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ProQuest Information and Learning
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SUBJECTIVE FATIGUE, ASSOCIATED VARIABLES

AND PERFORMANCE IN PEOPLE WITH COPD

BY

MARY C. BCAPELLA
B.S.N. Aurora University, 1990
M.S. University of Illinois at Chicago, 1994

THESIS

Submitted as partial fulfillment of the requirements
for the degree of Doctor of Philosophy in Nvirsing Science
in the Graduate College of the
University of Illinois at Chicago, 2003

Chicago, Illinois

United States Code. 80x1346 Ann Arbor. ProQuest Information and Leaming Company 300 North Zeeb Road P.O. This microform edition is protected against unauthorized copying under Title 17. Ml 48106-1346 . UMI Number: 3111432 UMI UMI Microform 3111432 Copyright 2004 by ProQuest Information and Learning Company. All rights reserved.

ASSOCIATED VARIABLES AND PERFORMANCE entitled IN PEOPLE WITH COPD be accepted in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY r (Chairperson of Defe^ Commmee) I concur with this recommendation Dq)artment Head/Chair Repe^nmendation concurr^ in: Members of Thesis or Dissertation Defense Committee I University of Illinois at Chicago . THE UNIVERSITY OF ILLINOIS AT CHICAGO Graduate College CERTIFICATE OF APPROVAL I hereby recommend that the thesis prepared under my supervision by MARY C. KAPELLA SUBJECTIVE FATIGUE.

Helen and the late Robert Krieger. dedication and persistence it takes to achieve such a high goal. They fostered in me the confidence. without whom it would never have been accomplished. This thesis is dedicated to my parents. iii .

iv . His promptness in providing feedback and making so many copies for me was greatly appreciated.and Dr. She gave me academic guidance. Without them the study would never have taken place. I would also like to thank the people who participated in my research as subjects. Dr. Dr. Finally. They graciously welcomed me into their homes and were so cooperative in completing the questionnaires. Minu Patel and Dr. Steve for helping me in so many ways. ACKNOWLEDGEMENTS First and foremost I thank Dr. Dr. A number of pulmonologists helped me recruit patients as subjects. mentoring and kept me employed throughout my doctoral studies. Carol Ferxans were crucial for developing the study and completing the analysis. long process. Rong S Tu for allowing me to send recruitment letters to their patients. I appreciate the time and attention they gave to my work. Thanks to the Midwest Pulmonary Consultants. Without their confidence I could never have completed the project. Janet Larson for her unflagging support. complain and laugh my way through these past years. Glenda Flemister. I extend thanks especially to my children Wendy and Matthew and to my husband. Nancy Kline Leidy. The insightful comments of my dissertation committee members. I am grateful to Dr. I wish to acknowledge my friends who listened to me moan. Her timeliness in returning the many drafts did not go unnoticed. George Cromydas and Lyn Tepper for allowing me to speak to a group of patients in pulmonary rehabilitation. Thanks also to my family for their emotional support throughout the long. rejoice. Jean Berry.

Fatigue as a subjective phenomenon 4 2. Design 23 B. Subjective fatigue as an unpleasant symptom 7 B. Functional performance 33 4. other symptoms and functional performance 17 5. Significance of the Problem 3 II. Subjective fatigue and dyspnea 15 3. Demographics 38 v . Key variables associated with subjective fatigue 18 a. CONCEPTUAL FRAMEWORK AND RELATED LITER. TABLE OF CONTENTS CHAPTER PAGE L INTRODUCTION 1 A. Recruitment strategy 24 C. Anxiety and depressed mood 35 6. Selection criteria 23 2. Dyspnea. Profile of Mood States Fatigue-Inertia subscale 27 c. Sleep quality 37 7. Review of Related Literature 11 1. Physiologic 18 b. Fatigue Assessment Instrument 30 2. Sleep quality 20 6. Subjective fatigue and functional performance 16 4. Summary and conclusion 21 III. Dyspnea 31 3. Disease severity 35 5. Sample 23 1. Subjective fatigue 26 a. Background 1 B.\TURE 4 A. Purpose of the Study 2 C. Psychologic 19 c. Conceptual Framework 4 1. METHODOLOGY 23 A. Nature of subjective fatigue 11 2. Instrumentation 25 1. Numerical Rating Scale 26 b.

Contributions to Knowledge 69 D. Sleep quality 62 c. Anxiety 67 b. Description of the Sample 41 1 Sample characteristics: Background 41 2. Sleep Quality and Affective States 47 E. Discussion of the Findings 57 1. Factors Predicting Subjective Fatigue 50 F. Procedures 38 E. Airflov/ obstruction 68 B. Depressed mood 67 3. Characteristics of Fatigue 45 D. Dimensions of fatigue and dyspnea 45 C. Limitations 68 C. Future Research 70 CITED LITERATURE 71 APPENDICES 82 Appendix A 83 Appendix B 84 vi . Subjective Fatigue. Functional performance 64 d. RESULTS 41 A. TABLE OF CONTENTS (continued) CHAPTER PAGE D. Comparison of Fatigue and Dyspnea Dimensions 43 1. Characteristics of subjective fatigue 57 2. Factors indirectly related to subjective fatigue 67 a. Functional Performance 50 G. Factors directly related to subjective fatigue 62 a. DISCUSSION 57 A. Overall fatigue and dyspnea 43 2. Final Path Model 52 V. Data Analyses 39 IV. Dyspnea 62 b. Sample characteristics: Disease-related 41 B.

TABLE OF CONTENTS (continued) CHAPTER PAGE Appendix C 87 Appendix D 88 Appendix E 98 Appendix F 99 Appendix G 100 Appendix H 103 Appendix I 104 Appendix J 105 VITA 106 vii .

LIST OF TABLES TABLE PAGE I QUALITY OF SUBJECTIVE FATIGUE IN PEOPLE WITH COPD 14 II VARIABLES AND MEASURES 25 III FATIGUE INSTRUMENTS 28 IV ASSOCIATED VARIABLES INSTRUMENTS 34 V SAMPLE CHARACTERISTICS 42 VI SAMPLE CHAR.ACTERISTICS: DISEASE-RELATED 43 VII DESCRIPTIVE STATISTICS: FATIGUE AND DYSPNEA 44 VIII PEARSON CORRELATIONS BETWEEN FATIGUE DIMENSIONS 46 IX PEARSON CORRELATIONS BETWEEN DYSPNEA DIMENSIONS 46 X PEARSON CORRELATIONS BETWEEN NRS FATIGUE DIMENSIONS AND ILLNESS-RELATED VARIABLES 46 XI DESCRIPTIVE STATISTICS: ASSOCIATED VARIABLES 48 XII PERSON CORRELATIONS: KEY VARIABLES 49 XIII FACTORS PREDICTING NRS FATIGUE: MULTIPLE STEPWISE REGRESSION 51 XIV FACTORS PREDICTING FUNCTIONAL PERFORMANCE: MULTIPLE STEPWISE REGRESSION 52 XV PATH ANALYSIS: SUBJECTIVE FATIGUE AND FUNCTIONAL PERFORMANCE 55 XVI SUMMARY OF MULTIPLE REGRESSION IN THE FINAL PATH MODEL 56 XVII COMPARISON OF POMS SCORES WITH NORMS 59 XVIII COMPARISON OF FAI SCORES: PREVIOUS STUDY WITH CURRENT STUDY 60 viii .

LIST OF FIGURES FIGURE PAGE 1 HYPOTHESIZED FATIGUE MODEL 10 2 FINAL PATH MODEL 54 ix .

LIST OF ABBREVIATIONS AN OVA Analysis of Variance [3 Standardized Regression Coefficient BMI Body Mass Index CFI Comparative Fit Index COPD Clironic Obstructive Pulmonary.Disease CRQ Chronic Respiratory Disease Questionnaire df Degree of Freedom F Fisher's F ratio FAI Fatigue Assessment Instrument FEV| % pred Percent Predicted Forced Expiratory Volume in One Second FPI Functional Performance Inventory IFI Incremental Fit Index SLE Systemic Lupus Erythematosus M Mean MANOVA Multivariate Analysis of Variance MS Multiple Sclerosis NFI Normed Fit Index NRS Numerical Rating Scale p Probability POMS Profile of Mood States X .

LIST OF ABBREVIATIONS (continued) PSQI Pittsburgh Sleep Quality Index r Pearson Product-Moment Correlation R. Pearson Product-Moment Correlation Squared SD Standard Deviation SPSS Statistical Package for the Social Sciences t Computed value of t test X" Chi-square xi .

Gift. depressed mood and sleep quality accounted for 42% of the variability in subjective fatigue. had spirometry testing and completed a questionnaire. A model of fatigue was proposed based on research of subjective fatigue in chronic diseases and the theory of unpleasant symptoms (Lenz. functional performance. assessment and interventions for people with COPD who report fatigue should focus on depressed mood. 1995). Lenz. The sample of 130 people age 45 years and older with moderate to severe COPD were briefly interviewed by phone. Path analysis was used to examine the relationships among variables. Subjects reported moderate amounts of fatigue with women reporting more intense fatigue than men. Dyspnea. 2) to test a theoretically and empirically supported model of the relationships among subjective fatigue and dyspnea. Pugh. These findings suggest that fatigue is a common problem that affects performance of daily activities in people with COPD. Suppe. Gift. amciety. Milligan. xii . anxiety and sleep quality. Pugh. Subjects also reported significant difficulty with sleep quality. SUMMARY A study of the multidimensional experience of fatigue was carried out using a descriptive. 1997. dyspnea. The specific aims were 1) to describe characteristics of fatigue in people with COPD . In addition to dyspnea. We anticipate that researchers and clinicians will use knowledge derived from this study to develop interventions that will minimize fatigue and its effects in people with COPD. airflow obstruction and anxiety accounted for 36% of the variability in functional performance. depressed mood and sleep quality in people with COPD. cross-sectional approach. & Suppe. Fatigue. & Milligan.

1 cases per 1000 persons between the ages of 65 to 74 and 43.4 cases per 1000 people 75 years of age or older (Adams & Marano. Background Chronic obstructive pulmonary disease (COPD) is one of the most common respiratory disorders in the developed world. et al. Chronic obstructive pulmonary disease ranks fifth in the United States as cause of death in people 45 to 64 years of age and fourth as cause of death in people 65 years and over (Anderson. INTRODUCTION A. & Murphy. 1986). 1996. Kochanek. I. 1998b). anxiety. In the United States t\vo million cases of emphysema are reported annually with 47. suggesting that fatigue experienced by individuals with COPD may have characteristics unique to the disease (Glaus. 1995). Research in other chronic illnesses indicates that the fatigue experience varies in different illnesses. Chronic obstructive pulmonary disease affects people in many ways. Crow. 1997). They struggle with managing daily activities and treatment regimens. For 1 . and problems with sleep. depressed mood.. In a crossectional study Chen found that 31% of men and 27% of women with emphysema experienced subjective fatigue (Chen. Relatively little is known about subjective fatigue and its effects on people with COPD but evidence suggests that it is a common problem and is associated with decreases in functional status. & Hammond. In addition to dyspnea people with COPD often have fatigue. People with this disease sustain periodic exacerbations during which they feel short of breath or unable to breathe adequately. Smets.

In people with Parkinson's disease physical fatigue was independent of mental fatigue and the two symptoms needed to be assessed separately (Lou. Sexton. 2 example. . 1999. its impact on daily life and its relationship with dyspnea and key variables known to be associated with subjective fatigue in other chronic illnesses. Most of the knowledge about fatigue in COPD comes from studies focusing on dyspnea or on a broader cluster of symptoms including fatigue. Woo. & Suppe. Gift & Shepard. Woo. 1999). Pugh. 1997. Gift. Gift. Only a few studies focused on the symptom of fatigue (Breslin. 1997. 1995). Pugh. Purpose of the Studv The purpose of this study was to examine subjective fatigue and related variables in a group of people with COPD. The model of unpleasant symptoms was used for the study (Lenz. Mercer. 1997. B. & Groningen. van der Schans. 2000b)]. & Volz. Breukink. 2001). Little is currently known about the specific nature of subjective fatigue in people with COPD. Henke. dyspnea functional performance and other key variables such as disease severity. Breukinlc. in a recent qualitative study. anxiety. Suppe. Keams. & Nutt. 1993). Lenz. 2) to test a theoretically and empirically supported model of the relationships among subjective fatigue. depressed mood and sleep quality in people. & Gillis. Oken. The specific aims were 1) to describe the multidimensional nature of fatigue. Epstein. Milligan. Yelin. Small and Lamb found that the fatigue experienced by people with COPD was more persistent in nature than that experienced by individuals with asthma (Small & Lamb. Strijbos. And in subjects with rheumatoid arthritis pain was an important factor influencing the level of fatigue (Belza. & Milligan. 2000a.

1999). Fatigue may also be a sign of changing or worsening condition in people with respiratory disease (Eidelman. & Stulbarg. Leidy & Haase. Pugsley. Guyatt. Moreover. Significance of the Problem Fatigue is one of the two most important symptoms affecting the lives of people with COPD (Breslin. 1980). Inactivity caused by fatigue may lead to physical deconditioning and muscle weakness which may then lead to a reduced ability to perform normal daily activities (Nail & Winningham. Breukink. A better understanding of variables that influence fatigue in COPD will be useful in identifying people at risk for fatigue. 1998. Strijbos. 1986) and is an important component of health-related quality of life (Guyatt. 1998. Feeney. 1996b. Koeter. & Breslin. Koom. In the long-term it is anticipated that knowledge derived fi^om this study will be used in designing and testing of interventions to minimize the effects of fatigue . 1987.. Townsend. & Chambers. 1993). Gormley. 1995). Gift & Shepard. & Patrick. Douglas. C. focusing on chnically relevant information and extends knowledge of the multidimensional nature of fatigue. 0 This study describes the symptom of fatigue. 1999. Fatigue interferes with the ability to perform daily (Breslin. Carrieri. & Hudes. Janson-Bjerklie. Berman. . Paul. clarifying the relationship between fatigue and associated symptoms and outcomes could provide rationale for specific interventions. Carrieri- Kohlman. 1998.. et al. et al.

From the opening of the Harvard Fatigue Laboratory to its closing in 1946. CONCEPTUAL FRAiMEWORK AiND RELATED LITERATURE A. tending toward a condition in which it is no longer possible to carry on "(Dill. There was an emphasis on the chronicity of the sensation. 1967). the study of fatigue moved from the area of chemistry to ergonomics. Although the focus was on muscle fatigue. chemistry. 1947). They saw fatigue as a generalized response to stress over a period of time. Muscio (1921) had defined fatigue not as "various disagreeable sensations. defined fatigue as subjective feelings of lassitude and disinclination toward activity (Bartley & Chute. drawing on their work in the area of aerospace. around the turn of the century. fatigue was described as "simultaneous changes of many things. Researchers described fatigue as various disagreeable sensations experienced by men during activity. In 1947 Bartley and Chute. 1967)." but a variety of unrelated phenomena. sociology. the Harvard Fatigue Laboratory opened to study fatigue through the combined efforts of researchers from medicine. physiology. Then. 11. During World War II there was a great interest in fatigue experienced during military service. 4 . perhaps beginning to identify its multidimensional nature. Conceptual Framework L Fatigue as a subjective phenomenon Researchers have tried to define fatigue since the 1800s but there is still no consensus on the definition. Anecdotal information before the year 1900 indicates that researchers thought that fatigue was caused by the "fatigue toxin" (Dill. and ergonomics and thus began a trend toward multidisciplinary examination of the symptom.

1971).1960s Grandjean.to late . 1970). "inability to sustain interest and effort". He placed general fatigue on a continuum of "sleepy" to "alert" with fatigue feelings ranging from " tiredness" to "exhaustion". pathologic and psychologic variables thought to be related to fatigue. and "difficulty performing tasks. Grandjean developed a visual analogue scale for fatigue and observed that subjective fatigue correlated weakly with measures of attention and reaction (Grandjean. wrote a series of articles describing and defining fatigue and noting a difference between general fatigue and muscle fatigue. He compared general fatigue to the level of liquid in a container with different sources of life stresses filling the container with more and more fatigue." "weariness". Measures for fatigue were largely objective in nature and included laboratory blood tests and measures of attention and reaction (Burkhardt." "weakness. He suggested a separation of the feelings and sensations of subjective fatigue from behavior (Yoshitake. In the mid . mental and sensory-neuro feelings. defined fatigue as a complex of unpleasant feelings and incongruous physical. slowed and impaired perception and thinking. 5 In 1955 Burkliardt from Cornell University suggested that fatigue be defined by the person experiencing it. 1955). His definition included adjectives such as "all tired out. Symptoms of general fatigue were decreased attention. 1968). In 1971 Yoshitake. ." There was great emphasis at the time on physiologic. a researcher in the area of ergonomics. and decreased performance (Grandjean. from the area of ergonomics. decreased motivation. Grandjean discussed variables that influenced general fatigue such as the balance between the reticular activating system and cortical inhibition and the role of these variables in determining the amount of general fatigue the person experienced.

Yellen. researchers were approaching fatigue from a subjective point of view. He defined subjective fatigue as a signal of reduced latent capacity whose state is constantly monitored by the brain.. and dimensions (Belza-Tack. Instnmients for its measurement reflect those definitions with items referring to the general sensation associated with the symptom (McNair.e. or performance. . et al. he also used a psychologic framework for his definition of subjective fatigue. 6 Behavior. 1995. &Droppleman. & JCJM. 1989. 1971. Garssen. the idea of fatigue as a subjective sensation was beginning to be accepted and more and more. "physiological potential of a tissue or organ at any given moment" of a person and lead to subjective fatigue. Webster. Eidelman (1980) used Selye's General Adaption Syndrome to explain that variables (such as stressors) may affect the "latent capacity" i. Piper. Blendowski. its elements (Piper. 1973). Lorr. & Kaplan. He postulated that subjective fatigue was the result of continuous repetition of mental processes ~ worry. was considered further by Cameron in 1973 who emphasized the role of recovery time in determining the intensity of subjective fatigue and described the importance of considering what the person's behavior was before developing fatigue in measuring performance at the time of fatigue (Cameron. 1989). Eidelman's work provided strong support for the idea that subjective instruments should be used to measure subjective fatigue. He fiarther described subjective fatigue as the possible sought-after non-specific alarm signal of the body. Bonke. 1997). Smets. By this time. Cella.1981. et al. Although Eidelman used a physiologic framework for his definition of fatigue. In the last twenty years researchers including several from the areas of nursing and psychology continue to refine the definition of fatigue. 1991.1992).

The sensation of tiredness is due to "an imbalance in the availability. For this definition subjective fatigue includes whole body sensation (Grandjean. The three components of the theory are 1) the symptom. Pugh. Gift.range theory. . This implies that interventions targeting one symptom may also affect other symptoms. objective measures such as biochemical markers and measures of attention and reaction are used to examine antecedents or consequences of the symptom but not the symptom itself 2. & Milligan. The term "perceiving the reduced capacity to function normally" refers to a feeling of reduction in the potential to perform activities necessary to meet their needs (Leidy. emotional and physical ability being reduced. utilization and/or restoration of resources needed to perform activity" (Aaronson. "Multidimensional" means that the sensation includes dimensions such as intensity. & Suppe. Ream & Richardson. According to this theory there are shared characteristics among symptoms. 7 For the purpose of the proposed study subjective fatigue is defined based on the definition of Aaronson and colleagues (1999). 1996) which incorporates the individual's awareness of mental. It is the multidimensional sensation of tiredness that the individual experiences when perceiving the reduced capacity to function normally. et al. 1995). 1968. 1997. Gift. Subjective fatigue as an unpleasant symptom The theory of unpleasant symptoms is a middle . 1999). 3) consequences of the symptom (Lenz.. The phrase "sensation that the individual experiences" implies that the fatigue experience is unique to each person and that the qualities associated with it may be dependent upon the individual's own interpretation of the state. and distress. Pugh. Suppe. frequency. Milligan. 2) influencing variables with respect to the symptom. Lenz. Because subjective fatigue is defined here as a subjective sensation. 1994).

. & Milligan. Dimensions identified for subjective fatigue include elements such as mental (cognitive). 8 According to the theory of unpleasant symptoms the symptom is a multidimensional experience which can be measured alone or together with other symptoms. Milligan. emotional aspects of the sensation of fatigue such as fhistration (Cella. Gift. Yoshitake. physical and general feelings of fatigue (Grandjean. frequency. quality and distress). fi^equency and distress. 1997) as well as the dimensions proposed by the theory of unpleasant symptoms (intensity. The temporal dimension refers to the frequency and duration of the symptom or when it occurs in the person's life. Piper. 1978). Dimensions of the symptom include quality. Quality refers to what the symptom feels like to the person and can be operationalized by descriptors of feelings and location. Gift. According to the theory of unpleasant symptoms physiologic. The measurement of fatigue in people with COPD has until recently consisted of measuring one or two dimensions. Many researchers examining fatigue in people with chronic illness propose that the symptom is multidimensional in nature but consensus has not yet been reached on the actual dimensions inherent in the symptom. Pugh. 1991. 1968. Lenz. Pugh. psychologic and situational variables may influence symptoms such as fatigue (Lenz. Suppe. & Suppe. Distress is defined as the degree to which the person is bothered by the symptom and is conceptualized as a dimension important to the quality of life of the person experiencing the symptom. intensity being the most frequent dimension measured. intensity. And there may be complex cyclical interactions of symptoms with other variables. 1989). et al. 1997. . Additional elements include lack of exercise tolerance and decreased activity (Belza-Tack. Intensity refers to the severity or strength of the symptom. 1995).

It covers empirical papers published in medical and nursing journals from 1975 to 2002. fatigue and lung disease. MEDLINE. Interventional studies were not included. . B. cancer. fatigue and function. its impact on the functional performance. 9 A model was developed to describe the relationships among factors that may influence subjective fatigue. Dissertation Abstracts International and CINAHL searches were undertaken to retrieve citations of studies with fatigue as a primary focus. sleep quality and functional performance in people with COPD as a focus. The model was based on clinical observation. fatigue and COPD. empirical studies of fatigue in COPD and other chronic illnesses and the theory of unpleasant symptoms. multiple sclerosis or arthritis. Dissertations are also included. Search terms used for the review included fatigue. and its relationship with dyspnea and key variables previously found to be associated with subjective fatigue in chronic illnesses. Reference lists of publications were examined for relevant studies to include in the review. dimensions of the symptom and their impact on the performance of daily activities (functional performance) (Figure 1). Papers were reviewed if the researchers described fatigue in COPD or examined factors associated with fatigue in COPD. Review of Related Literature This literature review describes the nature of subjective fatigue as currently understood. Search terms also included dyspnea. Both quantitative and qualitative studies were included.

10 AIRFLOW •OBSTRUCTION ANXIETY DYSPNEA 2 FUNCTIONAL i PERFORMANCE DEPRESSED MOOD FATIGUE SLEEP QUALITY Figure 1. Hypothesized fatigue model .

1999). Smets. 11 1. the quality or characteristics commonly associated with it and the distress they experience from it. 1997). McNamara. Subjective fatigue intensity was similar in other chronic illnesses. a person may create a picture representative of their usual experience with it (Teel. & Watson. Women and men differed in terms of subjective fatigue intensity when measured using a numerical rating scale. Hassey Dow. Cull. 1997. & Grimm. Woo (2000a. a. People describing fatigue may include the intensity and frequency of the symptom. 200b)observed relatively high fatigue intensity in subjects with moderate COPD. Belza-Tack (1991) observed that older adults with rheumatoid arthritis reported moderate levels of fatigue intensity. . 1999). Garssen. 1996). Breslin and colleagues (1998) reported higher levels of fatigue intensity in people with COPD compared to healthy people. Meek. Researchers observed moderate to high levels of fatigue intensity in people with cancer (Mock. Gift and Shepard found that both men and women reported moderate levels of subjective fatigue intensity when measured using the Energy/Fatigue subscale of the Medical Outcomes Study SF-36 (Gift & Shepard. Nature of subjective fatigue When asked to describe a symptom. Women reported more intense fatigue (Gift & Shepard. Belza and associates (2001) reported moderate fatigue intensity in 63 people (mostly men) with COPD and Reishtein (2001) observed moderate fatigue intensity in 100 people with moderate COPD. Intensity Evidence suggests that the sensation of subjective fatigue is moderate in intensity in people with COPD. In a study of 104 people with COPD. & de Haes.

et al. 1978. 1998b).. Lee. & Nino-Murcoa. Studies examining subjective fatigue in other chronic diseases have found temporal patterns associated with the symptom. with the symptom being experienced to a greater extent later in the day and with lowest levels in the morning (Hart. decreased exercise tolerance and emotional reactions to fatigue (decreased motivation and anxiety) than about specific mental and physical symptoms of fatigue. For example. In a qualitative study. 1991). 1998a. She found that people with severe COPD complained more about general tiredness. Hicks.. Frequency Three studies suggest that fatigue is a frequent occurrence in people with COPD. Quality The quality of fatigue was described in three studies. subjective fatigue intensity increased during the time the person was undergoing radiotherapy and then declined after finishing treatment (Smets.. et al. in a study of 154 cancer patients. In her dissertation work. a. Graydon and associates (1995) reported prevalent fatigue frequency in 71 people with severe COPD. exhausted. et al. 12 b. Pardue (1984) studied fatigue in a sample of 68 people with mild to severe COPD. And Gift and Shepard (1999) found that people with COPD reported a lack of energy one to four times during the previous week. Smets. 1998. Pattems in the experience of subjective fatigue in multiple sclerosis and psychiatric illness have been reported. Smets. Guyatt and colleagues (1987) observed that fatigue frequency and importance was high in a sample of 100 people with chronic airflow limitation. 1998b). Ream and Richardson found that people with COPD felt drained of energy. and too tired to plan . Patterns in the frequency and intensity of subjective fatigue during phases of illness were found in people with cancer (Berger.

1999). 1997). Emotionally they felt not in control and frustrated. Distress Results of recent studies support the notion that fatigue causes a considerable amount of distress in the person experiencing it.. 1998). McCorkle and Young (1978) observed moderate and high levels of fatigue distress in 18 of 45 cancer . et al. In a study of 41 people with COPD. In this study subjects also reported a feeling of reduced activity and lower motivation that was greater than in a healthy group. 13 activities. In these studies and a recent qualitative work people with COPD described their subjective feelings of fatigue as "tiredness" that affected them physically. both men and women reported distress associated with fatigue and women were observed to be more distressed than men in terms of their fatigue (Gift & Shepard. People commented on the household activities they were forced to give up because of their fatigue. 1999). But a recent observation by Breslin and colleagues supported the notion that the cognitive element plays a role in fatigue experienced by people with this disease. Importance of the cognitive element of fatigue in people with COPD is not yet clear. Table I summarizes findings on the quality of fatigue in people with COPD. emotionally and socially (Small & Lamb. They grieved over the loss of their previous lifestyle and didn't want to go far from home (Ream & Richardson. Pardue and Ream and Richardson reported that cognitive symptoms of fatigue were less problematic for people with COPD than general feelings of fatigue and its impact. Loss of concentration was less of a problem for people with COPD. Physically they complained of aching in the arms and legs. b. In a study of 104 people with COPD. These results are similar to those found by researchers studying fatigue distress in people with cancer.38) (Breslin. the mental or cognitive element of fatigue correlated with impairment in health-related quality of life (r=.

TABLE I QUALITY OF SUBJECTIVE FATIGUE IN PEOPLE WITH COPD GcncrnI I'iicdncss IMiyslcal Klcnicnt Cognilivc Reduced AcllvKy luiioflonnl Kluincnf Element (Piirduc. 1984) -feelings of general tiredness -less probleninlic -less problcniHiic -decreased exercise tolerance -decreased motivation was most problenuuic anxiety (Ream & -too tired to phin iiclivities -aching in the arms and -less problematic -didn't want to go far from -loss of control Richiirdson. -general feelings of fatigue -greater feeling of reduced -lower niotis'alion in COPD compared to 1998) were higher than in a noi mal activity compared lo normal normal sample snnipic sample (Small & Lamb.. 1997) -exhausted legs than in cancer home -frustration -drained of energy -different in people patients -forced to give up household -grief with COPD than in activities -insecure about leaving home those with cancer (Brcslin ct ill. -feelings of tiredness -labored breathing in -dccreascd ability to -gradual dcclinc in the ability to -irritabilily 1999) -lack of energy conjimciion with concentrate carry out daily activities -different than ordinary fatigue -frustration fatigue -more continuous problem for people with COPD than those with asthma I-" .

social and emotional impact. 2. each symptom may be unique in how it . Small and Lamb in their qualitative study observed a close connection between subjective fatigue and dyspnea with informants feeling that their fatigue was a result of dyspnea (Small & Lamb. McCormick.76) and that dyspnea did not emerge separately from fatigue in cluster analysis. & Hudes. Subjective fatigue and dvspnea Dyspnea is a common symptom in people with COPD and it is possible that it is one of several key stressors that lead to feelings of fatigue.patients. 1990). There is some evidence that dyspnea leads to fatigue. And most recently. Changing patterns in subjective fatigue may occur during phases of illness and on a daily basis. & Williams. In another study Janson . Carrieri. Kinsman and colleagues (1983) measured dyspnea and fatigue frequency in 146 people with chronic bronchitis and emphysema. Gift and Shepard (1999) found that dyspnea and physical symptoms predicted 42% of the variance in subjective fatigue. They found that the two symptoms were highly related (r=. Results of a path analysis suggested that dyspnea intensity influenced fatigue (Moody. In summary.Bjerklie and colleagues reported that 45% of 68 people with lung disease described their dyspnea as fatigue (Janson- Bjerklie. frequent and distressing problem with potential physical. 1986). 1999). previous research on subjective fatigue in people with COPD supports the idea that it is an intense. And Reistein (2001) observed a correlation between fatigue and dyspnea (. Holmes (1989) found that 43% of respondents with cancer reported significant distress from fatigue. Although fatigue frequently accompanies dyspnea.43) in 100 people with moderate COPD. suggesting that dyspnea may lead to fatigue.

Mishima. 1998). 1987. 1995. 1996) in people with COPD. Wijkstra. Prigatano and colleagues (1984) reported a correlation of r = . And fatigue was .. et al. Samet. 1996) and depressed mood and dyspnea intensity (Anderson. 1998). Graydon and Ross (1995) reported a direct influence of symptoms including fatigue on fiinctional performance measured by the Sickness Impact Profile via path analysis. 1992. Gift. Mishima. Kellner. It is possible that anxiety and dyspnea experienced by people with severe disease lead to increases in muscle tension and respiratory rate and ultimately to subjective fatigue (Knebel. Three recent studies provide additional support for the notion that subjective fatigue has a negative impact on functional performance in people with COPD.59 between fatigue intensity measured using the POMS Fatigue/Inertia subscale and functional performance measured by the Sickness Impact Profile (SIP) in a sample of 100 people with COPD. 3. & Pathak. 1994b). & Chambers. 1986. 1999). In addition to the relationship between fatigue and dyspnea. A negative correlation (0. et al. Subjective fatigue and functional performance Subjective fatigue is associated with decreases in functional performance. but it is yet unclear to what extent anxiety and depressed mood are both causes and/or effects of dyspnea. 16 affects the person experiencing it (Guyatt. Townsend. et al. previous research suggests that there are positive relationships between anxiety and dyspnea intensity (Anderson. Plaut. et al.. 1998. Berman. Fatigue was associated with reduction in motivation to carry out activities. Pugsley. reduction in activity and exercise tolerance and had a negative impact on the daily life of the person with COPD (Breslin. Jones.62) was observed between fatigue and functional performance in 22 people with COPD (Leidy & Knebel. & Jacox. 1995.

Negative associations between the intensity of fatigue and the ability to carry out everyday activities were found in people with cancer (Meyerowitz. 1995). et al. Sama & Brecht. 1992). & Grimm. Sparks.. 1997. Dvspnea. & Spears. other symptoms and functional performance Dyspnea intensity has been negatively associated with functional performance in many studies. 1996). In a study by Mahler and colleagues changes in dyspnea intensity. And Reistein (2001) observed that dyspnea predicted functional perfonnance in 100 people with moderate COPD . & Zeng. 4. Hassey Dow. Leidy and Traver (1995) observed that a combination of symptoms including dyspnea significantly predicted functional performance in women and that postwalk dyspnea was a significant predictor of functional performance in men. Weaver and others reported a direct influence of dyspnea intensity on performance of daily activities (Weaver. The frequency of the symptoms of fatigue. Mock. Coulthard-Morris. 1997). 1997). congestion and peripheral . And Schwartz and colleagues reported that subjective fatigue limited social. 1979. dyspnea. Richmond. Negative associations between total subjective fatigue scores and performance were also reported in people with arthritis (Belza. 17 negatively related to functional performance in 100 people with moderate COPD (Reishtein. A negative relationship between subjective fatigue levels and functional performance is also supported by several studies in people with chronic diseases other than COPD. work and overall performance in people with multiple sclerosis (Schwartz. 2001). impairment and effort were associated with change in physical function (Mahler. & Narsavage.

Breslin and colleagues (1998) found a weak correlation be^veen FEVl percent predicted and general fatigue (i=-. Goldstein. 1995. 5. Ross. Kev variables associated with subjective fatigue Although the mechanisms of subjective fatigue are not completely understood there is evidence that many factors contribute to the development of subjective fatigue. 1995. Pardue (1984) observed a correlation (T=-. Webster. 1988). Certain physiological. a. In her dissertation study on a sample of 68 people with COPD. Dirks. 1995. evidence supports a weak association between subjective fatigue and severity of airflow obstruction in people with COPD. 18 sensory complaints together have also been positively associated with impaired functioning in several studies (Graydon & Ross. And most recently. Traver. Graydon. & Avendano. To capture the physiologic factor it would be useful to add measures of other physiologic parameters to characterize the physical status of people with . psychological and situational variables are known to affect levels of subjective fatigue in people with chronic illnesses. The interplay of physiologic processes that are responsible for the general feeling of subjective fatigue might be very complex in people with COPD. Leidy & Traver.32) in 41 people with COPD.43) between the frequency of fatigue and severity of airflow obstruction (FEVl). Schocket. & Covino. 1983. Physiologic To date. Kinsman. Measuring spirometry alone does not capture all physiologic factors. Femandez. Gift and Shepard (1999) found no significant correlation between subjective fatigue and airflow obstruction as measured by FEVl percent predicated in a study of 104 people with COPD.

previous research supports a positive relationship between anxiety and depressed mood (Anderson.52). strength measures. These could include body mass index. in addition to the relationships between psychological factors and symptoms the relationships between psychological factors themselves also need to be considered. There is evidence of a positive association between psychological factors such as anxiety and depressed mood and fatigue in people with COPD. 1997). anemia and COPD. Chen (1986) found that anxiety and depressed mood were independent predictors of fatigue in subjects including people with arthritis. Richmond. 1995. Graydon and Ross (1995) observed that anxiety and depressed mood were highly associated with symptoms including fatigue. Psvchologic According to the theory of unpleasant symptoms. However the comprehensive measurement of the physiologic factors exceeds the scope of this research. & Narsavage. . 1995) with anxiety leading to depressed mood in this population and depressed mood interfering with flmctional performance (Weaver. Moody. & Williams. levels of stress hormones and exercise capacity to get a clearer picture of the total physical status of the person and physiological factors of the person that contribute to the feeling of subjective fatigue. And Gift and Shepard (1999) reported a moderate association between psychological factors and fatigue (i=. In people with COPD. The FEVl percent predicted was used to reflect disease severity. 1990). McCormick. Results of two studies suggest that fatigue may lead to depressed mood in people with COPD (Graydon & Ross. b. 19 COPD.

Traver (1988) observed that sleep difficulty was one of the most frequently mentioned symptoms in people with COPD.depressed mood and fatigue in people with other chronic diseases are well documented in the literature. One study of 55 subjects with emphysema reported significant differences between emphysema subjects and control subjects for disorders of initiating and maintaining sleep and excessive daytime sleepiness (Klink & Quan. 1996). 20 Positive relationships between anxiety. Wysenbeek and associates (1993) reported a positive correlation between anxiety and subjective fatigue intensity (r=. McCorkle & Young. And McCorkle and colleagues observed moderate positive correlations between low mood and fatigue intensity (r=. 1991). Kinsman et al. Sklar. Epstein. Mock and colleagues (1997) found that in people with cancer those with higher fatigue levels reported more anxiety and depressed mood than a group with lower fatigue levels. Positive associations between depressed mood and fatigue were observed in people with arthritis (r=. (1983) found that nearly 53% of subjects reported a high frequency of sleep difficulties.60) in people with cancer (McCorkle & Quint-Benoliel. .47) (Belza. Ahmed. Henke. Silber. 1983. c. Sleep quality Little research was found specifically describing the relationship between subjective fatigue and sleep quality in people with COPD but there is evidence that sleep quality is a problem. 1978). 1982. 1993) and renal failure (Cardenas & Kutner. Riesenberg. Yelin. Leidy (1995) in a literature review of ftinctional performance found that sleep disturbance reported on the Sickness Impact Profile was high across studies of people with COPD. & Gillis. & Ali.34) in people with systemic lupus erythematosus.

experienced by people with COPD.55) between subjective fatigue and insomnia in people with cancer. Mock (1997) reported positive correlations between subjective fatigue and low sleep quality (r=. Damato. Wolfe. Furthermore. 1999). McCorkle and Young (1978) found a significant correlation (r=. Koh. Although . Additionally.54 respectively) in two other studies of people with arthritis (Belza. Garrett. This notion has much support from recent research in healthy people as well as those with chronic illnesses (Gillin. And significant correlations were observed between subjective fatigue and sleep quality (r= . The true relationship between subjective fatigue and sleep quality in this disease remains to be determined. Sandor & Shapiro. 1996). 1995. 1990. Sleep quality may contribute to the subjective fatigue experienced by people with COPD. 21 Subjective fatigue is negatively associated with sleep quality in several chronic illnesses. 1994. Weiner.58 and . Jones and colleagues found in a study of people with artliritis that a group with subjective fatigue reported lower sleep quality with a greater amount of fatigue upon awakening (Jones. Hawley. Summary and conclusion Although some progress has been made. there are significant gaps in knowledge of fatigue in people with COPD. Hauri & Esther. The majority of the studies examining fatigue in people with COPD have been crossectional studies with small sample sizes. 1998. 6. 1996). Sillup.54) in people with cancer. & McMillan. & Calin. Results of qualitative and crossectional studies thus far suggest that fatigue is one of the two most common symptoms. Steiner. Higher levels of subjective fatigue were associated with lower quality sleep in studies of people with arthritis. anxiety and depressed mood. may negatively influence sleep quality. occurs in moderate levels and that it is distressing to those experiencing it. & Wilson. Zammit.

And although people with COPD report difficulties with sleep. To date. Although previous research indicates a relationship between psychological factors such as anxiety and depressed mood and fatigue and dyspnea it is yet unclear whether anxiety and depressed mood lead to or are a result of the symptoms. Evidence exists to support differences between men and women in fatigue frequency.results of one study suggest that fatigue levels in people with COPD are higher than in previously reported healthy older people the sample size of that study was small and results are tentative. . to date no studies have examined the relationship between sleep quality and fatigue levels in people with this illness. Currently there is evidence for negative relationships between subjective fatigue and dyspnea and functional performance but it is yet unknown specifically how these symptoms work to impact the performance of daily activities. results of studies have shown that fatigue and dyspnea are closely related and evidence suggests that dyspnea leads to fatigue in people with COPD. Little is currently known about physiologic factors associated with subjective fatigue in people with COPD but results of previous studies indicate only a weak relationship between fatigue and the amount of airflow obstruction measured by FEVl percent predicted supporting the idea that spirometry alone may not capture the physiologic factors influencing subjective fatigue. intensity and distress.

Design A crossectional. functional performance. Selection criteria Inclusion criteria were: 1. 3. disease severity. gender. employment history. ability to read. An attempt was made to obtain equal numbers of men and women for the study. Demographic variables included age. kidney disease. depressed mood and sleep disturbance. socioeconomic status. smoking history of at least 10 pack years. a diagnosis of moderate to severe chronic obstructive pulmonary disease (FEV. green 23 . Sample A convenience sample of 130 people with COPD was recruited. METHODOLOGY A. correlational design was used for this study. recent health problems and how long participants have been diagnosed with lung disease. understand and fill out forms. less than 70% predicted). dyspnea. medications. 1. B. congestive heart failure. 2. Exclusion criteria included. 4. The study was approved by the University of Illinois at Chicago Institutional Review Board (Appendix A). diabetes and hypertension met inclusion criteria if the disease was under control (only mild symptoms present) by treatment. presence of other major diseases (cancer. height and weight. stroke. Variables studied included subjective fatigue. 2. educational level. 1. liver failure) as determined by a screening question. III. exacerbation of COPD within the previous two months (exacerbation was defined as an increase in respiratory symptoms and sputum that changed in color to yellow. anxiety. age 45 years or older. People with arthritis.

A total of227 recruitment letters were sent. Seventy people from the larger muscle strength study became subjects in this study. Physicians' office volunteers were sent a letter from their physician explaining the study and asking them if they wished to participate. 3. Recruitment strategy Three strategies were used to recruit subjects. participation in phase one of pulmonary rehabilitation within the last 6 months. history of asthma diagnosed by a physician. Data of one subject were not included because stress (the death of the spouse) might influence the responses. 143 individuals inquired about the study and of these 131 met inclusion criteria. Volunteers were recruited from a larger study on respiratory muscle strength currently being conducted by Dr. . Volunteers were also recruited from phase III pulmonary rehabilitation programs. Sixty two people were recruited by letter from pulmonologists. People were not specifically asked about sleep apnea but those who reported a diagnosis of sleep apnea were excluded from the study. Larson. 5. 24 or brown). 2. Interested volunteers called. 4. from pulmonary rehabilitation programs and private practices. One hundred thirty one questiormaires were returned completed. Six people inquired about the study after a presentation to a group of COPD patients. history of Itmg transplant or lung reduction surgery. Potential participants from the larger study were contacted by a letter from Dr. Informational sessions were held for people to describe the study and fliers were made available at the rehabilitation center (Appendix C). Larson (Appendix B) and asked to participate.

Profile of Mood States (POMS). TABLE II V.^RIABLES AND MEASURES Variables Measures for the Variables 1. Dyspnea 2. Subjective fatigue 1. Spirometry . Numerical Rating Scale b. POMS. Dyspnea Scale 3. Depressed mood 6. Instrumentation Table II summarizes the variables and measures for the study.C. Disease severity 4. Sleep quality 7. Functional Performance Inventory 4.Forced expiratory volume in one second (FEVl) percent predicted 5. Numerical Rating Scale b. a. Fatigue-Inertia subscale c. Anxiety 5. Functional performance 3. Chronic Respiratory Disease Questionnaire. Pittsburgh Sleep Quality Index . Depression-Dejection subscale 7. Tension-Anxiety subscale 6. a. Fatigue Assessment Instrument 2. POMS.

the Profile of Mood States. Numerical rating scale A five point numerical rating scale (Appendix D) ranging from 1 to 5 was used to measure the frequency. Fatigue . The Fatigue-Inertia subscale of the POMS broadly measures the intensity of subjective fatigue and was used for comparing subjective fatigue experienced by people with COPD to normative values for healthy older adult. & Droppleman. consequences of fatigue and responsiveness to rest and sleep and was used for characterizing the symptom in people with COPD. One week was chosen for the time frame because it is a long enough time frame for the examination of usual fatigue yet is a short enough time frame for accurate recall. . intensity and distress of the usual subjective feeling of fatigue. a.Inertia subscale(McNair. This is a well established instrument and was used to validate the numerical rating scale. 1993). & Krupp. 1971. not only intensity. Jandorf. Subjective fatigue Three instruments were used to measure dimensions of usual subjective fatigue experienced in the last week: a numerical rating scale developed by the researcher. 1. Lorr. Respondents were asked to describe the feeling of tiredness they have experienced in the last week. 1981. 1992) and the Fatigue Assessment Instrument (FAI) (Schwartz. frequency and distress as described in the theory of unpleasant symptoms and the data from this instrument were used to test the model because it included three dimensions of fatigue. The 3-item numerical rating scale was used to measure the subjective fatigue dimensions of intensity. The Fatigue Assessment Instrument provided a description of specific characteristics of subjective fatigue such as the intensity of fatigue during certain times of the day.

p<. Numerical rating scales are easier and faster to complete than visual analogue scales (Aaronson. p<. It demonstrated divergent validit>. 27 Respondents were asked how often they had felt tired in the past week (ranging from 1 = "not at all" to 5 = "constantly"). 1999. and the POMS Fatigue/Inertia subscale (r=.65.60. Validity of the five-point numerical rating scale for intensity.89 (Table III). The total POMS measures mood disturbance and subscales of the POMS have been used separately . 1998. p<. & Droppleman. The NRS for fatigue demonstrated convergent validity with the FAI Global Fatigue subscale (r=. 1971. b. et al.1992) (Appendix D). The Cronbach's alpha for the 3-item NRS for fatigue used in this study was . Youngblut & Casper. Lorr. p<.Fatigue subscale of the SF-36 (r=. 1999) in a sample of people with COPD.with the POMS Vigor subscale (r=- . 1993). how severe the feeling of tiredness had been (1 = "not at all" to 5 = "extremely") and how much it had distressed or bothered them (1 = "not at all" to 5 = "extremely.001). Internal consistency reliability of the numerical rating scale was examined in this study and construct validity of the 3-item scale were explored by correlation with the POMS Fatigue/Inertia subscale and the Global Fatigue Severity subscale of the Fatigue Assessment Instrument. The three dimension scores were summed for a total subjective fatigue score with a potential range of 3-15.50. Gift & Narsavage.67.001). 1981. Profile of Mood States Fatigue -Inertia subscale Fatigue was also measured by the Fatigue/Inertia subscale of the Profile of Mood Scales (POMS) (McNair.") (Appendix D).001). frequency and distress of fatigue was supported by positive correlations with the Energy .01) (Gift & Shepard.

The total 65-item POMS (Appendix D) was administered.80 Responsiveness to Rest/Sleep 2 . Tension-Anxiety and Depression-Dejection subscales were used in this study. TABLE III FATIGUE INSTRUMENTS Instrument/Subscale/Potential Range # Items Cronbach's Alpha Numerical Rating Scale Fatigue J . 28 as measures of affect. but only the Fatigue-Inertia.89 (3-15) Frequency 1 N/A Intensity 1 N/A Distress 1 N/A Profile of Mood States Fatigue/Inertia 7 .93 (1-7) Global Fatigue Severity 11 .92 Fatigue Consequences 3 .87 (0-28) Fatigue Assessment Instrument 29 . The Tension-Anxiety and Depression-Dejection subscales are described later.87 Note: Raw items used for Cronbach's alpha. .

87 in a study of 479 older adults (Gibson. Subjects are instructed to rate how they had been feeling over the past week on a scale ranging from 1 = "not at all" to 4 = "extremely". 1991). exhausted. The subscale includes the descriptors worn out.. Construct validity was supponed by a strong negative correlation between the POMS Fatigue-Inertia subscale and the Chronic Respiratory Disease Questionnaire Fatigue subscale (r=- . 29 The Fatigue-Inertia subscale of the POMS is a 7-item scale that represents a mood of weariness. Luchetta. & Parmentier. The subscale score is obtained by summing the responses with a potential range of 0 to 28. 1997) and by a strong positive correlation between the POMS Fatigue-Inertia subscale and a visual analogue scale for fatigue (r=. If the numerical . Yamamoto. Also supportive of construct validity is the fact that the POMS Fatigue-Inertia subscale has been used to validate many other measures of subjective fatigue. 1988) and reported Cronbach's alpha of . The plan for this study was to use the POMS fatigue scale for validating the numerical rating scale for subjective fatigue and for comparing levels of fatigue intensity experienced by people with COPD to normative values in healthy older people.72) in 71 people with COPD (Larson. Kaye. bushed. et al. 1997). 1996). low energy level and inertia. 1988. et al. Nyenhuis.. 1997. The POMS Fatigue-Inertia subscale demonstrated high internal consistency reliability in a sample of 505 adults age 65 and over (Kaye. Normative data are available on normal adult and geriatric people (mean age = 68) (Gibson. fatigued. & Ross. 1999). weary and listless. Terrien. Graydon.80) in 43 people on chronic hemodialysis (Brunier & Graydon. sluggish. The total POMS had high intemal consistency in studies of people with COPD (Lee.

multiple sclerosis. Jandorf.70) (Krupp. & Krupp. 1993). and (d)"Responsiveness to Rest/Sleep" (2 items) in a 1 week period. The four factors were identified by factors analysis on 235 people with 7 different diagnoses including a normal control group. lupus erythematosus and psychiatric dysfunction. Schwartz. Jandorf. & Krupp. cold and stress (6 items). It uses a seven-point Likert scale that ranges from 1 = "completely disagree" to 7 = "completely agree". c. 1989. motivation or ability to concentrate( 3 items).87. Muir-Nash. (c)"Consequences of Fatigue" including loss of patience. Schwartz. Internal consistency reliability of the FAI has been supported by Cronbach's alphas ranging firom . & Steinberg. Content validity of the instrument was established by a factor analysis in 235 people with varied diagnoses (Schwartz. 1993)in healthy people and people with diseases including lyme disease. The FAI is a 29-item self-report instrument that assesses the factors (a)"GIobal Fatigue Severity" (11 items). dysthymia. 30 rating scale had been found to lack reliability and validity the POMS Fatigue-Inertia subscale would have been used to examine relationships among the variables instead of the numerical rating scale.. Jandorf.92 and moderate test-retest reliability has been reported (r=. Coulthard-Morris. Most items of this instrument address . chronic fatigue syndrome. 1996. & Krupp. & Zeng. The Cronbach's alpha of the POMS Fatigue-Inertia subscale in this study was . Fatigue Assessment Instrument The Fatigue Assessment Instrument (FAI) (Appendix D) was used to describe characteristics associated with subjective fatigue (Schwartz. 1993).50 .70 -. (b)"Situation Specificity" or sensitivity to circumstances such as heat. LaRocca.

& Chambers. The respondent chose the five most important activities that cause dyspnea. but for this study a one week period was used. Berman. Jandorf. The FAI elicits information regarding antecedents to fatigue and situations or activities that might alter fatigue (Schwartz. Chronic Respiratory Disease Questionnaire (CRQ) The CRQ Dyspnea Scale was employed to measure dyspnea experienced in the last week and was used as a measure of usual dyspnea in the path analysis. 1993). dyspnea. The same five activities identified by each individual were incorporated into the mailed questionnaire (Appendix D). & Krupp. The CRQ was chosen over the NRS for dyspnea for use in the path analysis because it is based on individualized activities and thus it is independent of the total amount of activity the person undertook in the last week. making it appropriate for this research. fatigue. 31 antecedents and consequences of subjective fatigue with one item concerning motivation and one item concerning cognitive functioning. The CRQ is a measure of respiratory symptoms and function that was developed for use with people with COPD (Guyatt. The Dyspnea Scale was originally structured to reflect the intensity of dyspnea experienced in the last two weeks while doing five common activities. Dvspnea a. emotional fimction and mastery but only the Dyspnea Scale was used for this study. The five activities were individualized to the respondent and were chosen firom a list of activities (Appendix D). The instrument scoring includes a Global Fatigue Severity score and subscale scores. 2. It is comprised of four scales. The response scale in the mailed . 1987). Pugsley. Townsend.

The score was obtained by summing the responses to the five items and dividing by 5 to obtain a mean CRQ Dyspnea score. et al. Recent evidence. the Baseline Dyspnea Index. the Oxygen Cost Diagram and the Activity subscale of the St. Covey. Guyatt. et al. Wirtz. CRQ Dyspnea Scale demonstrated approximately the same level of discriminatory power as the modified Medical Research Council Dyspnea Scale. b. Berry. . 2001). Respondents were asked how often they have had shortness of breath in the past week (ranging from "not at all" to "constantly". Reliability and validity of the instrument was supported in a study of 52 people with moderate to severe COPD (Williams. For instance. also supports its use as a discriminative instrument. 1998). The NRS for dyspnea was used to compare fatgue and dyspnea in this study. intensity and distress) was measured using a five-point numerical rating scale in the same manner as subjective fatigue (Appendix D). Wijkstra. A higher score indicated less dyspnea.. 1998. however. Validity and reliability of the CRQ has been supported in many studies of people with COPD (Lacasse. The numerical rating scale has been validated as a measure of present dyspnea in people with COPD (Gift & Narsavage. Recently.. Williams and colleagues developed and tested a self-report form of the CRQ. 32 questionnaire ranged from 1 = "extremely short of breath" to 7 = "not at all short of breath". & Guyatt. Sewell. et al. 1993. 1998). how severe it had been ("not at all" to "extremely")and how much it had distressed or bothered them ("not at all" to "extremely"). Singh. Wong. 1998). & Morgan. that is discriminating between groups of people with COPD in terms of level of dyspnea at the same point in time (Hajiro. & Kim. Numerical rating scale Usual dyspnea (firequency. Larson. Georges Respiratory Questionnaire in 161 people with COPD (Hajiro. 1994a).

Six subscales include Body Care. 1999. 1999). Cantril's Ladder of Life Satisfaction (r=. Recreation.75 to . Physical Exercise.62)and the Physical Activity Scale for the Elderly (r=.61). Subjects respond to each item by indicating how difficult it is for them to perform each activity that they do on a scale ranging from 1 = no difficulty in doing the activity to 4 = activity not performed due to health reasons or n/a if diey choose not to do the activity.61). The FPI also discriminates between people with FEVj greater than and lesser than 1 liter (Leidy.96) and subscales (alpha range . Covey. Leidy &Knebel. This is a 65-item instrument that measures performance of day-to-day activities. Kapella. Duke Activity Status Index (r=. A higher score reflects better functioning. Maintaining the Household. Validity has been supported by correlations of the total score with the Functional Status Questionnaire Activities Scale (r=. 1998).62) in 72 people with COPD (Larson. Basic Need Satisfaction Inventory (r=. 1999) (Appendix D). Functional performance Functional performance was measured with the Functional Performance Inventory (FPI) (Leidy. Wirtz.69) and the American Thoracic Society- Division of Lung Disease Breathlessness Scale (r=-. the Medical Outcomes Study Short Form 36 Physical Functioning subscale (r=.59). Spiritual Activities and Social Interaction.59).63) in a sample of 154 people with COPD (Leidy. Internal consistency reliability was high for the total instrument (alpha = . . 1999).68). Bronchitis-Emphysema Symptom Checklist (r=.93. Table IV). 3. & Berry.and correlations with the total Sickness Impact Profile (i=-.

92 (0-3) Body care 9 .232) (0-60) Depression 15 .82 Recreation 11 .90 Total mood disturbance (-32 .78 Profile of Mood States 65 .86 Physical E. TABLE IV ASSOCIATED VARIABLES INSTRUMENTS Instrument/Subscale/Potential Range # Items Reliability Chronic Respirator^' Disease 5 .83 Maintaining the Household 21 .84 Questionnaire Dvspnea Scale ( 1-7) Numerical Ratina Scale Dyspnea 3 .63 (0-3) Use of Sleep Medication 1 N/A (0-3) Daytime Dysfunction _2 N/A Note.72 (0-21 higher = more difficulty) (0-3) Sleep Quality 1 "N/A (0-3) Sleep Latency 2 N/A (0-3) Sleep Duration 1 N/A (0-3) Habitual Sleep Efficiency 2 N/A (0-3) Sleep Disturbance 8 .81 (3-15) Frequency 1 N/A Intensity 1 N/A Distress 1 N/A Functional Performance Inventory Total 65 .78 (0-48) Anger 12 .86 (0-32) Vigor 8 .\ercise 7 .67 Pittsburgh Sleep Quality Index Global 13 .85 Social Interaction 12 . Raw items were used for the Cronbach's alpha. .79 Spiritual Activities 5 .91 (0-36) Tension 9 .86 (0-28) Confusion 7 .

Dejection (Appendix D) subscales of the Profile of Mood States. For these subjects spirometry was performed within 1 year (either before or after) of completing the questionnaire. Subjects participadng in Dr. One would not expect significant changes in FEV. Independence of the subscales has been demonstrated in several studies (Gibson. 5. 1981) were utilized to calculate percent of predicted noiinal values. Subjects recruited from pulmonary rehabilitation programs and private practices had spirometry testing performed by the investigator during a home visit using a portable spirometer (Medgraphics Breeze SC) that meets ATS criteria. Spirometry was performed on each subject according to standard methods (Society. VaUdity of the total instrument was . McNair. Spirometry equipment used in the home was zeroed and calibrated using a calibration syringe before each subject was tested and all home tests were performed by the same person. 19S9). & Droppleman. The forced expiratoiy volume in one second (FEV.. 35 4. to be observed in one year. 1988. The normative values of Morris and Lane (1981) (Morris & Lane. gender and height of the person. Lorr. 1997. Anxiety and depressed mood Anxiety and depressed mood were measured by the Tension-Anxiety and the Depression . 1971.1981.) percent predicted was used because it takes into consideration the age. Kaye. Disease severit\^ Airflow obstruction was used as an indicator of disease severity and measured by spirometry.1992). et al. Larson's muscle strength study have annual spirometry testing and these data were used for the proposed study.

on edge. & Droppleman. McNair. Appropriate and significant correlations were observed between the POMS subscales and several other mood measures.. 1997). 1997.89 -. terrified. miserable. worthless. helpless. 1971. 1999). sad. psychiatric outpatients and dental patients (McNair.1992). And the instrument discriminated between healthy adults and patients with mood disturbance (Gibson. discouraged.95) in previous studies (Gibson. nervous. Lorr. Lorr. Luchetta. Lorr. 1997).1981. Items include: unhappy. 1984). restless. unworthy. The Tension-Anxiety subscale of the POMS consists of 9 items describing heightened musculoskeletal tension (McNair. lonely. Internal . the Irritability Depression Anxiety Scale and a visual analogue scale (Gibson. 1988. & Droppleman. desperate. &Prochaska. Significant correlations between POMS Tension-Anxiety subscale and indicators of wellbeing were observed . guilty. Kaye. & Droppleman. 1971. Norcross. 1981. 1992). panicky. Concurrent validity was supported by appropriate and significant correlations with the Speilberger State- Trait Anxiety Inventory. & Droppleman. Kaye (1988) observed that a factor analysis yielded a similar anxiet>' factor in 505 older adults as in younger adults. shaky. et al. hopeless. The Depression-Dejection subscale of the POMS consists of 15 items representing a mood of depression accompanied by a sense of inadequacy (McNair. gloomy. anxious. 1981. sorry for things done. Internal consistency was high (r=.1992. multimethod approach (Nyenliuis. 1981. Terrien. blue. Lorr. 1971. 36 supported by Nyenhuis and colleagues who demonstrated convergent and discriminant validity of the POMS subscales in 170 adults over the age of 55 using a multitrait. Yamamoto. 1971. uneasy. Construct validity has been supported in normal adults. & Parmentier. Items include: tense. Gibson reported a similar result with factor analysis in 479 community-dwelling adults age 60 to 98 years. relaxed. 1992). Guadagnoli.

1981. It is a questionnaire consisting of 24 items. & Droppleman. Reynolds. Monk. Kaye (1988) observed that a factor analysis yielded a similar depression factor in 505 adults age 65 and older as in younger adults and significant correlations between POMS Depression subscale and indicators of wellbeing. McNair. 37 consistency reliability has been high (r=. 1997.89 -. A Global Sleep Quality index score higher than 5 indicates poor sleep quality and difficulties with sleep in at least 2 areas (Buysse et al. Kaye. 1971. 1989). Construct validity has been supported by demonstration of concurrent and discriminant validity in adults. & Kupfer. psychiatric outpatients and dental patients (McNair. with higher scores indicating worse sleep quality. 1998) Validity was supported by correlations with known groups and sensitivity to diagnose was 89. & Droppleman. 1997. et al. Sleep Duration. & Parmentier. Luchetta. Scoring produces a Global Sleep Quality score (achieved by summing the seven components) and seven component scores.80 to . 1988.. Items are scored on a 0 to 3 scale with 0 = not during the past month to 3 = three or more times a week. Reynolds. Nyenhuis. Sleep Disturbance. 6. Lorr. Berman.83 in healthy people and several disease populations (Buysse.5% to detect good from poor sleepers (Buysse. 1988. Sleep quality Sleep quality was measured by the Pittsburgh Sleep Quality Index (Buysse. 1989) (Appendix D). Yamamoto. habitual Sleep Efficiency.95) in several studies of adults and older people (Gibson. Lorr.1981. 1989. Carpenter & Andrykowski. This instrument measures subjective sleep quality with 7 components: Sleep Quality. 1971. et al. Sleep Latency. Monk. Kaye. 1999). & Kupfer.. MorJc.. Cronbach's alpha was reported to be overall . Berman. use of Sleep Medication and Daytime Dysfunction. Reynolds. & . 1992) and adults over the age of 55(Gibson. Terrien.6% with specificity of 86.. Herman.1992).

Reynolds. Additionally. 1989. & Kupfer. middle aged (mean = 60 years old) and adults over the age of SO (Buysse. recent health problems and current medications. The five activities were written into the CRQ section of the printed questionnaire that was later mailed to each participant. Potential participants were given a full explanation of the study and the written consent was explained. educational and socioeconomic level (Hollingshead. 1975). Demographics Demographic data (Appendix D) were collected including age. D. 7. the PSQI scores were correlated with measures of sleep quality and sleep problems in several clinical populations (Carpenter & Andrykowski. Procedures The investigator phoned each potential participant. gender. Berman. et al. employment. 38 Kupfer. described the study and acquired phone consent. Monk. Subjects who .. People who agreed to participate were screened using inclusion/exclusion criteria (Appendix G). Buysse. All subjects signed a written consent prior to spirometry testing (Appendix H). Appointments were set during the initial phone call for those requiring spirometry testing. The investigator then administered the first part of the Chronic Respiratory Disease Questionnaire Dyspnea Scale to elicit the five activities during which the person experiences dyspnea during daily activities. A script was used for the initial phone contact (Appendix F). 1998). 1989). Normative data are available for several age groups including young adults. 1991).

Volunteers were given or mailed a packet containing a letter/instructions. In order to prepare the data for analysis. Confidentiality of data was assured by assigning codes to each respondent. individual missing items were examined and assessed for random or systematic qualities. All data collection forms were coded and the list of names and codes were stored separately.8% missing. The POMS had less than 3. Larson's muscle strength study signed a consent that was included as part of their questionnaire packet. Forms with respondents' names such as consents were kept in a file cabinet behind two sets of locked doors. Data Analyses Data were analyzed with descriptive statistics and bivariate relationships were examined with Pearson's correlations using SPSS 11 software (SPSS. Participants were asked to complete the questionnaire in the morning and to indicate the time of day it was completed. After some discussion.3% missing on any item. 2003).6% missing values on the numerical rating scales. The PSQI had no more than 2.3%) had more than 1. the missing data on this item were replaced with 0 as the question asked about .9% missing on any item except for items on the Work/School subscale (which was not used in analysis) and 1 item in the Recreation subscale which had 7. They were asked to retum the packet by mail within one week. 39 were currently enrolled in Dr. On the FAI only one item (2. Outliers were identified by visual inspection of plots and assessed for correct data entry and technical problems. questionnaires and a self-addressed stamped envelope for retum of the completed questionnaires.6% missing. E. And the FPI had no more than 3.9 % missing data on individual items. There were 1. Reliability coefficients were calculated on all variables included in the path model.

FPI and the CRQ Dyspnea Scale missing items were replaced with the mean value of other items on the same subscale. 1996). On the POMS. The structural model was refined until the theoretically based model with the best fit was determined. Statistical assumptions of normality. Simultaneous relationships among variables were tested by path analysis and structural equation modeling (SEM) using AMOS 4 software (Smallwaters. Six percent of respondents could identify 4 or less activities that caused them shortness of breath on the CRQ. 40 hobbies and it seemed that people left it blank if they didn't have any hobbies. linearity and homoscedasticity were tested using histograms. 1995). the incremental fit index (IFI) and the comparable fit index (CFI) (Hoyle. The sample size was 130 allowing 19 subjects per variable in the path analysis (Stevens. FAI. probability plots and residual scatterplots and necessary assumptions were met. Missing items on the numerical rating scales were not replaced. . the normed fit index (NFI). 2003). The fit of the hypothesized model was tested using maximum likelihood estimation. The following fit indexes were used to assess the fit of the hypothesized model: chi-square.

This is followed by descriptive statistics and bivariate correlations for independent and dependent variables. Table V provides funher information about the demographic characteristics of the subjects. Subjects reported a wide range (0-8) of colds or respiratory infections in the previous year with an average of 1. Finally the path analysis is presented. There were no differences between men and women in disease severity.1) (range 13-118). Most subjects were using inhaled bronchodilators (n=105.6 in the previous year. Twenty percent (n=26) were using oral bronchodilators and 14% (n=19) were using oral steroids on a daily basis. RESULTS An overview of sample characteristics is presented.0) (range 16-41). 68 (52.7%) women. 63%). There was no difference between men and women in whether they used bronchodilators and steroids.8(5.3). The mean BMI was 26. Sample characteristics: disease-related Subjects demonstrated a wide range of disease severity with a mean (SD) FEV. 82%) and many were using inhaled steroids (n=81. A. IV.1 (SD =6. Description of the Sample 1. age or number of RTFs in the last year (Table VI). 41 . The mean age was 69. Sample characteristics: Background The study sample consisted of 130 people with COPD. % predicted of 45 (18. 2.3%) men and 62 (47.

6 Housewife 7 5.6 Not working due to another reason 4 3.3 Inhaled steroids 81 63. but working part time 15 11.1 Retired. .1 Medications Inhaled bronchodilators 106 82.7 Housewife but with a part time job 2 1.1 = n=130.ACTERISTICS ^ Variables Number Percent Race White 125 96 Nonwhite 5 4 Education Grade school or less 3 4 High school 50 39 College 70 53 Graduate 5 4 Employment Fulltime 15 12. TABLE V SAMPLE CHAR.5 Not working due to illness 6 4.0 Oral bronchodilators 26 20.3 Oral steroids 19 14.0 Retired 77 58.7 Part time job 4 3.

5 (5.3) B.7 (4. There was a significant correlation between the overall numerical rating score (sum of frequency. the POMS Fatigue/Inertia scale and the FAI Global Fatigue score indicated that the subjects experienced a moderate amount of subjective fatigue in the last week.4) Number of colds in the last year L5 (1. Summary statistics for the fatigue and dyspnea instruments are presented in Table VII. The mean scores on the NRS Dyspnea and the CRQ Dyspnea Scale indicated that subjects experienced a moderate amount of dyspnea in the last week.74. Comparison of Fatigue and Dvspnea Dimensions 1. 43 TABLE VI SAMPLE CR/^RACTERISTICS: DISEASE-RELATED Men (n=68) Women (n=62) Variable M (SD) M(SD) Age 69. intensity and distress) for fatigue and dyspnea (r=0.5 (17.9 (5.7 (6.7) BMI 27. p<.001).6) L8 (1. Overall fatigue and dvspnea The mean scores on the NRS fatigue. % predicted 44. A t-test for paired samples was performed to determine if there was a significant difference between the overall fatigue score and the overall dyspnea .7) FEV.8) 68.6) 25.9) 46.1 (18.

5) Responsiveness to Rest/Sleep 5.001). TABLE VII DESCRIPTIVE STATISTICS.1 (1. The mean score for the overall NRS dyspnea was significantly higher than the mean score for the overall NRS fatigue (p<.6) 8.5(1.9 (2.7(1.2) 2.6(1.1) Questionnaire Dyspnea Scale ( 1-7) Numerical Rating Scale Dyspnea 9. subscales. **p<.9)+ Intensity 2. p<.7) 5.6(2.2 (0.9)* 3.4 (2.4(1.9(1.0) 2.1) 9. women.0(1.6 (0.2) 4.2 (0.6) 9. 1-5) Frequency 3.1(1.4) 11.4 (0.2 (2.7) 3. dyspnea vs.001.9) 3.5 (0.8) 3.4) 4.0 (0.7(1.8)** Distress 2.5(1. 44 score.9) Distress 2.001.1) 3.1 (0.7) 3.05.3) 4.6) 4.5 (2.0) 2.3) 9.8 (0. frequency vs.6 (6.7)** Intensity 3.8) 3.3) Fatigue Consequences 4.6) (total.3(1. distress vs frequency and intensity.4) (0-28) Fatigue Assessment Instrument N/A N/A N/A (1-7) Global Fatigue Severity' 4.3 (0.8) 3.4(1. . fatigue.6(1. -r p<.3(1.8(1.8) Chronic Respiratory Disease 3.4 (2.5) 4.2(1.9) 3. intensity and distress. men vs.1) 2.4(1.2)** (total.4(1. 1-5) Frequency 3.8) 5.1) 2.3-15.7(1.0(1. 3-15: subscales.1)'^ Profile of Mood States Fatigue/Inertia 11.2 (0.0)**^ * p<.5 (0.1 (0.001.7(1. F.5 (6.6(6.5) Situation Specific 4.5) 11.ATIGUE AND DYSPNEA Men Women Total I nstrum ent/S ubscale/Potential Range M(SD) M (SD) M(SD) N=68 N=62 N=130 Numerical Ranng Scale Fatigue 8.4)* 4.

Thirty-two percent agreed that fatigue is their most disabling symptom. Significant correlations were also observed between fatigue dimensions and the number of respiratory. Over 60% of respondents agreed that the fatigue they now experience is different in quality or intensity than the fatigue they experienced before developing this condition (69. . Characteristics of Fatigue Over 70% of respondents reported on the Fatigue Assessment Instrument that they are less motivated when they are fatigued (75. intensit}' and distress of fatigue (p<. Frequency was significantly greater than intensity and distress in both symptoms.001). There was no difference between men and women in the frequency of fatigue and dyspnea or the distress associated with these symptoms but women reported more intense fatigue than men (p=.9%).2%) and rest lessens their fatigue (72. sleep lessens their fatigue (75. Dimensions of fatigue and dvspnea The frequency.tract infections in the last year. intensity and distress of dyspnea were significantly greater than the frequency.2%).02).3%). Significant correlations were observed between fatigue dimensions and age. Correlations are presented for fatigue and illness-related variables (Table X). C. Distributions of NRS fatigue and dyspnea dimensions axe presented in Appendix I.8%) and that cool temperatures lessen their fatigue (68. The bivariate relationships between fatigue and dyspnea dimensions are presented in Tables VIII and IX. 45 2. Distress was significantly lower than frequency and intensity in both fatigue and dyspnea. Sixty-three percent of respondents agreed that fatigue is one of their 3 most disabling symptoms.

22* 0.03 0.23** 0.69** 51 ** TABLE IX PEARSON CORRELATIONS BETWEEN DYSPNEA DIMENSIONS DYSPNE.A. Variable Frequency Intensity Frequency Intensity .63** **p = 0.53** .63** Distress . n = 128. . ** p<.20* 0.000 (2-taiIed).001.31** 0.02 Number ofRTI's 0.17 0.27** in the last year' * p<.07 -0. missing CRQ data on 2 subjects. TABLE X PEARSON CORRELATIONS BETWEEN NRS FATIGUE DIMENSIONS AND ILLNESS-RELATED VARIABLES Frequency Intensity Distress Total Age' 0. 46 TABLE VIII PEARSON CORRELATIONS BETWEEN FATIGUE DIMENSIONS FATIGUE Variable Frequency Intensity Frequency Intensit>' .05.OL *** p<. Note.22* FEV.02 -0. %pred'' -0.20* 0.80** Distress .

05) than for men 6. fatigue and functional performance are presented in Appendix J. 47 Seventy percent of respondents reported their fatigue was not worse in the morning (51.89 (3.01).7) indicating that respondents had quite a bit of difficulty with sleep.2 (3. BMI.9 (9.5) subscales indicate that respondents had higher than normal levels of anxiety and depressed mood. Correlations between subscales of the PSQI and dyspnea. Tlie stepwise regression was repeated in men. Si. Mean (SD) scores for the POMS Tension 9. The mean (SD) score for the PSQI Global Sleep Quality was 6. age. . D. number of chest colds and anxiety to sleep quality in women.4)and Depression 9. No differences were observed between men and women.7 (4. airflow obstruction.2% agreed that fatigue was worse in the aftemoon). suggesting that there may be many causes. The POMS results are presented in Table VIII. Scores for women 7.1) were significantly greater (p< .05). Sleep Quality and Affective States Descriptive statistics for variables associated with fatigue are presented in Table XI and Pearson correlations between the key variables are presented in Table XII. Stepwise regression was performed to assess the relationship of depressed mood. Men agreed that exercise brought on fatigue whereas women disagreed (p=. dyspnea.xty-nine percent of respondents reported that fatigue did not predate other symptoms of their condition. Anxiety and age were the most significant determinants of sleep quality and accounted for 25% of the variability. Men disagreed that stress or depression brought on fatigue but women were neutral (p <.85 (6.1). There were wide variations in responses to questions about what brought on their fatigue. Depressed mood was the only significant determinant of sleep quality in men and accounted for 10% of the variability.

83) 1.5) 9.38) 2.9 (.7 (5.2(3.61) Profile of Mood States 27.8 (.7 (3.52) 1. men vs.7 (5.7) 6.93) .53) 1.2) (0-3) Use of Sleep Medication .38) 2.9 (.0) 1.75(1.7 (30.3 (4.8 (4.89 (.9 (3.88 (.1)* 6.94) (0-3) Sleep Duration .7(1.91 (1.2 (.1) 6.47) / A -JN Body Care 2.57) 1.6) 28.5 (6.0) 10.1) 1.9) (0-32) Vigor 16.0) 1.53 (1.0) 1.34 (.69) * p<.7 (.65) 1.1 (5.71) l.8) 14.8 (.I (.47) 1.8 (.83) (0-3) Habitual Sleep Efficiency .2 (9. women.1(30.7(1.61) Physical Exercise 1.8 (30. .5) (0-28) Confiision 6.05.7 (1.5) 10.71) .8 (.9 (.2) .00 (.55) 1.8 (.47) 1.6) Total mood disturbance (-32 to 232) (0-60) Depression 9.99 (.8 (.7 (.3 (5.7 (.0 (.0 (.8) 30.0) (0-3) Daytime Dysfunction 1.0) 15.7 (9.1) Pittsburgh Sleep Quality Index Global 6.4) (0-48) Anger 7.0) Social Interaction 2.7) ( 0-21 higher = more difficulty) (0-3) Sleep Quality .9) 6.82) 1.3 (6.7(4.4 (5.38) Maintaining the Household 1.0 (.2 (1.66)* 1.9) 9.56) Spiritual .62) 1.0 (.9 (.1 (1.0 (.66) 1.3) 5.88 (.1 (.1) 7.0 (6.58) 1.8 (6.00 (.93 (.84) .Activities 1.9 (9.71) (0-3) Sleep Latency .72) 1.5) (0-36) Tension 9.58) Recreation 1. 48 TABLE XI DESCRIPTIVE STATISTICS: ASSOCIATED VARIABLES Men Women Total Instrument/Subscale/Potential Range M (SD) M (SD) M (SD) Functional Performance Inventory Total 1.7 (.7 (LI)* .

05 1.05.00 Sleep Quality -0.27' 0.20* 0.32*»* Functional Performance * p<. Table XIT PEARSON CORRELATIONS: KEY VARIABLES Age Gender rnv.09 0.50*** 0.20* 0.66*'* 1.03 -0.16 0. ** p<.28* 0.05 -0.00 N R S Fatigue 0.2^1 • • 0.80'•• 1.00 P O M S Fatigue 0.00 -0.03 -0.13 0.46' -0.52' -0.18» 0.00 Body Mass Index ( B M I ) 0.48* • • -0.00 Depressed M o o d 0.69* 1.30*** 0.12 1. pp) 0.00 -0.46* • ' 0.07 1.22* 0.16 -0.20» 0.47* • • 0.20* -0.00 -0.2 ! • 1.00 Respiratory Tract Infection 0.09 -0.09 0.12 0.59*** -0.19* 0.38**» 0.2'l* -0.21* -0.OL p<.06 1.34* • • 0.09 -0.02 0.23* 0.44*»< 0.20* -0.28** 0.00 0.20* 0.19 0.00 A i r f l o w Obslniction ( F H V . pp DMI CRQ NRS POMS NRS Anxiety Depressed RTI Sleep Dyspnea Dyspnea Fatigue I'aligue Mood Quality Age 1.01 -0.00 Anxiety 0.OOL 4^ VO .40*«» 0.03 0.59*** 1.61 0.07 -0.00 Gender -0.00 C R Q Dyspnea N R S Dyspnea 0.24** -0.3P'* -0.07 -0.42' • • 0.09 1.57*** 0.23* • -0.01 0.08 0.21' 0.14 -0.45'^«» 0.74* 0.20* -0.49* • • 1.24» 0.43'•• -0.04 -0.03 0.02 -0.13 -0.

F(3. Twelve of these subjects indicated that they chose not to engage in spiritual activities. p = .% predicted. gender. CRQ dyspnea. F. depressed mood and sleep quality.= .001) revealed that the most significant determinants of subjective fatigue were dyspnea. A MANOVA was performed and demonstrated a significant difference between men and women in social interaction (F (1. number of respiratory tract infections or colds in the past year. 50 E.43. Sixteen subjects (12%) had a mean score of 0 on the Spiritual Activities subscale. dyspnea and depressed mood (R-= 44. Stepwise multiple regression was performed to assess the relationship of symptom and illness- related variables to functional performance. 96) = 24.p<. F(2. anxiety.39. FEV. The most significant predictors of fatigue in men were dyspnea and depressed mood (R-=. The model explained forty-three percent of the variation in subjective fatigue.001).1. Functional Performance The mean(SD) score for the total FPI was 1.4. Independent variables included age. p <.p<. fatigue and sleep difficulty are presented in Appendix K. Stepwise regression was performed to see if the model remained the same when men and women were examined separately.61.5. depressed mood and sleep quality.47) indicating a medium level of functional performance. Correlations between subscales of the FPI and dyspnea.001) and in women were sleep quality. gender. 128) = 7. Summary statistics for the FPI are presented in Table VIII.43)=11. Results of the regression are presented in Table XIII. F (3. Factors Predicting Subjective Fatigue Stepwise multiple regression was performed to assess the relationship of symptom and illness-related variables to subjective fatigue as measured by NRS fatigue. The final model (R.51)= 16. BMI.007) with women reporting more difficulty with social interaction than men.9 (. NRS . BMI. Independent variables included age.

. dyspnea and BMI.67*** Global Sleep Qualit>.% predicted. depressed mood and sleep quality. anxiety. FEV. 51 TABLE XIII FACTORS PREDICTIMG NRS FATIGUE: MULTIPLE STEPWISE REGRESSION = Final step Standardized beta (P) t F (3.5. Results of the regression are presented in Table XIV. * p < .001. .87** R = . Together. ** p < .42 -5. F (4. CRQ dyspnea. p <.001) revealed that the most significant determinants of f unctional performance were NRS fatigue. " Estimates of final model. these variables explained 43% of the variation in functional performance.35*** Depression 0. The final model (R.30 3. 0. sleep quality'. BMI.96) predictor variables coefficients'' CRQ Dyspnea -0. number of respiratory infections or colds in the last year. depression.= . fatigue.35*** 24. 94) = 17.43. CRQ dyspnea.65 R== . gender.23 2.05. airflow obstruction.OL *** p < .41 = Independent variables: age. FEV1% pred.43 Adjusted R-= . anxiety.

depression.49*** FEV. Because BMI was a significant predictor of functional performance in regression it was added to the model but was removed during refinement. The model was refined until the theoretically based model with the best fit was found. starting with the hypothesized model.06** BMl 0.24 2. * p <. anxiety.96*** Dyspnea 0. FEV. CRQ dyspnea. %pred 0. Subjective Fatigue: Final Path Model Path analysis was performed to assess the simultaneous relationships among variables.46 -5. NRS fatigue.01.65 R== . ** p <. *** p < .19 2.08*** 17. The hypothesized model was a good fit whether the numerical rating fatigue scale or the POMS Fatigue/Inertia scale was used.40 ' Independent variables: age. '' Estimates of the final model.05* R = . . G.05.16 2.94) predictor variable beta coefficient ((3) NRS Fatigue -0. sleep quality. gender.43 Adjusted R-= . 52 TABLE XIV FACTORS PREDICTING FUNCTIONAL PERFORMANCE: MULTIPLE STEPWISE REGRESSION ^ Final step Standardized t F (4.001. % predicted.

results indicate that 1. 53 Multicollinearity can be a problem in path analysis if the independent variables demonstrate high correlations. Results of the analysis indicated a fit model with a Chi-square of 9. dyspnea. as depressed mood and dyspnea increased and sleep quality decreased. A total of 42% of the variation in fatigue was explained by dyspnea.421. airflow obstruction and anxiety directly influenced the performance of daily activities. . fatigue.above . To summarize. Levv'is-Beck recommended that to test for multicollinearity each independent variable be regressed on all of the others to test for a high linear dependence among the independent variables (Lewis-Beck. The normed fit index (NFI). The final path model is depicted in Figure 2.0 with 9 degrees of freedom and a probability level of . depressed mood and sleep quality. the incremental fit index (IFl) and the comparable fit index (CFI) were all above . All of the paths were supported by the data. No R.99. 1980). the level of fatigue increased.70 was observed. Therefore. 2. Results of the path analysis are presented in Tables XV and XVI. each independent variable in this study was regressed on all of the others.

20 -.80 .24 -.43 FATIGUE .18 FUNCTIONAL -.39 -. 54 AIRFLOW OBSTRUCTION DYSPNEA .24 SLEEP QUALITY .30 .28 .30 DEPRESSED MOOD Figure 2. Final path model .05 ANXIETY PERFORMANCE -.

55

TABLE XV

PATH ANALYSIS: SUBJECTIVE FATIGUE
AND FUNCTIONAL PERFORMANCE

Subjective Fatigue'" Functional Performance^
Variable Direct Indirect Total Direct Indirect Total

Airflow Obstruction" 0.000 0.000 0.000 0.2] 1** 0.000 0.211

An.xiety' 0.000 0.211** 0.211 -0.180 -0.131** -0.311

Depressed Mood= 0.300*** 0.000 0.300 0.000 -0.090** -0.090

Dyspnea'' -0.387*** 0.000 -0.387 0.241** 0.116*** 0.357

Sleep Quality^ 0.239** 0.000 0.239 0.000 -0.072 -0.072

Subjective Fatigue -0.301** 0.000 -0.301

^ Effects are standardized.
'' Numerical Rating Scale
' Functional Performance Inventory
•' FEVl % predicted
" Profile of Mood States
CRQ Dyspnea Scale
^ Pittsburgh Sleep Quality Index

* p <.05.
** p <.0I.
*** p < .001.

TABLE XVI

SUMMARY OF MULTIPLE REGRESSION IN THE FINAL PATH MODEL

Dependent Variable Independent Variable Path Coefficient

L Dyspnea AnxietS' -0.28**
R-'=.08

Sleep Quality Anxiet>' 0.43*^
R= = .18

3. Subjective Fatigue Dyspnea -0.39***
R^ = .42 Depressed Mood 0.30***
Sleep Quality 0.24**

4. Functional Performance Subjective Fatigue -0.30**
R= = .40 Airflow Obstruction 0.21**
Dyspnea 0.24**
Anxiety -0.18*

* p < .05.
** p <.01.
***p <.001.

V. DISCUSSION

This is the first study to examine fatigue and its antecedents and consequences in a large

group of people with COPD. As expected, subjects reported higher levels of fatigue than did

healthy subjects of a similar age in other studies. Almost one-third of the subjects reported that

fatigue was their most disabling symptom. The level of dyspnea during activities, depressed mood

and sleep quality- directly influenced fatigue. Of the study variables, fatigue had the greatest direct

influence and dyspnea had the greatest total influence on the performance of daily activities. This

chapter includes discussion of the findings, limitations of the study, and suggestions for future

research.

A. Discussion of the Findings

1. Characteristics of subjective fatigue

Fatigue was a common and major problem for the subjects in this study. Subjects

reported that fatigue was one of their three most disabling symptoms and in many cases their most

disabling symptom. These results are consistent with the findings of ICinsman and associates

(1983), Janson-Bjerklie and colleagues (1986), and Gift and Shepard (1999): that fatigue is the

second most prevalent symptom in people with COPD.

Since just about everyone experiences fatigue periodically it is difficult to know whether

subjects in the study were more fatigued than healthy subjects in other studies. In this study fatigue

intensitj', which was measured with the POMS Fatigue/Inertia scale, was greater tlian previously

reported for older healthy adults and similar to subjects with other chronic illnesses such as

rheumatoid arthritis, lupus erythematosus, multiple sclerosis and subjects with psychiatric

illness (Table XVII). Previous researchers (Kaye, et al, 1988; Nyenhuis, Yamamoto, Luchetta,

Terrien, & Parmentier, 1999) reported POMS Fatigue/Inertia mean scores of 5.0 to 6.9 in healthy

57

Prigatano. 1989b). & Steinberg. Krupp et al.0 (Norcross. Nyenhuis. observed similar levels of fatigue on the Multidimensional Assessment of Fatigue scale in 133 subjects with rheumatoid arthritis. Muir-Nash. Fatigue intensity as obser\'ed on the Fatigue Assessment Instrument Global Fatigue subscale in this study was similar to previous repons of fatigue intensity in subjects with multiple sclerosis and lupus erythematosus (Table XVIII). 58 illness (Table XVII). & Parmentier. reported similar fatigue levels in people with systemic lupus erythematosus and multiple sclerosis (Krupp. & Levin. Luchetta. McNair and colleagues also observed moderate fatigue levels in male and female psychiatric outpatients using the POMS Fatigue/Inertia subscale (McNair et al. . 1984. Guadagnoli. 1984). Using a numerical rating scale Gift and Shepard observed higher levels of fatigue intensity. In previous studies of smokers and subjects with COPD. and distress in women with severe COPD than in men with severe COPD (Gift & Shepard. et al..0 to 6. LaRocca. Results of the current study are consistent with studies that found higher POMS Fatigue/Inertia scores in people with COPD and other chronic illnesses. 1981. Subjects in the current study had less severe COPD. so it is possible that differences between men and women become evident as the disease progresses. The difference between the fatigue intensity observed in subjects in this study and that observed in healthy subjects could be clinically significant. Previous researchers (Kaye. Belza et al. frequency. One explanation for this might be that subjects cannot differentiate between frequency and intensity of fatigue. Fatigue frequency and intensity were closely associated.9 in healthy older adults. 1999) reported POMS Fatigue/Inertia mean scores of 5. 1992 1992). 1999). 1988. Terrien. Wright. Yamamoto. & Prochaska.0 to 10. Because of its nature. researchers reported scores of 9. 1971. There were minor differences between men and women for fatigue.. but the difference was small and probably not clinically important.

Loi r.4) 7.0) DEPRIiSSED 8.4 (Nyenluiis.0 (5.2 (7.7) 8.3) 9.3) .1992 1992) Parmentier. Terrien. 1988) Luchetta. 1984) (Norcross.42) 8. 1999) Droppleman.4 (6.9 (5. Yamamoto.9 (5.6) 6. & = 83.0 (4.7) 10. 1981.68 (6.8 (10..7) 6.26) 7. Wright.9) 6.97 (8.4) 6.01(7. TABLE XVII COMPARISON OF POMS SCORES WITH NORMS POMS ADULT OLDER PEOPLE GEIUATUIC SAMPLE ADULT PSYCHIATRIC ADULTS WITH SMOKIZRS NORMS N=505.8) 10 9.9) 10.9) 9 9.3 Droppleman.10(12.13 (7.6 (3. mean age = 39.20) Procliaska. & (McNair.82 (8. 1971.89 (6.5) 8. mean age N= 170. 1971.9 (7. Giiadagnoli & (pp23) 1992 1992) (P.5) 12 11.8) 6.4) 5.2(10. (Prigatano.3) 7. et al.9) 4.70 (6.3 (5.7(9.2) 4. & & Levin. mean age = 68 OUTPATIENTS COPD^ N=941 N=298 (McNiiir.0(7. 1981.2 (8. (Kaye. Lorr.8) MOOD TENSION 9.97(11. 1984) Men Women Men & Women Men Women Men Women Men Women Men & Women M(SD) M(SD) M(SD) M(SD) M(SD) M(SD) M(SD) M(SD) M(SD) M(SD) FATIGUE 7.6) 8.3(8.

0(1. HEALTHY CHRONIC DISEASES" MULTIPLE LUPUS COPD ADULTS SCLEROSIS ERYTHMATOSUS N=I30 N=37 N=I98 N=40 N=47 M (SD) M (SD) M (SD) M(SD) M(SD) GLOBAL FATIGUE 4.4) 5. chronic fatigue.2) 4.1) 4. multiple sclerosis. o .0(1.2 (1.5(1.5) 2.3(1.5) 5.9(1.8) 5.6) 5.5) 5.8) OR SLEEP PSYCHOLOGICAL 4.6(1.1 (K4) 4.3(1.5) 5.2) 5.4) 5.5(1. dysthymia.1) 4.0(1.6(1.5(1.5(1.9) 5. o.2) SPECIFIC RESPONSIVE TO REST 5.2(1.3 (L3) 4.6) CONSEQUENCES " (Schwartz el al. 1993) chronic diseases include l^'nie disease.0 (L4) 5. TABLE XVm COMPARISON FAI SCORCS: PREVIOUS STUDY » WITH CURRENT STUDY CURRENT STUDY.6) SEVERITY SITUATION 4. pos" e chronic fatigue.3(1.2(1.1 (1. syslcmic lupus erythematosus.

It is not surprising that people with COPD would respond in this manner because in COPD. Schwartz. Interventions that incorporate pacing of activities in COPD may help ameliorate both the dyspnea and fatigue. dyspnea probably has the greatest effect on other symptoms. and it was associated with other disease symptoms and mood. Lou. whereas dyspnea is episodic and associated with activity' in COPD. Oken. subjects in the current study reported that work brought on their fatigue. 1996).fatigue may be more constant and pervasive. 1978. or with pain. Coulthard-Morris. & Nutt. Several other differences in fatigue v/ere observed between COPD and the other chronic illnesses. & Coryell. The fatigue of COPD was similar to that experienced by people with MS and rheumatoid arthritis in that cool temperatures lessened fatigue. Kraft. 1996. as in MS.. However. Fatigue in this group of subjects with COPD appears to be tliat of exertion. 1995. Sexton. Unlike subjects with MS. Characteristics of fatigue in this group of subjects with COPD were similar in some ways to people with other chronic illnesses but different in other ways. & Zeng. et al. 1984). Huyser. 1998. 2001. more than fatigue. et al. but subjects with COPD were neutral on whether fatigue made other symptoms worse. as in rheumatoid arthritis.. who reported that heat brought on their fatigue (Freal. Petajan. instead of being associated with neurological symptoms. Keams. People with MS responded that fatigue made other symptoms worse. fatigue in COPD was closely associated with dyspnea during activity. People with COPD may tire more easily during work-related activity because they decrease their activity level to avoid dyspnea and consequently become deconditioned. especially depressed mood (Belza. it was experienced more in the afternoon than in the morning. In COPD and other chronic illnesses fatigue was associated with other symptoms and functional performance. . Hart.

This response was also not unexpected. Sleep quality Subjects in this study reported low sleep quality compared to healthy adults over the age of 50 (Buysse et al. Interventions that help people manage dyspnea during these daily activities may help control fatigue levels. Woo (2000a) reported that dyspnea explained 26% of the variability in fatigue in a sample of 39 people with COPD.51) and a lack of energy question on a numerical rating scale (beta = . Factors directly related to subiective fatigue a. This is consistent with previous studies of smaller samples. In a path analysis. Lastly. not fatigue. Buysse et al. Moody and colleagues observed a direct influence of dyspnea severity on fatigue (beta=. using the SF36 Energy/Fatigue subscale (beta=. 1989. Gift and Shepard reported that dyspnea was a significant predictor of fatigue measured two ways. 2. Carpenter & Andrykowski. 1998). 62 People with systemic lupus erythematosus reported that fatigue predated other symptoms. Fatigue may become more prevalent as the disease progresses and as dyspnea experienced with activities increases. b. People with COPD who experience dyspnea during daily activities may become fatigued as their problems with dyspnea increase.47) in 45 people with COPD (Moody. 1990). McCormick. Dvspnea Dyspnea had the largest direct effect on fatigue. 1999).. but subjects with COPD and MS disagreed that fatigue predated other symptoms. 1991.. & Williams. people with lupus erythematosus reported that fatigue was their most disabling symptom but those with COPD and MS disagreed that fatigue was their most disabling symptom. Results of this study support the idea that dyspnea has a greater total effect on the performance of daily activities in COPD than fatigue has. One explanation for this variation is that in COPD dyspnea is the first symptom that is noticed.20) (Gift & Shepard. .

1984. Traver. Leidy & Traver. Larson. women reported lower sleep quality and greater use of sleep medications than men. Hart (1978) found that people with lower mobility reported more sleep interruptions and higher levels of . In the present study only 41% of the respondents would be considered "good" sleepers. Wright.50. Also Smith and colleagues observed significantly higher ratings of sleep disturbance in women than in men (F(l. found that nearly 53% of subjects with COPD reported a high frequency of sleep difficulties (Kinsman. & Levin. Parkinson's disease. 1989. responses concerning sleep on the Sickness Impact Profile were high across studies of people with COPD (Prigatano. 1983).02) in 153 people with Parkinson's disease and their spouses (Smith. Wirtz. 1988. Jones. 1995). Baveystock. Traver (1988) observed that sleep difficulty was one of the most frequently mentioned symptoms in people with COPD. Also. 1997).. Researchers reported significant differences between subjects with COPD and healthy controls for disorders of initiating and maintaining sleep and excessive daytime sleepiness (Klink & Quan. In previous studies. Kapella.400)=5. & Littlejohns. Findings are consistent with research in several other chronic illnesses. & Oertel. 1998. The finding of low sleep quality is consistent with previous findings in people with COPD Kinsman et al. These findings are consistent with Klink and Quan (1991) who observed a higher prevalence of sleep complaints in women subjects with asthma and chronic bronchitis. & Berr}'. Covey. This is the first report of a direct relationship between sleep quality and fatigue in people with COPD. 1991). Ellgring. p=. et al. The observed gender differences for sleep quality in the present study are consistent with previous research in subjects with COPD and subjects with another chronic illness.Buysse and colleagues (1991) found that 68% of healthy older subjects had PQSI global scores in the range of "good" sleepers (less than or equal to a score of 5).

Interventions that incorporate sleep hygiene tailored to individual needs could be beneficial in managing fatigue. Garrett.54. Reishtein found an inverse relationship (r=-0.27) between fatigue measured with a visual analogue scale and functional performance measured with the FPI in people with COPD (Reishtein. Jones and colleagues found that people with arthritis reported lower sleep quality with a greater amount of fatigue upon awakening (Jones. (Leidy. 1995. Hawley. 1999. The relationship between sleep quality and fatigue in COPD warrants further study. Fatigue demonstrated a strong direct effect on functional performance in this study. c.. Steiner.fatigue in a study of 335 patients with multiple sclerosis. Not surprisingly. Scores were consistent with FPI scores from other studies of people with COPD (Larson et al. Results of this study suggest that people with COPD who report problems with fatigue should be assessed for difficulties with sleep. 2001). 1998). & Wilson. Likewise.0001)in people with COPD (Graydon et al. Reishtein. 2001). 1995). respectively) in two other studies of people with arthritis (Belza. Graydon and colleagues observed a significant correlation between fatigue frequency during breathing problems measured with the Bronchitis- Emphysema Symptom Checklist and functional performance measured with the Sickness Impact Profile (r=0. Wolfe. More recently.65. Belza . p<. the highest fiinctional performance was observed on the Body Care subscale and the lowest was observed on the Physical Exercise subscale. 1996). Functional performance Subjects reported a moderate level of functional performance on the Functional Performance Inventory (FPI).58 and . Koh. significant correlations were observed between sleep quality and fatigue (r= .. and this is consistent with other repons that fo\ind significant relationships between fatigue and performance in people with chronic illnesses. & Calin. 1996).

73 respectively between a latent variable including pain and fatigue and self-reported physical and role and social functioning. 2002). & Narsavage. The relationship of dyspnea with functional performance in COPD is a robust finding consistent across studies of COPD subjects regardless of the instrument used to measure function. Testing a structural model of symptoms and function in 225 older adults. & Glaser.40) on functional status measured using the CDAT (Moody. Weaver and associates reported a strong direct relationship (beta = . Moody and colleagues reported that dyspnea severity had a strong direct effect (beta = -. Richmond. Reishtein found an inverse relationship between dyspnea and functional performance (r=0. Also. 1990). One possible explanation for the relationship between dyspnea and functional performance is that people with COPD experience dyspnea with activity and therefore may limit . & Williams. 2001). 1997). They suggest that interventions that affect fatigue could help increase the level of functioning in people with COPD. 1995).reported significant correlations (r=.56) between fatigue distress as measured with the Muhidimensional Assessment of Fatigue instrument and function in a sample of people with rheumatoid arthritis (Belza. Findings are in agreement with Bennett and colleagues who observed that fatigue along with pain strongly predicted functioning in older adults with a variety of illnesses (Bennett. Kayer-Jones. Results support the theory of unpleasant symptoms which postulates a mediating influence of symptoms on the performance of daily activities. Stewart.51) (Reishtein.50 and -. they reported standardized path coefficients of -. McCormick.32) between dyspnea and functional status using the Pulmonary Function Status Scale (Weaver. Similar to the current study they found that symptoms mediated the relationship between disease severity and functional performance.

Also. 1995). 1991). Graydon. Paul. exercise training could help decrease dyspnea by conditioning and desensitizing the person to the sensation of dyspnea (Carrieri-Kohlman. This may clarify the observations of Reishtein (2001) who previously observed no significant relationship between sleep quality and functional performance. Amount of airflow obstruction was directly related to functional performance. Anderson found a significant influence of airflow obstruction on functioning in 126 subjects with COPD (Anderson. For instance. 1996a: O'Dormell. 66 performance of actiA'ities to avoid dyspnea. One possible explanation for the difference in results could be that both of these studies used the Sickness Impact Profile to measure fimctioning. Graydon. No direct relationship was observed between sleep quality and functional performance. Douglas. & Stulbarg. & Ross. Gormley. 1995). Goldstein and Avendano. Weaver et al. This result is consistent with findings of previous studies in COPD. Two studies reported weak or non-significant influences of airflow obstruction on functioning in subjects with COPD (Leidy and Traver. Samis. (1997) observed that airflow obstruction had an indirect influence on functioning through exercise capacity. Finally. McGuire. But there was a direct relationship between sleep quality and fatigue which in turn influenced functional performance. . 1995). Current results suggest that sleep quality is important to performance of daily activities through its relationship with fatigue. Webster. Lee and colleagues found that airflow obstruction and symptoms (mainly dyspnea) accounted for 57% of the variance in level of functioning (Lee. Interventions that help people manage dyspnea during physical activity may lead to increased functional performance. Ross. 1995. & Webb. In that study sleep quality was measured with the PSQI and functional performance was measured with the FPI in people with COPD.

Chen (1986) found that depressed mood was an independent predictor of fatigue in people with COPD. Epstein. Recently. & Ali. Riesenberg. Anxiety Level of anxiety in this group of people with COPD was higher than that level reported for healthy elderly (Kaye et al. .. Silber. Lou and colleagues observed that depressed mood correlated with all dimensions of fatigue except physical fatigue in people with Parkinson's disease (Lou. 1999. The levels of depressed mood were higher than those reported previously in healthy older people (Table XVII). Sklar. 1993) and renal failure (Cardenas & Kutner. 1999) but similar to levels reported for other groups with COPD (Gift & Shepard. Kellner. & Nutt. Nyenhuis et al. Graydon and Ross (1995) observed that negative mood was associated with symptoms including fatigue. 2001). Moody and colleagues reported a significant positive relationship between depressed mood and fatigue (Moody. 1996). 1988. & Gillis.. 3. Sexton. 1982. Results of the current study suggest that depressed mood leads to fatigue. 67 d. 1990). McCormick. Henke. Keams. Similar relationships have been observed in people with other chronic illnesses. Positive associations between depressed mood and subjective fatigue were reported in people with arthritis (Belza. & Pathak. Oken. Samet. but it is also very possible that there are similar underlying mechanisms for depression and fatigue or tliat the combination of symptoms in COPD cause depressed mood. Ahmed. 1992). Factors indirectly related to subjective fatigue a. Studies using non-recursive path analyses may help clarify the relationship between fatigue and depressed mood. Depressed mood Subjects reported fairly high levels of depressed mood that were associated with fatigue. & Williams. Yelin. Results are consistent with those of previous researchers who reported a close association of depressed mood with fatigue.

Sandor & Shapiro. 1993).66) (Anderson. Zammit. 1990. Anxiety had an indirect influence on fatigue. Previous researchers have reported similar results.). which found a positive relationship between anxiety and depressed mood (r=. 1995) with anxiety possibly leading to depressed mood (beta = .Results are consistent with previous research in people with COPD. Weiner. Leibovici. Airflow obstruction The lack of significant correlations between airflow obstruction and fatigue is not surprising. & Guedj. Damato. & McMillan.. 1993. 1999). sleep qualit}'. In the current study anxiety had a strong direct influence on sleep quality.. Wysenbeek and associates reported a positive correlation between anxiety and subjective fatigue intensity (r=. Wysenbeek. Breslin and colleagues (1998) found a positive . Chen (1986) found that along with depressed mood. anxiety was an independent predictor of fatigue in people with chronic illness. 1997). but is consistent with previous research in healthy people and those with chronic illnesses (Gillin. The direct negative relationship observed between anxiet}' and sleep quality has not been reported in COPD.43) with forced expiratory volume in one second ( FEV. The relationship between anxiety. Although this is a new finding it is consistent with previous research. 1994. Hauri & Esther. women with COPD have reported higher anxiety levels than men in previous research (Gift & Shepard. Weinberger. .696) (Weaver et al. Although there was not a significant difference between men and women in anxiety levels in this study.34) in people with systemic lupus erythematosus (Wysenbeek et al. and fatigue is consistent with the theor\' of unpleasant symptoms which suggests that the relationships among all 3 factors may be interactive. 1998. 1999). Sillup.Assessment and treatment of anxiety especially in women with COPD may help lessen fatigue levels by promoting better sleep qualit>^ b. Pardue (1984) observed correlations between the frequency of fatigue and severity of airflow obstruction (r= -.

B. An important contribution is the observation that fatigue in COPD shared characteristics with fatigue in other chronic illnesses. New information about characteristics of fatigue. intensity and distress and their sum. percent predicted and general fatigue (r=-. C. Gift and Shepard (1999) found no significant relationship between subjective fatigue and airflow obstruction as measured by FEV. A third limitation was the marginal reliability of the PSQI. Although the number of chest colds or respiratory infections did not contribute uniquely to fatigue when stepwise regression was conducted they may still be important factors that contribute to fatigue and merit further consideration. depressed mood. Contributions to Knowledge This study used the theory of unpleasant symptoms to study fatigue in COPD. and the impact of fatigue in COPD were revealed. Findings support the idea that spirometry alone does not capture the physiologic factors influencing subjective fatigue. such as an association with other symptoms. The number of chest colds or respiratory infections in the last year significantly correlated with fatigue frequency. percent predicted. and sleep quality. so the results of this study provide valuable information regarding fatigue in this population.32) in 41 people with COPD. Nevertheless. factors that contribute to fatigue. as noted earlier. . A second limitation was that it would have been useful to compare fatigue characteristics in people with COPD with those in healthy people. Limitations The major limitation of this smdy was its cross-sectional design. However. The findings highlight the unique association of fatigue with dyspnea during activities. previous research on fatigue in people with COPD is limited. 69 correlation between FEV. NRS fatigue.

D. and psychologic factors influence the level of subjective fatigue. Examining the relationship of physiologic factors such as exercise capacitv'. Recommendations for future research follow: 1. gender differences in fatigue models may exist and should be explored. It would be helpful to compare fatigue in healthy older people and people with COPD in a future study. and aaxiety had a major impact on sleep quality. sociologic. Future Research This was an introductor>' study on subjective fatigue in people with COPD. Future researchers should explore the relationship between anxiety and other factors that may influence sleep quality in COPD. Less than half of the variance in fatigue was accounted for by the variables in this study. so it is probable that other physiologic. because there were differences betv/een men and women in some of the variables in the path analysis. 2. could allow for the development of a more complete model in people with COPD. Sleep quality was a significant problem for subjects in this study. strength and endurance and sociologic factors such as social support with fatigue. . The observation of significant relationships between anxiety. which suggests the need for future research in this area. Another important contribution is the finding of a strong direct influence of fatigue on the performance of daily activities (functional performance). Also. 4. Additional research could clarify the role of the frequency and duration of exacerbations as factors contributing to fatigue levels in people with this illness. 3. Findings of this study suggest a need for further research on symptoms in people with COPD. There was a positive relationship between the number of exacerbations and levels of fatigue in this study. sleep quality and fatigue represents a unique contribution to the literature.

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81

APPENDICES

APPENDIX A

UNIVERSITY OF ILLINOIS
AT CHiCAGO

Office for ihe Protection of Research Subjects (OPRS)
Office of the Vice Chancellor for Research (MC 572)
203 Administrative Office Building
1737 West Polk Street
Chicago, Illinois 60612-7227

Approval Notice
Initial Revie \Y - Expediteti Review

July 7, 2000

Mary Kapella, MS, R
Visiting Research Specialist
Medical Surgical Nursing (M/C S02)
226 NURS
phone: 312-996-9542
fax: 312-996-4979

RE: Research Protocol #2000-0502
"Subjective Fatigue, Associated Variables and Performance in People with Chr
Obstructive Pulmonary Disease"

Dear Ms. Kapella:

Members oflnstituiional Review Board (ERB) S2 conducted an initial review and approved y
research under expedited review procedures on June 29, 2000. Your research meets the criit
for expedited review as defined in 45 CFR 46.110(b)(1) under the following specific categori

(4) Collection of data through noninvasive procedures (not involving general anesthesia or sedation) routinely
employed in clinical praclicc, excluding procedures iivolving x-rays or microwaves. Where medical devices an
employed, they must be cleared/approved for marketing. (Studies intended to evaluate the safety and efTcciivem
the medical device are not generally eligible for expedited review, includmg studies of cleared medical devices
new indications )

(7) Research on individual or group characteristics or behavior (including, but not limited to, research on
perception, cognition, motivation, identity, language, communication, cultural beliefs or practices, and social
behavior) or research employing survey, interview, oral history, focus group, program evaluation, human facton
evaluation, or quality assurance methodologies.

You may now begin your research. Please note Ihe following information about your approv
research;

UlC
Phone (312) 996-1711 • Fax (312) 413-2929 • http://www.uic.edu/depts/over

Information from this study will be treated confidentially. If you decide to participate in the study you will participate in a brief phone interview and complete a questionnaire that asks about your symptoms and activities. You would be asked to complete it within a week of receiving it and mail it back in a postage paid envelope. The questionnaire would take about 40 minutes or less to complete.00PM. J. its cause and its effect on people is not fully understood. Thank you for your time and help. RN . For more information please contact Mary Kapella MS. Names and addresses will not be given to anyone. shortness of breath and their effect on daily activities of people with lung disease. doctoral candidate. This information will be used to design new treatments for people with fatigue. Sincerely. RN Associate Professor Doctoral Candidate . Janet L. Monday through Friday. But the specific nature of this tiredness. 84 APPENDIX B RECRUITMENT LETTER. We are writing to ask for your help with a dissertation research study of fatigue or tiredness in people with emphysema and chronic bronchitis. Larson. We are studying fatigue. Results of the study will be used to develop ways of managing fatigue for other people with lung disease. Kapella MS. We would be most happy to answer any questions you might have. RN Maiy C. The questionnaire will have an identification number. Ph D.LARSON Date Name Dear : Tiredness or fatigue is a problem for people with emphysema and chronic bronchitis. (312) 996-9542 from 9AM to 4. You are one of a small group of people (150) who are being asked to participate in this study. You may receive a summary of the results of this study for your own information.

Results of the study will be used to develop ways of managing fatigue for other people with lung disease. It would take about 5 minutes to complete and could be done during a home visit that would last about 30 minutes in total. Being a subject would mean that you would have a simple lung fiinction test (spirometry) that would be done in your own home or in our office if you prefer. Mary C. Kapella MS. what causes it and how it affects people in daily life is not yet fully understood. The questionnaire would take about 45 minutes or less to complete. This type of information is needed to develop ways to prevent the day-to-day difficulties that many people with lung problems have. Names and addresses will not be given to anyone. (312) 996-9542 from 9AM to 4:00PM. causes and daily activities of people with lung disease. RN Doctoral Candidate . Information from this study will be treated confidentially. Monday through Friday or (815) 727-3104 evenings & weekends. You may receive a summaiy of the results of this study for your own information. The questionnaire will have an identification number. Sincerely. You would complete a questionnaire that asks about your symptoms and activities. We would be most happy to answer any questions you might have. RN . 85 APPENDIX B (continued) RECRUITMENT LETTER. This study looks at symptoms. Dr. This tiredness. You would be asked to complete it within a week of receiving it and mail it back in a postage paid envelope. Thank you for your time and help. You are one of a small group of people who are being asked to be involved in the study. doctoral candidate. For more information please contact Mary Kapella MS. PHYSICIAN Date Name Address Dear Tiredness or fatigue is a problem for people with emphysema and chronic bronchitis. We are writing to ask for your help with a research study on fatigue or tiredness in people with emphysema and chronic bronchitis. All activities involved in the study are free of charge.

You are one of a small group of people who are being asked to be involved in the study. RN Director Doctoral Candidate . This tiredness. PULMONARY REHABILITATION Date Name Address Dear : Tiredness or fatigue is a problem for people with emphysema and chronic bronchitis. This study looks at symptoms. The questionnaire would take about 45 minutes or less to complete. We would be most happy to answer any questions you might have. Kapelia MS. (312) 996-9542 from 9AM to 4:00PM. RN . Results of the study will be used to develop ways of managing fatigue for other people with lung disease. This type of information is needed to develop ways to prevent the day-to-day difficulties that many people with lung problems have. causes and daily activities of people with lung disease. You would complete a questionnaire that asks about your symptoms and activities. Name Mary C. Thank you for your time and help. You would be asked to complete it within a week of receiving it and mail it back in a postage paid envelope. For more information please contact Mary Kapelia MS. Monday through Friday. what causes it and how it affects people in daily life is not yet fully understood. Sincerely. 86 APPENDIX B (continued) RECRUITMENT LETTER. Being a subject would mean that you would have a simple lung function test (spirometry) that would be done in your own home or in our office if you prefer. Information from this study will be treated confidentially. All activities involved in the study are free of charge. It would take about 5 minutes to complete and could be done during a home visit that would last about 30 minutes in total. You may receive a summary of the results of this study for your own information. We are writing to ask for your help with a research study on fatigue or tiredness in people with emphysema and chronic bronchitis. doctoral candidate. Names and addresses will not be given to anyone. The questionnaire will have an identification number.

Monday thru Friday. This will take about 1 hour of your time. or (815) 727-3104. WHO DO I CALL: Mary Kapetla MS^ /?N. . doctoral candidate^ (312) 999-9542^ SAM to 4:30PM. 87 APPENDIX C RECRUITMENT FLYER VOLUNTEERS NEEDED FOR A RESEARCH STUDY: "Fatigue^ Other Symptoms and Activities in People with Lung Disease" University of Illinois at Chicago College of Nursing WHO CAN VOLUNTEER: # people with emphysema or chronic bronchitis age 45 and over WHArS INVOLVED: You will have a simple lung function test (spirometry) and complete a questionnaire. evenings & weekends.

Kapella. Larson. RN University of Illinois at Chicago . Associated Variables and Performance in People with Chronic Obstructive Pulmonary Disease Questionnaire Mary C. RN. Doctoral Candidate Janet L. MS. PhD. 88 APPENDIX D ID Date Time Subjective Fatigue.

please return it to us in the stamped envelope provided. Thank-you for your participation. General Instructions: 1. 6. Below are the general instructions for it. Please take your time and don't rush when you are answering the questions. but we ask that you finish it within a week and return it. 7. 3. Remember that there is no right or wrong answer. Read each question careflilly and give us your best answer. 4. Please write in your name and the date and time you started the questioimaire. Specific instructions are provided at the top of each part of the questionnaire. If you have questions about this questionnaire please call Mary Kapella at (312) 996-9542 or (815)727-3104. . When you have finished. Please complete the questionnaire in order. 2. When you have finished the questionnaire and checked it. 5. 8. This information is confidential and we will not identify you or share your answers with anyone. please go back and check each page to make sure that none was missed. 89 APPENDIX D (continued) Dear Study Participant: Thank-you for agreeing to complete this questionnaire. The entire questionnaire does not have to be completed in one sitting.

90 APPENDIX D (continued) Please describe your symptom patterns over the last week. How often have you had each of the following symptoms over the last week? Not at all Rarely Occasionally Frequently Constantly Shortness of 1 2 3 4 5 breath Fatigue or 1 2 3 4 5 tiredness How severe were vour svmotoms over the last week? Not at all A little Moderately Quite a bit Extremely Shortness of 1 2 3 4 5 breath Fatigue or 1 2 3 4 5 tiredness How distressed or bothered were vou over the last week as a result of the followina symptom? Not at all A little Moderately Quite a bit Extremely Shortness of 1 2 3 4 5 breath Fatigue or 1 2 3 4 5 tiredness . Circle the appropriate number of your answer.

91 APPENDIX D (continued) FATIGUE ASSESSMENT INSTRUMENT REMOVED FOR COPYRIGHT PURPOSES .

92 APPENDIX D (continued) PITTSBURGH SLEEP QUALITY INDEX REMOVED FOR COPYRIGHT PURPOSES .

APPENDIX D (continued) PROFILE OF MOOD STATES REMOVED FOR COPYRIGHT PURPOSES .

APPENDIX D (continued) FUNCTIONAL PERFORMANCE INVENTORY REMOVED FOR COPYRIGHT PURPOSES .

College graduate G. Some college F. Please fill in the blanks or circle your answer. Graduate degree 5. Graduate degree . Race: A. What is the highest level of education you that you have completed? A. Junior high school ( 7th and 8th grade) C. Male 2. College graduate G. 1. Less than 7th grade B. Age: years 3. High School graduate E. High School graduate E. A. Some college F. Oriental D. 95 APPENDIX D (continued) We would like to ask you some questions about you and those close to you. African-American C. White B. Sex. If you are living with your spouse. Female B. Junior high school ( 7th and 8th grade) C. Some high school D. Some high school D. Other 4. Less than 7th grade B. what is the highest level of education he or she has completed? A.

Retired. Housewife. 96 APPENDIX D (continued) 6. Not working due to my illness E. list reason I. not working C. Retired. Housewife/homemaker D. Not applicable 2. list reason 9. Retired. but working part-time G. Full-time job B. but with a part-time job H. Retired. if working. Housewife. Housewife. what is your job title? 8. What is your current job status? A. Part-time job (occupation ) F. Not working due to my illness E. not working C. but working part-time G. list reason 7. but with a part-time job (occupation ) H. but with a part-time job H. Full-time job B. Part-time job F. Full-time job (occupation ) B. Housewife/homemaker D. Not working now due to another reason. Part-time job F. Not working due to my illness E. Not working due to another reason. What would best describe your job status 5 years ago? A. Retired. What is your spouse's employment status and occupation? A. Housewife/homemaker D. not working C. Not working due to another reason. Please list the medications ycu are taking: .

. APPENDIX D (continued) This is tiie end of the questionnaire. Thank-you again for taking the time to complete it.

98

APPENDIX E

Phone Script: Introduction and Explanation of Study

The following text will be read to potential participants w'hen they are contacted for participation
in the study:

"Hello, my name is Mary Kapella and I am calling from Dr. Janet Larson's laboratory at the
University of Illinois, College of Nursing. You were/are a volunteer for our study on respiratory
muscle strength and responded to our letter about my dissertation study (or for those volunteers
who are not subjects in Dr. Larson's study: I received the message about your interest in my
study). I am calling to tell you about my study. The purpose of the study is to find out more
about fatigue in people with lung disease, factors that influence fatigue and to describe daily
activity of people who experience fatigue. Participation would involve filling out a questionnaire
about your symptoms, daily activity, sleep quality and mood. The questionnaire would take
about 45 minutes or less to complete. I will also come to your home or convenient place to
complete a simple breathing test. You will breathe in until you are completely fiall and then you
will breathe out forcefully until you are completely empty. We will do this maneuver 3
times.(Note: subjects recruited firom Dr. Larson's study will not have spirometry done).

If you are willing to be involved as a subject in my study we will mail or give you the
questiormaire to your home with a self-addressed stamped envelope, asking you to complete it
within one week and mail it back to us. We would appreciate your assistance, but fully
understand if you don't have time or are not interested. All research done at the University must
first be approved by the Institutional Review Board to make sure that the research is done safely
and that it protects peoples rights. What it means is that your participation in this study is
voluntary; in other words, you know what you are getting into and we are not making you join
the study. Your decision whether or not to participate will not affect your current or foture
relations with the University. If you decide to participate, you are free to withdraw from the
study at any time without affecting that relationship. At this point I would like to answer any
questions you might have about the study.

I would like to find out when I can come to your home to discuss details of the study, do the
spirometry test and drop off the questionnaire. It should take less than 45 minutes for the visit.
When would be a good time for you? (Note: subjects recruited from Dr. Larson's study will not
have spirometry done)

APPENDIX F

SCREENING QUESTIONNAIRE

Subjective Fatigue, Associated Variables and Performance in People with COPD

Inclusion/Exclusion Criteria:

1. FEV] < 70% predicted

No otiier major heaitii problems which could influence fatigue or functional
performance;

Cancer

Congestive heart failure

Stroke

Kidney disease

Liver failure

J. Not currently participating or recently (last 1 month) in phase 1 of a pulmonary
rehabilitation program

_4. No history of lung surgery

_5. No history of asthma

_6. No major exacerbation of COPD within the last 2 months

1. Age is 45 years or older

_8. Smoking history includes at least 10 pack years

100

APPENDIX G

University of Illinois at Chicago

Consent for Participation in Research

"Subjective Fatigue, Associated Variables and Performance in People with

Chronic Obstructive Pulmonary Disease"

(For participants not enrolled in study H 95- 077)

Why am I being asked?

You are being asked to be a subject in a research study that will describe the symptom of fatigue in
people with lung disease. This study is being conducted by Mary C. Kapella, PhD candidate and Dr.
Janet L. Larson, PhD, RN at the University of Illinois at Chicago (UlC) College of Nursing.

You are being asked to join this study because you have emphysema and/or chronic bronchitis and
may be eligible to participate. We ask that you read this consent form and ask any questions you may
have before agreeing to be in the research.

Your participation in this study is voluntary. Your decision whether or not to participate will not affect
your current or future relations with the University. If you decide to participate, you are free to
withdraw from the study at any time without affecting that relationship.

Whv is this research being done?

The feeling of fatigue or tiredness is a common problem for people with chronic obstructive
pulmonary disease (COPD) but little is known about its nature in people with this disease. The
purpose of the study is to describe the nature of fatigue and its relationship with shortness of
breath, performance of daily activities, anxiety, depression and sleep quality in people with COPD.
A sample of 150 people age 45 years and older with moderate to severe COPD will be recruited.
You will be briefly interviewed by phone, perform spirometry testing and complete a questionnaire.
Spirometry testing includes taking a deep breath in and blowing hard into a spirometer. There is a
risk that you will feel light-headed for a short time after the spirometry test. A full explanation of
the study will be given to you by phone and prior to an informed written consent which will be
obtained before the spirometry testing. It is anticipated that knowledge derived from this study will
be used to help design and test treatments to help manage fatigue and its effects.

Spirometry testing measures the severity of your lung disease by measuring the amount of air you can exhale. I will be monitoring you closely and the test will be stopped if any discomfort is felt. No information about you. What about privacy and confidentiaiitv? The only people who will know you are a research subject are members of the research team. When the results of the research are published or discussed in conferences. If you qualify for the study you will fill out questionnaires that ask about your symptoms including fatigue and shortness of breath. You will receive a free lung function test. 101 APPENDIX G (continued) What is the purpose of this research? The purpose of the study is to find out more about fatigue in people with lung disease.if necessary to protect your rights or welfare (for example. will be disclosed to others without your written permission. I will leave them for you to fill out and return to us in the postage-paid envelope. Are there benefits to taking part in the research? This study is not being done to improve your condition or health. The test is done by taking a deep breath in then blowing hard into a spirometer.mpie breathing test . The study results may be of benefit to others with lung disease who have fatigue. except: .e during this visit. sleep quality. A si. This is not likely and the feeling is usually mild and lasts only a minute or so. This test will take about 5 minutes to complete and will be done here in your hom. activities in day-to-day life and use of medications and other treatment.a pulmonary function test like the ones you may have had before will be done to find out if you qualify for the study. The questionnaires should take about 40 minutes or less to complete and can be completed here at home. Your height and weight will be taken as part of the pulmonary function test. What are the potential discomforts and risks? The research has a risk that you will feel slightly faint after the pulmonary function test. Information about you will be kept in file cabinets that are behind a locked door. Any information that is obtained in connection with this study and that can be identified with you will remain confidential and will be disclosed only with your permission or as required by law. or provided by you during the research. no information will be included that would reveal your identity. A total of 150 people with lung disease will be involved in the study. if you are injured and need emergency care or when the UlC Institutional Review Board monitors the research or consent process). factors that influence fatigue and how it affects daily activity.if required by law. Keys are required to . Procedure: To qualify for this study you must have moderate to severe lung disease with no other major health problems. or .

Who should I contact if I have questions? You may call Mary Kapella. What are mv rights as a research subject? If you have questions about your rights as a research subject. you may contact the researcher. 102 APPENDIX G (continued) gain access to the files. Mary Kapella at (312) 996-9542 or her advisor. will be responsible for payment of this treatment. treatment will be made available through the University of Illinois at Chicago Hospital. However. at (312) 996-7955. except as may be required of the University by law. There is no compensation and/or payment for medical treatment from the University of Illinois at Chicago for such injury. You have the right to withdraw from the study at any time without penalty. What if I am injured as a result of mv participation? In the event of physical injury resulting from this research. Subject's Signature Date Signature of Researcher Date Signature of Witness Date . 1 have read (or someone has read to me) the above information. If you feel you have been injured. You will be given a copy of this form for your information. What are the costs for participating in this research? There will be no cost to you for participation in the study. Larson's research team will have access to the data. Janet Larson. your information will be shredded. her advisor. Only members of Dr. I have been given a copy of this form. You will receive no payment for participation in the study. if any. the principal investigator at (312) 996-9542 or Dr. you or your third party payor. Dr. any time for further questions. I agree to participate in this research. I have been given an opportunity to ask questions and my questions have been answered to my satisfaction. Five years after the results are published. Janet Larson at (312) 996-7955. you may call the Office for Protection of Research Subjects at 312-996-1711.

4) 5(3.7) 46(35.7) NRS Dyspnea" 15(11.2) 10(7. .7) 37(28.3) 16(12.9) 24(18.9) 57(44. 103 APPENDIX H DISTRIBUTION OF NRS FATIGUE AND NRS DYSPNEA DIMENSIONS FREQUENCY Variable Not at all Rarely Occasionally Frequently Constantly Number (Percent) NRS Fatigue ^ 3(2.1) DISTRESS Variable Not at all A linle Moderately Quite a bit Extremely Number (Percent) NRS Fatigue' 21(16. 6(4.0) 42(32.7) 8(6. " n=129.9) 4(3.2) 61(47.8) 36(27.5) 55(43) 46(35.6) 28(21.6) 6(4.2) NRS Dyspnea" 1(0.8) 26(20.1) ' n=128.3) 41(31.7) 34(26.6) 40(31.7) 4(3.9) NRS Dyspnea" 1(.3) 37(28.8) 7(5.8) INTENSITY Variable Not at all A little Moderately Quite a bit Extremely Number (Percent) NRS Fatigue.4) 54(41.

FATIGUE AND FUNCTIONAL PERFORJVLANCE WITH PSQI SUBSCALES Dyspnea Fatigue Functional Performance NRS CRQ NRS POMS FPI o Sleep Quality .411 ** .600** -.062 .139 Sleep Medication .163 .05. .046 .133 -.182 -.260** -.194* .247** 1 Sleep Latency .027 .167 344** -. 104 \ APPENDIX I CORRELATIONS OF DYSPNEA.102 .134 Sleep Duration .202* -.226* .462** .399** .185* -.121 .216** * p <.179* . ** p < .154 Sleep Efficiency .01.109 -.245** -.206* Sleep Disturbance 29*7** -.185* -.305** Daytime Dysfunction .

289** .187* Social Interaction -.373** -.363** -.388** -.0L .05.322** -.510** .332** -.262** Maintaining the -.458** .467** .319** -.407** -.2^7** -.384** -.190* Household Physical E. FATIGUE AND SLEEP DIFFICULTY WITH FPI SUBSCALES Dyspnea Fatigue Sleep Difficulty NRS CRO NRS POMS PSQI Body Care -.475** -. 105 APPENDIX J CORRELATIONS OF DYSPNEA.510** .xercise -.475** _442** -.376** -.193* Recreation -.467** .315** 242** -.360** -.270** Spiritual Activities -. ** p <.493** -.380** * p < .478** .

2002. Aurora. Doctoral Dissertation Award. Site Research Associate. 1994. Clinical Instructor. Critical Care Nursing. Medical . Introduction to Clinical Concepts and Processes. University of Illinois at Chicago. Teaching Assistant. Nursing. Aurora University. 1992. University of Illinois at Chicago. College of Nursing. Chicago. American Lung Association. University of Illinois at Chicago. Nursing. 2003. Substitute Clinical Instructor. Joliet. Bachelor of Science in Nursing. American Lung Association. Research Assistant. Fall. Illinois. 1993. Kapella EDUCATION: Associate Degree in Nursing. College of Nursing. RESEARCH Research Specialist. 1994. Illinois.2003. 1997. Illinois. Aurora University. Joliet Junior College. TEACHING Clinical Instructor. University of Illinois at Chicago. College of Nursing. Summer. Master of Science. Illinois. Chicago Metropolitan Assembly. AACN Thunder Project. 1990. College of Nursing. VITA NAiME: Mary C. College of EXPERIENCE: Nursing. 1999. 1994. Medical-Surgical Nursing. Introduction to Nursing Research and Statistics. 1996-1997. Doctoral Dissertation Award. HONORS. Doctor of Philosophy. 1998. Joliet. Aurora. 1997. Chicago Metropolitan Assembly. University of Illinois at Chicago. Medical-Surgical EXPERIENCE: Nursing. Joliet Junior College. 1997. IL. 106 . IL. Chicago. 1977. University of Illinois at Chicago. Fall. Pulmonary Nursing Research Laboratory. College of Nursing. 2000.Surgical Nursing.

MC. C. "Inspiratorymuscle strength in COPD: two-year followup". Keyton Nixon Scholarship Award. JL. Larson. Barriers Efficacy. K. Covey. Alex. F. CG. Albazzaz.. Kapella. J. Covey. Larson. Long-term effects of pulmonary exacerbation on pimax. (2001). MK. C. MK. MC. Kapella. FJ. JL. Sibilano. (1994). American Journal of Respiratory and Critical Care Medicine.3232. Chicago Metropolitan Chapter Midwest Nursing Research Society American Association of Critical Care Nurses. (2002). Albazzaz. A966. Patel. 165(8). Kapella MC. No. A57. Kapella. Joliet Area Chapter Sigma Theta Tau ABSTRACTS: Kapella.. Albazzaz F. 107 Sigma Theta Tau. Larson. Alex. Albazzaz. Covey. MK (2001). body composition. p. F. Bone mineral density in men and women with COPD.. MC. American Journal of Respiratory and Critical Care Medicine. WA. Alex. MK. (National Teaching Institute Abstracts). 163(5). Seattle. 163(5). Covey MK. SL. A737.ll. American Journal of Respiratory and Critical Care Medicine. MK. JL. American Journal of Critical Care. Nursing Assembly MEMBERSHIP: Respiratory Nursing Society. American Journal of Respiratory and Critical Care Medicine. Larson. MK. Knafl. National Respiratory Nursing Society. 1990. IL. MC (2003). PROFESSIONAL American Thoracic Society. Inspiratory muscle strength in chronic obstructive pulmonary disease. COPD Version. Lambda Upsilon. American Thoracic Society International Conference. Proceedings of the Midwest Nursing Research Society Conference. 1991.. Northern Illinois Chapter American Lung Association. CG. 3(3). 165(8). A460. Santefort K. Merritt. Inducted in May. H. . M. Alex. (2002). p224. Beriy. (2002). Subjective fatigue and performance in people with COPD. Chicago. Kapella.. JL. Larson JL. Larson. Covey MK. JL. Kapella. functional performance in COPD. Experiences and needs of surrogate decision-makers. Covey.

. JL... 6(1") 55-73. J. Review of Handbook of Nursing Diagnosis (5th edition) by Carpinito. MC. MC. MK. Journal of Nursing Measurement. S. (1994). (1998). Reliability and validity of the Functional Performance Inventory in patients with moderate to severe chronic obstructive pulmonary disease. Covey. . L. 108 PUBLICATIONS: Larson... Journal of Nursing Staff Development. & Berry. 10(2).. Kapella. Wirtz. Kapella.