Fatigue in older adults with stable heart failure

Sharon A. Stephen, RN, GNP, PhD

PURPOSE: The purpose of this study was to describe fatigue and the relationships among fatigue
intensity, self-reported functional status, and quality of life in older adults with stable heart failure.
METHODS: A descriptive, correlational design was used to collect quantitative data with reliable and
valid instruments. Fifty-three eligible volunteers completed a questionnaire during an interview. Those
with recent changes in their medical regimen, other fatigue-inducing illnesses, and isolated diastolic
dysfunction were excluded.
RESULTS: Fatigue intensity (Profile of Mood States fatigue subscale) was associated with lower quality
of life, perceived health, and satisfaction with life. Fatigue was common, and no relationship was found
between fatigue intensity and self-reported functional status. Marital status was the only independent
predictor of fatigue.
CONCLUSIONS: In stable heart failure, fatigue is a persistent symptom. Clinicians need to ask patients
about fatigue and assess the impact on quality of life. Self-reported functional status cannot serve as a
proxy measure for fatigue. (Heart Lung® 2008;37:122–131.)

F atigue is a defining symptom of heart failure

(HF) and is among the most disabling, particu-
larly for adults aged more than 65 years, who
bear the greatest burden of HF. Fatigue limits daily
activities and is the main reason for not participating
in outpatient HF treatment programs.1 Despite the
high prevalence of and problems associated with fa-
tigue, few studies have focused on HF-related fatigue.
An understanding of fatigue is essential for accurate
clinical assessment and intervention in the approxi-
mately 5 million men and women living with HF in the
United States today.2 The purpose of this study was to
describe fatigue and the relationships among fatigue
intensity, self-reported functional status, and quality
of life in older adults with stable HF.
From the Oregon Health and Science University School of Nurs-
ing, Portland, Oregon.
Funding for this study came from the National Institute of Nurs-
ing Research, National Institutes of Health, postdoctoral and
predoctoral fellowships, 5 T32 NR007061-15 (Judith Kendall, Prin-
cipal Investigator) Risk Assessment and Intervention Research,
Oregon Health and Science University, and 5 T32 NR 007071-04
(Karin Kirchhoff, Principal Investigator) Research Training in
Nursing Intervention, University of Utah.
Reprint requests: Sharon A. Stephen, RN, GNP, PhD, Geronto-
logical Nurse Practitioner, Legacy Health System, Legacy Good
Samaritan Clinics Geriatric Medicine, 1200 NW 23rd Avenue,
Portland, OR 97210.
0147-9563/$ – see front matter
Copyright © 2008 by Mosby, Inc.
doi:10.1016/j.hrtlng.2007.03.006
BACKGROUND
Studies to date have produced conflicting results
about the prevalence of HF-related fatigue and have
been limited to descriptive, cross-sectional designs
with small sample sizes. The seminal work on HF-
related fatigue reported an inverse relationship be-
tween fatigue and physical activities; however, fa-
tigue was not isolated from other HF symptoms and
was measured by clinician rating.3 Prospective, de-
scriptive studies have reported a prevalence of HF-
related fatigue ranging from 16% to 91%.4-7 Fatigue
is not consistently documented in the medical
record,8,9 limiting the validity of retrospective data
collection. Zambroski and colleagues10 measured
“lack of energy” and found that 85% of their sample
of men and women with HF endorsed this fatigue
synonym. Ekman and Ehrenberg11 reported that
women have more HF-related fatigue than men. In a
longitudinal study, Friedman and King5 assessed
fatigue in older women with HF at baseline and at
18 months using a general symptom checklist and
reported that fatigue increases over time. This body
of work shows the importance of examining fatigue
in persons with stable HF because fatigue may be a
persistent symptom. However, HF symptom re-
search has focused on acute exacerbation episodes
and inpatient hospital samples.7,12
The relationship between fatigue and functional
status has important implications for older adults

122 www.heartandlung.org MARCH/APRIL 2008 HEART & LUNG

Stephen
Table I
Model domains, study concepts, and related measures
Model domains Study concepts
Symptom experience: Fatigue intensity
Perception Global fatigue
Concurrent symptom severity
Severity of illness
Trait-negative affect
Symptom experience: Fatigue attribution
Evaluation
Symptom outcome Self-reported functional status
Exercise routine
Health-related quality of life
Satisfaction with life
Perceived health
Demographics
POMS-F, Profile of Mood States Fatigue; VAS-F, Visual Analogue Scale for Fatigue; NYHA, New York Heart Association; PANAS,
Positive and Negative Affect Schedule; HFFSI, Heart Failure Functional Status Inventory; LHFQ, Living with Heart Failure
Questionnaire; SWLS, Satisfaction with Life Scale.
because restricting daily physical activities has neg-
ative consequences on health and independence.
Oka and colleagues6 described daily physical activ-
ity levels that were below measured exercise capac-
ity in a sample of older adults with HF. Unexpect-
edly, this sample reported low fatigue prevalence
(16%). Investigators have hypothesized that persons
with HF purposely reduce their physical activities as
a strategy to avoid HF symptoms such as fatigue.3,6
Limitations in the performance of daily physical
activities may also be a response to fatigue.13 Zam-
broski and colleagues10 found that lack of energy
was one of the most frequent, severe, and burden-
some symptoms of HF and concluded that HF
symptom burden is a major contributor to poor
quality of life. However, no studies have systemat-
ically measured the relationships among fatigue,
functional status, and quality of life in older adults
with stable HF.
Although clinicians believe that fatigue is a
symptom amenable to treatment, there have been
no intervention studies aimed at reducing HF-re-
lated fatigue. The development of effective treat-
ments for fatigue has been delayed in part by the
lack of understanding of the underlying pathophys-
iologic mechanisms of fatigue. In addition, the scar-
city of valid and reliable instruments to measure
fatigue in HF has contributed to the limited number
of studies. However, there is a growing body of
HEART & LUNG VOL. 37, NO. 2
Fatigue in older adults with stable heart failure
Related measures
POMS-F subscale
VAS-F
Symptom checklist
NYHA classification
PANAS trait form
Attribution of fatigue to aging
HFFSI
Exercise routine (times per week)
Minnesota LHFQ
SWLS
Self-reported perceived health
Demographic questionnaire (age,
gender, marital status)
fatigue literature in cancer and other chronic dis-
eases that can inform fatigue research in HF.14-16
Several instruments are available to measure fa-
tigue and have been validated in older adults.17,18
This study, a description of fatigue and the relation-
ship among fatigue intensity, self-reported func-
tional status, and quality of life in older adults with
stable HF, addresses an important gap in the HF
symptom literature and lays the foundation for in-
tervention development.
THEORETIC FRAMEWORK
An established symptom model19,20 guided the
selection of concepts for this study. An underlying
assumption of this model is that symptoms are
distressing and that symptom-related distress dis-
rupts quality of life. The model is composed of three
interrelated domains: symptom experience, symptom
management strategies, and symptom outcomes. The
symptom experience is further delineated into three
interrelated components: perception of symptoms, eval-
uation of symptoms, and response to symptoms. The
perception and evaluation aspects of the symptom
experience and the symptom outcome domains of the
Symptom Management Model19,20 provided a frame-
work for the interpretation of study findings. Table I
lists the model domains, study concepts, and related
measures.
www.heartandlung.org 123
 Fatigue in older adults with stable heart failure
Perception of symptoms was evaluated with three
concepts: fatigue intensity, global fatigue, and
symptom severity of concurrent symptoms. Fatigue
is a subjective phenomenon involving an interac-
tion among physiologic, psychologic, behavioral,
and situational factors.21 Therefore, fatigue is mea-
sured by self-report. Severity of concurrent symptoms
is a known fatigue correlate in HF.5 In addition, sever-
ity of illness may explain fatigue intensity; advanced
stages of HF are generally associated with higher
amounts of fatigue. Finally, some personality traits
(eg, negative affect) are associated with overreporting
of symptoms22 and may confound the measurement
of fatigue. Thus, studies of perception of fatigue inten-
sity must also include concurrent symptoms, severity
of illness, and trait-negative affect.
Attribution of fatigue to aging is an aspect of
evaluation of symptoms that is important to consider
in a study of older adults. Underreporting of symp-
toms has been documented when symptoms such
as fatigue are attributed to age, and older adults
who attribute their symptoms to age are less likely
to seek medical help.23
Quality of life and functional status are important
symptom outcomes in HF because they reflect the
impact of symptoms on daily life. Quality of life is a
broad construct that includes health-related quality
of life. A more global aspect of quality of life is
satisfaction with life.
METHOD
A descriptive, cross-sectional, and correlational
design was used to achieve three study aims: (1)
describe the relationships between fatigue intensity
and symptom experience (concurrent symptom se-
verity and fatigue attribution); (2) describe the rela-
tionships between fatigue intensity and symptom
outcomes (self-reported functional status, exercise
routine, health-related quality of life, satisfaction
with life, and perceived health); and (3) identify the
demographic, clinical, and symptom outcome pre-
dictors of fatigue intensity in older adults with sta-
ble HF.
Sample
A convenience sample of men and women with a
diagnosis of HF with documented systolic dysfunc-
tion was recruited from outpatient clinics in south-
western Idaho over a 9-month period. Inclusion cri-
teria included the following: (1) 65 years of age or
older, (2) diagnosed with HF for at least 6 months,
(3) left ventricular ejection fraction (LVEF) of 40% or
less, (4) compensated HF as evidenced by stable
124 www.heartandlung.org
Stephen
medication regimen with no adjustments for the
past 3 weeks and physician’s assessment of stable
HF, (5) able to speak and read English, and (6)
community dwelling (not hospitalized or living in a
nursing home). To focus on fatigue caused by HF,
potential participants were excluded from the study
if they had any serious comorbidities or treatments
associated with fatigue (eg, fibromyalgia), cancer,
recent surgery, receiving sedatives, narcotics, dialy-
sis, or continuous oxygen, or if they had a psychi-
atric diagnosis. Individuals with isolated diastolic
dysfunction (LVEF ⬎ 40%) were excluded to avoid
misclassification because of uncertainty of HF diag-
nosis. Potential participants with greater than four
errors on the Pfeiffer Short Portable Mental Status
Questionnaire were also excluded.24
Measures
Fatigue intensity was measured with the Profile
of Mood States fatigue subscale (POMS-F),25 a reli-
able, valid, and easy-to-use scale (Table I). The
POMS-F has been used in HF and in older
adults.18,26 POMS-F scores range from 5 to 25, with
higher numbers indicating higher fatigue intensity.
Cronbach’s alpha of the POMS-F was .82 in this
sample. A visual analogue scale for fatigue (VAS-F)
was used to measure global fatigue. The VAS-F is a
single-item standardized 100-mm horizontal line
with polar ends labeled “no fatigue” and “ex-
hausted,” with higher values reflecting higher global
fatigue. Single-item VAS scales have been advo-
cated as a reliable and valid method to measure
subjective phenomena such as fatigue and are pop-
ular in clinical practice because of their ease of
administration.27 In addition, the VAS-F served as a
supporting measure for the POMS-F; the two fatigue
measures had moderate concurrent validity (r ⫽ .52,
P ⬍ .001). A moderate correlation of these two
measures was expected; each measure contributed
unique sources of measurement error, and the mea-
sures use different scales (adjective checklist vs
VAS).
Concurrent symptoms were assessed using a re-
vised symptom checklist.28 Concurrent symptoms
were defined as coexisting HF and age-related
symptoms. The symptom checklist includes 19
symptoms identified in the literature as common in
older adults in general and in HF in particular;
symptoms are rated for severity if present, and the
sum yields the concurrent symptom severity. Fa-
tigue attribution was assessed on an investigator-
developed, single-item, 5-point scale. Participants
were asked how likely they thought their tiredness
MARCH/APRIL 2008 HEART & LUNG
Stephen
and fatigue experienced in the last week was the
result of aging. This single item was developed to
identify those for whom age was perceived as a
cause of fatigue. Fatigue attribution has been mea-
sured in other populations to identify perceptions
of causes of fatigue.29
Self-reported functional status, operationalized
as the self-report of the ability to perform activities
of daily living, was measured with the 12-item Heart
Failure Functional Status Inventory (HFFSI).30 Each
item on the HFFSI is based on an everyday activity
for which participants choose one of three potential
responses (“Yes, I can do this,” “Yes, I can do this,
but only slowly,” or “No, I can’t do this”). Each
activity corresponds to the metabolic equivalent of
the task (MET) (1 MET ⫽ 3.5 mL O2/kg/min) pre-
dicted for a given level of activity. Higher MET levels
correspond to activities with higher exertion. Scor-
ing the HFFSI yields a global MET level derived from
the average of the three highest MET levels as-
signed to the activities that participants report that
they are able to perform. Internal consistency reli-
ability was reported as .84.31 In this study, the in-
terrater reliability for scoring the HFFSI was 98%.
Exercise routine was measured by asking partici-
pants to quantify the minutes and frequency per
week they engaged in structured exercise that ex-
cluded day-to-day activities (eg, vacuuming).
Health-related quality of life was measured with
the 21-item valid and reliable Minnesota Living with
Heart Failure Questionnaire (LHFQ).32 Scores range
from 0 to 105 with higher scores indicating lower
health-related quality of life. The internal consis-
tency reliability of the LHFQ in this sample was .92.
Global quality of life was assessed with the 5-item
Satisfaction with Life Scale (SWLS).33 Scores on the
SWLS range from 5 to 35, with higher scores indi-
cating higher satisfaction with life. The internal con-
sistency reliability of the SWLS in this sample was
.87. Perceived health was measured with a single
item; participants were asked to rate their own
health as excellent, good, fair, or poor. A demo-
graphic questionnaire was used to collect data
about gender, marital status, and age. A clinical
information form was used to collect relevant data
from the clinic records (duration of HF, cause of HF,
LVEF, and comorbidity). The New York Heart Asso-
ciation (NYHA) classification was collected from the
clinic record and used to control for severity of
illness. The trait form of the Positive and Negative
Affect Schedule was used to measure trait-negative
affect,34 another potential confounder. Internal con-
sistency reliability of the Positive and Negative Af-
fect Schedule was .87 in this sample.
HEART & LUNG VOL. 37, NO. 2
Fatigue in older adults with stable heart failure
Procedure
After university and clinical site institutional re-
view board approval, participants were recruited
from six physician practices, including nine clinical
sites. Physicians identified potential participants
who met the inclusion criteria. The clinic records of
referred participants were screened to ensure that
potential participants met both inclusion and exclu-
sion criteria. Eligible participants were contacted by
telephone and informed about the study. An ap-
pointment was made with eligible participants who
expressed interest in participation to answer any
questions, obtain informed consent, and administer
the Pfeiffer Short Portable Mental Status Question-
naire to verify cognitive eligibility.24
Most participants were interviewed in their
homes. More men than women were initially en-
rolled; this led to efforts to enroll more eligible
women during the second half of recruitment. A
standardized procedure was followed for complet-
ing the study instruments. Face-to-face interview
was used to minimize participant burden. One in-
vestigator collected all of the data. The order of the
questions was fixed to control for any order effect.
All participants completed the fatigue scales first
and the demographic questionnaire last. The 132
items took approximately 1 hour to complete. Clin-
ical data were obtained from clinic records.
All data were entered into an SPSS database.35
Mean substitution was used for missing data (five
items involving two participants; ⬍.4%). The attri-
bution of fatigue to aging item was transformed
from an ordinal to a categoric variable. Participants
who responded that their fatigue was “likely” or
“very likely” caused by aging were grouped, as were
participants who responded “unlikely” or “very un-
likely.” The relationships among fatigue intensity,
demographic and clinical variables, and other study
variables were described using Pearson product-
moment correlations. In addition, t tests were used
to assess differences in fatigue intensity by gender
and exercise groups. Finally, hierarchical multiple
regression was used to identify predictors of fatigue
intensity. The selection of independent variables
entered into the equation was based on the
strength of bivariate association with fatigue inten-
sity in variables theoretically linked to fatigue. A
total of six independent variables were entered into
the equation in two steps. Severity of illness (NYHA
classification) and trait-negative affect were entered
at step one to control for these potential confound-
ers. An alpha level of .05 was used for all statistical
tests.
www.heartandlung.org 125
Fatigue in older adults with stable heart failure
Table II
Sample characteristics
Mean (SD)
N (%) range
Men 36 (68%)
Married 34 (64%)
Ischemic heart 38 (72%)
disease
NYHA Class II 48 (91%)
or III
Age 77 (6.1) 65–91
Duration of HF 37 mo (40.2)
6–198 mo
LVEF 30.5% (7.0)
13%–40%
HF, Heart failure; NYHA, New York Heart Association;
LVEF, left ventricular ejection fraction; SD, standard
deviation.
RESULTS
Fifty-four participants gave informed consent and
completed all study measures. One participant, who
was an extreme outlier on several study measures
and was referred for treatment of depression after
data collection, was excluded from analysis. The
remaining 36 men (68%) and 17 women (32%) par-
ticipating in this study had a mean age of 77 years
(range 65–91 years). Table II presents sample char-
acteristics.
The prevalence of fatigue in this sample was
96% (POMS-F) but 100% on the VAS-F, which
captures the full range of fatigue from none to
exhausted. Fatigue intensity, measured as the
mean score on the POMS-F, was 11.5 (standard
deviation [SD] ⫽ 3.8) with a range of 5 to 20. The
mean fatigue intensity indicates that each item on
the POMS-F was rated between a little and mod-
erately. Global fatigue, measured as the mean
score on the VAS-F, was 51.8 mm (SD ⫽ 19.3) with
a range from 7 to 87 mm. Thirty-four participants
(64%) marked their fatigue at 50 mm or higher on
the VAS-F, suggesting the presence of moderate
levels of fatigue over the past week. Women rated
their fatigue higher than men when marking the
VAS-F (56.4 mm vs 49.6 mm). However, no statis-
tically significant differences were found in global
fatigue (VAS-F) or fatigue intensity (POMS-F) be-
tween men and women.
126 www.heartandlung.org
Stephen
Aim 1: Symptom experience
Table III presents the symptom experience and
symptom outcome results. Participants endorsed an
average of 6.1 concurrent symptoms on the symp-
tom checklist. Concurrent symptom severity, mea-
sured as the sum of the symptom severity scores,
was positively related to fatigue intensity (r ⫽ .52,
P ⬍ .001). Participants who had a higher number of
concurrent symptoms and who rated those symp-
toms as more severe had higher fatigue intensity
than participants with fewer and milder concurrent
symptoms. Specific concurrent symptoms that had
significant correlations with fatigue intensity were
breathlessness with activities (r ⫽ .25, P ⬍ .05) and
nocturia (r ⫽ .36, P ⬍ .01). However, difficulty sleep-
ing was not significantly correlated with fatigue in-
tensity (r ⫽ .20, P ⬎ .05).
Fatigue intensity was positively correlated with
age attribution (r ⫽ .29, P ⬍ .05), although age and
fatigue intensity were unrelated (r ⫽ .07, P ⬎ .05).
Participants who attributed their fatigue to aging
(by responding “somewhat” or “very likely” that their
fatigue was caused by aging) reported higher fatigue
intensity than participants who did not attribute
their fatigue to aging, regardless of actual age.
Aim 2: Symptom outcomes
Self-reported functional status, as measured by
the HFFSI, yielded a mean MET level of 5.88 (SD ⫽
1.5). A MET level of 5.5 corresponds to doing out-
door work such as digging in the garden, and a MET
level of 6 corresponds to carrying a load of wet
laundry up eight steps.36 Women had significantly
more limitations in performing high-exertional ac-
tivities than men (t ⫽ 2.43, P ⬍ .05). There was no
relationship between fatigue intensity and self-re-
ported functional status (r ⫽ ⫺.05, P ⬎ .05). Almost
all participants reported that they could perform
activities of daily living such as dressing, eating, and
bathing at a normal pace and without symptoms. A
few participants (8%) could not walk upstairs or
uphill, and among participants who could walk up-
stairs and uphill, 76% reported they did so slowly.
The primary symptom that limited walking upstairs
and uphill was shortness of breath (58%) followed
by fatigue (23%).
Seventy-five percent of the sample had been en-
couraged by their physicians or nurses to partici-
pate in a regular exercise program, and 53% reported
that they exercised at least three times per week. The
most common form of structured exercise performed
was walking. Exercisers (n ⫽ 28) had lower fatigue
intensity compared with nonexercisers (n ⫽ 25), but
MARCH/APRIL 2008 HEART & LUNG
 Stephen Fatigue in older adults with stable heart failure

Table III
Symptom experience and symptom outcome results
Model domains Measure Mean (SD) range

Symptom experience Fatigue prevalence, n (%) 49 (96%)

POMS-F 11.5 (3.8) 5–20
VAS-F 51.8 (19.3) 7–87
Concurrent symptom severity 16.7 (10.3) 0–44
Symptom outcome MET level (HFFSI) 5.88 (1.5) 2.33–7.83
Exercise ⱖ 3 times/wk, n (%) 28 (53%)
LHFQ 25.7 (19.0) 0–73
SWLS 26.8 (5.8) 13–35
Perceived health 2.5 (.67) 1–4

POMS-F, Profile of Mood States Fatigue subscale; VAS-F, Visual Analogue Scale for Fatigue; MET, Metabolic equivalent of the
task; HFFSI, Heart Failure Functional Status Inventory; LHFQ, Minnesota Living with Heart Failure Questionnaire; SWLS,
Satisfaction with Life Scale.

the difference was not significant (POMS-F ⫽ 10.8 ⫾
3.3 vs 12.4 ⫾ 4.1, t ⫽ 1.7, P ⬎ .05).
The relationship of fatigue intensity to three
quality of life concepts (health-related quality of life
[LHFQ], satisfaction with life [SWLS], and perceived
health) was assessed. To eliminate redundancy be-
tween the measure of fatigue intensity and the
LHFQ, the fatigue item on the LHFQ was removed
for the analysis. This item (making you tired, fa-
tigued, or low on energy) had the highest item mean
score (2.3, SD ⫽ 1.7, range 0 –5). Health-related
quality of life was positively correlated with fatigue
intensity (r ⫽ .53, P ⬍ .001). Participants who rated
their quality of life as poor, reflected by higher
scores on the LHFQ, had higher fatigue scores on
the POMS-F. Thus, fatigue intensity explained 28%
of the variance in health-related quality of life. In
addition, scores for health-related quality of life
varied by attribution of fatigue to aging. Health-
related quality of life scores were significantly
higher in the group who attributed their fatigue to
aging (mean ⫽ 17.7 vs 27.1; t ⫽ ⫺2.13, df 36, P ⬍
.05). Thus, health-related quality of life was worse in
the participants who attributed their fatigue to ag-
ing. Satisfaction with life, as measured by the SWLS,
was negatively correlated with fatigue intensity (r ⫽
⫺.46, P ⬍ .01); participants with higher fatigue in-
tensity had lower satisfaction with life. Perceived
health was inversely related to fatigue intensity (r ⫽
⫺.39, P ⬍ .01), reflecting that participants who rated
their current health as fair or poor had higher fa-
tigue intensity.
Aim 3: Predictors of fatigue
Severity of illness and trait negative affect, po-
tential confounders in this study, were both corre-
lated with fatigue intensity. Severity of illness, as-
sessed by the NYHA classification, was positively
related to fatigue intensity (r ⫽ .30, P ⬍ .05); there
was no association between LVEF and fatigue in-
tensity (r ⫽ .12, P ⬎ .05). In addition, there was a
moderate correlation between trait-negative affect
and fatigue intensity (r ⫽ .51; P ⬍ .001).
Six variables (severity of illness, trait-negative
affect, perceived health, life satisfaction, concurrent
symptom severity, and marital status) explained
55.7% of the variance in fatigue intensity (Table IV).
When confounders (severity of illness and trait-neg-
ative affect) were controlled, the remaining four
variables (perceived health, life satisfaction, concur-
rent symptom severity, and marital status) ex-
plained 24.5% of the variance in fatigue intensity.
Marital status was the only independent predictor
(controlling for severity of illness and negative af-
fect) of fatigue in this sample (t (52) ⫽ 3.3, P ⬍ .05).
Married participants reported higher fatigue inten-
sity than those who were not married (POMS-F ⫽
12.4 ⫾ 3.9 vs 9.9 ⫾ 2.9).
DISCUSSION
In this sample of community-dwelling older
adults with stable HF, the relationships between
fatigue intensity and symptom experience and out-
comes were described. Fatigue intensity was corre-
lated with concurrent symptom severity, attribution

HEART & LUNG VOL. 37, NO. 2 www.heartandlung.org 127

Fatigue in older adults with stable heart failure
Table IV
Summary of hierarchical multiple regression analysis for variables predicting fatigue Intensity (N ⫽ 53)
Concept (measure)
Step 1
Trait-negative affect (PANAS)
Severity of illness (NYHA classification)
Step 2
Perceived health (self-report)
Satisfaction with life (SWLS)
Concurrent symptom severity (symptom checklist)
Marital status
PANAS, Positive and Negative Affect Schedule; NYHA, New York Heart Association; SWLS, Satisfaction with Life Scale.
of fatigue to aging, all three dimensions of quality of
life, and being married. Marital status was the only
independent predictor of fatigue intensity when se-
verity of illness and trait-negative affect were con-
trolled. As in other studies,4,5,7,8 fatigue was com-
mon, reported by 96% of the sample. Friedman9
found that fatigue was the most common symptom
in community-dwelling older adults with HF 6 weeks
after an acute exacerbation. The present study ex-
tends the findings of previous research, which has
focused on measuring fatigue after acute exacerba-
tions, by revealing the persistent problem of fatigue
in older adults with stable HF.
The mean fatigue intensity in this sample was
11.5 on the POMS-F. There are no normative fatigue
values for the POMS-F in older samples with HF, but
the instrument has been used in older adults with
cancer. As expected, the older adults with stable HF
in this sample reported less fatigue intensity than a
comparison group who were undergoing active
treatment of cancer.37 However, fatigue was present
at mild to moderate levels in those with stable HF,
alerting clinicians to establish a baseline of usual
fatigue levels for comparison. It may also be helpful
for clinicians to ask patients to respond to a brief
standardized scale, such as the 5-item POMS-F or
VAS-F, to improve the consistency of assessment
and track changes in fatigue over time.
Fatigue intensity was positively related to the
presence and severity of concurrent symptoms, as
documented in other studies.3,5 Physical symptoms,
sleep disturbances, chest pain, and weakness have
been identified as correlates of fatigue in older
women with HF.5 Difficulty sleeping was not asso-
ciated with fatigue intensity in this study; however,
nocturia, a specific type of sleep disturbance, was
128 www.heartandlung.org
Stephen
B weights Simple r2 Cum R2 P
.476 .508 .312 .021
.235 .299 .472
.194 .349 .557 .093
⫺.204 ⫺.462 .077
.249 .520 .063
.342 .318 .002
significantly related to fatigue intensity. Dyspnea
was the sole symptom correlated with fatigue 18
months after an acute exacerbation of HF in Fried-
man and King’s5 longitudinal study; breathlessness
with activities was similarly related to fatigue in this
sample.
The dynamic relationships among multiple symp-
toms revealed in this study and supported by previous
research lend credence to recent efforts to move away
from single-symptom studies.38 Knowledge about the
relationship of fatigue to other HF symptoms aids
the development of interventions. Interventions
aimed at reducing fatigue might be targeted at con-
trolling concurrent symptoms. For example, reduc-
ing nocturia in older adults could positively impact
HF-related fatigue. Likewise, improved manage-
ment of HF dyspnea may reduce fatigue and lead to
better quality of life.
A problem specific to older adults is that fatigue
attributed to aging may be dismissed and not re-
ported to health care providers. Underreporting of
symptoms is a phenomenon that has important
implications for HF care.8,39 Older adults who at-
tribute their fatigue to aging may not recognize
important changes in fatigue severity caused by
worsening HF. This suggests that attribution of fa-
tigue to aging may be a barrier to early recognition
of and treatment seeking for exacerbation of HF. In
this study, attribution of fatigue to aging was corre-
lated with higher fatigue intensity, regardless of
actual age, and those who attributed their fatigue to
aging had worse health-related quality of life. The
relationship between attribution of fatigue to aging
and health-related quality of life may be due to
higher fatigue intensity in those who attributed fa-
tigue to their age in this sample, but this warrants
MARCH/APRIL 2008 HEART & LUNG
Stephen
further investigation. Interventions that help people
recognize the link between their fatigue and HF may
improve symptom recognition and prevent HF exac-
erbation.
Prohaska and colleagues23 found that older
adults were more likely to choose rest and relax-
ation as coping responses to symptoms such as
fatigue. Oka and colleagues6 provided evidence for
this coping response by documenting peak daily
activity levels below functional capacity as deter-
mined by exercise stress testing in older adults with
HF. Mayou and colleagues3 observed that older
adults cope with their HF symptoms by reducing
their walking pace and the speed at which they
perform physical activities. Unfortunately, older
adults may lose functional abilities and indepen-
dence if they choose to manage their fatigue by
restricting physical activities.
However, in this sample, fatigue intensity and
self-reported functional status were unrelated. It is
possible that self-report of the ability to perform
activities of daily living differs from objective mea-
sures of functional status. As shown in previous
work,9 women in this sample had lower self-re-
ported functional status than men. The lack of a
relationship between fatigue intensity and self-re-
ported functional status guides clinicians to avoid
using self-reported functional status as a proxy
measure to assess fatigue.
Ekman and Ehrenberg11 reported that women
with HF had more problems with fatigue than men
and that the difference was not explained by sever-
ity of illness. Women in the general population
report higher fatigue than men.40 In this sample,
women reported higher fatigue than men on the
VAS-F, but the difference was not significant. An
unanticipated result was that married participants
had higher fatigue than nonmarried participants. A
recent study reported a positive relationship be-
tween marital status and quality of life in a sample
of 179 patients with HF; being married or living with
a partner was associated with a higher quality of
life.41 In this sample, the nonmarried group had
more women than the married group, but subgroup
analysis by gender was precluded by small sample
size. Nonmarried older adults may report less fa-
tigue because they need to be self-reliant to main-
tain their independence. Marriage may contribute a
fatigue burden in the form of caregiver responsibil-
ities for both men and women. In addition, married
participants may have less control over their daily
activities, or keeping up with the activities of a
spouse may increase fatigue. The relationships
HEART & LUNG VOL. 37, NO. 2
Fatigue in older adults with stable heart failure
among marital status, fatigue, and gender need fur-
ther investigation in a larger sample.
In this study, fatigue intensity was associated
with reduced quality of life, satisfaction of life, and
perceived health. Similar to other studies,42 lower
self-perceived health status was associated with
higher fatigue intensity in this sample. Self-rating of
global health status has been found to be a predic-
tor of mortality and hospitalization in persons with
HF.43 Fatigue may be one of the sensations used by
a person to judge the global rating of health. Stud-
ies aimed at intervening to reduce fatigue should
include a global health status measure and evaluate
whether reductions in fatigue are associated with
improvements in global health appraisal.
Study results must be interpreted with the fol-
lowing limitations in mind. Results of this study
may not represent all community-dwelling older
adults with stable HF. On the other hand, by re-
stricting the eligibility to older adults with definitive
HF diagnosis (documented systolic dysfunction)
and excluding those who had conditions associated
with fatigue, this study was designed to maximize
internal validity. The effects of psychologic distress
such as depression and anxiety were not assessed
in this study, nor was the time since the last exac-
erbation of HF. Despite oversampling of women,
inclusion and exclusion criteria may have limited
the ability to recruit more women. The small sample
size and uneven group size restricted analyses by
and controlling for gender. Therefore, the influence
of gender on the relationships described in this
sample, such as between fatigue and marital status,
is not known. The cross-sectional study design did
not permit the description of changes in fatigue
over time.
Strengths of the study include isolating HF-re-
lated fatigue with a targeted sample, self-report
fatigue measures, and evidence of concurrent valid-
ity between the POMS-F and the VAS-F. Study meth-
ods (face-to-face interview conducted in the home
setting) minimized burden and optimized data qual-
ity in a sample of older adults. In contrast with other
studies that recruited participants during a hospi-
talization,7,12 recruitment strategies using ambula-
tory clinics was a feasible way to identify older
adults with stable HF who were living at home.
CONCLUSIONS
Fatigue is a common symptom in community-
dwelling older adults living with stable HF associ-
ated with systolic dysfunction. In this sample, fa-
tigue was not related to self-reported functional
www.heartandlung.org 129
 Fatigue in older adults with stable heart failure
status or exercise routine. This challenges the as-
sumption that proxy measures such as activity level
can be used to assess the presence or absence of
fatigue. Clinicians need to ask patients with HF
about fatigue to assess this common HF symptom.
By asking about current and usual levels of fatigue,
clinicians are able to establish a baseline to evalu-
ate the response to fatigue-reducing interventions.
Fatigue was associated with poorer quality of life in
this study; therefore, clinicians should assess the
impact of fatigue on daily life. Future longitudinal
studies are needed to describe fatigue patterns over
time. In addition, recent advances in the diagnosis
of diastolic HF permits the inclusion of older adults
with HF and an ejection fraction more than 40%;
these individuals should be included in future re-
search.
Dissertation Committee: Dr. Lillian M. Nail, chair, Dr.
Kathleen M. Baldwin, Dr. Barry J. Cusack, Dr. Muriel P.
Shaul, and Dr. B. Lee Walker. Dr. Anne G. Rosenfeld and
Ms. Blair G. Darney reviewed drafts of this article.
REFERENCES
1. Ekman I, Fagerberg B, Skoog I. The clinical implications of
cognitive impairment in elderly patients with chronic heart
failure. J Cardiovasc Nurs 2001;16:47-55.
2. American Heart Association. Heart Disease and Stroke Statistics:
2006 Update. Dallas, TX: American Heart Association; 2006.
3. Mayou R, Blackwood R, Bryant B, Garnham J. Cardiac failure:
symptoms and functional status. J Psychosom Res 1991;35:
399-407.
4. Baker DW, Brown J, Chan KS, Dracup KA, Keeler EB. A
telephone survey to measure communication, education,
self-management, and health status for patients with heart
failure: the Improving Chronic Illness Care Evaluation
(ICICE). J Card Fail 2005;11:36-42.
5. Friedman MM, King KB. Correlates of fatigue in older women
with heart failure. Heart Lung 1995;24:512-8.
6. Oka RK, Stotts NA, Dae MW, Haskell WL, Gortner SR. Daily
physical activity levels in congestive heart failure. Am J Car-
diol 1993;71:921-5.
7. Schaefer KM, Potylycki MJS. Fatigue associated with conges-
tive heart failure: use of Levine’s Conservation Model. J Adv
Nurs 1993;18:260-8.
8. Ekman I, Ehrenberg A. Fatigued elderly patients with chronic
heart failure: do patient reports and nurse recordings corre-
spond? Int J Nurs Terminol Classif 2002;13:127-36.
9. Friedman MM. Gender differences in the health related qual-
ity of life of older adults with heart failure. Heart Lung
2003;32:320-7.
10. Zambroski CH, Moser DK, Bhat G, Ziegler C. Impact of symp-
tom prevalence and symptom burden on quality of life in
patients with heart failure. Eur J Cardiovasc Nurs 2005;4:
198-206.
11. Ekman I, Ehrenberg A. Fatigue in chronic heart failure— does
gender make a difference? Eur J Cardiovasc Nurs 2002;1:77-82.
12. Schaefer KM. A description of fatigue associated with con-
gestive heart failure: use of Levine’s Conservation Model. In:
Parker M, ed. Nursing Theory in Practice. New York: National
League for Nursing; 1990:217-37.
130 www.heartandlung.org
Stephen
13. Painter LM. Living with stage III heart failure: Dissertation
Abstracts International. Doctoral dissertation. Washington,
D.C.: The Catholic University of America; 2004.
14. Winningham ML, Nail LM, Burke MB, et al. Fatigue and the
cancer experience: the state of the knowledge. Oncol Nurs
Forum 1994;21:23-36.
15. Swain MG. Fatigue in chronic disease. Clin Sci 2000;99:1-8.
16. Nail LM. Fatigue in patients with cancer. Oncol Nurs Forum
2002;29:537-46.
17. Aaronson LS, Teel CS, Cassmeyer V, et al. Defining and
measuring fatigue. Image J Nurs Sch 1999;31:45-50.
18. Meek PM, Nail LM, Barsevick A, et al. Psychometric testing of
fatigue instruments for use with cancer patients. Nurs Res
2000;49:181-90.
19. Dodd M, Janson S, Facione N, et al. Advancing the science of
symptom management. J Adv Nurs 2001;33:668-76.
20. University of California San Francisco School of Nursing
Symptom Management Faculty Group. A model for symptom
management. Image J Nurs Sch 1994;26:272-6.
21. Gift AG, Pugh LC. Dyspnea and fatigue. Nurs Clin North Am
1993;28:373-84.
22. Pennebaker JW. Psychological factors influencing the report-
ing of physical symptoms. In: Stone AA, ed. The Science of
Self-Report. Mahwah, NJ: Lawrence Erlbaum Associates, Pub-
lishers; 2000:299-315.
23. Prohaska TR, Keller ML, Leventhal EA, Leventhal H. Impact
of symptoms and aging attribution on emotions and coping.
Health Psychol 1987;6:495-514.
24. Pfeiffer E. A Short Portable Mental Status Questionnaire for
the assessment of organic brain deficit in elderly patients.
J Am Geriatr Soc 1975;23:33-41.
25. McNair DM, Lorr M, Droppleman LF. EdiITS manual for the
Profile of Mood States. San Diego, CA: EdITS/Educational
and Industrial Testing Service; 1992.
26. Hawthorne MH, Hixon ME. Functional status, mood distur-
bance and quality of life in patients with heart failure. Prog
Cardiovasc Nurs 1994;9:22-32.
27. Gift AG. Visual analogue scales: measurement of subjective
phenomena. Nurs Res 1989;38:286-8.
28. Nail LM. Symptom Checklist; 1991. (Available from L. M.
Nail, Oregon Health & Science University, Portland, OR).
29. Andrea H, Kant IJ, Beurskens AJ, Metsemakers JF, Van
Schayck CP. Associations between fatigue attributions and
fatigue, health, and psychosocial work characteristics: a
study among employees visiting a physician with fatigue.
Occup Environ Med 2003;60(Suppl 1):i99-104.
30. Dracup K, Walden JA, Stevenson LW, Brecht ML. Quality of
life in patients with advanced heart failure. J Heart Lung
Transplant 1992;11:273-9.
31. Dunbar SB, Jenkins LS, Hawthorne M, Porter LS. Mood dis-
turbance in patients with recurrent ventricular dysrhythmia
before insertion of implantable cardioverter defibrillator.
Heart Lung 1996;25:253-61.
32. Rector TS, Cohn JN. Assessment of patient outcome with the
Minnesota Living with Heart Failure questionnaire: reliability
and validity during a randomized, double-blind, placebo-
controlled trial of pimobendan. Pimobendan Multicenter Re-
search Group. Am Heart J 1992;124:1017-25.
33. Diener E, Emmons RA, Larsen RJ, Griffin S. The Satisfaction
with Life Scale. J Pers Assess 1985;49:71-5.
34. Watson D, Clark LA, Tellegen A. Development and validation
of brief measures of positive and negative affect: the PANAS
scales. J Pers Soc Psychol 1988;54:1063-70.
35. Statistical Package for the Social Sciences [computer pro-
gram]. Version 7.5. Chicago, IL: SPSS Inc. 1997.
36. Chryssanthopoulos SN, Dritsas A, Cokkinos DV. Activity
questionnaires; a useful tool in accessing heart failure pa-
tients. Int J Cardiol 2005;105:294-9.
37. Stephen S, Nail LM. Age-related differences in perceived
fatigue in persons receiving treatment for cancer. Paper pre-
sented at: Western Institute of Nursing, 1997; Portland, OR.
MARCH/APRIL 2008 HEART & LUNG
 Stephen
38. Barsevick AM, Whitmer K, Nail LM, Beck SL, Dudley WN.
Symptom cluster research: conceptual, design, measure-
ment, and analysis issues. J Pain Symptom Manage 2006;31:
85-95.
39. Friedman MM. Older adults’ symptoms and their duration
before hospitalization for heart failure. Heart Lung 1997;26:
169-76.
40. Chen MK. The epidemiology of self-perceived fatigue among
adults. Prev Med 1986;15:74-81.
HEART & LUNG VOL. 37, NO. 2
Fatigue in older adults with stable heart failure
41. Luttik ML, Jaarsma T, Veeger N, van Veldhuisen DJ. Marital
status, quality of life, and clinical outcome in patients with
heart failure. Heart Lung 2006;35:3-8.
42. Yu DS, Lee DT, Woo J, Thompson DR. Correlates of psycho-
logical distress in elderly patients with congestive heart fail-
ure. J Psychosom Res 2004;57:573-81.
43. Konstam V, Salem D, Pouleur H, et al. Predicting mortality
and hospitalization in 5,025 patients with heart failure uti-
lizing baseline quality of life. Congest Heart Fail 1998;4:31-7.
www.heartandlung.org 131