What is the appropriate workup for a senior patient experiencing increasing fatigue without any changes in medication?

Comprehensive Workup for Fatigue in Elderly Patients Without Medication Changes

A thorough evaluation of fatigue in elderly patients should include assessment of treatable contributing factors such as pain, emotional distress, sleep disturbance, medication side effects, nutritional status, activity level, and comorbidities. 1

Initial Assessment

• Screen fatigue severity using a numeric rating scale (0-10) or categorization as none, mild, moderate, or severe 1
• Patients with scores of 0-3 (mild) require only rescreening at regular intervals 1
• Patients with scores of 4-10 (moderate to severe) warrant a focused evaluation 1
• Document onset, pattern, duration, and changes in fatigue over time 1

Laboratory Studies

• Complete blood count with differential to evaluate for anemia, infection, or malignancy 2
• Comprehensive metabolic panel to assess liver and kidney function 2
• Thyroid-stimulating hormone (TSH) to rule out thyroid dysfunction 2
• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to evaluate for inflammation 2
• Vitamin B12 levels, especially in elderly patients who may have decreased absorption 3
• Consider HIV testing and tuberculosis screening if risk factors are present 2

Medication Review

• Review all current medications (including over-the-counter, herbal supplements, vitamins) 4
• Note any recent medication changes that might contribute to fatigue 4
• Evaluate for medication interactions that may cause excessive drowsiness 4
• Consider cardiac medications (such as β-blockers) that may cause bradycardia and fatigue 4

Assessment of Contributing Factors

Sleep Evaluation

• Assess sleep quality, quantity, and hygiene 4
• Screen for sleep disorders such as sleep apnea or insomnia 4
• Evaluate sleep environment and pre-bedtime activities 4

Nutritional Assessment

• Evaluate weight changes, caloric intake, and appetite 4
• Check for fluid and electrolyte imbalances 4
• Consider consultation with nutrition expert if substantial abnormalities exist 4

Physical Activity and Functional Status

• Assess changes in exercise or activity patterns 4
• Evaluate ability to accomplish normal daily activities 4
• Determine current conditioning level before recommending exercise 4

Psychological Evaluation

• Screen for depression and anxiety, which frequently co-occur with fatigue 1
• Assess emotional distress and coping strategies 1
• Consider cognitive behavioral therapy for chronic fatigue 4

Evaluation of Comorbidities

• Review status of existing medical conditions 4
• Optimize management of comorbidities that may contribute to fatigue 4
• Consider occult malignancy in elderly patients with persistent fatigue 2
• Screen for alcohol or substance use that may contribute to fatigue 4

Imaging Studies (When Indicated)

• Chest X-ray as initial screening for pulmonary pathology if respiratory symptoms present 2
• Consider CT scan if lymphadenopathy, organomegaly, or masses are suspected 2
• Further imaging based on specific clinical findings 2

Management Approach

• Treat any identified underlying causes of fatigue 4
• Implement structured physical activity plan with gradual increase in intensity 4
• Consider vitamin B12 supplementation if deficiency is detected 3
• Implement good sleep hygiene practices 4
• Address nutritional deficiencies 4
• Consider psychosocial interventions for emotional distress 4

Follow-up

• Schedule regular follow-up visits rather than sporadic urgent appointments 5
• Reassess fatigue severity at each visit 1
• Adjust management plan based on response to interventions 5

Cautions

• Avoid extensive "fishing expeditions" if initial workup is negative 6
• Be aware that fatigue rarely occurs in isolation and often clusters with other symptoms 1
• Don't overlook medication side effects as potential contributors to fatigue 1
• Consider myalgic encephalomyelitis/chronic fatigue syndrome if fatigue persists beyond 6 months with post-exertional malaise 7