Tiredness/Fatigue

INTRODUCTION

Tiredness can be a symptom of a great variety of serious and uncommon diseases, incl. malignant disease. The most probable diagnoses to consider are:

• psychological distress, e.g. tension, stress and anxiety, depression

• viral or postviral infection

• sleep-related disorders, e.g. sleep apnoea

It is important not to overlook drugs, whether self-administered or iatrogenic, as a cause. Other masquerades are endocrine disorders and anaemia.

Key screening investigations are FBE, ESR/CRP, blood sugar, serum electrolytes, LFTs, iron studies, TFTs, CXR.

SLEEP-RELATED DISORDERS

An important cause of daytime tiredness is a sleep disorder such as obstructive sleep apnoea, which results in periodic hypoventilation during sleep. It occurs in 2% of the general population in all age groups and in about 10% of middle-aged men. A history of snoring is a pointer to the problem.

Referral to a comprehensive sleep disorder centre is appropriate if this disorder is suspected.

NARCOLEPSY

Narcolepsy is a condition where periods of irresistible sleep occur in inappropriate circumstances and consists of a tetrad of symptoms:

• sudden brief sleep attacks (15–20 mins)

• cataplexy: a sudden loss of muscle tone in the lower limbs—may slump to floor

• sleep paralysis

• hypnagogic (terrifying) hallucinations on falling asleep

Treatment (specialist co-share)

• Modafinil

• Methylphenidate (Ritalin) or amphetamines (dexamphetamine)

• Tricyclic antidepressants (small doses) for cataplexy

Chronic fatigue syndrome (CFS)

CFS is defined as debilitating fatigue, persisting or relapsing over 6 mths, associated with a significant reduction in activity levels of at least 50% and for which no other cause can be found. Prevalence ~1%; ♀: ♂ ~3:2.

Three cardinal symptoms: fatigue and pain, unrefreshing sleep, and impairment of concentration and memory.

It does appear to be a real illness, probably caused by a virus. Standard screen—FBE, ESR, electrolytes, urea and creatinine, calcium, LFTs, FSH, urinalysis.

Management

• Recognition of CFS; education, encouragement and reassurance

• Ongoing support

• Rest and pacing activity; avoid aggr. factors, e.g. alcohol; holistic lifestyle

• A supervised self-management action plan/multidisciplinary intervention

• Cognitive therapy (best evidence) meditation, mindfulness and group support

Best evidence indicates CBT from a skilled therapist and exercise are beneficial. Insufficient evidence to support use of antidepressants and other agents, including NSAIDs.

BURNOUT

A clinical syndrome recognised by WHO: ICD-II. Three dimensions: exhaustion; feeling negative and cynical about job; reduced professional efficiency. Treatment is psychotherapy, incl. CBT.