TATT DR Trish Hurton 17th July 2013 GP MAsterclass
Tiredness - a lack of, or decreased energy, and or mental exhaustion! Fatigue-physical or mental exhaustion due to exertion!
What causes tiredness? • Psychological or psychosocial- depression, anxiety, stress, trauma • Physical- eg anaemia, diabetes, glandular fever • Physiological -pregnancy, inadequate rest or excessive exercise, menopause • Or a mix of the above
Tired all the time Prevalence • Between 10-18% of people in the uk report having tiredness lasting 1 month or longer (1990 DAvid et al) with 1.5% ( 2004 Gallagher et al)of people consulting their GP with a new symptom of tiredness each yr • Nice CKS http://cks.nice.org.uk/tirednessfatigue-in-adults • Springer 2002 general practice in Ireland showed a prevalence of 25% with it being the primary reason for attending in 6.5% and 19%a secondary reason with 62%being female. This study also showed that type of GP also influenced reporting, inverse relationship with duration qualified and direct relationship with female gender of GP
Risk factors • Female gender( Lewis and Wessely 1992, Pawlikowsa et al 1994, Gallagher et al 2004) • Lower socioeconomic status, a French study reported that people in lower social classes were less likely to be diagnosed with fatigue but were more likely to report symptoms (Fuhrer and Wessely 1995) • Physical illness ( Lewis and Wessely 1992) • Mental illness ( Lewis and Wessely 1992)
Prognosis • In primary care between 1/3 to 1/2 of people with tiredness/fatigue will recover within 1 year ( Nijroder et al, 2008) • Factors associated with recovery were; lower severity, shorter duration , no expectation of it becoming chronic, better perceived general health, less pain, not being a carer, more social support, better mental health, willingness to attribute fatigue to psychological factors, male sex
Assessment • Onset, duration, severity, precipitating factors, effect of rest and exercise, impact on activity. • Take a full history- what are they actually describing- sleepiness/weakness is not the same thing • Onset fast? -infection, MI ,drugs, toxins, PTSD • Onset slow? - uraemia, heart failure, liver failure, diabetes, hypercalcaemia, thyroid, anaemia , depression
Assessment • Fatigue worse in morning but never goes away ?depression- worse after exercise ?neuromuscular cause • Elicit the patients concerns and their perceptions of the cause of their tiredness -patients are more likely to perceive the cause as physical • Take a sleep history, quality, quantity, patterns, snoring, sleep apnoea, nocturia and restless legs • Lifestyle and psychosocial history -stress, illicit drug use, alcohol and diet, ?are they a carer
Assessment • Screen for depression and anxiety - evidence that the underlying cause is commonly psychological/social( 18-62%) • Review medications- many drugs are listed as causing fatique • Weight loss or gain • Fever or night sweats • Muscle or joint pain, headaches, sore throats, difficulty with memory or thinking, chronic pain • Travel, insect bites or skin rash, or risk taking behaviour • Allergies
Assessment-to exam or not? • Targeted physical examination if history highlighting possible cause, if not consider full examination in a follow up appointment • No evidence on diagnostic yield of a physical examination but it does reassure patient that their problem is being taken seriously and helps the therapeutic relationship • Consider whether investigations warranted
Red flags • Significant weight loss • Lymphadenopathy • Signs or symptoms of malignancy eg haemoptysis , dysphagia, rectal bleeding, breast lump, post-menopausal bleeding • Localising/ focal neurological signs • Signs of inflammatory arthritis, vasculitis etc. • Symptoms or signs of cardiovascular disease • Sleep apnoea
Investigations • In absence of significant symptoms consider delaying investigations until tiredness has lasted for 1 month • Evidence that a limited set of blood tests is almost as useful diagnostically as more extensive investigations
Investigations • FBC • Esr or C reactive protein • TFT's • FBG/HBA1C • IgA tissue transglutaminase( for coeliac disease)
Investigations additions to consider • Over 60 consider u+e, lfts, bone biochemistry, if under 40 consider monospot • Ferritin in women of child bearing age • Lfts in obesity - NASH • Vitamin D if consider patient to be at risk • ?at risk of Tuberculosis
Prognostic yield • Limited evidence in one randomised trial (Koch et al 2009) and 3 observational studies that blood testing has a low yield, detecting a physical cause in only 8-11% of people • No evaluation of harm in under or over investigation. Limited evidence that delaying test does not appear to miss serious diagnosis provided there are no red flags • Anaemia and diabetes are the most common physical cause in patients presenting with tiredness in primary care but only account for 0.6-6% of the presentations- malignancy is less than 1%
Secondary investigations if fatigue lasting for more than 3 months • Urinalysis for blood, protein and glucose • All previous tests plus serum calcium, creatinine kinase • If history indicative chronic bacterial infections such as borreliosis (Lyme disease) • Chronic viral infections - HIV and hepatitis • Latent infections such as toxoplasmosis ,Epstein Barr or cytomegalovirus • Consider referral
Treatment strategies • Treat any identified underlying cause • In women of child bearing age with a serum ferritin below 50mg/l consider iron supplementation for 4 weeks( based on limited trial evidence Verdon et al 2003) • Try to establish a supportive therapeutic relationship • Explain fatigue can be present without identifiable cause in the population, linking physical symptoms with psychosocial factors , which absolves patient from blame but offers ways for patient to manage their symptoms Address any modifiable psychological, social and general health • factors including stress, work, relationships, pain or alcohol.
Treatment strategies • Balance between activity and rest • Sleep management • Cognitive behavioural therapy, some evidence of benefit particularly if patient is psychologically minded and accepting of emotional distress (Chaldea et al 2003) • Graded exercise - one trial showed it is equivalent to CBT in reducing unexplained fatigue (Ridsdale et al 2004)
Chronic fatigue syndrome-ME • No universal definition • Tiredness /fatigue lasting 6 months or longer • NICE suggest looking at this as a possible diagnosis in someone who has persist at symptoms of 4 months after exclusion of other possible diagnosis.
Epidemiology The true prevalence of chronic fatigue syndrome (CFS) is unknown. The National Institute for Clinical Excellence (NICE) suggests 4 per 1,000 in the UK Women appear to be affected more than men with the ratio reported as being female:male 2:1 The average age at onset is 30 years and, although CFS has been diagnosed in adolescents it is not generally seen in children under the age of 12 or adults over the age of 65.
Chronic fatigue syndrome-Diagnosis • Fatigue that is persistent(4 months or longer) or recurrent, new or that has had a specific onset (not lifelong), unexplained by other conditions, has resulted in substantial reduction in activity, and occurs following exercise( typically delayed by at least 24 hrs, with slow recovery over several days) • One or more of the following symptoms are present; difficulty sleeping, muscle or joint pain, headaches, painful lymph nodes , sore throat, cognitive dysfunction , symptoms made worse by physical or mental exertion, flu-like symptoms, dizziness, nausea or palpitations
Describing severity Mild CFS: patient is mobile, can care for themselves and do Mild CFS: patient is mobile, can care for themselves and do light housework with difficulty light housework with difficulty Moderate: patient has reduced mobility and is restricted in all Moderate: patient has reduced mobility and is restricted in all activities of daily living. They have usually stopped work or activities of daily living. They have usually stopped work or education. Poor sleep quality and duration. education. Poor sleep quality and duration. Severe: patient is unable to do anything for themselves. They Severe: patient is unable to do anything for themselves. They suffer severe cognitive difficulties and depend on a suffer severe cognitive difficulties and depend on a wheelchair. They spend most of their time in bed and are wheelchair. They spend most of their time in bed and are sensitive to light and noise sensitive to light and noise
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