What evaluation and management are recommended for an adult with chronic fatigue and low energy?

Evaluation and Management of Chronic Fatigue and Low Energy in Adults

Initial Assessment

Begin by quantifying fatigue severity using a 0-10 numeric rating scale, where scores of 4-10 indicate moderate-to-severe fatigue requiring comprehensive evaluation, while scores of 0-3 warrant only education and periodic rescreening. 1

Focused History Elements

Document the following specific details:

• Onset, pattern, and duration of fatigue, including temporal changes and what makes it better or worse 2, 1
• Sleep patterns: Total hours, quality, daytime napping (frequency, duration, voluntary vs. involuntary), and symptoms suggesting sleep apnea 3, 2
• Medication review: All prescription drugs, over-the-counter medications, supplements, and recent changes—specifically assess for β-blockers, SSRIs, narcotics, antidepressants, antiemetics, antihistamines, stimulants, and decongestants 3, 1
• Weight changes: Amount gained, timeframe, and dietary intake patterns 2
• Activity level: Changes in exercise patterns, ability to perform daily activities, and any post-exertional worsening 2, 4
• Red flag symptoms: Fever, night sweats, unintentional weight loss, pain, pulmonary complaints, lymphadenopathy 1
• Mood symptoms: Depression (present in 25-33% of fatigued patients), anxiety, irritability 3, 1

Physical Examination

Perform a targeted examination focusing on:

• Thyroid examination for enlargement or nodules 2
• Lymph node assessment for adenopathy 1
• Cardiac and pulmonary examination 1
• Abdominal examination for hepatosplenomegaly 1

Laboratory Workup

For moderate-to-severe fatigue (scores ≥4), obtain the following initial tests: 1

• Complete blood count with differential to screen for anemia 1
• Comprehensive metabolic panel to evaluate electrolytes, hepatic, and renal function 1
• Thyroid-stimulating hormone (TSH) to detect hypothyroidism 2, 1
• Consider: Erythrocyte sedimentation rate and C-reactive protein if inflammatory process suspected 1

Additional testing based on clinical context:

• ECG and echocardiogram if cardiac risk factors or prior cardiotoxic therapy exposure 1
• Endocrine panel (cortisol, testosterone/estradiol, FSH, LH) if other symptoms suggest specific dysfunction 2

Avoid extensive "fishing expeditions"—if initial workup is negative, further testing is typically fruitless. 5

Management Strategy

Address Treatable Contributing Factors First

This is the cornerstone of management and must be prioritized: 3, 2

• Thyroid dysfunction: Treat if TSH abnormal 2
• Anemia: Iron repletion if indicated 1
• Depression/anxiety: Implement treatment with SSRIs or cognitive behavioral therapy 1
• Sleep disturbance: Address with cognitive behavioral therapy for insomnia (Category 1 recommendation) 6
• Pain: Optimize pain management 1
• Medication adjustment: Reduce doses or discontinue fatigue-inducing medications when possible 1
• Nutritional deficits: Correct identified deficiencies 3

Non-Pharmacologic Interventions (Category 1 Evidence)

Physical Activity (First-Line Treatment):

Implement a structured, gradual exercise program starting with low-level activities and progressing to 150 minutes of moderate aerobic exercise (brisk walking, cycling, swimming) per week plus 2-3 strength training sessions. 3, 6

• Walking programs are generally safe and can begin after physician consultation without formal stress testing 3
• Critical caveat: If postexertional malaise is present (worsening after activity that was previously tolerable), suspect myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), where exercise can be harmful and trigger symptom exacerbation 4
• For ME/CFS, teach activity pacing instead—patients should not exceed their limited energy capacity 4

Psychosocial Interventions (Category 1 Evidence):

• Cognitive behavioral therapy has proven efficacy for chronic fatigue management 3, 6
• Psychoeducational therapy can reduce fatigue 3
• Refer to mental health professionals trained in evidence-based interventions 3

Mind-Body Approaches:

• Mindfulness-based interventions and yoga show evidence for fatigue reduction 3, 6
• Acupuncture may be beneficial 3

Sleep Hygiene Optimization

Implement the following specific strategies: 6

• Consistent sleep-wake schedule daily 6
• Avoid: Caffeine after noon, alcohol near bedtime, electronic devices before sleep 6
• Create restful environment: Dark, quiet, comfortable temperature 3
• Eliminate incompatible bedroom activities: No TV watching, computer use, eating, or "clock watching" in bed 3

Energy Conservation Strategies

• Daily/weekly activity diary to identify peak energy periods 6
• Prioritize essential activities and schedule during high-energy times 6
• Avoid prolonged bed rest, which can worsen deconditioning 3

Patient Education

Provide specific information about: 3

• Difference between normal tiredness and pathologic fatigue 3
• Expected persistence of symptoms and realistic recovery timeline 3
• Contributing factors identified in their case 3
• Self-monitoring techniques using fatigue diaries 6

Follow-Up and Monitoring

• Outpatients: Screen at each routine follow-up visit 1
• Reassess regularly to determine if treatment is effective or needs adjustment 3
• Continue monitoring after initial improvement, as symptoms may fluctuate 1

Specialist Referral Indications

Refer when: 1

• Cardiology: Cardiac evaluation needed (abnormal ECG, suspected cardiomyopathy) 1
• Endocrinology: Complex endocrine abnormalities requiring specialized management 1
• Mental health: Refractory depression or anxiety despite initial treatment 1
• Physical therapy/exercise specialist: Severe fatigue interfering with function, neuropathy, or other injury risk 3

Critical Pitfalls to Avoid

• Do not order extensive imaging or laboratory testing in the absence of red flag symptoms—this is low-yield and can lead to false positives 1, 5
• Do not prescribe exercise programs without first assessing for postexertional malaise, as this can harm patients with ME/CFS 4
• Do not dismiss psychiatric contributions—depression and anxiety are common treatable causes, not diagnoses of exclusion 3, 5
• Do not overlook medication effects—polypharmacy with narcotics, antidepressants, antiemetics, and antihistamines commonly causes fatigue 3, 1
• Do not continue ineffective treatments—if interventions fail after adequate trial, reassess the diagnosis and consider specialist referral 3