Fatigue

Short Answer

A. Correct! The differential diagnosis of fatigue should be considered, including current treatments that may potential have greater detrimental effects on quality of life than potential benefits.

B. Incorrect. Dexamethasone may be helpful in selected patients, but has significant side effects and tolerance often develops. Nonpharmacologic options for management of fatigue should be addressed first.

C. Incorrect. Methylphenidate may be helpful in selected, advanced cases, but at this point other nonpharmacologic options should be addressed first.

D. Incorrect. More chemotherapy would likely worsen her fatigue. If the fatigue is severely impacting her quality of life, considering discontinuation of radiation therapy may be warranted.


Long Answer

The correct answer is A. Evaluate for other reversible causes; if none are found, consider discussing discontinuing radiation therapy.

Fatigue is a common and distressing symptom in severe and terminal illness, with an enormous impact on quality of life. The challenge to the internist is to determine whether the fatigue is evidence of progression of underlying disease, the onset of a new medical condition, or side effects from current treatment. In patients with more than weeks left to live, other causes should be ruled out before fatigue is assumed to be from progression of disease.

It is important to distinguish fatigue from sleep disturbances (see question 6). Common new medical conditions that may contribute to fatigue in palliative care include infection, adrenal insufficiency, anemia, hypothyroidism, cardiac arrhythmias or vascular disease. Depression, anxiety, psychosocial distress, dyspnea and uncontrolled pain or other symptoms may also be factors.

Current treatment, such as chemotherapy or radiation, may also be a factor. The goals of all treatments, including those for the life-limiting illness, but also those for other long-term conditions such as hypertension, diabetes, and hypercholesterolemia, should be readdressed and nonessential medications stopped.

If none of these approaches are effective, managing the fatigue may help to mitigate its effect on her quality of life. Patient and family education is very important. The first step is to focus on energy conservation and rest and whether or not physical or occupational therapy and/or assistive devices such as a walker or bedside commode can help reduce unnecessary effort. If assistance can be provided to help with shopping or other chores, the patient may have more energy to do what she really wants to do. Establishing realistic goals for daily living and readdressing priorities may be helpful. Scheduled rest periods prior to desired activity may be of use. Caregivers may interpret the patient[base ']s complaints of fatigue or decreased energy as evidence that the patient is giving up. Discussing openly that this is a symptom rather than a cause of the decline, often with the help of a social worker, may assist all members in their ability to cope.

Pharmacologic treatments are not often effective, but some patients may respond to steroids such as dexamethasone; dose in the morning. Effect may wane after 4-6 weeks. Psychostimulants may also be helpful in some cases, such as methylphenidate, dosed in the morning and at noon.

Last update: 7/13/02; 4:25:27 PM.