EMPI RI CAL STUDI ES doi: 10.1111/j.1471-6712.2007.00540.

x
Depression among elderly people with and without heart
failure, managed in a primary healthcare setting
Lena Ha gglund RNT, MSc (Doctoral student)
1,2
, Kurt Boman MD, PhD (Professor)
2,3
, Berit Lundman RN, PhD
(Professor)
1
and Christine Brulin RNT, PhD (Associate Professor)
1
1
Department of Nursing, Umea University, Umea , Sweden,
2
Department of Medicine-Geriatric, Skelleftea County Hospital, Skelleftea , Sweden
and
3
Department of Public Health and Clinical Medicine, Umea University, Umea , Sweden
Scand J Caring Sci; 2008; 22; 376382
Depression among elderly people with and without
heart failure, managed in a primary healthcare setting
Background and research objectives: Depression is common
among patients with heart failure (HF) and among elderly
in general. Problems in diagnosing and care planning can
arise as symptoms of HF, dyspnoea and especially fatigue,
are nonspecic and also overlap with symptoms of
depression. The objective of this study was to describe the
prevalence and compare degrees of depression among
patients with conrmed HF, patients with symptoms sim-
ilar to HF (no heart failure, NHF) and a reference group in
one primary healthcare centre (PHC), after adjusting for
background characteristics and fatigue.
Subjects and methods: A descriptive case-reference study was
conducted in one PHC in a middle-sized city. Participants
were 49 patients with conrmed HF, 59 patients with
symptoms similar to HF (NHF) and 40 people in a reference
group. After informed consent data were collected by
structured interviews using the Geriatric Depression Scale
and the Multidimensional Fatigue Inventory-20. Odds
ratios for the outcomes HF vs. NHF, HF vs. reference group,
and NHF vs. reference group were calculated.
Results: The HF and NHF groups had similar degrees of
depression which were signicantly higher than for the
reference group. This difference between the groups did
not remain signicant when adjusting for physical fatigue.
More patients in the NHF than in the HF group were living
alone and there were more women in the NHF than in the
reference group.
Conclusions: Prevalence of depression and degrees of fatigue
were higher among elderly from a PHC who experienced
HF symptoms, independent of objectively measured heart
function, compared with elderly without such symptoms.
When comparing degrees of depression between the three
groups and adjusting for fatigue, the physical dimension of
fatigue was of greater importance in explaining group
differences.
Keywords: heart failure, elderly, primary health care,
depression, fatigue, case-reference study.
Submitted 16 November 2006, Accepted 13 June 2007
Introduction
The comorbidity of depression among patients with heart
failure (HF) is common and has received an increased
interest in the last few years. The prevalence of depression
in hospitalised patients with HF ranges from 35% to 58%
(1, 2), and in outpatient groups from 11% to 48% (35).
Major depression is reported to be a risk marker for poor
prognosis and high mortality rates in HF (1, 6). Depressive
symptoms were also strong predictors of short-time decline
in health status (4) and correlated with poorer functional
status and poor mental quality of life among patients with
HF (7). Therefore, it is of great importance to detect, cor-
rectly diagnose and treat depression among patients with
HF. However, because of an overlap of symptoms between
depression and HF, especially fatigue, there is a risk of
under-diagnosing and under-treatment of depression in
patients with HF (8). Furthermore, depression is reported
to be common in old age (9) and as somatic symptoms may
be indicators of depression (10) it is possible that patients
experiencing symptoms similar to HF might be depressed.
As the symptoms and signs of HF are nonspecic, diagnostic
problems arise, probably leading to a highproportionof false
HF diagnosis (11, 12). This might have inuenced previous
study results. Thus, the question remains if there are dif-
ferences inprevalence of depressioninanelderlypopulation
between patients with and without a conrmed diagnosis of
HF. In general, most studies on patients with HF are com-
prised of patients in hospitals with a left ventricular ejection
Correspondence to:
Lena Ha gglund, Department of Nursing, Umea University,
SE-90187 Umea , Sweden.
E-mail: lena.hagglund@nurs.umu.se
376 2008 The Authors. Journal compilation 2008 Nordic College of Caring Science
fraction (LVEF) equal to or below40%, predominantly men
aged about 60 years. Several studies have also excluded
patients with coexisting debilitating diseases or those being
treated with psychotropic medication (13). Such studies are
not representative of patients with HF seen in primary
healthcare, where the mean age is about 78 years, the
proportion of women are higher thaninyounger age groups
(14) and comorbidity is common (15). Preserved systolic
function(LVEF >40%) is also frequent among older patients
with HF (15).
Although fatigue is one of the most troublesome symp-
toms for patients with HF (16), and common in depression
and other chronic illnesses, there is little knowledge about
the relationship between HF and depression in an elderly
population when different dimensions of fatigue also are
taken into account. The aim of this study was to describe
the prevalence and compare the degrees of depression
among patients with conrmed HF, patients with symp-
toms similar to HF and a reference group, in one primary
healthcare centre (PHC), when adjusted for background
characteristics and fatigue.
Method
Setting
This descriptive case-reference study is part of a cohort
study at one PHC in a middle-sized city (17). The PHC has a
catchment area of approximately 7800 inhabitants of
whom many are of advanced age. Patients were selected by
the responsible physician from a patient register, as well as
newly diagnosed with a diagnosis of suspected HF from
January 1999 to February 2003. Eligible patients who had
symptoms of at least 3 months duration, suffered mainly
from dyspnoea (89%), and fatigue or signs of peripheral
oedema (11%) indicating HF. Exclusion criteria for par-
ticipation in the study were terminal illness, cognitive
impairment and communication problems. The patients
were then referred for an echocardiographic examination
followed by a nal cardiology consultation. The diagnosis
of HF was established according to the criteria proposed by
the European Society of Cardiology (15). Seventy-seven
patients (45%) of 170 were found to have conrmed sys-
tolic and/or diastolic HF and 93 patients (55%) had no
heart failure (NHF).
Participants
A owchart of the participating patients in this study is
shown in Fig. 1. Of 65 patients with conrmed HF
recruited, 49 (75%) participated, mainly in New York
Heart Association functional classes IIIII. Of the 89
patients with NHF recruited, 59 (66%) participated in this
study. To nd participants for the reference group, 263
people were selected from a list of names supplied by the
National Tax Board matching the group of patients with HF
concerning age in 5-year intervals, sex and place of
residence. For each 5-year interval a random selection
procedure was applied. Thereafter, people with heart or
lung diseases, stroke, current or previously treated high
blood pressure or cognitive impairment were excluded.
Hence, 103 people were invited to participate. Of these, 49
people declined (15 men and 34 women) and 14 (six men
and eight women) did not reply to the invitation. The mean
age for the men and women not participating was 72 and
80 years respectively. In total, 40 people (40%) participated
in the reference group. For demographic data refer Table 1.
Procedure
Data collection took place during 2003. A letter with
information and an invitation to participate in the study
was sent to those selected. Once informed consent was
obtained, face-to-face interviews from a structured ques-
tionnaire were conducted in the participants home or at
the ofce of the interviewer.
Measurements
The questionnaire was designed to yield information about
depression, fatigue, and background characteristics such as
age, gender, cohabitation and self-reported diseases. Diag-
noses of cardiovascular and pulmonary diseases among the
HF and NHF groups were obtained from medical records.
The Geriatric Depression Scale-15 (GDS-15) (18) is a
15-item scale, well validated and recommended for
screening of late-life depression in primary care settings
(19) and among elderly people with medical diseases or
functional impairment (20). The possible range of scores is
89 65
93
30
4
77
11
1
16
Heart failure Non heart failure
Moved
Died
Recruited
Declined
Participants
170
49 59
Figure 1 Flowchart of the participants in the heart failure and nonheart
failure groups.
2008 The Authors. Journal compilation 2008 Nordic College of Caring Science
Depression among elderly people with and without HF 377
015. In this study individuals who scored from zero to
four were classied as not being depressed, 59 as having
mild depression and 1015 as having severe depression
according to Alden et al. (21). Cronbachs alpha for this
study was 0.74. In comparison between groups the GDS
was used as a continuous variable.
The Multidimensional Fatigue Inventory-20 (MFI-20)
(22) is a 20-item scale for measuring fatigue covering ve
dimensions: general fatigue, physical fatigue, mental fati-
gue, reduced motivation and reduced activity. MFI-20 has
been used in various samples of cancer patients (22, 23)
and among patients with HF (24) with good internal
consistency. In the current study Cronbachs alpha values
for the subscales were as follows: general fatigue 0.87,
physical fatigue 0.88, reduced activity 0.85, reduced
motivation 0.65 and mental fatigue 0.63. Each subscale
includes four items and ranges from four to 20 with a high
score indicating a high degree of fatigue.
Statistical analyses
Missing values were replaced with the mode value for the
respective item. Altogether four values in the MFI-20 scale
were imputed. For each subject, no more than two values
were imputed. Chi-squared tests were used to test for
associations between categorical variables. To test differ-
ences in mean values between several groups, analyses of
variance (ANOVA) or the KruskalWallis test were used.
Multiple logistic regressions were used to obtain estimates
of odds ratios, with a 95% condence interval, when
adjusting for background characteristics and fatigue. Three
separate logistic regression analyses have been performed
with the outcomes HF vs. NHF, HF vs. reference group and
NHF vs. reference group. Variables with a p-value <0.1
from the univariate logistic regressions were entered in the
multiple logistic regressions. In the logistic regression
analyses the GDS was used as a continuous variable.
Multicollinearity between independent variables was
tested by using Pearsons productmoment correlation
coefcients. The analyses were performed using the SPSS
for Windows version 11.0 (Chicago, IL, USA).
Results
Background characteristics and fatigue
The background characteristics gender, age and cohabita-
tion are reported in Table 1. Diagnoses and self-reported
diseases are reported in Table 2. Four patients in each of the
HF and the NHF groups took antidepressant drugs. Neu-
roleptica and anxiolytic drugs were used of seven patients
in the HF group, seven patients in the NHF group and two
participants in the control group. In the HF group, two
patients were prescribed drugs against dementia symptoms.
Patients with HF and NHF had signicantly higher degrees
of general fatigue, physical fatigue and reduced activity
compared with the reference group (Table 1).
Depression
The degree of depression in the HF group and the NHF
group were signicantly higher than in the reference
group (Table 1). In the HF group 25.5% (12/47) and in the
NHF group 25.4% (15/59) of the patients had GDS scores
indicating mild depression. The corresponding proportion
in the reference group was 12.5% (5/40). In addition, in
the NHF group 3.4% (2/59) had severe depression. In the
HF group women had a signicantly higher degree of
Table 1 Descriptive for background characteristics, depression and fatigue for patients with heart failure (HF) symptoms similar to heart failure (NHF)
and people in the reference group
HF (n = 49) NHF (n = 59) Reference (n = 40) p-value
Gender (male/female) 21/28 14/45 20/20 0.018
a
Living alone 22 (45%) 38 (64%) 22 (55%) 0.129
a
Living alone (male/female) 2/20 6/32 6/16 <0.001
a
Age, m (SD) 77.7 (8.7) 77.6 (7.9) 77.5 (8.7) 0.929
a
m (SD) m (SD) m (SD)
Depression 3.49 (2.22) 3.34 (2.92) 1.93 (1.91) 0.006
b
General fatigue 14.6 (3.9) 14.0 (4.1) 9.9 (5.2) <0.001
b
Physical fatigue 15.5 (3.9) 13.9 (4.5) 10.0 (4.9) <0.001
b
Reduced activity 14.6 (3.8) 14.1 (4.3) 11.4 (4.8) 0.002
b
Reduced motivation 9.9 (3.1) 9.3 (3.9) 8.4 (2.9) 0.125
b
Mental fatigue 10.1 (3.4) 9.9 (3.0) 9.6 (3.7) 0.769
b
Mean (m) and standard deviation (SD) of age and the Multidimensional Fatigue Inventory-20 scales and p-values for differences among groups.
a
KruskalWallis test.
b
ANOVA.
Signicance level p-value 0.05 in bold gures.
2008 The Authors. Journal compilation 2008 Nordic College of Caring Science
378 L. Ha gglund et al.
depression than men (GDS mean 2.35 vs. 1.78, p 0.05).
For the reference group there was a signicant correlation
(r = 0.611, p 0.01) between GDS and reduced motiva-
tion, but not for the HF (r = 0.255) and NHF (r = 0.241)
groups.
In all multiple regression analyses, the variables general
fatigue and reduced activity were excluded because of high
correlation with physical fatigue, (r = 0.794 and 0.769
respectively). Comparing the HF and NHF groups in the
univariate regression analysis, it was less likely for women
and patients living alone to belong to the HF group, and
there was a tendency that patients who perceived more
physical fatigue suffered from HF (Table 3). In the multi-
variate analysis the difference in physical fatigue became
statistically signicant, while the other variables did not
contribute signicantly to explain differences between the
groups (Table 4).
In the univariate analysis, people with higher degrees of
depression and higher degrees of all dimensions of fatigue,
except mental fatigue, were more likely to belong to the
HF group than to the reference group (Table 3). In the
Table 2 Numbers of cardiovascular and pulmonary diagnoses from
records and self-reported diseases among patients with heart failure
(HF) symptoms similar to heart failure (no heart failure, NHF) and people
in the reference group
HF
(n = 49)
NHF
(n = 59)
Reference
(n = 40)
Cardiovascular and pulmonary diagnoses from records
Hypertension 23 19
Ischaemic heart diseases 46 30
Stroke 10 8
Pulmonary diseases 3 3
Self-reported diseases
Respiratory 5 18 0
Musculoskeletal complaints 30 31 22
Diabetes 5 7
Malignant tumours 5 6 2
Others
a
11 12 22
a
Most common diseases in eyes and ears, urinary and sexual organs and
in the control group other circulatory diseases, like low blood pressure,
rhythm disturbances and peripheral vascular diseases.
Table 3 Crude odds ratio (OR) and 95% condence intervals (CI) for people in the heart failure (HF) group, the no heart failure (NHF) group and the
reference group
HF vs. NHF
a
(n = 49, n = 59)
HF vs. reference
b
(n = 49,
n = 40)
NHF vs. reference
c
(n = 59,
n = 40)
OR (95% CI) p OR (95% CI) p OR (95% CI) p
Depression (GDS) 1.02 (0.881.18) 0.768 1.47 (1.151.88) 0.002 1.28 (1.061.56) 0.012
Gender
Male 1.0 1.0 1.0
Female 0.42 (0.180.95) 0.036 1.33 (0.583.09) 0.502 3.21 (1.367.62) 0.008
Cohabiting 1.0 1.0 1.0
Living alone 0.45 (0.210.98) 0.044 0.67 (0.291.54) 0.344 1.48 (0.653.36) 0.348
General fatigue 1.04 (0.941.14) 0.483 1.24 (1.121.37) 0.001 1.21 (1.101.33) 0.001
Physical fatigue 1.10 (1.001.20) 0.057 1.30 (1.161.45) 0.001 1.19 (1.081.31) 0.001
Reduced activity 1.03 (0.941.13) 0.532 1.19 (1.071.32) 0.002 1.14 (1.041.25) 0.007
Reduced motivation 1.05 (0.951.17) 0.355 1.18 (1.021.37) 0.027 1.07 (0.951.21) 0.240
Mental fatigue 1.02 (0.901.15) 0.790 1.04 (0.921.18) 0.496 1.03 (0.911.17) 0.605
GDS, Geriatric Depression Scale.
a
0 = NHF group, 1 = HF group,
b
0 = control group, 1 = HF group,
c
0 = control group, 1 = NHF group.
Signicance level p-value 0.05 in bold gures.
Table 4 Adjusted odds ratio (OR) and 95% condence intervals (CI) for people in the heart failure (HF) group, in the no heart failure (NHF) group and
the reference group
HF vs. NHF
a
(n = 49, n = 59) HF vs. reference
b
(n = 49, n = 40) NHF vs. reference
c
(n = 59, n = 40)
OR (95% CI) p OR (95% CI) p OR (95% CI) p
Female 0.47 (0.181.23) 0.124 Depression 1.08 (0.791.48) 0.641 Depression 1.11 (0.881.41) 0.388
Living alone 0.43 (0.171.1) 0.079 Physical fatigue 1.31 (1.131.53) 0.001 Female 2.68 (1.056.85) 0.040
Physical fatigue 1.15 (1.031.28) 0.014 Reduced motivation 0.90 (0.731.11) 0.310 Physical fatigue 1.14 (1.021.28) 0.024
a
0 = NHF group, 1 = HF group,
b
0 = control group, 1 = HF group,
c
0 = control group, 1 = NHF group.
Signicance level p-value 0.05 in bold gures.
2008 The Authors. Journal compilation 2008 Nordic College of Caring Science
Depression among elderly people with and without HF 379
multivariate analysis, only the potential confounding
variable physical fatigue remained signicant (Table 4).
Comparing the NHF and reference groups in the uni-
variate analysis, participants reporting higher degrees of
depression, general fatigue, physical fatigue and reduced
activity, and being female, were more likely to belong to
the NHF group (Table 3). The multivariate analysis showed
that the variables physical fatigue and gender remained
signicant. Differences in depression did not remain sig-
nicant in the multivariate analyses (Table 4).
Discussion
A main nding in this study among elderly in a primary
healthcare setting was that there was almost no difference
in the prevalence of depression between patients with
veried HF and patients with similar symptoms (NHF).
However, compared with the reference group without
such symptoms depression was signicantly more common
in the groups of patients. This is in accordance with earlier
studies indicating that depression is common among
patients with HF (5), coronary heart disease (25) and other
chronic illnesses (26). Our ndings also underlines that it is
the symptoms of HF rather than the measurable heart
function that is of importance for mood status, which is in
line with the ndings in the Heart and Soul study (27)
among patients with coronary disease. The impact of
functional limitations on mood status was also described by
Dent et al. (28) who found that the effect of chronic dis-
ease on depressive symptoms in a population aged 75 and
older, was mediated through disability.
The studies mentioned above also correspond with our
ndings concerning fatigue. Although the patients in the
HF and NHF groups had higher levels of depression than
the reference group, another main nding of the present
study was that the physical dimension of fatigue, when
included as a potential confounder, was of greater impor-
tance in explaining differences between the groups than
levels of depression. Both depression and fatigue are inter-
related in HF but the design of our study was not suitable
for assessment of cause-relationship between these vari-
ables. In addition, in the current study the correlation
between depression and reduced motivation was signi-
cant only in the control group, while such associations
were not found in the HF and NHF groups. As one typical
symptom in depression is reduced pleasure or interest in
activities (29) this might indicate differences in the expe-
rience of depression depending on physical health status
within this sample of elderly people. Furthermore, in all
groups women were more often living alone, and in the HF
group women had higher degrees of depression compared
with men. These ndings stress the need to further study
the impact of gender, social situation and different
dimensions of fatigue on depression in elderly with HF.
Our ndings also support the conclusion made by David-
son et al. (30) that there is a need of planning interven-
tions targeted for the specic needs of elderly women with
heart diseases, especially concerning psychosocial aspects.
Methodological considerations
An important strength in the study is the careful diagnostic
evaluation, separating patients with conrmed HF from
those with similar symptoms. Many studies fail to report
such procedures and it is not unlikely that patients without
HF are incorrectly included in study samples. However,
since the diagnostic evaluation started in 1999 and data
collection for the current study took place in 2003 there
might be a small risk that some patient in the NHF group
could have developed HF in the mean time. From a cal-
culated incidence of HF in this population of about 1% per
year we believe that this risk is negligible. One limitation
in our study is the proportion of people who declined to
participate in the reference group (60%). Tiredness was a
common reason for nonparticipation, probably leading to
the exclusion of those most fatigued in all groups. It is also
plausible that those who declined to participate could be
more depressed. However, the proportion of depressed
people in the control group is in line with the prevalence of
depression among elderly in community samples (31). The
relatively small number of patients in all groups does, of
course, give rise to a substantial risk of type-II errors in the
current study. Some of the reported diseases and medicines
might inuence both mood status and fatigue. Because of
the small sample size and lack of data from medical records
for the reference group, these variables were not included
in the logistic regression analyses. During the face-to-face
interviews the interviewer knew to which group the
interviewee belonged. As the questions were read literally
from the structured questionnaire in the same manner for
all participants, the risk for bias was judged as limited. In
this study depression was not examined by psychiatric
diagnostic interviews, but the GDS is reported to be a
reliable tool among elderly with medical diseases and
functionally impairment (20). Participants were reminded
of the possibility to discontinue the interview if answering
the questions were experienced as troublesome.
Clinical considerations
Our results emphasises that the subjective illness experi-
ence is of high importance for mental health among elderly,
more than differences in objectively measured heart func-
tion. From a clinical perspective, our ndings stress the
importance of careful investigation of each patients expe-
rienced problems, physical as well as mental. Especially, the
impact of different dimensions of fatigue must receive
broader attention. Studies among elderly, fragile patients
with symptoms of depression are needed to evaluate if
interventions aimed at reducing physical fatigue also prove
2008 The Authors. Journal compilation 2008 Nordic College of Caring Science
380 L. Ha gglund et al.
to inuence mood status. One example of such interven-
tions is physical exercise training, also recommended for
patients with HF but until now principally examined in
younger, predominantly male populations (32).
Conclusions
Prevalence of depression and degrees of fatigue were
higher among elderly from a PHC who experienced HF
symptoms, independent of objectively measured heart
function, compared with elderly without such symptoms.
When comparing degrees of depression between the three
groups and adjusting for fatigue, the physical dimension of
fatigue was of greater importance in explaining group
differences.
Acknowledgements
We thank Hans Stenlund, PhD, for statistical advice.
Author contributions
Lena Ha gglund was involved in the design of the study,
made almost all data collection, made the analyses and
wrote the manuscript with supervision fromthe co-authors.
Kurt Boman made the cardiology examinations and diag-
noses decisions. He also has taken active part in designing
the study, data analysis and manuscript writing. Berit
Lundman has provided important comments during the
time of manuscript writing. Christine Brulin was the main
supervisor, involved in designing the study, data collection,
data analyses and manuscript writing.
Funding
This work was supported by HeartNet, an interdisciplinary
research and development project, nanced by EU struc-
tural funds, Skelleftea Municipality, the County Council
and the County Administrative Board.
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