What is the approach to evaluating and managing fatigue?

Evaluation and Management of Fatigue

The approach to evaluating fatigue should follow a structured four-phase algorithm: screening, primary evaluation, intervention, and reevaluation, with targeted laboratory testing and assessment of contributing factors to guide appropriate management. 1

Initial Screening and Assessment

• Quantify fatigue severity using a numeric rating scale (0-10):

  • Mild: 1-3
  • Moderate: 4-6
  • Severe: 7-10 2

• For children, simplify the scale (1-5) or ask young children (5-6 years) if they are "tired" or "not tired" 2

Primary Evaluation

Essential Laboratory Tests

• Complete blood count (CBC) with differential
• Comprehensive metabolic panel
• Thyroid-stimulating hormone (TSH)
• Urinalysis 1

Additional Testing Based on Clinical Presentation

• Fasting blood glucose or glycohemoglobin
• Lipid profile for cardiovascular risk assessment
• For dyspnea, orthopnea, or edema: 12-lead ECG and chest radiograph
• Consider echocardiography to assess left ventricular function
• Assess orthostatic blood pressure changes 1

Key Considerations

• Laboratory studies affect management in only 5% of patients 3
• If initial results are normal, repeat testing is generally not indicated 3
• Medical causes of fatigue typically present with other symptoms and are usually evident on initial presentation 4

Assessment of Contributing Factors

Evaluate for treatable factors:

• Anemia
• Electrolyte abnormalities
• Renal or hepatic dysfunction
• Endocrine disorders (especially thyroid dysfunction)
• Sleep disturbances
• Pain
• Emotional distress (depression, anxiety)
• Medication side effects 2, 1

Intervention Strategies

Non-pharmacologic Approaches

1. Physical Activity

   • Implement a structured plan for regular physical activity
   • Include stretching and aerobic exercise, such as walking 3
   • CAUTION: For suspected myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), exercise may trigger postexertional malaise and should be approached cautiously 5

2. Sleep Hygiene

   • Short naps (proven performance enhancers) 3
   • Regular sleep schedule

3. Cognitive Behavioral Therapy

   • Particularly effective for chronic fatigue 3, 5

Pharmacologic Approaches

• For depression-related fatigue: Consider SSRIs (fluoxetine, paroxetine, sertraline) 3
• For episodic situations requiring alertness: Caffeine or modafinil may be useful 3
• Treat underlying medical conditions causing secondary fatigue 5

Reevaluation

• Schedule regular follow-up visits rather than sporadic urgent appointments 3
• Continue to monitor fatigue throughout and after treatment 2
• For cancer patients, monitor fatigue beyond the period of active treatment 2

Special Considerations

Cancer-Related Fatigue

• Requires an interdisciplinary approach involving medicine, nursing, social work, physical therapy, and nutrition 2
• Education and counseling are central to effective management 2

Chronic Fatigue/ME/CFS

• Characterized by postexertional malaise as the most important symptom 5
• Patients should be educated about pacing activities to not exceed limited energy capacity 5
• Treatment should prioritize addressing comorbidities and symptoms based on severity 5

Common Pitfalls to Avoid

• Conducting extensive "fishing expeditions" after initial normal workup 4
• Dismissing fatigue as "just depression" without proper evaluation 4
• Failing to recognize that laboratory abnormalities are common but often don't contribute to diagnosis or affect clinical outcomes 6
• Overlooking the significant impact of fatigue on work performance, family life, and social relationships 3
• Neglecting to inform patients that managing fatigue is an integral part of total health care 2

By following this structured approach to fatigue evaluation and management, clinicians can effectively identify underlying causes, implement appropriate interventions, and improve patients' quality of life and functional status.