FATIGUE FATIGUE

By Dr. Cuong Ngo-MinhBy Dr. Cuong Ngo-Minh

Back to Basics Back to Basics April 14th 2010 April 14th 2010

Objectives LMCCObjectives LMCC

• To differentiate organic from psychologic etiologies of To differentiate organic from psychologic etiologies of fatigue. fatigue.

• To assess the impact of fatigue on work, relationship, daily To assess the impact of fatigue on work, relationship, daily function, sleepfunction, sleep

• To identify red flags (symptoms and signs) in history and To identify red flags (symptoms and signs) in history and

physical exam to orient differential diagnosis physical exam to orient differential diagnosis

• To investigate appropriately according to clinical findings To investigate appropriately according to clinical findings and hypothesis about diagnosis. Refer appropriatelyand hypothesis about diagnosis. Refer appropriately

• To create a plan of management with client. 4 goalsTo create a plan of management with client. 4 goals(IADLs, return to work, maintain relationships, exercice). (IADLs, return to work, maintain relationships, exercice).

Definitions 1Definitions 1

• Fatigue: Feeling of lack of energy, tiredness, weariness Fatigue: Feeling of lack of energy, tiredness, weariness described by patients as exhaustion. It is often described by patients as exhaustion. It is often accompanied by subjective sensation of weakness and accompanied by subjective sensation of weakness and strong desire to rest or sleep.strong desire to rest or sleep.

May or not associated with other symptoms May or not associated with other symptoms Remember: fatigue is a symptom NOT a diseaseRemember: fatigue is a symptom NOT a disease

• Fatigue is recent (duration Fatigue is recent (duration < < 1 month) vs 1 month) vs chronic (lasting chronic (lasting >> 6 months) 6 months)

• In most cases (around 80%) is PSYCHOGENICIn most cases (around 80%) is PSYCHOGENIC(eg. Not improved by rest, « tired all the time », no other (eg. Not improved by rest, « tired all the time », no other

symptoms or signssymptoms or signs vs ORGANIC (20%). Can be both.vs ORGANIC (20%). Can be both.

Definitions 2Definitions 2

• Chronic fatigue syndromeChronic fatigue syndrome: Debilitating fatigue recurrent or : Debilitating fatigue recurrent or persistent over 6 months. persistent over 6 months.

DX: 1) new onset of fatigue with impairement of 50% or more DX: 1) new onset of fatigue with impairement of 50% or more of daily activities lasting more than 6 weeks 2) EXCLUSION of daily activities lasting more than 6 weeks 2) EXCLUSION of organic or psychiatric illness. of organic or psychiatric illness.

PLUS PLUS 2 of 3 physical criteria: 1) Low grade fever 37.5-38.6C 2) 2 of 3 physical criteria: 1) Low grade fever 37.5-38.6C 2)

Pharyngitis nonexudative 3) Palpable tender cervical-Pharyngitis nonexudative 3) Palpable tender cervical-axillary nodesaxillary nodes

PLUS 6 or more of 11 symptoms: 1) Chiils or mild fever 2)Sore PLUS 6 or more of 11 symptoms: 1) Chiils or mild fever 2)Sore throat 3) Painful lymph nodes 4) Generalized muscle throat 3) Painful lymph nodes 4) Generalized muscle weakness 5) Myalgia 6) Generalized fatigue for more 24h of weakness 5) Myalgia 6) Generalized fatigue for more 24h of duration after strenuous exercice 7) Headache generalized duration after strenuous exercice 7) Headache generalized 8) Arthralgia migratory 9) Depressive 8) Arthralgia migratory 9) Depressive symptoms/neuropsychiatric complain 10) Sleep disturbancesymptoms/neuropsychiatric complain 10) Sleep disturbance

11) Onset of fatigue with physical criteria within few days 11) Onset of fatigue with physical criteria within few days

Differential diagnosis of fatigueDifferential diagnosis of fatigue• Organic etiologies (20%): Usually fatigue is worse at the END Organic etiologies (20%): Usually fatigue is worse at the END

of the DAY, worse with physical activity, BETTER WITH REST. of the DAY, worse with physical activity, BETTER WITH REST. To rule out mainly by good history and physical exam.To rule out mainly by good history and physical exam.

B1) Infectious (HIV, TB, mononucleosis, etc...)B1) Infectious (HIV, TB, mononucleosis, etc...)B2) Neoplastic/Hematologic (Anemia, leukemia-lymphoma and B2) Neoplastic/Hematologic (Anemia, leukemia-lymphoma and

all other cancer according to gender and age group)all other cancer according to gender and age group)B3) Metabolic-endocrine (Diabetes, Hypothyroidism, Adrenal B3) Metabolic-endocrine (Diabetes, Hypothyroidism, Adrenal

insufficiency, Hypercalcemia, Acute renal failure, Electrolyte insufficiency, Hypercalcemia, Acute renal failure, Electrolyte imbalance, etc...)imbalance, etc...)

B4) Inflammatory/autoimmune (Cronh, rhumatoid arthritis, B4) Inflammatory/autoimmune (Cronh, rhumatoid arthritis, PMR,...)PMR,...)

B5) Cardio-pulmonary (Congestive heart failure, Unstable angine B5) Cardio-pulmonary (Congestive heart failure, Unstable angine (think grade of dyspnea), COPD, pulmonary fibrosis, Aortic (think grade of dyspnea), COPD, pulmonary fibrosis, Aortic stenosis and valvulopathy...)stenosis and valvulopathy...)

B6) Neuromuscular (Multiple sclerosis, myasthenia gravis,...)B6) Neuromuscular (Multiple sclerosis, myasthenia gravis,...)B7) Sleep disorders (Sleep apnea, sleep deprivation, ...)B7) Sleep disorders (Sleep apnea, sleep deprivation, ...)B8) Medications and intoxication (B-blockers, anti-hypertensives, B8) Medications and intoxication (B-blockers, anti-hypertensives,

psychotropes, narcotics, digitalis, marijuana, ...) psychotropes, narcotics, digitalis, marijuana, ...)

Differential diagnosis of fatigueDifferential diagnosis of fatigue

• A) Psychologic/psychiatric (80%): Usually fatigue worse in A) Psychologic/psychiatric (80%): Usually fatigue worse in MORNING (hard to get up from bed!)MORNING (hard to get up from bed!)

Depression (especially with guilt, self depreciation and Depression (especially with guilt, self depreciation and poor self-esteem), anxiety, somatization. Often triggered poor self-esteem), anxiety, somatization. Often triggered by psycho-socio-economic factors. by psycho-socio-economic factors.

History for fatigue 1History for fatigue 1• Acute vs chronic onset? First episode or recurrent? Acute vs chronic onset? First episode or recurrent?

Reason on consultation today. Disability or impact on daily Reason on consultation today. Disability or impact on daily life activities at work, home? Search for triggering factor life activities at work, home? Search for triggering factor (infectious contact (eg mononucleosis), change in (infectious contact (eg mononucleosis), change in medications, life stressors). Worse in morning or evening? medications, life stressors). Worse in morning or evening? Is rest helping? How is sleep (amount, timing, disruption, Is rest helping? How is sleep (amount, timing, disruption, restorative) ? How is appetite/libido?restorative) ? How is appetite/libido?

Review of system to look for « red flags » Review of system to look for « red flags »

Change of weight: weight loss (r/o neo), weight gain (r/o Change of weight: weight loss (r/o neo), weight gain (r/o congestive heart failure, ascite). Change of bowels pattern congestive heart failure, ascite). Change of bowels pattern (r/o neo, IBD) Diaphoresis (r/o neo), chills/fever (r/o (r/o neo, IBD) Diaphoresis (r/o neo), chills/fever (r/o infection), weakness (r/o neurological process), dyspnea infection), weakness (r/o neurological process), dyspnea (r/o cardio-pulmonary condition), somnolence (r/o intox-(r/o cardio-pulmonary condition), somnolence (r/o intox-metabolic, sleep problem), blood loss? metabolic, sleep problem), blood loss?

History for fatigue 2History for fatigue 2

• Past medical history (? Neo, cardiopulmonary condition, Past medical history (? Neo, cardiopulmonary condition, endocrine disease,anemia, psychiatric Hx...) and endocrine disease,anemia, psychiatric Hx...) and investigations/hospitalizationsinvestigations/hospitalizations

• Familial history (r/o neo, metabolic, psychiatric illness)Familial history (r/o neo, metabolic, psychiatric illness)

• Medications list updated (b-blockers, cardiac meds, benzo, Medications list updated (b-blockers, cardiac meds, benzo, antipsychotic, antidepressant, narcotics, over-the-counter drugs, antipsychotic, antidepressant, narcotics, over-the-counter drugs, herbs)herbs)

• Leisure drugs use (? Ivdu), alcohol, cannabis, risk for HIVLeisure drugs use (? Ivdu), alcohol, cannabis, risk for HIV

• Work and psycho-socio-economic condition (recent change?)Work and psycho-socio-economic condition (recent change?)

Physical examination for fatiguePhysical examination for fatigue

• Focused according to clinical hypothesis coming from Focused according to clinical hypothesis coming from history. history.

• Cachexia? Vitals signs including Oxygen sat., glucocheck + Cachexia? Vitals signs including Oxygen sat., glucocheck + weight, weight,

(? somnolence, ? fever, ?bradycardia, ?hyper-hypoglycemia), ? (? somnolence, ? fever, ?bradycardia, ?hyper-hypoglycemia), ? skin pallor/jaudiceskin pallor/jaudice

• Head and neck: nodes, thyroidHead and neck: nodes, thyroid

• Chest: heart sounds, ? Murmur Chest: heart sounds, ? Murmur Lungs creps, wheezing, air entry, effusion? Abdomen: Lungs creps, wheezing, air entry, effusion? Abdomen:

abnormal mass, asciteabnormal mass, ascite• Neuro exam: sign of focal deficit strength (look for Neuro exam: sign of focal deficit strength (look for

assymetry), assymetry),

• NB. Breast or prostate exam if clinically suspiciuos of neoNB. Breast or prostate exam if clinically suspiciuos of neo

Investigations and management for fatigueInvestigations and management for fatigue

• Investigation are done to confirm or infirm hypothesis of Investigation are done to confirm or infirm hypothesis of diagnosisdiagnosis

CBC (for anemia, leukemia), fasting glucose (r/o diabetes), CBC (for anemia, leukemia), fasting glucose (r/o diabetes), TSH (r/o hypothyroidism), Creatinine and electrolytes, TSH (r/o hypothyroidism), Creatinine and electrolytes, CRP/ESR for inflammatory process +/- mono test.CRP/ESR for inflammatory process +/- mono test.

Use tests appropriately. With « absence of other symptoms Use tests appropriately. With « absence of other symptoms and presence of normal physical examination usually and presence of normal physical examination usually indicates that tests will be of value in indicates that tests will be of value in < 5% of patients ». < 5% of patients ». Unnecessary test creates anxiety and can reinforce Unnecessary test creates anxiety and can reinforce perception of serious disease. perception of serious disease.

If needed, refer to specialists appropriately for investigations If needed, refer to specialists appropriately for investigations and treatment. and treatment.

Goal of care for fatigueGoal of care for fatigue

• Treat specific identified cause of fatigue (if found) Treat specific identified cause of fatigue (if found)

for return to baseline FUNCTIONAL status for return to baseline FUNCTIONAL status

at work, in their daily life activities at home, exercice, at work, in their daily life activities at home, exercice, interpersonal relationships interpersonal relationships

• Advocate for healthy nutrition, regular physical activity (as Advocate for healthy nutrition, regular physical activity (as tolerated), stress coping strategies and regular sleep tolerated), stress coping strategies and regular sleep

scheduleschedule

Truth telling (CLEO 4.4)Truth telling (CLEO 4.4)

• Chronic fatigue syndrome is diagnosis of exclusion after Chronic fatigue syndrome is diagnosis of exclusion after investigations. Empathic approach: symptoms are real for the investigations. Empathic approach: symptoms are real for the clientclient

Non judgemental: « sidestep any consideration of the origin of Non judgemental: « sidestep any consideration of the origin of the symptoms (whether psychogenic or organic) »the symptoms (whether psychogenic or organic) »

• Ethically, duty to inform of no specific therapy, unclear Ethically, duty to inform of no specific therapy, unclear diagnosis. Graded exercice and CBT (cognitive behavior diagnosis. Graded exercice and CBT (cognitive behavior therapy may help)therapy may help)

• Do not harm principle: « physicians should guard against the Do not harm principle: « physicians should guard against the temptation to prescribe empiric treatment of any type », client temptation to prescribe empiric treatment of any type », client should be advised caution about « high-priced and potentially should be advised caution about « high-priced and potentially unsafe courses of therapy » (eg if client wants colon cleansing unsafe courses of therapy » (eg if client wants colon cleansing therapy, explain health risks he/she is exposed to ) therapy, explain health risks he/she is exposed to )

Resources Resources

1)Essentials of Family Medicine, 4th edition by Sloane and al. 1)Essentials of Family Medicine, 4th edition by Sloane and al. Lippincott Williams & Wilkins, pp 523-532Lippincott Williams & Wilkins, pp 523-532

2) Problem-Oriented Medical Diagnosis, 6th edition by 2) Problem-Oriented Medical Diagnosis, 6th edition by Friedman, A Little Brown spiral manual, pp 4-7Friedman, A Little Brown spiral manual, pp 4-7

3) Practice Based Learning program from McMaster University, 3) Practice Based Learning program from McMaster University, Module on Chronic Fatigue Syndrome, Vol 8 (10), October Module on Chronic Fatigue Syndrome, Vol 8 (10), October 20002000

4) Salit IE and the Vancouver chronic fatigue syndrome 4) Salit IE and the Vancouver chronic fatigue syndrome

consensus group. The chronic fatigue syndrome: a position consensus group. The chronic fatigue syndrome: a position paper, consensus conference, Vancouver, B.C. June 12-14, paper, consensus conference, Vancouver, B.C. June 12-14, 1994. J Rheumatology 1996;23(3): 540-441994. J Rheumatology 1996;23(3): 540-44