Original Study| Volume 21, ISSUE 9, P1267-1272.e2, September 2020

Development and Validation of the Norfolk Quality of Life Fatigue Tool (QOL-F): A New Measure of Perception of Fatigue

Published:December 19, 2019DOI:



      To design a questionnaire to evaluate and distinguish between cognitive and physical aspects of fatigue in different age groups of “nondiseased” people and guide appropriate prevention and interventions for the impact of frailty occurring in normative aging.

      Study design and participants

      The Norfolk QOL-Fatigue (QOL-F) with items of cognitive and physical fatigue, anxiety, and depression from validated questionnaires including items from the Patient-Reported Outcomes Measure Information System (PROMIS) databank was developed. The preliminary QOL-F was administered to 409 healthy multiethnic local participants (30-80 years old) in 5 age groups.


      The authors distilled the item pool using exploratory (EFA) and confirmatory factor analysis (CFA). EFA identified 5 latent groups as possible factors related to problems due to fatigue, subjective fatigue, reduced activities, impaired activities of daily living (ADL), and depression.


      CFA demonstrated good overall fit [χ2(172) = 1094.23, P < .001; Tucker-Lewis index = 0.978; root mean square error of approximation = 0.049] with factor loadings >0.617 and strong interfactor correlations (0.69-0.83), suggesting that fatigue in each domain is closely related to other domains and to the overall scale except for ADL. The 5-factor solution displayed good internal consistency (Cronbach α = 0.78-0.94). Total and domain scores were fairly equivalent in all age groups except for the 40 to 49-year-old group with better overall scores. In addition, 70 to 79-year-olds had better ADL scores. In item response analysis, factor scores in different age groups were similar, so age may not be a significant driver of fatigue scores. Fatigue scores were significantly higher in females than in males (P < .05).

      Conclusions and clinical implications

      The developed Norfolk QOL-F tool demonstrated fatigue as a perceived cognitive phenomenon rather than an objective physical measure, suggesting mandatory inclusion of cognitive as well as physical measures in the evaluation of people as they age. QOL-F is able to distinguish QOL-F domain scores unique to different age groups, proposing clinical benefits from physical, balance, and cognitive interventions tailored to impact frailty occurring in normative aging.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ranjith G.
        Epidemiology of chronic fatigue syndrome.
        Occup Med (Lond). 2005; 55: 13-19
        • Junghaenel D.U.
        • Christodoulou C.
        • Lai J.S.
        • Stone A.A.
        Demographic correlates of fatigue in the US general population: Results from the Patient-Reported Outcomes Measurement Information System (PROMIS) initiative.
        J Psychosom Res. 2011; 71: 117-123
        • Yang C.M.
        • Wu C.H.
        The situational fatigue scale: A different approach to measuring fatigue.
        Qual Life Res. 2005; 14: 1357-1362
        • Shapiro C.M.
        • Flanigan M.
        • Fleming J.A.
        • et al.
        Development of an adjective checklist to measure five FACES of fatigue and sleepiness. Data from a national survey of insomniacs.
        J Psychosom Res. 2002; 52: 467-473
        • Tiesinga L.J.
        • Dassen T.W.
        • Halfens R.J.
        DUFS and DEFS: Development, reliability and validity of the Dutch Fatigue Scale and the Dutch Exertion Fatigue Scale.
        Int J Nurs Stud. 1998; 35: 115-123
        • Krupp L.B.
        • LaRocca N.G.
        • Muir-Nash J.
        • Steinberg A.D.
        The Fatigue Severity Scale. Application to patients with multiple sclerosis and systemic lupus erythematosus.
        Arch Neurol. 1989; 46: 1121-1123
        • Piper B.F.
        • Dibble S.L.
        • Dodd M.J.
        • et al.
        The revised Piper Fatigue Scale: Psychometric evaluation in women with breast cancer.
        Oncol Nurs Forum. 1998; 25: 677-684
        • Schwartz J.E.
        • Jandorf L.
        • Krupp L.B.
        The measurement of fatigue: A new instrument.
        J Psychosom Res. 1993; 37: 753-762
        • Vinik E.J.
        • Hayes R.P.
        • Oglesby A.
        • et al.
        The development and validation of the Norfolk QOL-DN, a new measure of patients' perception of the effects of diabetes and diabetic neuropathy.
        Diabetes Technol Ther. 2005; 7: 497-508
        • Vinik E.
        • Carlton C.A.
        • Silva M.P.
        • Vinik A.I.
        Development of the Norfolk Quality of Life tool for assessing patients with neuroendocrine tumors.
        Pancreas. 2009; 38: e87-e95
        • Cella D.
        • Yount S.
        • Rothrock N.
        • et al.
        The Patient-Reported Outcomes Measurement Information System (PROMIS): Progress of an NIH Roadmap Cooperative Group during its first two years.
        Med Care. 2007; 45: S3-S11
        • Cella D.
        • Riley W.
        • Stone A.
        • et al.
        The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005-2008.
        J Clin Epidemiol. 2010; 63: 1179-1194
        • Horn J.L.
        A rationale and test for the number of factors in factor analysis.
        Psychometrika. 1965; 30: 179-185
        • O'Connor B.P.
        SPSS and SAS programs for determining the number of components using parallel analysis and velicer's MAP test.
        Behav Res Methods Instrum Comput. 2000; 32: 396-402
        • Tiesinga L.J.
        • Dassen T.
        • Halfens R.
        • van den Heuvel W.
        Validation and application of the Dutch Fatigue Scale and the Dutch Exertion Fatigue Scale.
        Int J Nurs Terminol Classif. 2003; 14: 59-62
        • Chalder T.
        • Berelowitz G.
        • Pawlikowska T.
        • et al.
        Development of a fatigue scale.
        J Psychosom Res. 1993; 37: 147-153
        • Morrison S.
        • Colberg S.R.
        • Parson H.K.
        • et al.
        Walking-induced fatigue leads to increased falls risk in older adults.
        J Am Med Dir Assoc. 2016; 17: 402-409
        • Leavitt V.M.
        • DeLuca J.
        Central fatigue: Issues related to cognition, mood and behavior, and psychiatric diagnoses.
        PM R. 2010; 2: 332-337
        • Ren P.
        • Anderson A.J.
        • McDermott K.
        • et al.
        Cognitive fatigue and cortical-striatal network in old age.
        Aging (Albany NY). 2019; 11: 2312-2326