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Elderly people tend to tire more quickly and recover more slowly and incompletely than younger ones. Sleep in older people is generally shorter in duration and of lesser depth, and they feel less refreshed and sometimes irritable on awakening.
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Fatigue may be present as a result of emotional frustration. Whenever the prospect of gratification is small, a person tends to tire quickly and to remain so until something stimulating appears. Since the prospects for gratifying experience wane with the years, easy ‘fatigueability’ or tiredness is common in this age group.
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Although a bereavement reaction is common and a normal human response that occurs at all ages, it is more frequently encountered in the elderly, with the loss of a spouse or a child (young or middle-aged). Fatigue that occurs during the initial mourning period is striking and might represent a protective mechanism against intense emotional stress. With time, usually around 6 to 12 months, a compensated stage is reached, fatigue gradually abates, and the patient resumes normal activities as the conflicts of grief are gradually resolved. Freud pointed out the complexities of mourning as the bereaved person slowly adjusts to the loss of the loved one. In others, various symptoms persist as an ‘abnormal grief reaction’, including persistence of fatigue. Some factors that may lead to this include:
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Studies in general practice have shown that widows see their family doctors for psychiatric symptoms at three times the usual rate in the first 6 months after bereavement. The consultation rate for non-psychiatric symptoms also increases, by almost 50%.
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Role of the family doctor
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Following bereavement it is important to watch for evidence of depression, drug dependency, especially on alcohol, and suicidal tendencies. In cases of expected death, management should, if possible, start before the bereavement. Supportive care and ongoing counselling are very important.
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Burnout is a clinical syndrome with three components:
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long-term emotional exhaustion
depersonalisation of others and
lack of personal accomplishment7
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It is similar to stress-related depression but mood lowering is temporary and work-specific.
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Burnout is not a recognised disorder in the DSM-5 criteria, although the ICD-10 classifies it under ‘problems related to life management’ as a ‘state of vital exhaustion’.8
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Patients sometimes claim that they feel ‘burnout’. Burnout can mean many things and include a whole constellation of psychogenic symptoms, such as exhaustion, boredom and cynicism, paranoia, detachment, heightened irritability and impatience, depression and psychosomatic complaints, such as headache and tiredness. Ellard9 defines burnout as the syndrome that arises when a person who has a strong neurotic need to succeed in a particular task becomes confronted with the impossibility of success in that task. This seems a realistic explanation, but the important factor is to clarify the nature of the problem with care and determine whether the patient has a psychoneurotic disorder, such as hypomania, anxiety state or depression, or a personality disorder or simply unrealistic goals.
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Another viewpoint is that it is caused by chronic emotional stress resulting from prolonged intensive involvement with people.10 Burnout can be work related. Those who tend to be prone to it are musicians, authors, health professionals, teachers, athletes, engineers, emergency service workers, soldiers, reporters and high-technology professionals. Management involves appropriate counselling, which aims to help the patient to identify life stressors, set realistic personal goals and develop good support mechanisms.
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Chronic fatigue syndrome
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This complex syndrome, which causes profound and persistent tiredness, is also referred to as myalgic encephalomyelitis, chronic neuromuscular viral syndrome,11 postviral syndrome, chronic EBV syndrome, viral fatigue state, epidemic neuromyasthenia, neurasthenia, Icelandic disease, Royal Free disease and Tapanui disease. CFS is not to be confused with the tiredness and depression that follow a viral infection such as infectious mononucleosis, hepatitis or influenza. These postviral tiredness states are certainly common but resolve within 6 months or so.
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Typical features of CFS (see FIG. 74.1):11
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extreme exhaustion (with minimal physical effort)
headache or a vague ‘fuzzy’ feeling in the head
aching in the muscles and legs
poor concentration and memory
hypersomnia or other sleep disturbance
waking feeling tired
emotional lability/anxiety
depressive-type illness, mood swings
arthralgia (without joint swelling)
sore throat
subjective feeling of fever (with a normal temperature)
shortness of breath
tender, swollen lymph nodes
usually occurs between 20 and 40 years of age
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Epidemiologically it has been related to Coxsackie B virus infections. The responsible organism is referred to as a slow virus infection by some authorities.8
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In approximately two-thirds of patients the illness follows a clearly defined viral illness. However, no single virus has been consistently associated with the development of the syndrome, which is known to develop following a wide range of viral and non-viral infective illness. Immune system dysfunction with chronic overproduction of cytokines (e.g. interferon) is a possible pathogenetic mechanism.
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Every family doctor probably has patients with this disorder and the syndrome has been observed in isolated endemics from time to time. Hickie et al3 found that only 0.3% of those with prolonged fatigue had been diagnosed with CFS by their family doctor. Veterans of the Gulf War show a tenfold incidence of CFS compared with non-deployed military personnel.10
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There is no doubt that the syndrome is real in these patients. One of the major problems confronting clinicians is that there is no diagnostic test for this illness, so it remains a clinical diagnosis backed up by normal baseline investigations.
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Diagnostic criteria for CFS have been published13 (see TABLE 74.4), which emphasise the positive clinical features of the syndrome and the chronicity of symptoms (greater than 6 months), in addition to the need for careful exclusion of alternative diagnoses by history, physical examination and laboratory investigation.
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Examination and investigation
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Apart from mild pharyngeal infection, cervical lymphadenopathy or localised muscle tenderness, the physical examination is normal.
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Investigations should be directed towards excluding possible diagnoses for that patient, such as chronic infection, autoimmune disorders, endocrine and metabolic disorders, primary neuromuscular disorders, malignancy and primary psychiatric disorders. The last mentioned is the most difficult of the differential diagnoses and psychiatric referral will often need to be considered.
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Patients who have CFS are really suffering and unhappy people, similar to those with fibromyalgia (see CHAPTER 37). They require considerable understanding and support. Multidisciplinary intervention is recommended. Symptoms last approximately 2½ years.
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Management strategies include:11
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CFS recognition—explain that the illness is real but the cause unknown and tests are likely to be normal
explanation and reassurance that the illness is usually self-limiting with no permanent complications; and that a slow, steady improvement can be anticipated, with most CFS patients returning to normal health
provide continued psychological support
review for diagnostic reappraisal (examine at least every 4 months)
avoid telling patients they are depressed
treat symptomatically—pain relief, consider NSAIDs and antidepressants if significant depression
refer to counselling and support groups
provide a realistic, regular, graduated exercise program
reduce relevant stress factors (map a realistic living program)
psychiatric referral if appropriate
ask the patient to keep a diary of exercise/stress and symptom severity, in particular
avoid long-distance travel, which is poorly tolerated
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Cognitive behaviour therapy appears to help some patients, as do relaxation therapy, meditation, stress management and psychotherapy, where indicated.
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The emphasis should be placed on caring, rather than curing, until a scientific solution is found.
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A systematic review has found that cognitive behaviour therapy administered by skilled therapists and exercise are beneficial. Although few patients are cured with CBT, the therapeutic effect is substantial.12 There is insufficient data or evidence to support the use of antidepressants, corticosteroids, complementary therapies and dietary supplements, including vitamins B12 and C and co-enzyme Q10.5 Prolonged rest and immunotherapy was unlikely to be beneficial.14