Weakness & Fatigue Introduction Fatigue is a persistent, subjective feeling of tiredness, weakness or lack of energy related to advanced chronic illness. It has many contributory causes though the exact aetiology is poorly understood. Patients may use many terms to describe their experience of fatigue. Fatigue is a common symptom in progressive chronic disease. The severity and impact of fatigue may change in the course of the disease trajectory. It is frequently regarded as more distressing than pain by patients. It is often under-recognised by professionals. Fatigue may be unrelated to level of activity and not fully alleviated by rest or sleep. It is multidimensional affecting physical function, cognitive ability, social, emotional and spiritual wellbeing. Reduced physical function limits participation in preferred activities and activities of daily living. Cognitive involvement limits activities such as reading, driving and social interaction. Fatigue can influence the patient s decision-making regarding future treatment and may lead to refusal of potentially beneficial treatment. It is important to recognise that towards the end of life there will be a time point when intervention is no longer appropriate and may be distressing. At this stage, fatigue may provide protection and shielding from suffering for the patient. Assessment All palliative care patients should be assessed for fatigue and its effects. Explore the person s experience and understanding of fatigue. Acknowledge and validate the reality and significance of the symptoms. Be aware that patients may have multi-morbidities impacting on fatigue, eg cardiac/respiratory disease, renal or hepatic impairment, malignancy, hypothyroidism, hypogonadism, adrenal insufficiency, neurological conditions. Consider: o Symptom pattern, duration o Severity: mild, moderate or severe Patient-rated assessment on a 0-10 scale o Impact on function and quality of life, eg everyday activities can seem impossible o Impact on family or carers o Contributing factors: o General factors: patient/family roles and responsibilities sleep disturbance nutrition diet, absorption deconditioning due to reduced activity levels, fitness and/or muscle wasting over-exertion psychological factors, eg anxiety, fear depression. o Condition-related factors: Copyright 2014 NHS Scotland Page 1 of 5
o metabolic abnormalities consider checking sodium, potassium, calcium, magnesium, glucose, renal function, C-reactive protein, albumin anaemia infection Disease recurrence or progression. If weakness present, exclude malignant spinal cord compression (MSCC) Anorexia/cachexia skeletal muscle wasting may be mediated by tumour necrosis factor, cytokines or both Poorly controlled symptoms, eg pain. Treatment factors: dialysis biological therapy, eg interferon surgery prescribed medication, eg beta-blockers, sedating drugs, corticosteroids, opioids over-the-counter medications cancer treatments radiotherapy, chemotherapy, hormone therapy. Management A combination of person-centred approaches in partnership with the individual using the multidisciplinary team will be required to maximise potential. Treat potentially reversible factors if appropriate, eg blood transfusions may be helpful for some patients. Other symptoms and co-morbidities should be managed, and all medications reviewed. Non-pharmacological management Diary - an activity/fatigue diary may help to identify precipitants and timing of symptoms. Energy conservation/restoration o consider a self-management plan set priorities, delegate tasks o pace activities and attend to one activity at a time o schedule activities at times of peak energy and conserve energy for valued activities o eliminate non-essential activities o occupational therapy referral for advice on minimising energy expenditure and appropriate aids/equipment. Physical activity and exercise o An appropriate level of exercise can reduce fatigue and should be recommended. o Consider physiotherapy referral to ensure exercises are tailored to individual needs particularly for those patients who have advanced disease or are experiencing effects of treatments, eg anaemia, osteoporosis/bone metastases, falls. Psychosocial interventions Consider: o Stress/anxiety management o Relaxation/complementary therapy o Sleep pattern advice, eg hot drink at night, avoid stimulants. o Offer appropriate verbal and written information Copyright 2014 NHS Scotland Page 2 of 5
Pharmacological management For patients with anorexia/cachexia-related fatigue, see Anorexia guideline There is currently insufficient evidence to recommend pharmacological treatment, including the use of psychostimulants by non-specialists. Practice Points As an invisible symptom, fatigue is often misunderstood by patients, family, friends, colleagues and healthcare professionals. Open discussion should be encouraged. Often patients feel guilty about being no longer able to contribute fully to family life and this should be acknowledged. People who have fatigue will have limited energy and may find it difficult to do simple everyday things that are usually taken for granted. The basis of managing fatigue is to ensure that the best levels of energy are available and used in the most efficient way. The Macmillan Get Active, Feel Good resource may be helpful. For many patients, fatigue will be part of their experience of living with their illness. Through awareness and acknowledgement of the symptoms, consideration of lifestyle and the use of particular techniques, it is possible to manage fatigue and take steps to reduce the impact it has on daily life. Resources Macmillan Cancer Support Macmillan Cancer Support, Coping with fatigue Macmillan Cancer Support, Get Active, Feel Good Cancer Research UK Cancer Research UK, Tiredness with cancer (fatigue) National Cancer Institute, Fatigue Marie Curie Cancer Care Chest Heart and Stroke Scotland British Lung Foundation British Heart Foundation NHS Inform, Long term health conditions and mental health NHS Inform, Palliative care My Condition, My Terms, My Life Self Management Epsom and St Helier University Hospitals NHS Trust, Chronic Fatigue Service Copyright 2014 NHS Scotland Page 3 of 5
References Cramp, F. and Byron-Daniel, J. 2012. Exercise for the management of cancer-related fatigue in adults. Cochrane Database of Systematic Reviews [Online]. Available: http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd006145.pub3/abstract Finnegan-John, J., Molassiotis, A., Richardson, A. and Ream, E. 2013. A systematic review of complementary and alternative medicine interventions for the management of cancer-related fatigue. Integrative Cancer Therapies, 12(4), pp. 276-90. Goedendorp Martine, M., Gielissen Marieke, F. M., Verhagen Constantijn, A. and Bleijenberg, G. 2009. Psychosocial interventions for reducing fatigue during cancer treatment in adults. Cochrane Database of Systematic Reviews [Online]. Available: http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd006953.pub2/abstract Hauser, K., Rybicki, L. and Walsh, D. 2010. What's in a Name? Word descriptors of cancerrelated fatigue. Palliative Medicine, 24(7), pp. 724-30. Hawthorn, M. 2010. Fatigue in patients with advanced cancer. International Journal of Palliative Nursing, 16(11), pp. 536-41. Johnson, R. L., Amin, A. R. and Matzo, M. 2012. Cancer-related fatigue. American Journal of Nursing, 112(4), pp. 57-60. Lerdal, A., Bakken, L. N., Kouwenhoven, S. E., Pedersen, G., Kirkevold, M., Finset, A. and Kim, H. S. 2009. Poststroke fatigue--a review. Journal of Pain & Symptom Management, 38(6), pp. 928-49. Mcgeough, E., Pollock, A., Smith Lorraine, N., Dennis, M., Sharpe, M., Lewis, S. and Mead Gillian, E. 2009. Interventions for post-stroke fatigue. Cochrane Database of Systematic Reviews [Online]. Available: http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd007030.pub2/abstract Minton, O., Richardson, A., Sharpe, M., Hotopf, M. and Stone, P. 2010. Drug therapy for the management of cancer-related fatigue. Cochrane Database of Systematic Reviews [Online]. Available: http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd006704.pub3/abstract Minton, O., Strasser, F., Radbruch, L. and Stone, P. 2012. Identification of factors associated with fatigue in advanced cancer: a subset analysis of the European palliative care research collaborative computerized symptom assessment data set. Journal of Pain & Symptom Management, 43(2), pp. 226-35. Mishra Shiraz, I., Scherer Roberta, W., Snyder, C., Geigle Paula, M., Berlanstein Debra, R. and Topaloglu, O. 2012. Exercise interventions on health-related quality of life for people with cancer during active treatment. Cochrane Database of Systematic Reviews [Online]. Available: http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd008465.pub2/abstract Mitchell, S. A. and Berger, A. M. 2006. Cancer-related fatigue: the evidence base for assessment and management. Cancer Journal, 12(5), pp. 374-87. Payne, C., Wiffen Philip, J. and Martin, S. 2012. Interventions for fatigue and weight loss in adults with advanced progressive illness. Cochrane Database of Systematic Reviews Copyright 2014 NHS Scotland Page 4 of 5
[Online]. Available: http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd008427.pub2/abstract Peuckmann-Post, V., Elsner, F., Krumm, N., Trottenberg, P. and Radbruch, L. 2010. Pharmacological treatments for fatigue associated with palliative care. Cochrane Database of Systematic Reviews [Online]. Available: http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd006788.pub2/abstract Radbruch, L., Strasser, F., Elsner, F., Goncalves, J. F., Loge, J., Kaasa, S., Nauck, F., Stone, P. and Research Steering Committee of the European Association for Palliative, C. 2008. Fatigue in palliative care patients -- an EAPC approach. Palliative Medicine, 22(1), pp. 13-32. Whitehead, L. 2009. The measurement of fatigue in chronic illness: a systematic review of unidimensional and multidimensional fatigue measures. Journal of Pain & Symptom Management, 37(1), pp. 107-28. Copyright 2014 NHS Scotland Page 5 of 5