What is the approach to fatigue screening and management?

Fatigue Screening and Management Approach

Routine screening for fatigue should be performed using a 0-10 numeric rating scale at least annually, with comprehensive assessment for patients reporting moderate to severe fatigue (score ≥4). 1, 2

Initial Screening Process

• Use a quantitative scale where:

  • 0 = no fatigue
  • 1-3 = mild fatigue
  • 4-6 = moderate fatigue
  • 7-10 = severe fatigue 1

• For children, simplify to a 1-5 scale or "tired" vs "not tired" for ages 5-6 1

Comprehensive Assessment for Moderate-Severe Fatigue

Focused Fatigue History

• Onset, pattern, and duration
• Change over time
• Associated or alleviating factors 1, 2

Evaluation of Disease Status

• Risk of recurrence based on stage and treatment history
• Review of systems to detect symptoms suggesting recurrence 1

Assessment of Treatable Contributing Factors

1. Comorbidities:

   • Cardiac dysfunction
   • Endocrine dysfunction (especially thyroid)
   • Pulmonary dysfunction
   • Renal dysfunction
   • Anemia
   • Arthritis
   • Neuromuscular complications
   • Sleep disturbances
   • Pain
   • Emotional distress (depression, anxiety) 1, 2

2. Medications:

   • Review sedating medications (sleep aids, pain medications, antiemetics)
   • Evaluate medication side effects 1, 2

3. Lifestyle factors:

   • Alcohol/substance abuse
   • Nutritional deficiencies
   • Weight/caloric intake changes
   • Deconditioning/decreased activity level 1

Laboratory Evaluation

Laboratory testing should be guided by clinical findings rather than performed as an extensive battery 2

For patients with moderate-severe fatigue, consider:

• Complete blood count with differential
  • Compare current hemoglobin/hematocrit with previous values
  • Assess WBC and platelets
• Comprehensive metabolic panel
  • Electrolytes
  • Hepatic and renal function
• Thyroid-stimulating hormone (TSH) 1, 2

Management Interventions

Education and Counseling (All Patients)

• Explain differences between normal and pathological fatigue
• Discuss persistence patterns and contributing factors
• Provide strategies for self-monitoring fatigue levels 1

Treat Contributing Factors First

• Address medical conditions identified in assessment
• Review and adjust medications with sedating side effects
• Address alcohol/substance abuse
• Correct nutritional deficiencies
• Implement sleep hygiene measures 1, 2

Physical Activity

• Recommend 150 minutes of moderate aerobic exercise weekly plus 2-3 strength training sessions unless contraindicated 1, 2
• Walking programs are generally safe for most patients
• For patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), avoid exercise that could trigger postexertional malaise 3

Energy Conservation Strategies

• Prioritize important activities
• Plan rest periods
• Delegate tasks when possible 2

Additional Interventions

• Cognitive behavioral therapy for persistent fatigue
• Consider referral to specialists (cardiologist, endocrinologist, mental health professional) based on identified causes 1, 2

Reevaluation

• Inpatients: screen daily
• Outpatients: screen at routine follow-up visits
• Continue monitoring even after treatment completion, as fatigue may persist 1

Common Pitfalls to Avoid

• Failing to recognize medication side effects as potential causes 2
• Excessive focus on rare somatic causes leading to overdiagnosis 4
• Overlooking common causes like sleep disorders, depression (18.5%), and psychosocial stress 4
• Excessive laboratory testing when not indicated by clinical findings 2, 5

By following this structured approach to fatigue screening and management, clinicians can effectively identify and address this common symptom that significantly impacts patients' quality of life and mortality risk.