Asian J Gerontol Geriatr 2006; 1: 121–32

Psychological distress in elderly ORIGINAL ARTICLE

patients with congestive heart failure
DSF Yu1 PhD, RN, DTF Lee1 PhD, RN
J Woo2 FHKAM (Medicine), MD (Cantab)

ABSTRACT 1
The Nethersole School of Nursing, The
Chinese University of Hong Kong
Objectives. Congestive heart failure (CHF) is a pervasive cardiac 2
Chairman and Professor of Medicine,
syndrome with an elevated prevalence in the older population. High Department of Community and Family
Medicine, Prince of Wales Hospital, The
level of psychological distress has been reported in this patient group, Chinese University of Hong Kong
resulting in more hospital readmissions, poorer quality of life, and
increased mortality. Yet, little is known about its relating factors. This
study identified the significant demographic, clinical, and psychosocial
factors relating to psychological distress in CHF patients.
Methods. Cross-sectional data were obtained from a consecutive
sample of CHF patients (n=227) in an acute hospital setting.
Psychological distress was measured by the Hospital Anxiety and
Depression Scale (HADS). Functional status, symptom status, social
support, and health perception respectively were assessed using the
New York Heart Association Classification, Chronic Heart Failure
Questionnaire, Medical Outcome Study Social Support Survey, and a
100-mm horizontal visual analogue scale. Other clinical variables were
obtained from the hospital record.
Results. The results indicated high level of psychological distress
among CHF patients; the negative emotion of depression being the
most dominant. In hierarchical regression analysis, poorer perceived
emotional-informational support, higher levels of fatigue, poorer health
perception, and not living with family were identified as the significant
factors in association with psychological distress. In total, they
explained for 49% of the variance for the HADS score. Among these
factors, emotional-informational support and fatigue demonstrated the
greatest explanatory power with the standardised coefficient (b) being
-0.40 and -0.34 respectively.
Conclusion. These findings highlight the importance of addressing
the social support needs of the CHF patients. Assisting this vulnerable
patient group to control the symptom of fatigue and cultivate a positive
health perception should also be high priority treatment goals. Correspondence to: Prof Doris Yu, Room 729,
Esther Lee Building, The Nethersole School
of Nursing, The Chinese University of Hong
Key words: Aged; Chinese; Depression; Heart failure, congestive; Stress, Kong, Shatin, Hong Kong. E-mail:
psychological dyu@cuhk.edu.hk

INTRODUCTION affecting people in older age. In this disease, failure

of myocardial pumping subjects elderly CHF patients
Congestive heart failure (CHF) is a terminal to the distressing symptoms of fatigue, dyspnoea,
manifestation of various cardiac pathologies, mainly and activity intolerance. Besides, management of

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Yu et al

elderly CHF patients requires that they follow a patients, and found that psychological distress
series of treatment-related lifestyle restrictions. was the most significant predictor of functional
The progressively deteriorating nature of CHF, decline in intermediate and social activities of daily
however, renders the episodic adverse cardiac events living (ADL). Tsay and Chao15 reported similar
and hospital readmission as inevitable outcomes.1 findings, indicating that elderly CHF patients with
Apart from impairing the physical integrity of depression had poorer perceived functional status
elderly patients, these ramifications of CHF also and demonstrated more deficits in ADL functioning.
tremendously disrupt their normal social and role High-level psychological distress was also associated
functioning. with more severe symptom manifestations16 and
poorer quality of life,17 and in elderly CHF patients
Previous studies have examined the ways elderly it predicted an almost two-fold increase in hospital
CHF patients conceived their life situation. Mahoney2 readmissions and mortality.18 The literature suggests
indicated that patients regarded the disease as several mechanisms to explain the negative
burdensome and causing a lot of disruptions to their prognostic impact of psychological distress in elderly
physical, emotional, social, economic, and spiritual CHF patients. High-level psychological distress
well-being. They described their own situations exaggerates the neuro-endocrine activities,19 resulting
as drowning in both physical and emotional in impaired myocardial blood flow and arrhythmia
perspectives. The debilitating symptoms and the in CHF patients. This emotional factor also reduces
enforced lifestyle modification imposed a strong patients’ motivation to comply with the treatment
sense of restriction onto elderly, and the associated and interferes with their social interactions.20,21 All
loss of role functioning, social activity, and leisure of these effects appear to compromise the cardiac
pursuits amplified feelings of loss of self and condition of elderly CHF patients, hinder effective
worthlessness. They viewed themselves as a burden self-care management, and deprive them of social
on others in their surroundings.3 The loss of physical support to cope with their debility.
integrity, functional capacity, family and social role
functioning also posed a great psychological threat The tremendous negative impact of psychological
to elderly CHF patients.4 They expressed a strong distress on the health outcomes of elderly CHF
sense of insecurity and lack of harmony within patients indicate an urgent need to promote the
themselves, described their own situation as “a big psychological well-being in this vulnerable group.
cutback everywhere”,5 and even conceived their own As psychological reactions to chronic illness are
existence as “passive waiting for death”.3 According complex and determined by the patient’s personal
to these findings therefore, this vulnerable group attributes, social context, and illness manifestation,6
suffers intense internal feelings of powerlessness identifying factors that are significantly associated
and hopelessness. with psychological distress appear crucial for
planning effective care.
Molassiotis6 stated that the psychological reaction
to a chronic illness is constructed from the way the Previous work has examined the relationships
patient conceives their life experience. All of the between the psychological distress and various social,
negative life conceptions of elderly CHF patients demographic, and clinical characteristics of elderly
reported in the literature, are in fact, core triggering CHF patients. Among these, the relationship between
factors for anxiety and depression.7,8 Previous studies social factors and psychological distress seems to
have documented the high level of such deleterious be most conclusive. Higher levels of social support
emotions in elderly CHF patients,9,10 and the protected elderly CHF patients from developing
prevalence of major depression in these patients has depressive symptoms22 or clinical depression.23 In
been reported to be as high as 26% to more than addition, elderly CHF patients who perceived more
40%.11-13 emotional support reported higher life satisfaction,
whilst those who received more tangible support
Numerous studies have documented that had less psychological distress. Social network
psychological distress is especially detrimental characteristics also affect psychological well-being;
for elderly CHF patients. Clarke et al14 conducted “living alone”24 and “without spouse”25 was most
a large-scale study (n=2992) in elderly CHF detrimental. In elderly CHF patients, perceived

122 Asian Journal of Gerontology & Geriatrics Vol 1 No 3 December 2006

 Psychological distress in elderly patients with congestive heart failure

clinical status such as symptom severity and perceived criteria included: paroxysmal nocturnal dyspnoea,
functional impairment have also been identified as orthopnoea, rales, jugular venous distention, third
having a prominent relationship with psychological sound and radiological signs of pulmonary congestion
distress.26,27 On the other hand, objective indicators of and/or cardiomegaly. The minor criteria include
clinical status including ventricular ejection fraction effort dyspnoea, oedema, hepatomegaly, and pleural
and other functional measures, as well as the number effusion. To be eligible, patients were age ≥60 years,
of comorbidities demonstrate a less significant Chinese speaking, able to communicate, cognitively
association with psychological status.12,28 Previous intact as indicated by the Abbreviated Mental Test
studies also reported significant gender differences score (AMT) [Hong Kong version] of ≥6/10,32 with
in the psychological status of elderly CHF patients; no psychiatric illness and had not been planned for
females being more disadvantaged.29 However, the any surgery or invasive cardiac procedure.
relationship with other demographic characteristics,
including lower income, lower educational level, Measures
younger age and psychological distress, were less
prominent.9,12,30 The Hospital Anxiety and Depression Scale
(Chinese-Cantonese version)
Although previous studies have provided The Hospital Anxiety and Depression Scale (HADS)
information about factors that are associated with [Chinese-Cantonese version] was used to measure
psychological distress in elderly CHF patients, psychological distress.33 Its 14 items are evenly
they have not adequately incorporated all divided into two subscales for measuring anxiety
possible related attributes in the social, clinical, or and depression in patients with medical illness. The
demographic dimensions that might account for the response set is 4-point‘0-3’fixed statements; a higher
phenomenon. Moreover, little is known about the score represents greater psychological distress. The
relative importance of the possible factors associated total score ranges from 0 to 42, and the cut-off points
with psychological distress in such patients. The for the overall scale and depression subscale of the
purpose of this study was therefore to identify the Chinese version are suggested to be 15/16 and 8/9
social, clinical, and demographic factors that were respectively for the presence of psychiatric symptoms.
significantly associated with psychological distress in The HADS (Chinese version) is psychometrically
elderly CHF patients. Nineteen variables including sound. Its concurrent and criterion-related validity
age, gender, marital status, living arrangements, were supported by its significant correlations with
educational level, income, number of comorbidities, the Hamilton Rating Scale of Depression34 and the
years with CHF, number of medications, use of psychiatrist’s diagnosis respectively. The Cronbach’s
beta-blockers, functional status, health perception, alphas were reported as 0.77-0.86,33 and its two-
dyspnoea, fatigue, tangible support, affectionate factor structure is affirmed by factor analysis. The
support, social interactional support, emotional- current study also demonstrated its good internal
informational support, and size of social network consistency with a Cronbach’s alpha of 0.82.
were studied.
The Chronic Heart Failure Questionnaire
METHODS (Chinese version)—Fatigue and Dyspnoea
Subscales
Study design and subjects The fatigue and dyspnoea subscales of the Chronic
Heart Failure Questionnaire (Chinese version)
This was a cross-sectional study conducted in the [CHQ-C] were used to measure the symptoms
Medical Unit of a regional hospital in Hong Kong of fatigue and dyspnoea in elderly CHF patients.35
between January 2002 and March 2003. The sample It was translated from the original version.36 The
was comprised of patients admitted with an index dyspnoea and fatigue subscale contains five and
diagnosis of CHF. The validity of the diagnosis four items respectively. They are scored on a 7-point
was ascertained by the use of the Framingham Likert scale. The score of both subscales range from
criteria.31 Confirmation of the diagnosis required the 1 to 7, with higher subscale scores indicating lesser
presence of two or more major criteria, or one major severity of the respective symptom. Psychometric
criterion plus two or more minor criteria. Major properties of CHQ-C have been established.37

Asian Journal of Gerontology & Geriatrics Vol 1 No 3 December 2006 123

Yu et al

The content validity index of CHQ-C is 0.81. The overall scale and subscale of the MOS-SSS-C were
construct and criterion-related validity are supported established.43 Its internal structure was also affirmed
by its significant correlations with the HADS and by factor analysis. Its criterion-related and construct
New York Heart Association (NYHA) Classification validity are supported by its significant correlations
respectively. High internal consistency and 2-week with the Chinese version of Multidimensional Scale
test-retest reliability are reported with Cronbach’s of Perceived Social Support Scale44 and HADS
alpha of 0.95 and intra-class correlation coefficient respectively. Factor analysis confirms its four-factor
of 0.75 respectively. structure. High internal consistency and 2-week test-
retest reliability are reported with Cronbach’s alpha
The New York Heart Association Classification as 0.98 and intra-class correlation coefficient as 0.84
The NYHA Classification was used to measure respectively. Its internal consistency as indicated by
functional status. It is a 4-class system that grades Cronbach’s alpha in the current sample was 0.96.
the functional impairment of patients with heart
failure.38 The classification is based on symptoms Demographic and clinical data collection sheet
of fatigue, dyspnoea, and palpitation resulting from A demographic and clinical data collection sheet was
performing ordinary and less-than-ordinary activity. developed to collate information collected on gender,
The grading is in ascending order of increased age, marital status, living arrangement, educational
functional impairment. The NYHA classification is level, occupation, monthly income, duration of
a clinically sound functional measure when used CHF diagnosis, number and types of comorbidities,
in elderly CHF patients, and it demonstrates good mediations and number of previous hospitalisations
correlation with other valid instruments that measure within the last 6 months. These data were collected
functional status in cardiac patients. by record review and structured interview.

Visual analogue scale Procedures

The visual analogue scale (VAS) was used to measure
health perception of the subjects. It is a 100-mm Approval was obtained from the Ethics Committee
long horizontal line, with both ends labelled with of the Chinese University of Hong Kong before
“poorest health” and “best health” respectively. conducting the study. The research nurse firstly
Subjects were invited to put a cross on the line to screened the eligibility of all the patients admitted
indicate how healthy they perceived they were. The with an index diagnosis of CHF. She then invited
score is indicated by the distance (in mm) between those who met the selection criteria to participate,
the end labelled with “poorest health” to the marked and obtained their written consent. This was followed
cross. Higher score therefore indicates better health by a face-to-face interview, during which the nurse
perception. The VAS is a common method used to administered all the study instruments.The nurse also
measure health perception in clinical research.39-41 graded the functional status of eligible subjects with
NYHA, and obtained the other socio-demographic
The Medical Outcomes Study Social Support and clinical data by reviewing the hospital record.
Survey (Chinese version)
The Medical Outcomes Study Social Support Survey Statistical analysis
(Chinese version) [MOS-SSS-C] was used to
measure perceived social support.42 It is a 20-item Statistical analysis was performed using Statistical
self-reported measure, one of its items assesses the Package for the Social Sciences (Windows version
size of the subject’s social network, whereas the 11.0; SPSS Inc, Chicago [IL], US). Hierarchical
others constitute four subscales each measuring regression analysis was used to identify the
the perceived adequacy of tangible support, significant correlates of psychological distress in
emotional and informational support, positive social elderly CHF patients. Predictive variables that
interaction, and affectionate support. The response showed significant bivariate correlation with the
set is a 5-point Likert scale. The score for the overall HADS score were identified and entered into the
scale and subscales are rescaled to the range of 0- regression model sequentially. According to the
100, with higher scores indicating better-perceived level of measurement, the Pearson product-moment
social support. The psychometric properties of the correlation and Spearman rank-order correlation

124 Asian Journal of Gerontology & Geriatrics Vol 1 No 3 December 2006

 Psychological distress in elderly patients with congestive heart failure

were used to examine the bivariate relationships NYHA Class III or above, indicating that their cardiac
between the continuous predictive variables and functional status was greatly impaired. In addition,
the HADS score. As for the nominal variables of they reported higher levels of fatigue as compared to
gender, marital status, living condition and use of dyspnoea. The health perception score was generally
beta-blockers, the independent t-test was used to low, indicating poor self-perceived health status. As
identify significant differences in the HADS scores for social support, the mean social network size was
between respective dichotomous groups. The order around three. This was considered as reduced when
of entry of these variables for regression analysis was compared with the previous data reported for older
determined by their respective least linear regression Hong Kong Chinese people (M=20.80).45 However,
coefficients, with the one independently accounting the subjects rated social support, particularly tangible
for greater variance of HADS score entered first. In and affectionate support as moderately adequate.
order to avoid redundancy, potential correlates with
high covariability (i.e. r≥0.8) were not collectively Among the 15 potential continuous independent
incorporated into the model. Instead, the one with variables, 12 showed a significant bivariate relation-
higher percentage of variance would be selected. ship with the HADS score. Table 2 presents the correl-
In successively formulating each regression model, ation matrix. Psychological distress demonstrated
variables that remained significant in the regression significant positive correlations with more severe
model were retained for analysis in the subsequent symptom of fatigue, poorer health perception, more
model. The level of significance was set at p≤0.05. shrunken social network, and lower perceived social
support. A higher level of psychological distress was
RESULTS also significantly positively correlated with a poorer
functional status, older age, and more comorbidities.
Of 553 elderly CHF patients consecutively admitted For the nominal independent variables of gender,
to the study setting, 227 met the eligibility criteria marital status, living arrangement and use of beta-
and consented to participate. Comparison of these blocker, the HADS scores were significantly higher in
participants with the non-participants who refused those who had no spouse (t [225]=4.26, p≤0.001) or
to consent or were discharged early (n=102) were not living with a family (t [225]=4.71, p≤0.000).
revealed no significant difference in their age and However, no significant difference in psychological
sex. For the recruited subjects, Table 1 summarises distress was detected among patients of different
their demographic, clinical, and psychosocial gender (t [225]= –1.20, p=0.23), and among users and
characteristics. The mean age was 77.1 (standard non-users of beta-blockers (t [225]= –0.17, p=0.87).
deviation [SD], 7.9; range, 60-95) years and 48%
were male. About half of the sample (48%) had Table 3 outlines the results of simple linear
spouses, and most (75%) were living with families. regression for the 14 variables that demonstrated a
The majority (89%) had low monthly incomes of significant relationship with the HADS score. For the
<HK$3000. The mean duration of being diagnosed two nominal variables of marital status and living
with CHF was 3.0 years. Comorbidities were highly arrangement, dummy variables were created with“no
prevalent in the sample; 88% of them suffered from spouse”and“not living with family”as their respective
one to as many as six other chronic diseases. The reference group. In accordance with the values of the
mean number of medications used was 4.1 (SD, 1.7) regression coefficients for these variables, they were
and a beta-blocker was prescribed to 17% of the successively entered into the hierarchical regression
sample. model. However, as high covarability existed between
positive social interaction and the other two correlates
As indicated by the HADS overall and subscale of emotional informational support and affectionate
scores, the sample was characterised by a high level support (i.e. r≥0.80) [Table 2], which all gave rise
of psychological distress, with depression being more to similar variances for HADS scores—only social
severe than anxiety. The mean values of both the interactional support was omitted to allow the other
overall score and depression subscale score exceeded two correlates to be entered into the model.
their respective cut-off points of 15/16 and 8/9,
suggesting the presence of psychiatric symptoms.32 Table 4 presents the results of hierarchical
Almost 40% of the patients were categorised as regression analysis. Among the 12 variables entered

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Yu et al

Table 1
Demographic, clinical, and psychosocial characteristics of the sample (n=227)

Demographic, clinical, and psychosocial characteristics* Value†

Age (mean ± SD) [years] 77.1 ± 7.9
Gender
Male 108 (48%)
Female 119 (52%)
Marital status
Single 6 (3%)
Married 109 (48%)
Divorced 5 (2%)
Widow/ widower 107 (47%)
Living condition
Living alone 27 (12%)
With couple 38 (17%)
With family 132 (58%)
With friend 5 (2%)
Old-age home residents 25 (11%)
Educational level
Illiterate 84 (37%)
Under primary 39 (17%)
Primary 71 (31%)
Secondary 24 (11%)
University 8 (4%)
Above university 1 (0.4%)
Source of income
From relatives 115 (51%)
From salary 11 (5%)
From public allowance 101 (44%)
Monthly income (HK Dollar)‡
≤$3000 202 (89%)
$3001- $5000 15 (7%)
$5001- $8000 7 (3%)
>$8000 3 (1%)
Years of having congestive heart failure (mean ± SD) 3.0 ± 2.6
NYHA grading
Class I 28 (12%)
Class II 113 (50%)
Class III 77 (34%)
Class IV 9 (4%)
No. of medication (mean ± SD) 4.1 ± 1.7
Type of medications
Anti-coagulant 132 (58%)
Angiotensin-converting inhibitor 83 (37%)
Nitrates 94 (41%)
Digitalis 40 (18%)
Diuretics 187 (82%)
Beta-blocker 38 (17%)
No. of comorbidities
Zero 28 (12%)
One 53 (23%)
Two 67 (30%)
Three 49 (22%)
Four 13 (6%)
Five 15 (7%)
Six 2 (1%)
Type of comorbidities
Ischaemic heart disease 58 (26%)
Myocardial infarction 13 (6%)
Diabetic mellitus 82 (36%)
Hypertension 116 (51%)

into the model, only four demonstrated a significant perception, and living conditions. A higher level
contribution to the variance of the HADS score. They of fatigue, lower perceived emotional-information
were fatigue, emotional-informational support, health support, poorer health perception, and not living with

126 Asian Journal of Gerontology & Geriatrics Vol 1 No 3 December 2006

 Psychological distress in elderly patients with congestive heart failure

(Continued from previous page)

No, of hospitalisation within the previous 6 months

Zero 134 (59%)
One 68 (30%)
Two 13 (6%)
Three 4 (2%)
Four 5 (2%)
Five 3 (1%)
Subjective health perception (mean ± SD) 3.41 ± 2.37
Psychological distress score (HADS) [mean ± SD]
Overall 15.54 ± 6.83
Anxiety subscale 5.15 ± 3.90
Depression subscale 10.39 ± 4.49
Social support score (MOS-SSS-C) [mean ± SD]
Overall 56.89 ± 22.73
Tangible subscale 67.04 ± 27.94
Affectionate subscale 62.67 ± 25.11
Emotional and informational subscale 43.71 ± 25.90
Positive social interaction subscale 54.16 ± 24.66
Social network size (mean ± SD) 3.5 ± 2.78
Symptom score (CHQ-C) [mean ± SD]
Dyspnoea subscale 4.22 ± 0.94
Fatigue subscale 3.74 ± 1.21

* NYHA denotes New York Heart Association Classification; HADS Hospital Anxiety and Depression
Scale; MOS-SSS-C Medical Outcomes Study Social Support Survey (Chinese version); and CHQ-C
Chronic Heart Failure Questionnaire (Chinese version)
†
Values are shown as mean ± SD, or No. (%)
‡
1 U.S. Dollar = 7.8 H.K. Dollar

family were significantly associated with a higher informational support demonstrated the most
HADS score. These four variables significantly prominent psychological protective effect on elderly
accounted for 49% of the variance of the HADS CHF patients. The more severe symptom of fatigue
score; F (5, 221)=44.12, p≤0.000. With reference to was significantly associated with higher levels of
the values of change in R2 of Model 1 and Model 2, psychological distress. In addition, psychological
the symptom of fatigue and emotional-informational distress was more likely to be manifested in those
support demonstrated better explanatory power for who had poorer health perception or did not live
the variance of the HADS score. Their comparatively with a family member. None of the objective clinical
high-standardised regression coefficients in the indicators were identified as significantly associated
final model (Model 4) also indicated that they were with psychological distress in elderly CHF patients.
more significant correlates of psychological distress This concurred with previous work and provided
in elderly CHF patients. The addition of the other further evidence to support the need to perform
two variables of “health perception” (Model 3) and individualised psychological assessment for such
“living with family” (Model 4) into the model also patients.
resulted in significant increments in the R-square for
explaining the variances of HADS scores. However, Among the four factors that were significantly
their contribution was comparatively minimal and associated with psychological distress, both
explained only an additional 5% of the variance. perceived emotional-informational support and
living arrangement were social support attributes.
DISCUSSION The former concerns functions served by an
individual’s social network and the latter reflects his
This study has identified factors that were or her embeddedness to the network system.46 These
significantly associated with psychological distress in findings support the stress-buffering hypothesis of
elderly CHF patients. As with previous studies, the social support.47 Previous work also identified the
level of psychological distress, especially depression positive influence of perceived social support and
was high. Of the various demographic, clinical stronger social ties to the psychosocial adaptation
and social factors, better-perceived emotional- of cardiac patients.22,23,25,48 In this study, the superior

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Yu et al

Table 2
The bivariate relationship between the potential correlates and the Hospital Anxiety and Depression Scale (Chinese version)
score*

1 2 3 4 5 6
1. HADS 1.00
2. Age 0.22† 1.00
3. Education 0.20‡ -0.37† 1.00
4. Income -0.13 -0.35 †
-0.28† 1.00
5. No. of comorbidities 0.24† -0.11 0.17‡ 0.04 1.00
6. Years with congestive heart failure 0.03 0.05 0.05 0.03 0.00 1.00
7. No. of medications -0.04 -0.14 ‡
0.05 -0.04 0.31 †
0.10
8. NYHA 0.21† 0.13 0.03 0.03 0.04 0.07
9. Health perception -0.45 †
-0.12 0.17 ‡
0.11 -0.06 -0.07
10. CHQ-C dyspnoea -0.17‡ -0.04 -0.02 -0.03 -0.11 0.02
11. CHQ-C fatigue -0.50 †
-0.23 †
0.19 ‡
0.06 -0.06 -0.07
12. MOS-SSS-C tangible -0.34† -0.18‡ 0.24† 0.15‡ 0.06 -0.06
13. MOS-SSS-C affectionate -0.47 †
-0.18 ‡
0.23 †
0.10 -0.07 -0.05
14. MOS-SSS-C positive social interaction -0.49 †
-0.17 ‡
0.17 ‡
0.25 -0.10 -0.11
15. MOS-SSS-C emotional-informational -0.48† -0.14‡ 0.02 0.09 -0.22† -0.10
16. Size of social network -0.43 †
-0.12 0.03 0.06 -0.16 ‡
-0.06

* HADS denotes Hospital Anxiety and Depression Scale; NYHA New York Heart Association Classification; CHQ-C Chronic Heart Failure Questionnaire
(Chinese version); and MOS-SSS-C Medical Outcomes Study Social Support Survey (Chinese version)
†
p<0.001
‡
p<0.05

Table 3
Indices from simple linear regression for significant potential correlates of the
Hospital Anxiety and Depression Scale*

Potential correlates R2 B SE
CHQ-C (fatigue) 0.251 -2.832 §
0.327
MOS-SSS-C (emotional-informational) 0.225 -0.126§ 0.015
MOS-SSS-C (positive social interaction) 0.242 -0.136 §
0.016
MOS-SSS-C (affectionate support) 0.223 -0.128§ 0.016
Health perception 0.199 -1.286 §
0.172
MOS-SSS-C (social network size) 0.180 -1.044 §
0.148
MOS-SSS-C (tangible support) 0.115 0.083§ 0.015
Living arrangement †
0.090 -4.860 §
1.032
Presence of spouse‡ 0.075 -3.725§ 0.875
No. of comorbidities 0.058 1.195 §
0.320
Age 0.048 0.189§ 0.056
Educational level 0.039 -1.126 §
0.374
NYHA 0.036 1.771 §
0.610
CHQ-C (dyspnoea) 0.029 -1.232II 0.475

* B denotes unstandardised coefficient; SE standard error; CHQ-C Chronic Heart Failure Questionnaire
(Chinese version); MOS-SSS-C Medical Outcomes Study Social Support Survey (Chinese version);
NYHA New York Heart Association Classification
†
“not living with family” as reference group
‡
“no spouse” as reference group
§
p<0.01
II
p<0.05

role of perceived emotional-informational support as might be related to its conceptualisation. Being

compared to other types of functional social support measured by MOS-SSS-C, emotional-informational

128 Asian Journal of Gerontology & Geriatrics Vol 1 No 3 December 2006

 Psychological distress in elderly patients with congestive heart failure

7 8 9 10 11 12 13 14 15 16

1.00
0.11 1.00
0.10 -0.20† 1.00
-0.16‡ -0.46† 0.12 1.00
-0.03 -0.29 †
0.50 †
0.15‡ 1.00
0.00 -0.13 0.21† 0.05 0.22† 1.00
0.00 -0.31 †
0.28 †
0.17 ‡
0.31 †
0.72† 1.00
-0.03 -0.30 †
0.22 †
0.15 ‡
0.25 †
0.67 †
0.86† 1.00
-0.05 -0.27 †
0.11 0.14 ‡
0.09 0.48 †
0.65† 0.81† 1.00
0.05 -0.16 ‡
0.20 †
0.05 0.24 †
0.27 †
0.38 †
0.45 †
0.53† 1.00

Table 4
Hierarchical regression analysis for the correlates of the psychological distress (HADS score) in patients with
congestive heart failure (n=227)*

Model R2 Change in R2 B Standard error Beta

Model 1 0.25 0.25†
CHQ-C (fatigue) -2.80† 0.33 -0.50
Model 2 0.44 0.19†
CHQ-C (fatigue) -2.60† 0.29 -0.46
MOS-SSS-C (emotional-informational) -0.12† 0.01 -0.44
Model 3 0.48 0.04†
CHQ-C (fatigue) -1.97† 0.32 -0.35
MOS-SSS-C (emotional-informational) -0.11† 0.01 -0.42
Health perception -0.65† 0.16 -0.23
Model 4 0.49 0.01‡
CHQ-C (fatigue) -1.94† 0.32 -0.34
MOS-SSS-C (emotional-informational) -0.11† 0.01 -0.40
Health perception -0.60† 0.16 -0.21
Living with family -1.62‡ 0.82 -0.10

* B denotes unstandardised coefficient; Beta standardised coefficient; HADS Hospital Anxiety and Depression Scale; CHQ-C Chronic Heart
Failure Questionnaire (Chinese version); MOS-SSS-C Medical Outcomes Study Social Support Survey (Chinese version); NYHA New York
Heart Association Classification
†
p<0.01
‡
p<0.05

support is defined as the expression of positive also reduced the uncertainty arising from disease
affect, empathetic understanding, encouragement exacerbation and the associated hospitalisation.50 As
of expressions of feelings, provision of guidance, for living arrangements, family interdependence is
advice, and feedback.49 These actions are relevant highly valued in Chinese culture.51 A previous study
to resolving the negative emotions of self-blame, also found that coresidence with a family was a factor
anger, and shame that were frequently reported significantly associated with higher satisfaction in
by elderly CHF patients.30 As hospitalised subjects elderly Chinese patients with chronic illness.52 The
were included in this study, informational support current study therefore also served to emphasise

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Yu et al

the beneficial effect of living with the family in CHF patients. First, emotional support and family
maintaining the psychological well-being of elderly cohesiveness should be highly prioritised goals of
CHF patients. care. As most elderly CHF patients are advanced
in age, family is an important source of emotional
In addition to social support, the study also support and should be mobilised. Encouraging
highlighted the negative psychological impact of the coresidence of elderly CHF patients with their families
typical somatic symptom of fatigue in elderly CHF also requires health care professionals to address
patients. The strong association between fatigue the problem of caregiver strain, which is one of the
and psychological distress in such patients might be major causes of institutionalisation of this vulnerable
related to their reduced physical ability to continue group.58 Second, it is important to equip elderly CHF
with their daily activities, usual role and social patients with information on disease management,
functioning. Disturbance in these functions seems with particular reference to coping with the symptom
associated with a negative psychological outcome. of fatigue. The empirical value of relaxation therapy,
Previous studies that examined the life experience activity pacing for this purpose has been widely
of elderly CHF patients, consistently highlighted established.59,60 Recent studies have focused on the
the psychological element in the somatic symptom possible therapeutic effect of exercise therapy in
of fatigue. Martensson et al3 found that fatigue was CHF,61 and preliminary findings are encouraging in
experienced by elderly CHF patients not only as a terms of controlling symptoms. Further empirical
physical lack of energy to take part in daily life, validation of this intervention in Chinese elderly
but also a mental block to initiate the intended CHF patients is therefore warranted. Finally, effort
physical work. Elderly CHF patients also described should also be placed at helping them to cultivate a
this physical symptom of fatigue as overwhelming positive attitude towards their own health status. The
tiredness.53 They conceived fatigue as both physical value of educational programmes that enhance self-
exhaustion and psychological feelings of decreased care management of elderly CHF patients to pursue
self-worth, helplessness, annoyance, and lack of this objective has been confirmed,62,63 and should be
ambition. Thus, our findings further highlighted the incorporated into the discharge planning for all such
psychological manifestations of fatigue as a symptom patients in Hong Kong.
in elderly CHF patients.
This study has several limitations. First, the
As for the significant positive relationship cross-sectional study design has limited potential
between poorer health perception and psychological for making causal inferences on the relationship
distress in elderly CHF patients, previous studies between psychological distress and possible
also reported conclusive findings. Thus, elderly CHF associated factors. Psychological distress might
patients who reported lower rankings in perceived affect an individual’s interpretation of his or her
health had a significantly higher risk of sustaining support system, resulting in an unrealistically
poor health outcomes including poorer quality of low perception of their social support.64 Fatigue
life,54 more hospital readmission and mortality.55 can also be manifested as a somatic symptom of
Health perception, in fact, is an individual’s emotional distress.65 Future studies should adopt
judgement about one’s own health, which is based on a longitudinal design to clarify the directionality of
the information about one’s biological, physiological, such relationships in elderly CHF patients. Second,
functional, and symptomatic status.56,57 The negative this study was conducted in a group of hospitalised
psychological impact associated with deterioration subjects. Therefore caution is advised before
in any of these health perspectives is therefore well generalising its findings to community-dwelling
recognised. Thus, our findings in elderly CHF patients elderly CHF patients. Finally, the literature suggests
further highlight the need to recognise patients’ a negative impact on the psychological well-being
self-appraisal of health status, especially as none of of cardiac patients with certain personality traits
the clinical indicators appear to be associated with such as neuroticism22 and hostility.48 The lack of such
psychological distress. information as independent variables in this study,
could possibly confound interpretation of some of
Based on our findings, several recommendations the relevant factors associated with psychological
are proposed to enhance the care for the elderly distress we assessed.

130 Asian Journal of Gerontology & Geriatrics Vol 1 No 3 December 2006

 Psychological distress in elderly patients with congestive heart failure

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