyes-Gibby. R.. Pain and fatigue in community-dwelling adults. Reckamp. Richardson..W. 2004. the elderly population. 498–520. Lee.. Archives of Gerontology & Geriatrics Geriatrics Society 56 (3). A. R. 254–265. compensation. Tiesinga. 2007..F. Schroll.F.. Press.. Onset of mobility disability 325. F.. Halfens. K. Franklin. K. 2006.. Johnson.M.J..O. 2003.A. Physical Medicine and Rehabilitation Clinics Baltes. Skott. activities at age 70 as a predictor of mortality during the next 10 Parse. J. J. mobility. Halfens. 2006.. A...B. J. I.N. American Family Physician 65 (3).F. Quint..E. S. J. V.. Davidsen. J. Western Journal of Nursing Research 21 (4). endurance in elderly nursing home residents is related to fatigue Schultz-Larsen. Rooksby. Exploring the nature and impact of fatigue in patients with advanced cancer.. P. Journal of the Chinese patients with heart failure. I. 579–584.. Brodaty.. Cristea.. Nied. Journal of (3). L... Adapting to aging losses: do psychologic distress and symptom status in older Chinese patients resources facilitate strategies of selection. Rantanen. B. M.. Dassen. Ferrau. Journal of Psychosomatic Research 62 Hellstrom. 1–34. Cambridge University Press..A. Influence of person- older adults. Journal of Advanced Oncology Nursing Journal 18 (3). the parse research method. C. B.. C.. Concept analysis: chronic fatigue. 2002.. K. Borneman. 519–529.. J. van den Heuvel. and indicators.F. Fatigue in an older population.L. 1996. Cook. Nursing Terminologies and Classifications 7 (2). Reviews in Oncology-Hematology 48 (Suppl). J. Dodd.