How to deal with fatigue

Saul Berkovitz MRCP, MCPP, MFHomConsultant Physician, Chronic Fatigue ServiceRoyal London Hospital for Integrated Medicine University College London Hospital NHS Trust

“Everyday” fatigue

• A normal sensation experienced by everyone

• Exhaustion or tiredness (physical or mental)

• Temporary and relieved by rest

• Different from:– Weakness– Shortness of breath– Effort intolerance– Sleepiness– loss of motivation and pleasure

Fatigue in the population

• Main complaint in 5-10% of GP consultations

–an important factor in another 5-10%

• ‘TATT’

• Half of patients are still fatigued 6 months later

Medically significant fatigue

• Persistent or relapsing fatigue

• Lasting several months

• Not the result of over-exertion

• Not relieved by rest or sleep

• Causing substantial impact / disability

Associated symptoms

• sore throat

• tender lymph glands

• muscle pains

• joint pains

• new headaches

• unrefreshing sleep

• post-exertional malaise

• poor memory or concentration

Maintaining factors

• Older age

• Mood disorders

• Illness beliefs

• Inactivity

• Sleep problems

• Search for legitimacy, benefits, diagnostic label

Cancer-related fatigue

• Variety of cancers

• Before diagnosis (40%)

• During treatment (80-90%)

• Beyond treatment completion (33% at one year)

• High impact (more than pain, depression, nausea)

Possible mechanisms of fatigue

• Alteration in serotonin (“happy hormone”)

• Alterations in cortisol (“stress hormone”)

• Alterations in circadian rhythm (“biological clock”)

• Alterations in muscle metabolism

Approach to management

• “Biopsychosocial” rather than “biomedical”

• A definite diagnosis

• Over-investigation vs. under-investigation

• Empathy

• Non-judgemental style

• Commitment to continued care if required

• Associated anxiety & depression

Management – drug treatment

• Anaemia (epoetin alpha)

• Antidepressants

• Night time sedation (amitriptyline)

• Corticosteroids

• Psychostimulant (methylphenidate (Ritalin))

• Wakefulness enhancer (modafinil)

• Metabolic enhancer (L-Carnitine)

Management – non-drug treatment

• Self-management

• Professional management– Multidisciplinary; integrated; group or individual

• Activity management therapy

• Graded exercise therapy (GET)

• Cognitive behavioural therapy (CBT)

Activity Management Therapy

Activity management therapy

• Pacing advice

• Activity diaries and scheduling

• Energy conservation

• Stress management + relaxation training

• Management of sleep problems

• Longer term target setting

• Coping with setbacks

Graded exercise therapy

Graded exercise therapy

• Appropriate exercise is safe and beneficial in fatigue

• Gradually progressed exercise programme starting from an individualised baseline

• Assessment

• Aerobic exercise, strength training, core stability training and stretching

• Gym / home

• Short- and long-term goal setting

Cognitive Behavioural Therapy

Cognitive behavioural therapy

• How thoughts and feelings influence behaviour (and affect health and well-being)

• Aims to promote self-management

• Short-term

• Collaborative

• Problem-solving

• Goal-focused

• Individual or group

Cognitive behavioural therapy

• Unhelpful beliefs / thoughts about illness

– “Activity makes me feel worse, so it will damage me”

– “I can’t do X as well / often as I used to so I won’t do it any more”

– “I can’t do X any more so I’m a failure”

• Guilt / denial / embarrassment

• Overestimating threats (catastrophising)

– “I might collapse in the street so I won’t risk going out”

• Over-vigilance of symptoms

• Shift away from the pursuit of cause

• Functioning the best we can within our constraints

Self-management

Pacing

Graded exercise

Stress and mood management

Fatigue services:

www.afme.org.uk/me_cfsDirectorySearch.asp

Books: “Fighting Fatigue: Managing the Symptoms of

CFS/ME” by Sue Pemberton

Computerised CBT: www.fatiguefighter.org.uk

Acknowledgements

• Chronic Fatigue Team, Royal London Hospital for Integrated Medicine

• Chris Perrin (Nurse Specialist)

• Mary Queally (Occupational Therapist)

• Margaret Hooper / Raj Sharma (Psychologists)

• Esther Odetunde (Physiotherapist)

• Sue Thurgood (Dietician)