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fatigue; lassitude; tiredness

Etiology: 1) mood disorder - depression is most common cause (20-30%) - see depression in the elderly 2) stress, physical or social, anxiety 3) infection, especially viral infection, HIV1 infection 4) endocrine disorder a) thyroid disease, hypothyroidism & hyperthyroidism b) diabetes mellitus c) adrenal dysfunction 1] Cushing's disease 2] Addison's disease 5) adverse effect of medication - beta blockers - antihistamines - antidepressants - benzodiazepines - antipsychotics - opiates 6) cardiovascular disease: heart failure 7) sleep apnea 8) chronic liver disease 9) chronic renal failure 10) cancer 11) anemia 12) chronic lung disease, hypoxia 13) obesity 14) lifestyle a) sleep deprivation & poor sleep habits b) work schedule, night shift or swing shift c) diet d) exercise e) substance use - substance abuse & withdrawal, alcohol abuse f) work/life imbalance 15) frailty 16) systemic exertion intolerance syndrome Clinical manifestations: 1) manifestations suggesting organic etiology a) duration of < 4 weeks b) progressive deterioration 2) manifestations suggesting psychosocial etiology a) duration of symptoms > 4 months b) peak symptomatology in AM c) non-specific & multiple symptoms Laboratory: 1) complete blood count (CBC) 2) serum chemistries: - basic metabolic panel, - liver function tests, serum albumin - serum phosphate - serum TSH 3) as indicated a) HIV testing b) urinalysis c) erythrocyte sedimentation rate (ESR) d) cancer screening as appropriate 1] Pap smear vs HPV DNA 2] fecal occult blood 4) avoid excessive tests Special laboratory: - Psychological screening tests: 1) Beck Zung 2) Center for Epidemiological Studies Depression Scale [CES-D] 3) Minnesota Multiphasic Personality Inventory [MMPI] - Screening tests for support & stress 1) Duke social support & stress scale [DUSOCS] 2) family APGAR & circle 3) genogram Complications: - not strongly associated with increased mortality Differential diagnosis: 1) hypersomnolence 2) narcolepsy Management: 1) treat underlying medical illness, if any 2) brief counseling or referral for psychotherapy if indicated 3) establish therapeutic relationship a) listen b) reassure c) empathy 4) plan to reduce or manage stress 5) discontinue suspect medications 6) empirical trial of antidepressants 7) healthy diet and aerobic exercise 8) diary of symptoms 9) patient education a) mind-body connection b) stress & personal management skills c) cognitive behavioral therapy [2] d) graded exercise therapy [2] 10) follow-up a) physical examination b) evolution of symptoms 11) palliatve care a) analeptics - methylphenidate - dextroamphetamine - modafinil b) glucocorticoids - promote sense of well-being - effects may wane after 4-6 weeks - dexamethasone - prednisone c) erythropotein/analog for fatigue related to anemia - epoeitin alpha - darpoeitin alpha

Related

chronic fatigue syndrome; myalgic encephalomyelitis; neurasthenia; systemic exertion intolerance disease (CFS) depression hypersomnia (hypersomnolence, excessive sleepiness) narcolepsy

General

sign/symptom

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1090-92
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 18, 19. American College of Physicians, Philadelphia 1998, 2012, 2018, 2021.
  3. Abrahm JL A Physician's Guide to Pain and Symptom Management in Cancer Patients,2nd ed, Baltimore, MD, Johns Hopkins University Press, 2005
  4. Nijrolder I, van der Horst H, van der Windt D. Prognosis of fatigue. A systematic review. J Psychosom Res. 2008 Apr;64(4):335-49. PMID: 18374732
  5. Alexander NB, Taffet GE, Horne FM Bedside-to-Bench conference: research agenda for idiopathic fatigue and aging. J Am Geriatr Soc. 2010 May;58(5):967-75. PMID: 20722821 Free PMC Article
  6. Murphy SL, Alexander NB, Levoska M, Smith DM. Relationship between fatigue and subsequent physical activity among older adults with symptomatic osteoarthritis. Arthritis Care Res (Hoboken). 2013 Oct;65(10):1617-24. PMID: 23592576 Free PMC Article
  7. Schnelle JF, Buchowski MS, Ikizler TA Evaluation of two fatigability severity measures in elderly adults. J Am Geriatr Soc. 2012 Aug;60(8):1527-33. PMID: 22860899 Free PMC Article