Management

Before considering it as part of an illness it is worth checking if it is likely to be physiological. At first consultation consider physical causes.

• physical examination reassures both doctor and patient
  • patient feel that that their complaints are considered seriously by the doctor
  • doctor may identify organ based illness (1)
• investigations should be restricted to those that are appropriate
  • abnormal investigation are related to symptoms in less than 10% of patients (2)
• psychological causes - some doctors fear that probing emotional illness will precipitate emotional distress. It is an opportunity to relieve anxiety and distress
  • in fatigue lasting more than 2-3 months with other symptoms or signs of depression or anxiety, antidepressants such as sertraline 50 mg daily can be tried out (should be discontinued after 4 weeks if there is no improvement) (2)
• the following clinical features should be explored carefully to determine any serious physical disorder:
  • localizing and/or focal neurological signs
  • signs and symptoms of inflammatory arthritis or connective tissue disease
  • signs and symptoms of cardio-respiratory disease
  • significant weight loss
  • sleep apnoea
  • clinically significant lymphadenopathy (2)

Advice should be given to patients to manage symptoms in order to minimize their impact on daily life (2).

• regular physical activity e.g. - walking, stretching and aerobic exercise (3)
• diet
  • regular meals with a well balanced diet which comprises of slow release starchy foods
  • nausea can be managed conservatively (e.g. - eating little and often, snacking on dry starchy foods and sipping fluids) but in severe cases anti emetic drugs can be used (2)
• sleep management
  • advice on sleep management and sleep hygiene
  • treat any concomitant diseases e.g. - depression, anxiety
• rest and relaxation
  • explain about the role of rest and short naps which will enhance performance (2,3)
  • relaxation methods may help in managing pain, sleep problems and concomitant stress or depression (2)
• for patients with depression selective serotonin reuptake inhibitors, such as fluoxetine, paroxetine, or sertraline may be used to increase the energy (3)
• education and employment
• advice people about continuing education or work and review regularly (2)

Reference:

• 1. Cornuz J. Fatigue: a practical approach to diagnosis in primary care. CMAJ 2006;174(6)
• 2. Simon C. Tiredness, fatigue and lethargy. InnovAiT 2008 1(3):199-205
• 3. Rosenthal TC et al. Fatigue: an overview. Am Fam Physician. 2008;78(10):1173-9