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How to deal with fatigue
Saul Berkovitz MRCP, MCPP, MFHom
Consultant Physician, Chronic Fatigue Service
Royal 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
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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
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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
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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
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Chris Perrin (Nurse Specialist)
Mary Queally (Occupational Therapist)
Margaret Hooper / Raj Sharma (Psychologists)
Esther Odetunde (Physiotherapist)
Sue Thurgood (Dietician)