Thanks to XKCD

So patients present to clinic with fatigue all the time. What do you do? What does the evidence suggest you should be doing? Let’s delve into the literature and see if we can improve some clinical practice!

The NHS homepage on fatigue sums up the issue nicely. It suggests that patients should see their doctor if they have fatigue and have had any of the following:

Confusion, dizziness, blurred vision, weight loss, weight gain, swelling (just… generally I guess), constipation, insomnia, depression, headaches etc.

Ummm. If you haven’t had these at some point you may not actually be a human being. *pinch* – yep, still hurts!

Fatigue/tiredness is a common complaint, occurs regularly in Australian general practice (1.5 in 100 in BEACH (though I am sure I see more than that!)), and while investigations may be used to make some diagnoses and help rule out dangerous conditions, the battery of tests which doctors perform is wide ranging and not always evidence based. Unfortunately, patients will often want ‘tests’ and doctors feel under pressure to order these. They believe that if they refuse and miss a serious condition, the patient may be harmed and there may be medico legal issues.

I want to review some of the main investigations which may help in the Australian patient presenting with fatigue to general practice and briefly talk about some ‘furfy’ (read – not evidence based) diagnoses which I have come across recently.

Thanks Luke Surl.com

Question 1: What actually IS fatigue and what are the related commonly held beliefs by doctors and their patients?

Fatigue is “extreme tiredness resulting from mental or physical exertion or illness.” The precipitating factors for patients to present for consultation are frequently related to stressful life events (which account for 2/3rds of fatigue complaints). 3/4’s of all patients presenting with fatigue will only have an isolated single appointment and will not represent for follow up, and approximately half will be given the diagnosis of ‘tiredness’. Half of all presenting patients will have on average four tests ordered on by their GP. Interestingly, the average patient is female, 34-39yo, and they present to a female GP.

The most commonly ordered tests include: FBC 45%, TSH 32%, Ferritin 21%, LFTs 17%, EUC 15%, and BSL 11%

It is thought that a major reason doctors order tests to relieve their own, and their patients, anxieties. A recent systematic review however, has shown that ordering tests for symptoms with a low pre-test probability of serious illness (as is the case with fatigue) does little to reassure patients or decrease their anxiety

Most patients present because of a precipitating factor. These are primarily stressful life events (underlying about two thirds of fatigue complaints)— for example, work disputes, family problems, bereavement, or financial difficulties.

It has been shown that a limited set of blood tests (haemoglobin, erythrocyte sedimentation rate [ESR], BSL and thyroid stimulating hormone [TSH]) is as useful in diagnosing serious pathology as a more extensive set of investigations; and this will be discussed further below.

Many guidelines for the management of fatigue recommend an initial 4-week postponement of test ordering and subsequent restricted investigation. Delaying investigation has been shown not to affect patient satisfaction or anxiety levels.

Finally, GPs tend to perceive the cause of tiredness as psychological, whereas people with tiredness are more likely to perceive the cause as physical. Don’t trivialise their fatigue – it is a real problem even if it is likely to be self resolving.

Question 2: Is there a test or questionnaire for fatigue?

There appear to be many different types of fatigue tests available (MFIS, FSS, FACIT, Fatigue questionnaire, Short form-36 Vitality… etc.) An old adage by a great mentor of mine once said ‘if there are many ways to do something it means that probably none of them is the best’. Also, as for when or where an Australian GP would use these I am uncertain. If a check-list had a list of red flags this might be beneficial but I could not find one for this. Better off taking a history then!

Question 3: What are the red flags and key issues to consider when a patient presents with fatigue?

NPS Medicinewise – has a great resource listing red flags – Link

RACGP article on fatigue (2014) also has a great table with red flags – Link

While the red flags are important, we must also point out there are times where fatigue may be somewhat appropriate. For example, in pregnancy, children or adults recovering from chemotherapy, or patients with chronic illness. These patients need our understanding and can benefit from small lifestyle changes to improve their energy levels and subsequent health.

Thanks to Luke Surl

Question 4: Tips for history taking:

Remember to elicit what a patient means by ‘fatigue’. Often, just listening and not interrupting your patient initially can give you the answer.

It is important to ask, and acknowledge, the impact of fatigue on their life. This may be affecting their sleep, relationships, and workplace.

Remember to take a full history. Unfortunately, these undifferentiated problems can be the most time consuming as they require a full extensive history to elicit possible causes.

Dr John Murtagh’s famous seven masquerades can be very helpful in these undifferentiated problems. Remember to consider: depression, diabetes, drugs, anaemia, thyroid disorder, spinal dysfunction and urinary tract infections. I would add considering also asking about safety in the home (domestic violence) and about alcohol use (arguably – a drug). Really important other causes of fatigue which can have dire consequences if overlooked.

I really like asking a patient where I cannot find a cause “when was the last time you took some time to yourself or went on a relaxing holiday?” (not a “see as much as we can” type holiday). It is often a nice segway to talking to patients about non physical causes of fatigue such as stress and burn out.

Question 5: Can I wait before ordering any tests?

The brilliantly named “VAMPIRE” trial (VAgue Medical Problems In REsearch) run by the Dutch College of General Practitioners looked at postponement of blood tests until 4 weeks after initial presentation. Amusingly, because there were so few people who actually re-presented at 4 weeks in their trial, they were unable to give a statistical answer because of loss of these patients to follow up! They did suggest there were very little differences in the positive test result for blood tests between initial bloods or the 4 week group (though obviously those who would have got a negative result were not unnecessarily tested).

Question 6: What ‘screening’ tests are MOST LIKELY to yield useful clinical information in evaluation of fatigue?

NPS Medicine wise summarises this well in 3 key points: 3% of patients you order tests on will have a somatic cause, repeated testing will yield more false positives, and the majority will self resolve.

First, aim for targeted testing. For example, if a patient presents with weight loss, night sweats, bowel habit change, and PR blood loss – please don’t order the fatigue battery tests – just perform your basic bloods (FBC, Fe studies, ESR) for ?Colon cancer and refer for colonoscopy.

If you perform a full history and examination (remember, a patient seeing a doctor perform a thorough and professional exam and finding nothing CAN be therapeutic) and find no focus, then NPS suggests:

Performing a urine dipstick and fingerprick BSL.

FBC , TSH, Serum Ferritin (not iron studies – which would involve transferrin etc.)

Some guidelines also suggest ordering an ESR. (I am currently writing an article on CRP vs ESR so stay tuned!)

Thanks to XKCD

Question 7: Is there any evidence of any treatment for patients with fatigue but no cause found?

There are several steps you can consider with treatment of fatigue. If not ordering tests, you need to help the patient feel that their fatigue is acknowledged. It is important you highlight that you are planning to help them recover.

UpToDate suggests a stepwise approach to fatigue: 1. Accomplishing activities of daily living 2. Returning to work 3. Maintaining interpersonal relationships 4. Daily exercise

Antidepressants: Only if evidence of depression

Cognitive Behavioural Therapy (CBT): Can be beneficial if fatigue ongoing. This is a common therapy for patients with chronic fatigue and problem solving ways of dealing with fatigue and the patients cognitions and beliefs around their fatigue.

Graded Exercise Therapy (GET): Slow reintroduction of exercise sometimes in consultation with a physiotherapist / exercise physiologist

Sleep hygiene information: Can be very beneficial if sleeping is a significant component of fatigue. Patients often need to control daytime sleepiness and establish appropriate and ongoing sleeping patterns

Patient Education: Can help patients understand their own fatigue, normalise the issues, and possibly begin to build insight into non-organic causes of their fatigue.

Question 8: What patient resources can I use to print out for my patients?

Brilliant handout from NPS – Link

Better health channel has a good handout on simple things people can do to increase their energy levels – Link

Thanks to Webdonuts

Question 9: What about chronic fatigue syndrome or fibromyalgia?

These are ‘rule out’ diagnoses (once you have ruled everything else out). They are difficult to define, difficult to study, and difficult to treat. However, they are expected to be medical conditions with a currently undetermined cause. They could fill a full FOAM4GP Map themselves – so I will currently link to reputable information below and may tackle these further in the future.

Chronic fatigue syndrome (CFS) – MJA 2002 Guideline – Link

Fibromyalgia – AFP article 2013 – Link

Question 10: Time for the fun stuff! What diagnoses do some patients come in ‘insisting’ is the cause for their fatigue; which ‘may not’ be evidence based?

Adrenal Fatigue

Pyroluria

Lyme Disease

Ok, so Rob after looking at all this, will it change what you do in clinic?