Transcript No Slide Title

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)