International Journal of Nursing Studies 47 (2010) 216228

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International Journal of Nursing Studies

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Review

Fatigue among older people: A review of the research literature

Doris S.F. Yu *, Diana T.F. Lee 1, Ng Wai Man 2
The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong (Special Administrative Region)

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

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

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

o Reviews international research on fatigue among the

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

0020-7489/$ see front matter 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2009.05.009
 D.S.F. Yu et al. / International Journal of Nursing Studies 47 (2010) 216228
1. Introduction
Fatigue is a universal experience in the population and
is a common symptom among older people. Epidemiology
of this symptom indicated that as many as 2750% of
community-dwelling older people complain of moderate
to severe levels of fatigue (Hellstrom et al., 2004, Reyes-
Gibby et al., 2003; Wijeratne et al., 2007). The prevalence is
even higher for those who are residing in long-term care
setting (Liao and Ferrell, 2000). However, fatigue manage-
ment has not received adequate attention in gerontological
nursing practice. Health care interventions for ameliorat-
ing or improving this condition have been scarcely
researched. Some studies have even indicated that nurses
were not able to recognize this symptom among the older
population (Tiesinga et al., 2002).
The inadequate attention to fatigue management among
the older population may be related to the confusion
surrounding the phenomenon of fatigue itself. First, diverse
denitions on fatigue have been formulated, which vary
considerably on the proposed causes, dening attributes,
related factors and how the condition might best be
alleviated (Ream and Richardson, 1996; Trendall, 2000).
Second, although it is generally agreed that fatigue can have
a devastating impact on overall well-being, some report in
literature characterize fatigue as a protective bodily
response to prevent overtaxing of functional reserve
(Tiesinga et al., 1996). All of these inconsistencies may
affect proper assessment of the symptoms and add
difculties to recognition and management of the condition.
Concept analysis has been conducted so as to clarify the
dening concept of fatigue and to identify the phenom-
enon in subjects (Aaronson et al., 1999; Ream and
Richardson, 1996; Tiesinga et al., 1996; Trendall, 2000).
Fatigue has been identied as a subjectively reported very
unpleasant experience typically described as being odi-
ous, troublesome, comfortlessness and even over-
whelming (Ream and Richardson, 1996; Trendall, 2000).
Instead of a normal response to bodily exertion, it is a
sustained sense of whole body exhaustion that is
disproportionate to the level of physical exertion and is
not relieved by rest (Tiesinga et al., 1996; Trendall, 2000).
The occurrence of fatigue involves a complex interplay of
medical, physical and psychiatric factors, but can also be
strikingly idiopathic. Its manifestation is multi-dimen-
sional in nature (Ream and Richardson, 1996), and a
fatigued individual may present with a lower physical
capacity (Tiesinga et al., 1996; Trendall, 2000), poorer
motivation to work (Aaronson et al., 1999), reduced
memory, decreased attention and concentration, impaired
thought processes, poorer coping ability, increased irrit-
ability and diminished social functioning (Aaronson et al.,
1999; Ream and Richardson, 1996; Tiesinga et al., 1996).
The overall fatigue experience is, hence, a debilitating
compromise of quality of life.
The devastating consequences of fatigue are especially
detrimental to older people, who have more seriously
depleted reserves to make up for physical and psycholo-
gical deconditioning. Inaccurate assessment, under-appre-
ciation and under-treatment of this condition in the older
population (Liao and Ferrell, 2000) suggest a need to
217
enhance awareness and understanding of this complex and
poorly dened phenomenon among nurses and other
health care professionals. Indeed, as compared with the
population in general, the age-related changes in func-
tional status, co-morbidities and energy requirement may
render fatigue a profoundly different experience for older
people (Poluri et al., 2005). The purpose of this review is to
describe the existing research on fatigue on older adults
with focus on the lived experience of fatigue, factors
related to such fatigue experience and the impact of fatigue
on overall health. Focus was placed on the fatigue
phenomenon associated with aging but not related to a
specic disease.
2. Method
Relevant research studies were sourced using the
databases OvidMedline (1997September 2008), CINAHL
(1997September 2008), PsycINFO (1997September
2008) and the keywords fatigue, mental fatigue, muscle
fatigue, older people, were used. Studies were included if
they focused on fatigue among older people. Paper focuses
on fatigue of older people in specic disease groups was
excluded, as such fatigue experience would be more
affected by the nature of the disease and less representa-
tive of the age-related changes. Other exclusion criteria
include studies which: (1) were published in non-English
language; or (2) were review, abstracts or discussion
papers. In addition, a manual search of the bibliographies
of retrieved studies was also done.
A total of 131 articles were located in OvidMedline
(n = 78 studies), CINAHL (n = 37 studies) and PsycINFO
(n = 16 studies) and another 10 from secondary references.
Paper whose titles indicated of irrelevance to fatigue in
older people or were published in forms of abstracts,
reviews, discussion papers, case studies, editorials, com-
mentary letters or conference proceedings were excluded.
Of the remaining 112 articles, a total of 97 articles were
further exempted after reviewing the abstracts because
they were irrelevant or duplicated articles (n = 52),
included clients of other age groups (n = 8) or disease
groups (n = 16), or non-research based articles (n = 21).
This review, hence, included 15 articles.
Two researchers (D.Y. and W.M.N.) independently
extracted data from each eligible paper. Information
about the study setting, research design, sample char-
acteristics, and data collection methods were extracted
for data synthesis (Table 1). Major ndings from the
studies were compared with one another for similarities
and differences.
3. Findings
The reviewed studies were conducted in Denmark
(n = 6), the USA (n = 6), Australia (n = 2) and Belgium
(n = 1). The majority of these studies (n = 13) adopted a
quantitative approach to examine fatigue, while the others
used a qualitative approach. The samples in the reviewed
studies were mainly recruited from community settings,
while some also recruited institutionalized older people.
The sample size for the quantitative studies ranged from
 218
Table 1
Summaries on fatigue in older adults studies.

Author(s) Research design Aims and objectives Sample characteristics Data collection methods/key Major ndings
measurements

Avlund Secondary To examine whether N = 734 older people participated Tiredness in mobility: Tiredness in mobility was an independent
et al. (1998) analysis of self-reported tiredness in a comprehensive medical survey mobility-tiredness scale predictor of mortality of older people
Denmark data in a in mobility and physical done in the period of 19841985 after adjusted for the actual disability
longitudinal activities of daily living Tiredness in physical activity: at baseline, demographic background,
survey predict mortality in the Male:female = 366:368 lower limb-tiredness self-rated health and smoking habit.
next 10 years The predictive effect was also signicant
Age = 70 years (baseline) Functional activity: for the non-disabled counterpart
mobility-help scale
No information about the health

D.S.F. Yu et al. / International Journal of Nursing Studies 47 (2010) 216228

status Dependency in ADL: PADL-H scale

Global self-rated health:

self-developed items

Mortality: retrieved from Central

National Register

Avlund Secondary To examine whether N = 275 participated in a medical Tiredness in daily activities: Self-reported tiredness in mobility
et al. (2001) analysis of self-reported tiredness survey at their age of 75 and 80 Mobility-tiredness scale signicantly predicted the use of
Denmark data in a in daily activities at age 75 Age = 75 years (baseline) Lower limbtiredness scale home-help and hospital service
longitudinal predict hospitalization and Health status in older people irrespective of
survey use of home services Musculoskeletal disease (28.7%) their baseline level of disability
5 years later Cardiovascular disease (20%) and chronic illness
Mental and neuro-sensory
disorders (10.2%)
Respiratory disorders (5.1%)
Digestive disorders (7.6%)
Endocrinologic and metabolical
disorders (4.7%)
Various tumors (5.1%)

Avlund Secondary To examine whether Baseline data from surveys with Mobility disability: mobility-help After adjusting for the effect of chronic
et al. (2002) analysis of self-reported tiredness random sample from the [mobility disability is dened illness, cognitive function and self-rated
Denmark data in a in daily activities at population in Demark (N = 480) as need help in one or more of the health, older people who felt tired in
longitudinal age 75 predict the onset and Finland (N = 355) six included activities] their daily activities had a three time
survey of disability 5 years later increased risk of developing mobility
disability than those without tiredness
Age = 75 years (baseline) Disability in daily activity: After adjusting for chronic illness,
Non-disabled PADL-help scale [ADL disability cognitive function and self-rated
is dened as need help in one health, feeling tiredness in daily
Sample completed follow-up or more of the six daily activities] activities had a double risk of
study = 517 becoming disabled in daily activities
Health status: 2 chronic illness: 32% Tiredness in daily activities: Lower compared to person without tiredness
Depressive symptoms: 27.7% limb T scale
Avlund Secondary To determine the impact
et al. (2003a) analysis of of change in self-reported
Denmark data in a tiredness in daily activities
longitudinal in the preceding 5-year
study period on functional
decline from age 8085
Avlund Prospective To examine whether
et al. (2003b) study with self-reported tiredness
Denmark 1.5 year in daily activities predict
follow up the onset of mobility disability
among non-disabled elderly
men and women 1.5 years
later
Bautmans Quantitative, To explore:
et al. (2008) exploratory
Belgium study (1) the relationship
between muscle
endurance and perceived
fatigue in general as well
as during daily activities
(2) the relationship
between muscle endurance
and circulatory inammatory
mediators including
circulating interleukin
(IL)-6, tumor necrosis factor
alpha (TNF-a) and heat
shock protein (Hsp) 70
(3) the relationship
between muscle
endurance and mobility
N = 226 older people from a
prospective longitudinal study
with subjects recruited in Denmark
and Finland
Age = 75 years (baseline)
Health status not reported
N = 1396 non-disabled
[3_TD$IF]community-dwellers from the
non-disabled control group of a
randomized controlled trail who
completed follow-up data
collection at 1.5 years
Male:female = 648:748
Age = 7475 years (baseline)
N = 77 nursing homes residents
Male:female = 24:53
Age:
Male = 81.9 (7.7) years
Female = 78.8 (7.0) years
Health status:
Dementia: 50.6%
Depression = 46.8%
Osteoarthritis = 7.8%
Chronic heart failure = 42.9%
Hypertension = 37.7%
Chronic obstructive airway
disease = 5.2%
Gastro-intestinal disorder = 16.9%
Tiredness in daily activity:
Mob-T scale
Functional ability: Mob-H scale
Mobility disability: mobility-help
[mobility disability is dened as
need help in one of the six
included activities]
Tiredness in daily activity:
mobility-tiredness scale
Fatigue:
Visual analogue scale
Mobility-tiredness scale
World Health Organization Quality
of Life questionnaire
Inammatory mediators: blood test
Muscle endurance: Martin vigorimeter
Mobility and physical dependence:
Tinetti test for balance and gait
Elderly mobility scale for functional
mobility
Majority of the subjects did not
change their perceived tiredness
over the 5 years (i.e. sustained
tiredness: 24% or sustained
no tiredness: 40%)
Elderly with sustained self-reported
tiredness in daily activities from
age 7580 were associated with
two times increased risk in having
functional decline/death during
the subsequent 5 years
Tiredness in daily activity was
associated with 2 time increased
risk of developing mobility
D.S.F. Yu et al. / International Journal of Nursing Studies 47 (2010) 216228
disability in 1.5-year times in
older men and 3 times increased
risk in the female counterpart
Older RCH elders with higher level
of muscle endurance reported lower
level of perceived fatigue in general
and fatigue during daily activities.
Higher level of muscle endurance also
associated with better balance and
mobility functions. Lower muscle
endurance was associated with
higher level of inammatory
mediators which involved in the
catabolic process associated with
inammation
219
 220
Table 1 (Continued )
Author(s) Research design Aims and objectives Sample characteristics Data collection methods/key Major ndings
measurements

Bennett Secondary To determine whether N = 225 communities-dwelling Symptoms: pain and fatigue scale There was a lack of signicant
et al. (2002) analysis on fatigue and pain mediate older people who did not have of the Short-Form 36 Survey association between medical
USA data of a the effect of medical serious medical conditions that conditions and physical status.
randomized conditions on functioning could limit participation in light Medical conditions: sum of eight However, medical condition was
controlled in older adults to moderate physical activity common self-reported medical found moderately associated with
trial conditions or syndromes in older symptoms, which, in turn, were
Male: 29.2% people strongly associated with self-reported
physical functioning and self-reported
Age = 6590 years Functional status: role and social functioning
Physical Performance battery to
Health status measure lower body performance

D.S.F. Yu et al. / International Journal of Nursing Studies 47 (2010) 216228

Arthritis: 59% SF-36 Physical functioning scale
Hypertension: 36% SF-36 role physical and social
Heart disease: 18% functioning subscales

Galindo-Ciocon Quantitative, Examine the prevalence N = 173 outpatients from Depression: geriatric depression scale Chronic fatigue was common
and Ciocon comparative of chronic fatigue in a multispecialty clinic among community-dwelling
(1997) study community-dwelling older Fatigue: Chronic fatigue questionnaire older people with prevalence
USA people Male:female = 39:129 as 47.9%
Cognitive function: Mini-mental status
To compare the chronic Age = 72.5 years examination Except bromyalgia, prevalence
illness, sleep disorder, of chronic illness was comparable
exercise habit, use of Older people with severe Pain: between fatigue and non-fatigue
medication and chronic illness, terminal group
cafne-containing food condition, or severe Visual analogue scale
between fatigued older depression (GDS > 10) were Sleep disorder and lack of exercise
people and those without excluded Data on sleeping habits and level were more common in the fatigued
fatigue of physical activity was also collected older people but not in the
Health status: non-fatigued counterpart. There
Obesity: 50.9% was no difference in the pattern
Hypertension: 68.2% of medication use and caffeine
Cardiac disease: 63.6% consumption between the two
Respiratory diseases: 69.3% groups
Neurological disease: 73.4%
Arthritis: 68.8%
Depression: 75.1%
Liao and Quantitative, To examine prevalence
Ferrell (2000) cross-sectional of fatigue in older people
USA correlational using the residential
study care services.
To examine the relationship
between fatigue and
various clinical and
demographic factors
To examine the subjects
perceived sources of
fatigue and their
self-care interventions
Martin Quantitative, To explore the longitudinal
et al. (2006) longitudinal inuences of personality
USA study and health behaviors on
changes in fatigue [fatigue
was regarded as a state
characterized by a general
lack of energy or vigor]
Parse (2003) Qualitative, To explore the lived
USA phenomenological experience of feeling very
[89_TD$IF]study tired from older adults a community projects
phenomenological- perspectives
hermeneutic
approach
Recruited from a 750-bed
multilevel long-term care facility
N = 199 institutionalized elders
Male:female = 36:163
Age = 87.8  4.9 years
N = 178 community-dwellers
Male:female = 54:124
Age:
6069 years (37.6%)
8089 years (32.0%)
100+ years (30.3%)
N = 10 community-dwellers
who were volunteers in
Women aged 65 years or above
Fatigue: modied piper fatigue scale
Depression: Geriatric depression
scale (GDS)
Cognitive state: mini-mental state
exam
Functional status:
Katz activities of daily living scale
Lawton intermediate activities of
daily living
Pain: 7-item pain scale
Functional performance: Walking tests
Data was collected by means of survey
at baseline and during follow-up
18 months later for centenarians
and 5 years for non-centenarians
Personality (anxiety and extraversion):
16PF personality factor inventory
Health behaviors (physical activity/stress
management): single item indicator
Health behavior (nutritional): nutritional
risk measures
Fatigue: fatigue scale of the Eight State
Questionnaire
Unstructured interviews asking
participants the experience of feeling
very tired
98% of subjects reported fatigue with
51% as mild, 40% as moderate and
7% as severe
Multivariate analysis indicated that
fatigue was independently predicted
by higher level of depression, greater
number of routine medications,
higher level of pain and lower level
of functional performance. By
comparing the standard regression
coefcients,
the effect of depression was most
prominent.
D.S.F. Yu et al. / International Journal of Nursing Studies 47 (2010) 216228
There was no signicant relationship
between fatigue and demographic
characteristics
After adjust for the socio-demographic
variables, more anxious persons,
and those who were less physically
action and with higher nutritional risk
were more likely to show increased
fatigue on subsequent longitudinal
assessment
Feeling very tired was described as
a devitalizing languor that caused
by engaging too many activities
Feeling very tired impaired older peoples
well-being in the physical, psychological
and social dimensions. Such feeling
depleted their energy for doing or
continuing any activities. Even though
they wanted to keep going on, the
energy and motivation fades and
resulted in strong feeling of
incompetence and disgraceful. Such
debilitating feeling also stopped
participants from continuing with
their social relating activities
221
 222
Table 1 (Continued )
Author(s) Research design Aims and objectives Sample characteristics Data collection methods/key Major ndings
measurements

Living with such feeling prompted

the participants to introduce
repose-revive rhythm in their life.
They reported that getting rest made
them felt refreshed and could move
on vigorously thereafter

Schultz-Larsen Secondary To determine the effect of N = 705 community-dwelling Disability: mobility-help scale Self-reported tiredness in daily
and Avlund analysis of self-reported tiredness in older people who had activities was an independent
(2007) data from daily activities on onset of participated in the longitudinal Tiredness in daily activities: predictor of disability and mortality
Denmark a longitudinal disability and mortality in medical survey in Demark mobility-tiredness scale in older people in 5-, 10- and 15-year

D.S.F. Yu et al. / International Journal of Nursing Studies 47 (2010) 216228

study 5-, 10- and 15-year among a
group of community-dwelling
older people
times
Age = 70 years
After adjusting for gender and
Health status: comorbidity, self-reported tiredness
Cardiovascular disease: 20.6% was associated with nine time
increase in onset of disability
Respiratory disease: 3.3% in 5 years and 2 time increase
Musculoskeletal disease: 10.6% in 10- and 15-year. Tiredness
Endocrine disease: 8.5% also doubled the risk for mortality
at the three time points

Teel and Ex post facto To compare the perceptions
Press (1999) research design of fatigue between older
USA people who were spousal
caregiver of patients with
Alzheimers disease, person
with Parkinsons disease
and cancer and those who
did not
Recruited from a neurology Fatigue: The visual analogue scale Caregiver groups reported signicantly
research clinic at a medical for fatigue greater fatigue and sleep difculty
center and a cancer center when compared with control groups.
Sleep pattern: The Verran and The caregiver group also reported
N = 33 non-caregiver (control) Snyder-Halpern sleep scale poorer overall health and poorer
N = 30 Alzhimers disease patients health as compared with 5 years
caregivers Distress symptoms: the symptom ago than the control
N = 29 Parkinsons disease patients distress scale
caregivers There was no signicant difference in
N = 33 cancer patients caregivers Mood disturbance: the prole of the fatigue and sleep difculty between
mood states (short form) the different caregiving groups. However,
Age: the caregiving situation in terms
Physical health of the care recipient: of functional impairment, cognitive
74 years (control group) older American resources and services status and problematic behaviors
72 years (Alzheimers disease) scale (OARS) was different between the three
73 years (Parkinsons disease) caregiving groups. All groups reported
70 years (Cancer) Problem behaviour of the care recipient: a relatively high level of perceived
problematic behaviors scale social support and there was no
Male:female= signicant difference
Cognitive impairment: cognitive status
16:17 (control) scale
14:16 (Alzheimers Disease)
14:15 (Parkinsons Disease) Perceived social support: expressive
16:17 (Cancer group) social support scale
Toye Qualitative, To explore and describe N = 12 frail elderly people residing
et al. (2006) exploratory the experiences of fatigue in aged care facilities
Australia and descriptive of frail older people
study Male:female = 2:10
Age = 7293 years
Health status:
One participant with just one single
diagnosis, and the other had
multiple diseases including various
from various cardiovascular diseases,
musculoskeletal diseases, eye and
hearing problems, mood disorders,
respiratory disease, diabetes mellitus,
Semi-structure interview was used
to explore participants perceptions
of fatigue. The discussion focused on
the way participants felt when fatigued,
the way fatigue affected them and the
ways to cope with fatigue
The ndings described more on the
psychosocial consequence of living
with fatigue and the ways frail
older people cope with the feeling.
Five major themes emerged including
battling on, hitting rock bottom,
pacing yourself, moving on
For the rst two themes, the former
described the sense of frustration
with the limitation imposed by
fatigue whereas the latter described
the psychological impact of failure
to function in day-to-day life.
Feelings of despair, worthlessness and

D.S.F. Yu et al. / International Journal of Nursing Studies 47 (2010) 216228

or chronic fatigue syndrome being a burden of others were reported

As for the later three themes, they

were concerned with the way older
people coped with the feelings.
Pacing yourself referred to the ways
clients interspaced their activities with
breaks and moving on described other
strategies participants used to increase
energy level and cope with fatigue.
Feeling safe and belonging mentioned
the positive psychological reaction
of the participants when they were
supported by others at the time
of getting fatigue

Wijeratne Quantitative, To determine the N = 124 outpatients from medical Psychological symptom: The overall rate of fatigue is 27.4%
et al. (2007) correlational characteristics of fatigue clinics 6 anxiety/depression items from the in which 16.9% was cases comorbid
Australia study and its relationship with General Health Questionnaire (GHQ). fatigue and psychological disorder,
psychological disorder Male: 50% 10.5% was cases with fatigue alone,
in older primary care elders Fatigue symptom: six somatic symptoms and 9.7% with psychological disorder
Mean age = 73.4 years from GHQ
By using logistic regression analyses,
Fatigue cases with psychological disorder: it was found that female gender,
International Statistical Classication of current psychological disorder,
Diseases, 10th Revision for neurasthenia psychotropic drug use, and greater
physical illness predicted fatigue.
Physical health: Cumulative Illness
Rating Scale for Geriatrics By following up the subjects for
another year, the ndings indicated
that non-cormobid fatigue cases did
not tend to evolve into psychological
cases, nor vice versa. 5 out of 13
non-comorbid fatigue cases also had
the symptom resolved at 12 months

223
224 D.S.F. Yu et al. / International Journal of Nursing Studies 47 (2010) 216228
77 to 734. As for the two qualitative studies, both of them
met the criterion of data saturation in sampling (Parse,
2003; Toye et al., 2006). The studies explored different
aspects of the fatigue phenomenon in older people and the
ndings can be categorized into three main areas
including: (1) the lived experience of fatigue; (2) related
factors of fatigue; and (3) impact of fatigue on overall
health.
3.1. The lived experience of fatigue among older people
Two studies examined the lived experience of fatigue in
older people, one in institutionalized elders (Toye et al.,
2006) and the other in the those who were dwelling in the
community (Parse, 2003). The ndings in both studies
reinforced fatigue being a multi-dimensional phenomenon
which encompasses physical, emotional and social com-
ponents. Older people described fatigue as a heavy
feeling, fading, and organs (bodily organs) are slowing
down (Parse, 2003). The use of such metaphors reects the
non-specicity of the fatigue experience. It also indicates
that older people are pre-occupied with the debilitating
consequences. Indeed, the term devitalizing languor
emerged from the descriptions of the disabling effects of
fatigue among the community-dwelling older people
(Parse, 2003). Older people reported that fatigue had
stopped them from doing much of anything except, as one
person put it, shutting their eyes. The symptom also
hindered them from participating in social activities. Toye
et al. (2006) identied a similar experience in the
institutionalized older people, who perceived that there
was a natural rhythm requiring them to interspersing
activities with breaks in the course of living with fatigue.
These ndings highlighted the devastating effect of fatigue
as a state of energy depletion among older people. The self-
chosen terms such as stopped them from doing anything
and natural rhythm imply older people may have little
control over fatigue-related debilitation.
Older people tend to describe themselves as struggling
to live with the problem of fatigue. Toye et al. (2006) used
the theme battling on to illustrate such self-characterized
experience. Yet, there was a feeling of frustration that
typically resulted when fatigue limited certain activities.
Such experience was described by the older participants as
fading when wanting to continue working (Parse, 2003).
Other negative emotions associated with the reduced
capacity to function also included feelings of despair,
incompetency and being a burden to others. Using the
theme hitting rock bottom to illustrate such emotions
highlighted the devastating impact of fatigue on the
psychological well-being of older people (Toye et al., 2006).
Older people used various strategies to live with the
debilitating effects of fatigue. The deliberate pacing of
activities was the most common accommodative method
reported by the institutionalized older people (Toye et al.,
2006). Other coping strategies were more restorative in
nature. They included eating sugary food to gain energy,
attending exercise class, and various relaxation therapies.
Indeed, social support also acted as an important coping
resource for the institutionalized older people suffering
fatigue. The benet of such support was highlighted as
something more than the tangible assistance per se, as the
older people also reported a sense of security and
belongingness when support was received to cope with
the fatigue-related physical incapacity. As for the com-
munity-dwelling older people, they reported that instilling
a repose-revive rhythm to daily living was the most
effective means of moving beyond fatigue-related debil-
itation. These older people reported that they could move
on with renewed strength after resting. Although it is
difcult to conclude which group of older people, the
institutionalized or community-dwelling, has a higher
level of fatigue, the difference in the coping methods may
indicate that fatigue in the latter group may be more
responsive to periods of physical rest.
3.2. Relating factors of fatigue among older people
Quite a number of the reviewed studies identied
factors related to fatigue among older people (Avlund et al.,
2007; Bautmans et al., 2008; Galindo-Ciocon and Ciocon,
1997; Liao and Ferrell, 2000; Martin et al., 2006; Teel and
Press, 1999; Wijeratne et al., 2007). As fatigue is a complex
phenomenon, these studies covered a wide range of factors
from the physiological, physical, behavioral and psycho-
social perspectives. Although the use of cross-sectional
design in the majority of these studies imposed restrictions
on drawing any causal inferences (Bautmans et al., 2008;
Galindo-Ciocon and Ciocon, 1997; Liao and Ferrell, 2000;
Martin et al., 2006; Teel and Press, 1999; Wijeratne et al.,
2007), the ndings still provide important insights into
potential factors and consequences of fatigue in older
people.
Three studies examined the relationship between
physical health and fatigue among older people. Liao
and Ferrell (2000) found that fatigue was independently
predicted by poor walking capacity, the presence of bodily
pain and the use of medication among institutionalized
older people. Bautmans et al. (2008) reported similar
ndings and indicated that institutionalized older people
with poorer muscle endurance perceived a higher level of
fatigue in day-to-day life. By collecting the blood sample
for circulating inammatory mediators, this study found
that the low muscle endurance might be the result of low-
grade inammation. The ndings of these two studies
hence hinted that fatigue might be an early symptom of
physical deconditioning or even underlying pathological
changes in older people.
The relationship between physical factors and fatigue
was different in the community-dwelling older people. By
comparing the characteristics of older people whose
complaint of fatigue persisted for more than 3 months
with those whose complaint did not last this long, Galindo-
Ciocon and Ciocon (1997) found that fatigue was not
related to the majority of chronic illnesses in older people.
Instead, fatigued older people reported poorer sleep
patterns and were more likely to have no habit of regular
exercise than the older people without complaining fatigue.
The lack of a relationship between chronic illness and
fatigue may be related to the exclusion of all older people
with debilitating chronic illnesses such as chronic
obstructive airway disease and chronic heart failure.
 D.S.F. Yu et al. / International Journal of Nursing Studies 47 (2010) 216228
However, it should also be noted that the fatigued older
people attributed the poor sleep patterns to various
physical health problems such as nocturia, severe leg pain
and arthritic pain. There is a possibility that the poor sleep
patterns may mediate the relationship between medical
illness and fatigue.
Martin et al. (2006) identied a relationship between
fatigue and lifestyle factors among the community-dwell-
ing older people (N = 178). By conducting a longitudinal
evaluation of the fatigue level of older people (non-
centenarians) for 5 years and centenarians for a period of 8
months, this study identied physical inactivity and
nutritional risk as important causative factors of fatigue
in older people. The authors explained that keeping oneself
physically active might improve mood status and prevent
depression, which in turn protected an individual from
suffering psychological-related fatigue. An optimal nutri-
tion state was in fact crucial to prevent the development of
fatigue-related physical conditions such as anemia. Health
life-style is, hence, an important resource for protecting
older people from becoming fatigued. In fact, Martin et al.
(2006) also included personality factors such as trait
anxiety and extraversion as predictors of fatigue in later
life. They found that whereas extraversion showed no
predictive effect, older people with a high level of trait
anxiety reported more fatigue and less vigor over time. The
inuence of trait anxiety on fatigue was even more
prominent than that of the previously mentioned lifestyle
factors.
The relationship between psychological factor and
fatigue has been further conrmed by Wijeratne et al.
(2007), who determined the characteristics of fatigue and
its relationship with psychological disorders (including
anxiety and affective disorder) in the community-dwelling
older people. In that study, fatigue was dened as a
somatic phenomenon and was characterized by the
presence of six somatic symptoms, including the presence
of muscle pain or tired muscles after activity, the need to
sleep longer, poor sleep, prolonged tiredness after activity,
and poor concentration. By using these diagnostic criteria,
the presence of a psychological disorder was found to
associate with eight times an increased risk of having
fatigue. Such a detrimental effect was far more prominent
than the impact of medical morbidity which only
associated with four times the increased risk. Indeed, this
nding was also reported for older people who were
dwelling in residential care setting (Liao and Ferrell, 2000).
Nevertheless, despite previous studies consistently
reporting a prominent effect of psychological factors in
relating to fatigue, Wijeratne et al. (2007) pointed out that
among the 27.4% of older people who identied as having
persistent fatigue in the past year, approximately 10.5% of
them did not have any comorbid psychological disorder.
Indeed, none of them evolved into an identiable
psychological problem in the subsequent year. As for the
other 12 older people who only had a psychological
disorder but not fatigue at baseline, only one of them
reported fatigue at 1-year follow up. The authors suggested
that fatigue might be better depicted by a model utilizing
somatic and psychological phenomena in parallel, rather
than in a hierarchical conguration.
225
Meeting the role expectations of later life is also a
contributing factor to fatigue in older people. This is
especially relevant to those who are involved in caregiving
activities. Teel and Press (1999) found that older spousal
caregivers of patients with Alzhimers disease, Parkinsons
disease and cancer reported more fatigue, lower energy
levels and more sleep disturbances as compared with
those who did not have any caregiving duties. However, it
was interesting that the level of disturbance reported by
the elderly spousal caregiver was independent of the
caregiving situation in terms of the length of time engaged
in the role of a caregiver, the time of care provided each day
and the functional as well as cognitive impairment of the
care recipients. Such ndings may indicate that instead of
the actual caregiving responsibilities draining the energy
from older people, it was the perceived role requirement
which contributed to the feeling of fatigue and exhaustion.
Such ndings further reinforce the complexity in the
etiology of the fatigue phenomenon.
3.3. Impact of fatigue on overall health
Not many studies have examined the impact of fatigue
on the health of older people. There was only one study,
which explored the mechanism of functional decline in
older people with medical condition that identied fatigue
as a mediating factor of poor health (Bennett et al., 2002).
Fatigue which resulted from medical conditions was found
to be strongly associated with lower levels of self-reported
physical activity as well as limited role and social
functionings among older people. Another series of studies
may give greater insight into the health impacts of fatigue
(Avlund et al., 1998, 2001, 2002, 2003a,b; Schultz-Larsen
and Avlund, 2007). They examined the effects of tiredness
in daily activities on functional and health outcomes of
community-dwelling older people.
In these studies, the baseline data were mainly obtained
from the selected samples of a number of large-scale
surveys. Tiredness in the course of daily activities was
measured by a validated instrument which asked older
people the level of tiredness after performing various daily
activities such as transfer, such as walking indoors and
going outdoors (Avlund et al., 1996). Follow-up assessment
on different health outcomes took place at different time
points over the subsequent 15 years. The ndings
consistently identied the devastating effects of tiredness
on the health outcomes, service utilization and even
mortality of older people. Older people who reported
tiredness in daily activities were associated with signi-
cantly higher risk of having new onset of mobility
disability in the following 1.5 years (Avlund et al.,
2003b). After controlling for the effects of chronic illness,
cognitive impairment and self-rated health, self-reported
tiredness also signicantly predicted a three times
increased risk in decline in performance in functional test
among older people in the subsequent 5 years (Avlund
et al., 2002, 2006), and the effect was sustained for up to 15
years (Schultz-Larsen and Avlund, 2007). Such debilitating
effects may explain why older people who reported
tiredness would have signicantly higher utilization of
home-help and hospital services in the subsequent 5 years
226 D.S.F. Yu et al. / International Journal of Nursing Studies 47 (2010) 216228
irrespective of their baseline level of disability and
comorbidity (Avlund et al., 2001). Indeed, this subjective
complaint even associated with two times increased risk of
mortality in 10 years time, after controlling for the relevant
clinical and life-style factors (Avlund et al., 1998).
Although tiredness has been differentiated from
fatigue, with the former characterized as a normal
sensation which occurs after exertion and the latter as
an abnormal state of excessive whole body tiredness (Piper
et al., 1998), tiredness has been recognized as one of the
manifestations of fatigue (Tralongo et al., 2003). Ream and
Richardson (1996) gave a similar opinion by dening
fatigue as on a continuum, with the milder form being
tiredness and the other extreme being exhaustion. As a
result, the studies by Avlund and colleagues may imply the
possibly of even more devastating effects of fatigue on the
health outcomes of older people.
4. Discussion
Through a thorough review of the ndings from studies
which examined fatigue in older people, this review
provides a comprehensive picture of the fatigue phenom-
enon in later life. The research evidence clearly illustrates
that fatigue is a distressing and overwhelming experience
affecting the overall well-being of older people. Its
debilitating effect constrains physical capacity and the
energy reserve required for appropriate functioning and
social participation. Many older people report frustration
with the undesirable performance. Such feelings may in
turn lower their sense of control and eventually weaken
their sense of purposeful coherence. Yet, the complexity of
this phenomenon, in terms of its ubiquitous nature,
heterogeneous etiologies and multi-dimensional manifes-
tations, poses challenge to its proper diagnosis and
treatment. The lack of studies on fatigue management
may imply that this problem is poorly recognized and
undertreated in older people. Such inadequacy of care
would denitely pose a threat to the functional capacity of
fatigued older people, and worsen their morbidity and
mortality outcomes.
Fatigue has been a more common research topic in
chronic disease management. The ndings on the lived
experience of fatigue in older people are similar to those
identied in patients with chronic illnesses such as cancer
and congestive heart failure, especially in terms of the
physical and psychosocial impact (Fitch et al., 2008; Falk
et al., 2007). This may suggest that fatigue has quite a
universal manifestation irrespective of its underlying
causes. However, a key difference in the fatigue experience
between the two populations is that patients with chronic
illness usually related the fatigue experience to the disease
and the associated treatment, whereas older people were
less likely to mention the cause of fatigue.
Indeed, previous studies also indicated that fatigue in
patients with chronic illness are strongly associated with
the disease severity (Falk et al., 2007), other disease-
specic symptoms (Yennurajalingam et al., 2008), health
perception (Yu et al., 2004) and frequency of disease
exacerbation (Baghai-Ravary et al., 2009). Such difference
between patients with chronic illness and the general older
population may explain the variation in their ways of
coping with the fatigue experience. Patients with chronic
illness may believe that treatment for the disease could
have a restorative effect on fatigue. They were hence more
likely to resort to more sedentary pursuits so as to prevent
exacerbating fatigue in the disease course.
As for the older people, fatigue may be interpreted as a
kind of progressive functional decline. According to the
Selection, Compensation and Optimization Model as
proposed by Baltes and Baltes (1990), older people may
use compensation to adapt to such aging losses.
Compensation is a coping strategy characterized by using
alternative means or resources to maintain a desired state
once losses have occurred. When older people experience
fatigue and energy depletion, pacing is used as a
compensation strategy to enable them to keep up with
the daily activities. Getting additional rest during the
daytime, eating sugary food, and exercise are regarded as a
kind of regenerative compensation by which an addi-
tional resource (i.e. energy) is generated to cope with the
fatigue experience (Lang et al., 2002). Such nding
highlights nurses vital role in optimizing the resources
of older people in coping with this debilitating condition in
day-to-day life.
Symptom recognition is a crucial step to help older
people cope with the fatigue experience. The ndings here,
which suggest fatigue may be an early symptom of
physical deconditioning and/or pathology among older
people, further reinforce the importance of fatigue
assessment in gerontological care. However, the vague
nature of fatigue may hinder older people from reporting
such experience. The situation can get even worse if older
people characterize the fatigue experience as a normal
consequence of aging. Therefore, nurses and other health
care professionals need to take a more active role in
assessing fatigue in older people. This requires a good
awareness of the high risk group for fatigue, so that further
assessment of this symptom can be conducted in the
course of care planning. In the current review, we have
identied a number of factors related to fatigue in older
people. The ndings indicate that older people who have
multiple cormorbidities, poorer functional performance,
higher trait anxiety, and the presence of a psychological
disorder were more susceptible to this distressing condi-
tion. Thus, attention needs to be directed to all of these
factors.
As for the assessment of fatigue itself, the ubiquitous
and subjective nature of fatigue adds difculty to its
clinical assessment. Although various scales have been
developed to measure it, the lack of consensus in the
denitions of fatigue has led to great variation in the
content and design of these scales. Indeed, as a majority of
the instruments have been developed to measure fatigue
for specic research purposes, their content has been
criticized as inadequate to providing the comprehensive
fatigue assessment needed for thorough care planning
(Aaronson et al., 1999). This review indicates that fatigue in
older people is etiologically heterogeneous, has physiolo-
gical, physical, and psychosocial manifestations, and has a
very detrimental impact on physical capacity and emo-
tional well-being. It is recommended that capturing such
 D.S.F. Yu et al. / International Journal of Nursing Studies 47 (2010) 216228
complex phenomenon among older people require
detailed assessment on characteristics and quantication
of fatigue, the key biological parameters and predisposing
factors, as well as the associated distressing feelings, along
with limitations on physical activities and social function.
In view of the devastating consequences of fatigue,
nurses can be understood to play a substantial role in
relieving the burden of such debilitation on older people.
However, our review suggests that there is a lack of
research-based evidence to inform the practice. Based on
our ndings about the nature of fatigue and its related
factors, fatigue may be managed from the biomedical,
physical and psychological perspectives.
From the biomedical and physical perspectives, fatigue
can be managed by identifying and correcting any
treatable underlying pathology or cause of fatigue such
as chronic inammatory conditions, sleep-related dis-
orders or metabolic abnormalities which affect tissue
oxygenation. Indeed, reduced physical capacity is not only
a common consequence of fatigue, but may also cause
muscle wasting and further aggravate an existing fatigue
problem. Managing fatigue hence requires a concerted
effort to improve the physical capacity of older people.
There is compelling evidence to indicate the benecial
effects of exercise on the muscle strength and cardior-
espiratory tness of older people (Nied and Franklin,
2002). As both of these parameters are crucial to maintain
an individuals physical capacity, exercise therapy may be
a valuable strategy to reduce fatigue in older people.
As for the psychological perspective, the current review
indicates a signicant role for psychological factors in
fatigue. Fatigue itself may lead to emotional manifestation.
Hence it is important for nurses to make efforts to alleviate
this psychological component of fatigue in older people.
Relaxation therapy has well-recognized effect in relieving
psychological distress. Its calming effect on the mind can
prevent those negative emotions which wear people out.
The evidence indeed suggests the benecial effect of
relaxation therapy in relieving fatigue among patients with
chronic illness (Yu et al., 2007). Besides, the literature
suggests the use of a narrative approach for symptom
management. This method involves a gradually evolving
process by which older people discuss the fatigue
experience in the context it is experienced and its impact
on their daily life. Such a recount of the fatigue experience
facilitates older people developing an awareness of both
the nature of the problem and coping behaviors (Ekman &
Skott, 2005). The process also provides nurses with an
opportunity to gain a better understanding of the clients
situation so that they are more able to engage in
meaningful discussion with them. The narrative approach,
indeed, has been demonstrated to be an effective means to
promote an adaptation of older people to their situation
(Krishnasamy, 1997). Attention needs to be given to the
value of this method in future investigation of fatigue
management for older people.
Although this review identies evidence on various
aspects of fatigue in older people, several methodological
issues are worth considering in interpreting the ndings.
Despite the reviewed studies shared the common objec-
tives of examining fatigue in older people, majority of them
227
did not clearly dene the fatigue phenomenon. This would
add difculty to the data synthesis or lead to biased
conclusion. Indeed, a majority of the studies used a cross-
sectional design to examine the relating factors of fatigue.
The ndings would have limited value for understanding
the etiology or consequences of fatigue. Besides, all the
reviewed evidence was derived from the Western popula-
tion. Knowing that fatigue is a subjective phenomenon for
which its interpretation and manifestation would be
inuenced by an individuals cultural value and belief,
the ndings would have limited generalizability to the
non-Caucasian population. Finally, the study ndings may
also be enriched by including more databases into the
search strategy. Excluding studies into older people in
specic disease groups also limited research evidence
which evaluated strategies to address fatigue in these
groups (Borneman et al., 2008), though the current
ndings would be more generalizable to the broader older
population in general. Based on the above limitations,
future research examining fatigue among the older
population need to clearly dene the construct of fatigue
and adopt a longitudinal approach to depict the etiologies
and consequences of fatigue. Further investigation of the
cultural inuence on fatigue experience would also be
signicant to shed light on developing culturally relevant
care for fatigue management.
5. Conclusion
Fatigue is a known to be a substantial health problem in
the older population. This review indicated that it is in fact
a devastating condition that compromises the quality of
life and other health outcomes of older people. However,
the complexity of this phenomenon, in terms of its
ubiquitous nature, heterogeneous etiologies, and multi-
dimensional manifestation imposes real challenges to
health professionals in managing this distressing symp-
tom. The ndings of this review provide preliminary
indications on how to assist older people to cope with the
fatigue experience. More effort needs to be placed on
developing research-based evidence to improve fatigue
management.
Conict of interest
None.
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