Approach to Fatigue

GPImmunology
Written By Maladywise

Overview

Fatigue is

  • A state of lessened capacity for work accompanied by a feeling of weariness, sleepiness, irritability or a loss of ambition

  • 1 in 70 presentations to GP

    • Some studies show main complaint in 5 to 10%

    • Subsidiary complaint in 5 to 10% more

  • Can be synonymous with malaise, exhaustion, tiredness

Prevalence

  • 5 to 20% of the population

Diagnosis

  • No diagnosis in > 50% at 12 months

  • Psychological cause in 18%

  • Somatic pathology in 4%

  • Undiagnosed cancer = 0.6%

  • Sleep

  • Post infectious

  • Substances

History

  • Clarify what is meant by fatigue

  • Impact on function

  • Patients’s ideas and concerns

  • Onset, duration, severity

  • Associated symptoms - somatic and psychological, pain

  • Social history - alcohol, other drugs

  • Sleep

  • Exercise

  • Diet

  • Family history + similar symptoms in contacts

  • Occupational history e.g. shift work

  • Medications including OTC + CAM

  • Red flags

Causes

  • Heart and Lungs

    • CHF

    • COPD

    • OSA

  • Sleep

    • Allergic rhinitis

  • Endo / Metabolic

    • Thyroid

    • CKD

    • CLD

    • Adrenal

    • UEC abnormalities

  • Bloods / Cancer

    • Anaemia

    • Cancer

  • Infection

    • IM

    • Hepatitis

    • HIV

    • Endocarditis

    • TB

  • Rheum

    • Fibromyalgia

    • PMR

    • SLE

    • RA

    • Sjogren’s

  • Psych

    • Anxiety / Depression

    • Somatisation

  • Neuro

    • MS

  • Medication

    • Benzo

    • Antidepressants

    • Muscle relaxants

    • Antihistamines

    • B Blockers

    • Opioids

Evaluation

  • Onset - acute or gradual

  • Course - stable, improving, worsening

  • Duration and daily pattern

  • Factors that alleviate or exacerbate

  • Impact on daily life

  • Accommodations made

  • Associated symptoms

  • Ask about depression

  • Ask about substances

  • Ask about sleep

  • Family history

Exam

  • Appearance, body habitus, pallor, jaundice, rashes

  • Pallor, jaundice, rashes

  • Thyroid exam

  • Lymph nodes, liver, spleen

  • Heart and lungs

  • Neuromuscular

  • MSE

  • U/A

  • BSL

Testing

  • 16% of tests ordered returned abnormal results

  • 4% of patients ended up with a clinically significant diagnosis

  • Limited testing of HB, ESR, BSL, TSH is almost as useful in diagnosing serious pathology as extensive testing

Red Flags

  • Recent onset fatigue in a previously well older patients

    • Malignancy

    • Anaemia

    • Cardiac arrhythmia

    • Renal failure

    • Diabetes Mellitus

  • Unintentional weight loss

    • Malignancy

    • HIV

    • Diabetes Mellitus

    • Hyperthyroidism

  • Abnormal bleeding

    • Anaemia

    • GIT malignancy

  • Shortness of breath

    • Anaemia

    • Heart failure

    • Cardiac arrhythmia

    • COPD

  • Unexplained lymphadenopathy

    • Malignancy

  • Fever

    • Serious infection

    • Hidden abscess

    • HIV

  • Recent onset of CV, GIT, Neuro or Rheum symptoms

    • Autoimmune diseases

    • Malignancy

    • Arrhythmias

    • Parkinson’s

    • MS

    • Haemochromatosis

When to test

  • Many guidelines suggest 4 weeks postponement of tests

  • Delaying tests has been shown to not affet patient satisfaction or anxiety levels

  • A second line of testing is suggested if tiredness persists for 3 months

Investigations

  • Uptodate - FBC, UEC, LFT, CMP, Glucose, TSH, CK if weakness, Hep C + HIV screening

  • Australia - FBC, UEC, LFT, ESR or CRP, BSL, TSH, Ferritin

Other tests

  • ESR/CRP if older

  • TB testing if history

  • Extensive lab testing not helpful and clarifies the cause only 5% of the time

  • Cancer screening

  • UK guidelines suggest coeliac disease in all patients

  • Pregnancy if appropriate

Localised findings

  • Follow the symptoms

Without localised findings

  • Review in 1 to 3 months with baseline tests repeated

  • Additional bloods unlikely useful

  • Don’t routinely screen for these without symptoms

    • EBV, CMV, Lyme, ANA, RF, Vitamins, Coeliac, ANA

Diagnosis

  • If no cause identified after 6 months are designated as having

    • Idiopathic chronic fatigue (prevalence of 1 in 16 people)

    • Chronic fatigue syndrome if meets criteria (1 in 500 people)

Management

  • Establish supportive relationship and create goals

    • Accomplish ADLs

    • Maintain relationships

    • Return to work

  • Identify modifiable factors

    • Workload, stress, coping strategies, depression, overcommitment

  • Once study shows patients were seeking to

    • Engage with the doctor

    • Convey suffering

    • Receive reassurance

  • Schedule brief regular appointments to monitor progress

  • Address underlying medical conditions identified

  • Address idiopathic fatigue

    • 6 weeks trial of antidepressant therapy for patients with depressive symptoms SSRI or SNRI

  • CBT

  • Exercise therapy

    • 4 weeks of aerobic, strength or flexibility training improves fatigue

  • Improve sleep

  • Manage chronic pain

Resources:

Maladywise https://www.maladywise.org
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