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Fatigue
Jane Hartwell
Cumberland Infirmary, Carlisle
Fatigue
The Syndrome
that wears you
out!
Fatigue should receive the
same attention as other
symptoms associated with
advanced cancer such as
pain.
However, to develop effective
strategies to control fatigue
we must first gain a greater
understanding of what fatigue
is.

It is a BIG PROBLEM for patients
Fatigue is multidimensional

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In its cause
In its treatment
It is subjective: how a patient perceives and feels
about their weakness.
It is measurable: measurable decrease in physical
or mental performance
Effect on Patients
Physiological (acute)
Positive effect on body allowing
recuperation
Pathological (chronic)
Negative effects on body- associated with
chronic conditions
5 Dimensions to Subjective Fatigue
Physical sensations
•feeling tired
Cognitive sensations
• reduced concentration
• easy tiring
• memory loss
• difficulty thinking clearly
• reduced capacity to
maintain performance
Advanced Stage of Fatigue
Affective sensations
• low mood
• low motivation
• anticipatory sensation of difficulty
initiating any activity
• Low energy
Fatigue of dying
Secondary Fatigue
The wearying effect of
living with fatigue
Overview
Reported as the most prevalent and
disturbing symptom of cancer and its
treatment
Up to 80-96% of patients receiving
chemotherapy, (Richardson (2000) 65-95%
of patients receiving radiotherapy
experience fatigue (Nail 1993)
60% of patients with cancer claim that fatigue
had a major effect on their lifestyle ( Cella,
1993, Vogelzang, 1997)
Is fatigue an effect of cancer,
cancer treatment or both?
Difficult to research, ethically unable to
give cancer treatment to patients unless
they have cancer.
However, survivors of nuclear fallout all
experienced fatigue as a major problem..
Causes of fatigue
Radiotherapy
Accumulation of metabolites as a result of normal tissue
damage (Greenberg, 1992)
High anabolic processes involved in molecular and cellular
repair ( Beach, 2001)
? Linked to anaemia where large fields or marrow producing
bones are included in treatment area
Chemotherapy
Neurotoxic drugs e.g. vincaalkaloids
Immunosuppression- release of
cahectin 14
Magnesium depletion (Piper, 1981)
Surgery
Anaesthesia
Analgesia
Decreased ventilatory capacity
Altered sleep patterns
Causes of cancer related fatigue

Physiological factors
A.
Cytokines
tumours release chemicals known as
cytokines- which affect the bodies
metabolism.
tumours also secrete macrophages
and other immune cells, which
produce and secrete cytokines
CNS effects
The reticular activating system is believed to be
the area of the brain controlling fatigue.
Muscular Skeletal Effects
Several abnormalities in muscle structure and
function occur in cancer patients, even in the absence
of cachexia/malnutrition.
Cytokines are believed to have a major role in the
development of these changes in muscle tissue.

Biochemical and Endocrine Abnormalities
 Hypocalcaemia
 Diabetes
 Hypothyroidism
 Hypomagnesia
 Polypharmacy
 Haematological Abnormalities
Anaemia: Controvesial
How is Hb mechanically associated with fatigue?
damage/changes to
the actual cell
(Andrews, 2003)
numbers of red
blood cells are
depleted
Chemotherapy
Reduced O2 capacity
Quality as well as quantity affected
Studies have shown a link between the severity of
physical symptoms and fatigue.
Pain
Insomnia
Nausea
Constipation
Dyspnoea
Dyspnoea is associated with the greatest
fatigue. In a study by Thatcher (2001) looking at
QOL in patients with lung cancer,all questionnaire
respondents said that fatigue was their major
debilitating symptom.
These patients have a short survival time, therefore,
they deserve more intense recognition and treatment
of their worst symptom.
Fatigue is often accepted as “part of the illness” but
it has a huge and often underestimated impact on
patient’s quality of life
Fatigue
Relationships
Leisure
Social
activities
Self image
Self care
Psychological factors
Depression
Personality type
Stress:
Cancer patients experience
extreme physical, mental and
environmental stresses.
Social and Environmental
factors
Gradual decline in social performance
experienced by many patients may
induce fatigue if not replaced by
meaningful activities.E.g

loss of social contacts/activities.

Perceived inability to fulfil former role.
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Increased reliance on others.
Assessment
Listen to the patient
 Family support
 Patient information and education

“ Meaning before measurement”
Assessment tools
Piper Fatigue Scale (Piper, 1988)
The multidimensional fatigue scale (Smets et al,
1996)
Fatigue assessment questionnaire (Glaus, 1998)
Brief Fatigue inventory (Mendoza, 1996)
Also
QOL tools which contain a measurement of
fatigue e.g. EORTC QLC C30
Fatigue Management
Medical
correct any physiological causes
e.g. Anaemia
Nursing
Support and advice in hospital
and community reinforcing
advice from other
team members.
Dietician
Allied professionals
Social worker
help in maintaining independence
assistance/advice with
maintaining good nutritional
intake
Assessment and Monitoring
Correct the Correctable
Establish
Their understanding of their illness,
prognosis/treatment
The nature of their fatigue
Their coping mechanism
How it affects their lives
Their pre-morbid personality/lifestyle
What they want to achieve
Treatment
Balance of activity
Pacing (5 minute more syndrome)
Prioritisation
Delegation of tasks
Ergonomics
Medication
Analysis of current activity and fatigue
levels e.g. use a simple fatigue inventory.
 Planning
 Goal
setting
 Adaptation of environment/energy
conservation advice
 Support re managing family relationships
 Relaxation
 Advice and support re managing
sleeplessness
 Graduated exercise programme/ regular
exercise
 Advice re nutrition intake
Exercise
• Balance between exercise and rest
• Try to maintain a routine
• Regular light exercise if possible.
Exercise has been shown to decrease
fatigue as well as nausea and can
improve sleep
• Drink fluids before and after exercise
Fatigue Management
Exercise
Physical activity may improve the QOL and physical
performance of cancer patients during and after treatment.
(British Journal of Sports Medicine,2001)
Moderate intensity walking showed a significant improvement
in physical functioning – no increase in fatigue Windsor et al, 2004)
Results from Porock’s Study in 2000 showed walking
programme for patients with advanced cancer
Increased
Decreased
Activity levels
Anxiety
QOL scores
Remember
Fatigue is:
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A Syndrome not a symptom
Correct what you can
Any intervention is a therapeutic trial
keep monitoring
Keep listening
Keep Positive