Fatigue

Aka: Fatigue, Asthenia, Fatigue Red Flags

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II. Definitions

  1. Fatigue
    1. Unable to perform activity repeatedly
  2. Asthenia
    1. Physical exhaustion without weakness

III. Epidemiology

  1. Fatigue is among the top 10 primary care presentations
    1. Reported by up to 5 to 10% of patients

IV. Types

  1. Secondary Fatigue (20% of non-chronic causes)
    1. Fatigue with underlying medical cause
    2. Fatigue lasts between 1 and 6 months
    3. Fatigue is among the most common complaints in those with chronic disease
  2. Physiologic Fatigue (80% of non-chronic causes)
    1. Fatigue due to lifestyle causes
  3. Chronic Fatigue
    1. Fatigue that lasts longer than 6 months
    2. See Chronic Fatigue Syndrome

V. Risk Factors

  1. Female gender
  2. Unmarried
  3. Lower educational achievement
  4. Frailty
  5. Junghaenel (2011) J Psychosom Res 71(3): 117-23 [PubMed]

VI. Causes

  1. Fatigue Causes
  2. See Medication Causes of Fatigue
  3. See Generalized Muscle Weakness Causes
  4. See Hypersomnolence Causes
  5. See Frailty

VII. History

  1. General
    1. Triggers or events preceding the original onset of Fatigue
    2. Symptom pattern and duration
    3. Palliative and provocative measures
  2. Function
    1. What type and duration of activity can you tolerate before symptom onset?
    2. How long does it take to recover from activity?
    3. What activity modifications have you made to compensate for Fatigue?
    4. Activities of Daily Living
    5. House chores
    6. Workplace responsibilities
  3. Sleep
    1. Difficulty in falling or staying asleep
    2. Is sleep restorative (do you feel rested on awakening)?
    3. Do you nap more than other people you know?
    4. What is the overall quality of your sleep?
  4. Cognitive Impacts
    1. Driving
    2. Reading
    3. Conversation
    4. Multitasking
    5. Work oir school success
  5. Contributing Factors
    1. Substance use (e.g. Caffeine, Tobacco, Alcohol, drugs)
    2. Eating Habits (e.g. restrictive diet, Eating Disorders)
    3. Emotional Stressors and Mood Disorders (e.g. Major Depression, Anxiety Disorder)
    4. Chronic disease (e.g. Diabetes Mellitus, COPD, cancer, Fibromyalgia)
  6. Chronic Fatigue Syndrome related features
    1. Postertional malaise
      1. Prolonged worsening of symptoms with even a small increase in previously tolerated activity
    2. Orthostasis
      1. Symptoms with prolonged standing (e.g. Light Headedness, Nausea, Fatigue, Palpitations, Syncope)

VIII. Symptoms: General

  1. Frequent presentations
    1. "I can't get out of bed in the morning"
    2. "I'm feeling 'all in'"
    3. "I'm tired all the time"
  2. Lack of pep or energy
    1. Usually complaint of "always tired"
    2. However on careful questioning, varies throughout day
  3. Low vitality
  4. Persistent Exhaustion or Tiredness
  5. Strongly desire rest or sleep
  6. Associated symptoms
    1. Subjectively weak
    2. Headache
    3. Assorted pain

IX. Symptoms: Differentiate from Sleepiness

  1. Fatigue is provoked by activity with delayed recovery
    1. Exercise offers a temporary respite from Sleepiness
  2. Nonrestorative rest and sleep
    1. Sleepiness improves with a nap
  3. Poor Muscle endurance and mental exhaustion

X. Diagnosis: Factors suggestive of psychogenic cause

  1. Fatigue lasting longer than 4 months
    1. No associated signs or symptoms
  2. Fatigue that is worse in morning
    1. Improves with activity
  3. Fluctuating course
  4. Stressful social history
  5. Exhaustive lifestyle
  6. History of psychological condition

XI. Symptoms: Red Flags (suggestive of organic or physical cause)

  1. Fatigue relieved with rest or sleep
    1. Refreshed in morning
  2. Less than ordinary activity causes Fatigue
  3. Ill appearing, tired or worn patient
  4. Weight loss
  5. Dyspnea

XII. Signs: Red Flags (suggesting Organic Fatigue Causes including neoplasm)

  1. Cachexia (wasting or profound weight loss)
  2. Lymphadenopathy
  3. Cardiac murmur
  4. Thyroid Goiter
  5. Edema
  6. Inflammatory Arthritis findings
  7. Decreased Muscle tone or other focal neurologic deficit
    1. Careful Neurologic Exam is critical

XIII. Labs

  1. See Fatigue Diagnostic Testing

XIV. Evaluation

  1. Consider organic causes and medication causes
    1. See Medication Causes of Fatigue
    2. See Fatigue Causes
  2. Screen for psychogenic or lifestyle causes
    1. Anxiety Scales (e.g. GAD-7)
    2. Depression Screening Tools (e.g. PHQ-9)
    3. Substance Abuse Evaluation (e.g. DAS-10, DAS-1, AUDIT-C, CAGE Questions)
    4. Intimate Partner Violence Screening
    5. Obstructive Sleep Apnea Screening (e.g. STOP-Bang Questionnaire)
    6. Eating Disorder (e.g. SCOFF Questionnaire)
  3. Screen for other presentations similar to Fatigue
    1. Is there Orthostasis?
    2. Is there a history or findings of Muscle Weakness
      1. See Generalized Muscle Weakness Causes
    3. Is there excessive Daytime Somnolence?
      1. See Hypersomnolence Causes
    4. Is there a component of Frailty on exam?
      1. See Frailty

XV. Management: General

  1. Ensure adequate daily nutrition
  2. Daily Exercise (30 minutes of Moderate Aerobic Activity)
    1. Start gradually (e.g. 5 minutes each day) and titrate to target
    2. Avoid excessive Exercise or prolonged intensity (e.g. Overtraining)
  3. Stress reduction
  4. Adequate sleep (8 hours per night)
    1. See Sleep Hygiene
  5. Treat underlying causes of Fatigue
    1. See Fatigue Causes
    2. Anemia
    3. Obstructive Sleep Apnea
    4. Mood Disorders (e.g. Major Depression)
    5. Substance Use Disorder
    6. Alcohol Use Disorder

XVI. Course

  1. Fatigue may persist for >1 year in 50% of patients

XVII. Complications: Work-Related costs

  1. Fatigue is reported by 38% of workers in one study
    1. Ricci (2007) J Occup Environ Med 49(1): 1-10 [PubMed]
  2. Adverse Effects
    1. Work absenteeism
    2. Decreased work productivity
    3. Work-related accidents
    4. Gaines (2020) Aerosp Med Hum Perform 91(5): 440-7 [PubMed]

XVIII. References

  1. Goroll (2000) Primary Care Medicine, Lippincott, p. 41
  2. Lipken in Dornbrand (1992) Ambulatory Care, p. 5-8
  3. Latimer (2023) Am Fam Physician 108(1): 58-69 [PubMed]
  4. Morrison (2001) Obstet Gynecol Clin North Am 28:225-40 [PubMed]
  5. Rosenthal (2008) Am Fam Physician 78(10): 1173-9 [PubMed]
  6. Valdini (1988) J Fam Pract 26:33-8 [PubMed]

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