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Journal of Cardiovascular Nursing

Vol. 26, No. 2, pp 99Y105 x Copyright B 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Impact of Sleep Quality and Daytime


Sleepiness on Global Quality of Life in
Community-Dwelling Patients With
Heart Failure
Ju-Chi Liu, MD, PhD; Hsiang-Lien Hung, MSN; Yuh-Kae Shyu, MSN; Pei-Shan Tsai, PhD

Background and Research Objective: Although it is well established that symptom burden in heart failure (HF)
often leads to poor health-related quality of life (QOL), the contributions of quality of sleep and daytime sleepiness
to the overall perception and satisfaction with life in the HF population have yet to be determined. We thus tested
the hypothesis that quality of sleep and daytime sleepiness are significant predictors of QOL as measured by the
World Health Organization Quality of LifeYBREF (WHOQOL-BREF) in patients with HF. Subjects and Methods:
Included were 88 medically stable patients with echocardiographically documented HF. This cross-sectional study
used a correlational design, and data were collected using self-report questionnaires including the Chinese version
of the Pittsburgh Sleep Quality Index (CPSQI), Epworth Sleepiness Scale, and WHOQOL-BREF Taiwan version.
Multiple linear regression analyses were used to address the study hypotheses. Results and Conclusions: With
the exception of the environmental domain (P = .078), poor sleepers had significantly lower scores in physical
(P G .001), psychological (P = .001), and social (P = .040) domains of the WHOQOL-BREF. Multivariate regression
analysis revealed that age, CPSQI, perceived health status, and comorbidities significantly predicted the physical
QOL (adjusted R2 = 0.59, P G .001). For the psychological QOL, only perceived health status and CPSQI score
remained in the regression model (adjusted R2 = 0.28, P = .016). For the environmental QOL, perceived health
status and Epworth Sleepiness Scale were the only predictors remaining in the model (adjusted R2 = 0.17,
P G .001). The findings from this study add support to the evidence that in medically stable persons with HF, poor
sleep independently predicts the overall perception and satisfaction with life, in particular, in the physical and
psychological domains of QOL, whereas daytime sleepiness independently predicts the environmental QOL.
KEY WORDS: daytime sleepiness, heart failure, quality of life, quality of sleep

Ju-Chi Liu, MD, PhD


Associate Professor and Director, Division of Cardiovascular Medicine, Taipei
Medical University Shuang-Ho Hospital, Taipei County, Taiwan; School of
P oor sleep has a profound impact on a person’s psy-
chological well-being1 and quality of life (QOL).2,3
Thus, improving QOL has long been an implicit, but
Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. not explicit, goal of interventions to improve quality
Hsiang-Lien Hung, MSN of sleep (QOS). Sleep complaints are common in
Head Nurse, Graduate Institute of Nursing, College of Nursing, Taipei
Medical University, Taipei, Taiwan; Department of Nursing, Taipei patients with chronic disease including heart failure
Medical University Wan Fang Hospital, Taipei, Taiwan. (HF).4 In view of a growing recognition of the impor-
Yuh-Kae Shyu, MSN tance of patient-centered outcomes, such as patient
Doctorate Student, Graduate Institute of Nursing, College of satisfaction and QOL,5 it is important to examine the
Nursing, Taipei Medical University, Taipei, Taiwan.
impact of QOS on QOL in patients with HF.
Pei-Shan Tsai, PhD
Professor, Graduate Institute of Nursing, College of Nursing, Taipei Poor sleep is independently associated with poor
Medical University, Taipei, Taiwan; Department of Nursing, Taipei health-related QOL (HRQOL) in patients with chronic
Medical University Wan Fang Hospital, Taipei, Taiwan; Sleep Science illness.4 Among the HF patients, those with poor QOS
Center, Taipei Medical University Hospital, Taipei, Taiwan.
reported significantly lower HRQOL than those with-
J.-C.L. and H.-L.H. are equal-contribution first authors.
out.6 However, the impact of poor QOS on global
This study was supported by a grant from Taipei Medical University
Wan Fang Hospital (95TMU-WFH-14).
QOL, taking the impact of confounders into consid-
Correspondence
eration, has not yet been adequately studied in pa-
Pei-Shan Tsai, PhD, Graduate Institute of Nursing, College of tients with HF. To this end, QOS in this study was
Nursing, Taipei Medical University, 250 Wu Hsing St, Taipei 110, assessed using the Pittsburgh Sleep Quality Index
Taiwan (ptsai@tmu.edu.tw). (PSQI), which was developed to measure sleep qual-
DOI: 10.1097/JCN.0b013e3181ed7d12 ity during the previous month and to discriminate

99

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100 Journal of Cardiovascular Nursing x March/April 2011

between good and poor sleepers.7 Quality of life in Briefly, medical history was obtained trough a thor-
this study was defined as an individual’s physical, ough history taking and chart review. Signs and symp-
psychological, social, and environmental well-being toms of HF and an abnormal echocardiography (ie,
in the context of his/her culture and value systems left ventricular [LV] ejection fraction G50% for im-
and his/her personal goals, standards, and concerns.8 paired LV systolic function and/or mitral inflow E/A
Daytime sleepiness is a subjective perception of the ratio G1 assessed by Doppler technique for impaired
propensity to sleep during the day, which has been LV diastolic function) were used to confirm the di-
commonly estimated by the Epworth Sleepiness Scale agnosis of HF. Severe chronic obstructive pulmonary
(ESS).9 Daytime sleepiness is a highly prevalent self- disease was defined based on a pulmonary function
reported symptom in poor sleepers1 but had received test, indicating the ratio of forced expiratory volume in
less attention in the HF population. Of the HF pa- 1 second (FEV1) to forced vital capacity of less than
tients studied, 21% had daytime sleepiness as assessed 0.70 and 30% e FEV1 G 50% predicted. Included in
by the ESS in a previous study.6 We tested the hy- the study were 88 men and women with HF.
pothesis that the HF patients with poor QOS have
significantly higher levels of daytime sleepiness than
those with good QOS. Although it is well established Instruments
that symptom burden in HF often leads to poor Chinese Version of the PSQI
HRQOL,10 the contributions of QOS and daytime sleep- The PSQI is a self-report questionnaire that assesses
iness to the overall perception and satisfaction with multiple dimensions of sleep over a 1-month period.7,11
life in the HF population have yet to be determined. Nineteen individual items generate 7 ‘‘component’’
We thus tested the hypothesis that subjective QOS scores: subjective sleep quality, sleep latency, sleep
and daytime sleepiness are significant predictors of duration, habitual sleep efficiency, sleep disturbances,
QOL as measured by the World Health Organization use of sleeping medication, and daytime dysfunction.
Quality of LifeYBREF (WHOQOL-BREF) question- The sum of the 7 component scores yields 1 global
naire in patients with HF. score of subjective QOS (range, 0Y21); higher scores
represent poorer subjective QOS. The PSQI had been
used to assess self-reported QOS in patients with
Methods HF.12 A Chinese version of the PSQI (CPSQI) was
Design used to assess QOS in this study, which has been
previously developed and validated.13
This cross-sectional study used a correlational design,
and data were collected using self-report questionnaires.
The Epworth Sleepiness Scale
Epworth Sleepiness Scale, a subjective measurement of
Study Participants sleepiness, is a self-report questionnaire. It measures
A purposive sample of community-dwelling patients the likelihood of dozing off under certain environ-
with systolic or diastolic HF was recruited from a car- mental conditions in daily life in the recent weeks9 and
diology outpatient clinic in a medical center located in had been used to assess self-reported daytime sleepi-
northern Taiwan. Subjects were eligible if they were ness in patients with HF.6,14 There are 8 items cor-
30 years or older, had a diagnosis of HF of more than responding to 8 conditions. These items are rated on
3 months, were receiving a stable medication regimen a scale of 0 to 3, with a score of 10 or greater indi-
for at least 2 months, could communicate in Mandarin cating excessive daytime sleepiness (EDS). The Chi-
or Taiwanese, and had a New York Heart Association nese version of the ESS was used in this study, which
(NYHA) functional class I or II. Subjects were ex- has been validated in a previous study.15
cluded if they were shift workers, were admitted to the
hospital at the time of data collection, or had a history The WHOQOL-BREF Taiwan Version
of a major psychiatric disorder, severe chronic obstruc- The brief version of the World Health Organization
tive pulmonary disease, malignant neoplasm, demen- Quality of Life (WHOQOL-BREF) questionnaire con-
tia, and Parkinson disease. Participation was delayed tains 28 items, with each item representing one facet of
if potential participants had a recent hospitalization life that is considered to have contributed to a person’s
(within 1 month of enrollment) or a recent (within 6 QOL.16 Among those 28 items, 24 of them assess 4
months of enrollment) coronary artery bypass surgery domains of QOLVphysical health (7 items), psycho-
or coronary intervention (angioplasty, stent, atherec- logical health (6 items), social relationships (4 items),
tomy, or laser). and environment (9 items); 1 item measures overall
Each potential participant was seen by a cardiolo- QOL, and 1 item measures general health. Two
gist to verify the eligibility to participate in the study. national items that measure Taiwan-specific QOL

Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Quality of Sleep and Quality of Life in Chronic HF 101

are included in the environment domain and the analyses were used to identify predictors of global
social relationship domains.16 All domain scores were QOL.
calculated by taking the mean score for all items
included in each domain and multiplying by a factor Results
of 4. The score for each domain therefore ranged
from 4 to 20, with a higher score indicating better A total of 88 subjects, aged 30 to 92 years, were in-
QOL. The score of each domain was then converted cluded in the study. Among this convenience sample of
to a P score with 0- to 100-point score range using the patients with HF, 66% were poor sleepers (global
following formula: P = (x j 4 / 20 j 4)  100, where CPSQI 95). As expected, the 2 groups were signifi-
x is the actual domain score.17 cantly different in all CPSQI component scores and the
global score (Table 1).
A comparison of sociodemographic data (ie, age,
Data Collection and Analysis
weight, body mass index [BMI], sex, marital status,
Sociodemographic and lifestyle data included age, body education, income, and religion), lifestyle habits (ie, smok-
height, weight, sex, marital status, educational level, ing and alcohol consumption), comorbidity, use of "-
personal monthly income in Taiwan dollar (NT), re- blockers, use of ACEIs, and use of diuretics between
ligion, and habits of smoking and alcohol consumption. poor and good sleepers revealed that the 2 groups were
Comorbid diseases investigated included diabetes, not significantly different in any one of the charac-
hypertension, skeletomuscular disease, hepatobiliary teristics (all P 9 .05; Table 2). Moreover, age, weight,
and pancreatic disease, gastrointestinal disease, kid- BMI, sex, marital status, educational level, monthly
ney disease, and cerebrovascular accident. Information income, religion, smoking, alcohol consumption, use
regarding use of "-blockers, angiotensin-converting en- of "-blockers, use of ACEIs, and use of diuretics were
zyme inhibitors (ACEIs), and diuretics was also col- not associated with QOS (ie, CPSQI score) as a con-
lected. Perceived health status was assessed using a tinuous variable (all P 9 .05). The majority of the
5-point Likert-type question, with 1 indicating very subjects (81.8%) had 1 or more comorbid diseases.
poor health and 5 indicating very good health. For data Diabetes (P = 1.0), hypertension (P = .216), skeleto-
analysis, perceived health was recoded into 3 catego- muscular disease (P = 1.0), hepatobiliary and pancre-
ries: ‘‘poor,’’ ‘‘on average,’’ and ‘‘good.’’ All participants atic diseases (P = 1.0), gastrointestinal disease (P =
completed the CPSQI, ESS, and the WHOQOL-BREF 1.0), kidney disease (P = 1.0), cerebrovascular acci-
questionnaires. Ninety-seven subjects consented to par- dent (P = 1.0), and other illness (P = 1.0) were not
ticipate in the study. Among them, 9 subjects had 1 or significantly associated with poor QOS in the HF
more missing data and were excluded from the analy- patients.
sis. The final sample size was 88. Two subjects did not Of notice was that poor sleepers had higher ESS score
provide data on perceived health status, and thus, only than good sleepers (8.21 [SD, 5.02] vs 6.23 [SD, 3.21];
86 subjects were included in the multiple regression P = .016). Among the poor sleepers, 34.5% had an ESS
models. score of 10 or greater, whereas in good sleepers, only
Data were analyzed using the Statistical Package for 16.7% had an ESS score of 10 or greater. Neither
the Social Science (version 15.0; SPSS inc, Chicago, weight nor BMI significantly correlated to ESS score
Illinois). Bivariate correlations were used to examine (P = .327 and .316, respectively). Those who were
the relationship between variables. Multiple regression taking "-blockers, ACEIs, and diuretics and those who

TABLE 1 Component and Global Score of the Pittsburgh Sleep Quality Indexa
Sleep Quality
Poor Sleepers (n = 58) Good Sleepers (n = 30) P
c
Subjective sleep quality 1.71 (0.68) 0.83 (0.53) G.001
Sleep latencyc 1.67 (0.98) 0.37 (0.56) G.001
Sleep durationc 1.40 (0.95) 0.73 (0.79) .002
Habitual sleep efficiencyc 0.97 (1.17) 0.13 (0.43) G.001
Sleep disturbancesc 1.52 (0.54) 1.17 (0.38) .002
Use of sleeping medicationc 1.38 (1.32) 0.13 (0.35) G.001
Daytime dysfunctionc 1.19 (0.87) 0.47 (0.57) G.001
Global scoreb 9.88 (3.02) 3.83 (1.26) G.001
a
Values are expressed as mean (SD).
b
Group comparison was tested by independent t test in continuous data.
c
Group comparison was tested by Mann-Whitney U test in continuous data.

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102 Journal of Cardiovascular Nursing x March/April 2011

TABLE 2 Distribution of Sample Characteristics


Sleep Quality
Variable Poor Sleepers (n = 58) Good Sleepers (n = 30) Pa
Age, mean (SD), y 56.67 (13.47) 56.17 (10.26) .845
Body weight, mean (SD), kg 68.60 (16.16) 70.42 (8.92) .598
BMI, mean (SD), kg/m2 26.53 (5.87) 26.03 (2.46) .614
Sex, n (%) .147
Men 22 (37.9) 17 (56.7)
Women 36 (62.1) 13 (43.3)
Marital status, n (%) .711
Yes 52 (89.7) 28 (93.3)
No 6 (10.3) 2 (6.7)
Education, n (%) .366
High school and below 38 (65.5) 15 (50)
College 17 (29.3) 13 (43.3)
Graduate and above 3 (5.2) 2 (6.7)
Monthly income (1000 NT), n (%) .383
20 26 (44.8) 9 (30)
20Y60 18 (31) 9 (30)
60Y100 8 (13.8) 8 (26.7)
Above 100 6 (10.3) 4 (13.3)
Religion, n (%) 1.000
Yes 51 (87.9) 27 (90)
No 7 (12.1) 3 (10)
Smoking group, n (%) .757
Current smoker 8 (13.8) 5 (16.7)
Nonsmoker 50 (86.2) 25 (83.3)
Alcohol consumption, n (%) .221
Yes 7 (12.1) 7 (23.3)
No 51 (87.9) 23 (76.7)
Comorbidities, n (%) .393
Yes 9 (84.5) 23 (76.7)
No 49 (15.5) 7 (23.3)
Use of "-blockers, n (%) 1.000
Yes 28 (48.3) 15 (50)
No 30 (51.7) 15 (50)
Use of ACEIs, n (%) 1.000
Yes 25 (43.1) 12 (43.3)
No 33 (56.9) 17 (56.7)
Use of diuretics, n (%) 1.000
Yes 28 (48.3) 14 (46.7)
No 30 (51.7) 16 (53.3)

Abbreviations: ACEIs, angiotensin converting enzyme inhibitors; BMI, body mass index.
a
Group comparison was tested by independent t test in continuous data and by # 2 test or Fisher exact test in categorical data.

were not taking these medications had comparable ESS respectively), but not with the psychological and
score (P = .630, .806, and .369, respectively). social domains (P 9 .05).
Poor sleepers had significantly lower scores in
TABLE 3 Domain Scores of the World Health
physical (P G .001), psychological (P = .001), and so-
cial (P = .040), but not environmental (P = .078), do- Organization Quality of Life in Poor and
mains of the WHOQOL-BREF (Table 3). Good Sleepers
Quality of sleep as measured by the CPSQI was Sleep Quality
inversely correlated with the physical and psychologi- Poor Sleepers Good Sleepers
cal domains of the WHOQOL-BREF (r = j0.65, r = Domain (n = 58) (n = 30) P
j0.41, respectively; P G .001, P G .001, respectively) Physicala
56.91 (13.76) 74.07 (11.13) G.001
but not with the social (P = .434) and environmental Psychologicala 56.72 (14.07) 67.00 (12.91) .001
(P = .072) domains. Daytime sleepiness as measured Socialb 59.21 (15.33) 66.20 (11.20) .040
by the ESS inversely correlated to the physical and Environmentala 63.22 (12.62) 68.07 (10.97) .078
environmental domains of the WHOQOL-BREF (r = a
Group comparisons were tested by independent t test.
j0.29, r = j0.29, respectively; P = .009, P = .005, b
Group comparison was tested by Mann-Whitney U test.

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Quality of Sleep and Quality of Life in Chronic HF 103

TABLE 4 Predictors of the Physical Domain ment to call for the attention on the promotion of self-
Score of the WHOQOLa care in persons with HF in 2009.19 Sleep disturbances
" 95% Confidence have been outlined by the American Heart Association
Variable Coefficient Interval P as one of the factors that make self-care difficult for
Constant 91.98 78.54 to 105.41 G.001 patients with HF. In this study, we examined the impact
CPSQI j2.07 j2.66 to j1.47 G.001 of self-reported QOS on global QOL in HF patients who
Age j0.29 j0.47 to j0.11 .002 were asymptomatic or present symptoms only after
Comorbidities (yes) j5.90 j11.46 to j0.35 .038 physical activity. Findings from this study supported the
Healthb
notion that poor QOS is a likely target for interventions
Health (1) 15.35 8.96 to 21.74 G.001
Health (2) 8.73 3.51 to 13.94 .001 to improve QOL among patients with HF as we found
that poor sleepers had significantly lower scores in 3 of
Abbreviations: CPSQI, Chinese version of the Pittsburgh Sleep Quality the 4 domains of the QOL as compared with good
Index; WHOQOL, World Health Organization Quality of Life.
a 2
R for the model is 0.62, adjusted R2 for the model is 0.59, n = 86. sleepers. The salient finding from this study was that after
b
Reference = poor health; (1) = good; (2) = on average. adjusting for other important correlates of QOL, QOS
remained a significant predictor of both the physical and
psychological domains of the QOL in medically stable
As expected, the presence of comorbidities was HF patients. Poor QOS secondary to medical conditions
associated with the physical and environmental do- has often been overlooked because of the traditional
mains of the WHOQOL-BREF (P = .018 and P = .037, notion that the associated medical condition must be
respectively). However, the presence of 1 or more co- treated first before any treatment of sleep difficulties can
morbidities was not significantly related to the other 2 be initiated. Nevertheless, nonpharmacological interven-
domains (P 9 .05). tions such as cognitive behavioral therapy and relaxation
As expected, perceived health status was significantly have demonstrated measurable improvement in objective
associated with the physical (P G .001), psychological and subjective QOS in older adults with sleep difficulties
(P G .001), social (P = .034), and environmental (P = secondary to medical conditions20,21 and can therefore
.004) domain scores. be applied to patients with HF. Moreover, future clinical
Multivariate regression analysis revealed that age, trials aiming at improving QOS for patients with HF
CPSQI, perceived health status, and comorbidities sig- should make explicit QOL as one of the treatment ef-
nificantly predicted the physical QOL. Together these ficacy outcomes.
variables explained 59% of the variance of the physical Physical symptoms and functional status have been
QOL (adjusted R2 = 0.59, P G .001; Table 4). identified as major predictors of poor HRQOL in patients
For the psychological QOL, only perceived health with HF.10 In accordance with previous findings, we
status and CPSQI score remained in the regression found that perceived health status was a major determi-
model (adjusted R2 = 0.28, P = 0.016; Table 5). nant of all 4 QOL domains. Health care professionals,
Marital status and perceived health status were the including nurses, should make efforts to provide appro-
only predictors of the social relations QOL (adjusted priate interventions to improve HF patients’ physical
R2 = 0.22, P G .001). For the environmental QOL, symptom status and hopefully improve QOL.
perceived health status and ESS were the only pre- Among the sociodemographic and lifestyle vari-
dictors remaining in the model (adjusted R2 = 0.17, ables studied, only age and marital status were iden-
P G .001; Table 6). tified to be significant predictors of QOL in this study:
The CPSQI score was a significant predictor of age partially explained the physical QOL, whereas
neither the social relations nor the environmental marital status accounted, partially, for the social
QOL. Daytime sleepiness as measured by the ESS was
not a significant predictor of the physical, psychol- TABLE 5 Predictors of the Psychological
ogical, and social QOL domain scores after socio- Domain Score of the WHOQOLa
demographic factors, comorbidity, perceived health
" 95% Confidence
status, and QOS were accounted for in the regression Variable Coefficient Interval P
models.
Constant 59.63 50.86 to 68.40 G.001
CPSQI j0.95 j1.70 to j0.21 .013
Discussion Healthb
Health (1) 16.34 8.38 to 24.30 G.001
The HF population experiences a cluster of symptoms Health (2) 8.05 1.55 to 14.56 .016
including dyspnea, anorexia, fatigue, poor QOS, and
anxiety that often lead to poor HRQOL.18 In light of Abbreviations: CPSQI, Chinese version of the Pittsburgh Sleep Quality
Index; WHOQOL, World Health Organization Quality of Life.
the burden of HF on poor HRQOL and mortality, the a 2
R for the model is 0.31, adjusted R2 for the model is 0.28, n = 86.
American Heart Association issued a scientific state- b
Reference = poor health; (1) = good; (2) = on average.

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104 Journal of Cardiovascular Nursing x March/April 2011

TABLE 6 Predictors of the Environmental Domain Score of the WHOQOLa


Variable " Coefficient 95% Confidence Interval P
Constant 68.15 63.31 to 72.99 G.001
ESS j0.75 j1.28 to j0.22 .006
Healthb
Health (1) 9.14 3.60 to 14.68 .002

Abbreviations: ESS, Epworth Sleepiness Scale; WHOQOL, World Health Organization Quality of Life.
a 2
R for the model is 0.19, adjusted R2 for the model is 0.17, n = 86.
b
Reference = poor health; (1) = good.

relationship domain of the QOL. Of notice was that would be strengthened had the diagnosis of SDB such
in our sample all the sociodemographic and lifestyle as central sleep apnea with Cheyne-Stokes respiration
variables were not associated with QOS. Female sex and obstructive sleep apnea and the information on the
has been found to be associated with poor HRQOL in use of sleep medications been included. Third, 2 major
HF patients.10,22 In this study, however, female sex determinants of poor HRQOL in HF patients, fatigue
was not a predictor of any one of the QOL domains. and depression,24,25 were not assessed in this study.
This discrepancy can be explained by the differences Therefore, the exact cause of daytime sleepiness and
in the concepts assessed between ours and previous the mechanisms through which poor QOS and day-
studies. We defined QOL as the overall perception time sleepiness affect QOL could not be determined.
and satisfaction with life, whereas previous studies Fourth, this study included only patients with NYHA
assessed the HRQOL. functional class I or II but not markedly symptomatic
A previous study of the adult Taiwanese population HF patients (ie, NYHA classes III and IV). Therefore,
demonstrated that the risk of EDS was 3 times as high the study findings can be generalized only to commun-
for adults with sleep complaints as for those without.1 ity-dwelling HF patients without marked limitation of
Findings from this study supported this notion and activity. Lastly, this study was cross-sectional in nature.
demonstrated that among the patients with HF in The cause-effect relationship between QOS and QOL
Taiwan poor sleepers had significantly higher levels of could not be ascertained, and one cannot rule out the
daytime sleepiness than good sleepers. Moreover, we possibility that there exists a bidirectional relation-
found that daytime sleepiness was an independent ship between QOS and QOL. Nevertheless, even after
determinant of the environmental QOL in patients adjustment for sociodemographic factors, perceived
with HF. This finding is of profound clinical implica- health status, and comorbidities, subjective QOS re-
tions because the environmental domain of the mained a significant predictor of both the physical and
WHOQOL-BREF measures important environmental psychological domains of th QOL in HF patients
issues that affect one’s perception of general well- without marked limitation of physical activity, whereas
being such as transportation, leisure activities, and self-reported daytime sleepiness was an independent
access to health care.8,17 HF patients with daytime predictor of the environmental QOL.
sleepiness may be less likely to participate in leisure
activities and have limited access to health care ser-
vices and thus have a lower level of satisfaction with
Conclusions
environmental QOL. Daytime sleepiness not only re- The findings from this study add support to the evidence
duces environmental well-being as we observed but that in persons with medically stable HF without
may also impair self-care and result in depression in marked limitation of physical activity, poor QOS
persons with HF as proposed by others.23 Thus, health independently predicts the overall perception and sat-
care providers must use valid tools to assess the isfaction with life, in particular, in the physical and
problem of daytime sleepiness and to identify and al- psychological domains of QOL, whereas daytime sleepi-
leviate factors that may cause daytime sleepiness in ness independently predicts the environmental QOL.
this population.
Several limitations of this study must be addressed.
First, this study included HF patients with a wide age
Summary and Implications
range (30Y92 years old). Second, data on sleep dis- h In community-dwelling persons with HF without
ordered breathing (SDB) and on the use of sleep medi- marked limitation of physical activity, self-reported
cations were not available. Poor QOS in HF patients poor QOS impairs not only the HRQOL as pre-
is often caused by SDB.12 Interestingly, SDB was found viously demonstrated but also the overall perception
to independently predict HRQOL in middle-aged and satisfaction with life, in particular, in the physical
(mean age, 61 [SD, 11] years)12 but not in elderly and psychological domains, even after taking into
(970 years)14 HF patients. The significance of the study consideration possible confounders of QOL.

Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Quality of Sleep and Quality of Life in Chronic HF 105

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