Fatigue
FATIGUE – one of the most common complaints I hear as a Primary Care Physician
By Gabrielle Klein, MD
Complaints of fatigue are common to both men and women. (Such complaints are less common in children).
While the dictionary describes fatigue as a “temporary loss of strength and energy from hard physical or mental work,” patients often use other language to convey a broader scope of symptoms:
• weakness
• dizziness
• imbalance
• shortness of breath
• feeling worn out
• falling apart
• sapped
• lethargic
• listless
• tired
• weary
• or just plain exhausted
These are some of the complaints I hear daily from patients.
HOW DOES FATIGUE AFFECT DAILY LIFE?
Fatigue can affect every system of the body. Often the symptoms present gradually and the patient is not aware that his/her abilities and functioning have decreased. They often don’t realize the amount of energy being expended as compared to the amount required for the same tasks prior to the onset of symptoms.
Fatigue can impact:
1. MOTIVATION – there may be lack of motivation to begin an activity
2. STAMINA – a person tires easily once the activity has begun
3. CONCENTRATION – a person fatigues mentally or has difficulty with the concentration and memory required to begin or complete an activity
WHAT ARE THE SYMPTOMS OF FATIGUE?
• Fatigue interferes with physical well-being
Fatigue can manifest itself with head and neck symptoms such as headaches, swollen lymph nodes, double vision, blurry vision, fullness in head and sinuses, recurrent sore throats. The heart can be affected with symptoms of chest pain, increased heart rate and occasionally even palpitations. Often people affected by fatigue experience respiratory symptoms including shortness of breath, both perceived and actual. Digestive symptoms include stomach aches, nausea, diarrhea, and heartburn – all of which can be exacerbated by fatigue. Certainly muscle weakness, pain, and occasionally swelling can be caused by fatigue as well as joint tenderness and stiffness.
• Fatigue impairs mental acuity & productivity
Short term memory can be greatly affected and concentration reduced due to fatigue. Many studies exist showing the negative impact of fatigue on truck drivers and operators of heavy machinery. There have been numerous large scale tragedies due to human error, caused mostly by fatigue due to too little sleep for the people who are working. Even medical schools are breaking with the age-old tradition of 36-hour shifts for interns. Just as fatigue can make you less effective and productive in the workplace, it can cause you to be less effective and safe in caring for your family at home.
• Fatigue has hormonal and emotional effects
Mood, emotional stability, libido, regularity of periods, and general feelings of well-being are often adversely affected by fatigue.
WHAT ARE SOME COMMON CAUSES OF FATIGUE?
We can divide the causes into three categories:
1. purely physical causes, stemming from an organic problem,
2. psychological and emotional causes, and
3. Lifestyle causes.
Often it is a combination of factors. We try to identify the cause because that is the first step in identifying the treatment.
As family doctors, we start by looking at possible physical causes of fatigue.
When a patient presents to me with their main complaint being fatigue and weakness, my first task is to rule out the obvious causes which are easily ruled out with simple blood tests.
Anemia is very common in all populations but mostly in nursing, pregnant, and post- menopausal women. People of Sephardic origin can have genetic underlying abnormalities in hemoglobin and suffer from chronic anemia. Anemia can be a manifestation of lack of vitamin B12 or lack of iron or iron stores (Ferritin).
Thyroid disease (in particular, poor functioning of the thyroid gland) can also lead to tiredness, weakness, and fatigue (TSH and FREE T4 are the first blood tests your doctor will order to screen for this).
Diabetes can make you tired and a simple fasting glucose blood test will rule this out.
Vitamin D deficiency has been attributed to general malaise in recent years. The vitamin D level should be above 30. If you are below this you should be taking vitamin D to supplement. Most people are vitamin D deficient even though we live in a very sunny climate.
Certainly one needs to rule out infectious disease such as Infectious Mononucleosis (EBV) and Cytomegalovirus (CMV). If your blood work shows IGM antibodies to either of the above, it means you are currently suffering from Mono. However, positive IGG antibodies simply means you had the disease at another time in your life.
Other infectious diseases can include, but are not limited to Hepatitis and Lyme disease.
Menopause (measured by FSH in the blood work) and Pregnancy are common causes of fatigue.
One of the first symptoms of heart disease in women can manifest as fatigue. Heart disease is especially a concern if the fatigue is only related to exertion.
Autoimmune diseases such as Rheumatoid Arthritis, Lupus, Scleroderma, and Psoriatic Arthritis can first present with tiredness as the main concern.
Chronic Urinary Tract Infections, Malabsorption Syndromes, Inflammatory Bowel Disease, or Irritable Bowel Syndrome can present with general malaise.
Asthma sufferers are particularly prone to feelings of fatigue and need to get their asthma well controlled to restore energy
One thing that is often overlooked or not addressed at all is medications. Anything that one ingests or applies to the skin is absorbed in the body and can have adverse effects.
Even alternative medication or herbs from the health food store can affect and alter symptoms of fatigue or weakness.
Chronic Fatigue Syndrome is another frustrating and often debilitating cause of fatigue.
Chronic Fatigue vs. Chronic Fatigue Syndrome: While fatigue can last for a prolonged period of time, the presence of chronic fatigue is different than Chronic Fatigue Syndrome which has specific criteria set by the Centers for Disease Control and Prevention as follows:
1. Have severe chronic fatigue for at least six months or longer with other known medical conditions (whose manifestation includes fatigue) excluded by clinical diagnosis; and
2. Concurrently have four or more of the following symptoms:
o post-exertion malaise
o impaired memory or concentration
o un-refreshing sleep
o muscle pain
o multi-joint pain without redness or swelling
o tender cervical or Axillary lymph nodes
o sore throat
o headache
After all the physical causes are ruled out, we cannot forget to look at mental, psychological and emotional causes. The most prevalent symptom of depression is feeling unable to complete or initiate tasks, feeling tired, unwell, and an inability to function.
Stress, anxiety, eating disorders, and post-traumatic stress disorder can all manifest as fatigue being the chief complaint.
WHAT ARE SOME THINGS YOU CAN DO ABOUT YOUR FATIGUE?
Physical causes and emotional or psychological causes of fatigue are easier to identify and sometimes harder to treat.
However, lifestyle choices can influence and affect feelings of fatigue and exhaustion.
There are three major categories:
1. Exercise. Exercise.. Exercise. Many studies show the positive effect of a regular daily exercise routine on health, mood, and chronic disease. The focus of treatment in Chronic Fatigue Syndrome is exercise. Everyone should have a regular routine built into their schedule. The recommendations are for at least 30 minutes of aerobic exercise daily. This means walking, running, swimming, biking (and you should have your heart racing and be sweating). If this is too much at first, start with 20 minutes, three times per week. Be careful not to over-exercise, as this can also lead to fatigue and tiredness.
2. Sleep. We are all sleep-deprived. However, if you are suffering from fatigue, it is time to reevaluate your sleep patterns. Most adults need between 7-8 hours per night on a regular basis. You need to assess your sleep hygiene to evaluate if your fatigue is simply due to lack of sleep. Sleep hygiene, defined as the controlling of “all behavioral and environmental factors that precede sleep and may interfere with sleep,” is important. Making sure you get enough sleep is just a part of good sleep hygiene. You may be suffering from sleep apnea, restless leg syndrome, or the disturbance involved in shift work. Simple solutions include only using the bed for sleeping, sleeping in a dark room at night that is light during the day. No electronic devices, activity, caffeine, or stimulants before bed. Meditation before bedtime can also be very helpful.
3. Food. What you put into your mouth can affect fatigue and exhaustion. If you are eating foods that are mildly intolerant to you, this can make you feel tired and groggy. Being aware of foods that affect your ability to function can make a big difference in your life. Eating a balanced diet with few processed foods and a lot of green leafy vegetables can give you more energy. At least 8 glasses of water per day will also help alleviate dehydration and its accompanying feelings of fatigue.
In conclusion, physical, mental and psychological factors can affect fatigue.
If you are suffering from fatigue it is important to get a full physical from your family doctor.
It is also important to examine your lifestyle and assess what you can positively change.