Week 6 Non-organic fatigue Flashcards
1
Q
A
2
Q
what is fatigue
A
A state of physical or mental exhaustion with difficulty or inability to initiate or maintain activity. It can compromise on a person’s mental alertness, physical motor skills, judgement and decision-making.
3
Q
time line of fatigue? cause?
A
Fatigue is common, usually short-lived, and often related to some identified cause
4
Q
what does fatigue effect?
A
Fatigue can impact an individual’s work performance, and family and social relationships
5
Q
how many patients in family medicine present with fatigue
A
1/5
6
Q
sex differences in describing fatigue
A
- Men typically say they feel “tired”
- Women say they feel “depressed” or “anxious”
7
Q
what is the lifetime prevalence of fatigue (>2 weeks)
A
25%
8
Q
common causes of fatigue
A
overexertion, deconditioning, viral illness, upper respiratory tract infection, anemia, lung disease, medications, cancer, depression, and surgery
9
Q
fatigue from recovering from surgery
A
6-12 weeks of fatigue is not unusual during recovery from even minor surgery
10
Q
what is idiopathic fatigue
A
unknown cause
11
Q
how many patients with psychaitric symptoms have fatigue
A
75%
12
Q
what makes up the greatest proportion of fatigue cases?
A
- Fatigue of unknown cause (idiopathic fatigue) or related to psychiatric illness is a greater proportion of cases compared to fatigue due to physical illness, injury, alcohol, or medications
- No etiology can be identified in 1/3 of cases
13
Q
fatigue and sleep
A
Sleep disorders, especially Obstructive Sleep Apnea and insomnia
syndromes, are common in patients with fatigue
14
Q
fatigue and health outcomes
A
Fatigue in older adults increases the risk of developing negative health outcomes (mortality OR, 2.14), disabilities in basic activities of daily living (OR, 3.22), or the occurrence of physical decline (OR, 1.42)
15
Q
Acute fatigue
A
lasts ≤ 1 month and is relieved with rest
16
Q
subacute fatigue
A
lasts between 1 to 6 months
17
Q
chronic fatigue
A
lasts ≥ 6 months and is not relieved with rest
18
Q
acute vs subacute vs chornic fatigue
A
acute- <1 month, relieved with rest
subacute- 1-6 months, relieved with rest
chronic- >6 months and not relieved with rest
19
Q
secondary fatigue
A
due to an underlying medical condition; may last ≥ 1 month but generally lasts < 6 months
20
Q
physiologic fatigue
A
caused by a lifestyle imbalance in routines of sleep, exercise, diet, or other activity not attributed to an underlying medical condition; and is alleviated with rest
21
Q
secondary vs physiologic fatiguer
A
secondary- from underlying medical condition
physiologic- lifestyle imbalance
22
Q
3 major components of fatigue
A
- Generalized weakness (difficulty in initiating activities)
- Easy fatigability (difficulty in completing activities)
- Mental fatigue (difficulty with concentration and memory)
23
Q
sleepiness vs fatigue
A
sleepiness: Temporarily aroused by activity, at least in the short-term
fatigue: intensified by activity
sleepiness: better after a nap
fatigue: Report lack of energy, mental exhaustion, poor muscle endurance, delayed recovery after physical exertion, nonrestorative sleep
24
Q
sleep quality and quantity evaluation
A
- What time do you go to bed?
- What time do you fall asleep?
- After you lie down, how long does it take you to fall asleep?
- Do you leave the TV or radio on as you are attempting to fall asleep?
- After falling asleep, what time do you first wake up? What awakens you?
- How often do you use the bathroom at night?
- Do you have pain at night?
- How long does it take you to return to sleep after waking up? * What time do you get out of bed in the morning?
- Do you feel rested in the morning?
- Do you nap during the day?
- What medications do you take?
- Do you drink alcohol or use other drugs? * Do you exercise? What time of day?
25
epworth sleepiness scale
fatigue severity scale
xx
26
chronic fatigue
> 6 months
27
prevalence of chronic fatigue
gender or age?
5 – 40 per 100,000
Chronic fatigue occurs in all age groups, including children
* Women, minority groups, and the socioeconomically disadvantaged have a higher prevalence of chronic fatigue
28
groups with highest prevalence of chronic fatigue
women, minorities, low SES
29
how many patients with chronic fatigue dont meet the criteria for "chronic fatigue syndrome" – but share many similarities and have only a slightly better prognosis
2/3
30
resolution and improvement in chronic fatigue
* 64% of patients have limited improvement
* Only 2% of patients report complete long-term resolution of symptoms
31
poor prognosis in chronic fatigue
* Patients whose symptoms worsen for longer than 24 hours after physical exertion have a poor prognosis
32
what % of patients with chronic fatigue have a medical
or psychological explanation
70%
33
predominant causes of chronic fatigue
* Psychiatric disorders (depression or anxiety) are the
predominant causes
* Approximately 25% of patients have an acute or chronic medical condition that is the cause of their fatigue
34
causes of chronic fatigue
social or personal factors (E.g., home and outside work, poor sleep, interpersonal problems, caregivers to ill family members, financial worries)
* Other studies point to social, geographic, environmental, and genetic factors are contributors to the development of fatigue and depression
35
referral and management of chronic fagtigu
treat underlying condition
adjust meds
follow ups
co-management referral
36
chronic fatigue syndrome is aka
systemic intolerance disease
37
systemic intolerance disease aka
Systemic Exertion Intolerance Disease (SEID), Chronic Fatigue Syndrome (CFS), or Myalgic Encephalomyelitis (ME)
38
why dont use chronic fatigue syndrome label
term “Chronic Fatigue Syndrome” affects patients’ perceptions of their illness, can diminish its seriousness, and promote a misunderstanding of the condition
39
what's wrong with myalgic encephalomyelitis term
misleading because of the lack of evidence for brain inflammation, and myalgia is not a core symptom of the disease
40
why use the term systemic exertion intolerance disease
captures the main characteristic that multiple organ systems are impacted by exertion of any kind (physical, cognitive, emotional) and associated with autonomic, neuroendocrine, and immune dysfunction
41
cause of systematic intolerance disease? what do labs show?
* A complex syndrome of uncertain etiology, causing profound unexplained fatigue
* No physical finding or lab test can be used to confirm the diagnosis
42
how many people does systemic intolerance disease effect globally
17 to 24 million people worldwide – approximately 1% of the population
836,000 to 2.5 million individuals in the U.S.
* In 2014, about 1.4% of the adult Canadians
43
women vs men for systemic intolerance disease
Higher rate in women (1.5 to 2x) verses men
44
highest age group prevalence for systemic intolerance disease
Prevalence is significantly higher between 40 – 70 years of age * Average age of onset is 33
* Has been reported in patients < age 10 and > age 70
45
ethnicity for systemic intolerance disease
Most patients currently diagnosed in the White population – though some studies suggest that the condition is actually more common in minority groups
46
income and systemic intolerance disease
Higher prevalence in low-income verses higher-income and higher- educated cohort, which suggests social risk factors (e.g., stress) in the causation of SEID
47
systemic intolerance disease and all cause mortality
SEID is not associated with increased all-cause mortality, but one study showed a substantially increased risk of completed suicide
* Early diagnosis and prompt treatment are critical to prevent high morbidity and the overwhelming effect on the quality of life
48
epidemiology of chronic fatigue? early life events?
Patients report a greater frequency of childhood trauma and psychopathology, and display higher levels of emotional instability and self-reported stress, compared to individuals who do not have chronic fatigue
49
employment and systemic intolerance disease
Associated with a poorer quality of life, with over half of patients being unemployed
50
emotions and systemic intolerance disease
As with any chronic illness, it is very common for patients to experience depression, stress, and anxiety as they navigate the ongoing challenges that the condition brings to the various aspects of their lives
51
what type of disorder is systemic intolerance disease
biological (NOT psychological)
52
pathogenesis of systematic intolerance disease
* The exact pathogenesis is not fully understood; however, various mechanisms and biochemical changes have been shown to affect immune function, hormonal regulation, and response to oxidative stress, which may play a role in disease progression
* An infectious cause has been proposed, but no causal relationship has been identified to date
53
genetics and systemic intolerance disease
* Twin studies have shown increased familial and genetic predisposition to the condition
* One study observed variability in specific gene expression of patients, particularly post-exercise, affecting metabolic and immune responses (Sapra and Bhandari, 2023)
* Other studies have identified abnormalities in the genes controlling immune modulation, oxidative stress and apoptosis (Kerr, 2018), and DNA methylation (Sapra and Bhandari, 2023)
54
infections and systemic intolerance disease
* Various infectious triggers have been proposed: Epstein-Barr virus (EBV), human herpesvirus (HHV)-6, human parvovirus B19, enterovirus, and human cytomegalovirus
* Anti-HHV06 IgM antibodies and HHV-6 antigens have been detected more commonly in the peripheral blood of patients with SEID, compared to the general population (Sapra and Bhandari, 2023)
55
immune systemic dysrgeulation and systemic intolerance disease
* In patients with SEID, there have been observed alterations in the levels of CD 21+ CD19+ and activated CD5+ cells
* Several studies have described the presence of autoantibodies against nuclear and membrane structures, and neurotransmitter receptors
* Evidence of ongoing inflammation (increased production of proinflammatory interleukins), which can explain the malaise and flu-like symptoms
56
other possible etiological factors of systemic intolerance disaese
* Exposure to toxins, chemicals, pesticides, or heavy metals
* Dysbiosis of gut microbiota
* Muscular biochemical abnormalities
* Trauma/prior stressful life events
* Neuroinflammation
* Alterations in neuroendocrine system (e.g., serotonin transmission, hypocortisolism)
57
diagnostic criteria for systemic intolerance disease
lack of standard criteria
58
primary symptom in systemic intolerance disease as by Oxford
stated fatigue to be the primary symptom, present for at least 6 months and affecting the patient > 50% of the time (severe, disabling, and affecting mental and physical functions)
59
4 major criteria and 3 physical and many minor diagnostic criteria of systemic intolerance disease via CDC, 1994
----Major criteria----
* At least 6 months’ duration
* Does not resolve with bed rest
* Reduces daily activity to < 50%
* Other conditions have been excluded
----Physical criteria----
* Low-grade fever
* Nonexudative pharyngitis
* Lymphadenopathy
----Minor criteria----
* Sore throat
* Mild fever or chills
* Lymph node pain
* Generalized muscle weakness
* Myalgia
* Prolonged fatigue after exercise
* New-onset headaches
* Migratory noninflammatory arthralgia
* Sleep disturbance
* Neuropsychological symptoms (photophobia, scotomata, forgetfulness, irritability, confusion, inability to concentrate, depression, difficulty thinking)
* Description of initial onset as acute or subacute
60
in 2015, what did the institute of medicine diagnostic criteria make the 3 symptoms of systemic intolerance disease
and what other 1/2 criteria must they have
1. Substantial reduction/impairment in the ability to engage in pre- illness levels of occupational, educational, social, or personal activities. This persists for > 6 months and is accompanied by fatigue that is often profound and of new/definite onset (not lifelong), and is not substantially alleviated by rest.
2. Post-exertional malaise lasting > 24 hours
3. Unrefreshing sleep
AND at least one of:
1. Cognitive impairment (in short-term memory, concentration)
2. Orthostatic intolerance (lightheadedness, dizziness, and headache that worsen with upright posture and improve with recumbency)
61
criteria of systemic intolerance disease 2015
1. reduced/impaired functioning for > 6 months
2. post exertion malaise >24 hours
3. unrefreshing sleep
1 of 2
1. cognitive impairment
2. orthostatic intolerance
62
prognosis of systemic intolerance disease
unknown; recovery unknown, treatment is more to manage (no cure)
63
hypothesis for cause of systemic intolerance disease
* Current research is attempting to identify a specific biomarker that may play a role in the pathophysiology of SEID
* As patients with SEID possess a particular alteration in metabolism, mitochondrial dysfunction is also hypothesized to be the root cause
64
better prognosis in systemic intolerance disease
* Favourable outcomes are associated with less severity of fatigue at baseline, a better sense of control over symptoms, and the absence of attribution to a physical cause (Sapra and Bhandari, 2023)
* Patients who believe that their symptoms are related to modifiable factors (e.g., workload, stress, coping strategies, depression) are more likely to recover than those who emphasize external factors (e.g., viral infection)
* In one study, 90% of patients seeking support for their chronic fatigue reported greatest satisfaction when physicians provided reassurance and explanation of how physical and psychological factors are linked to psychosocial management plans
65
goals of treatment for systemic intolerance disease
-prevent: healthy and active
-good relationship w dr
-relieve symptoms to maximize quality of life
-support groups
* Patient education on self-management (e.g., pacing exercise to avoid post-exertional malaise or deconditioning), setting stepwise realistic goals, and coming to a shared understanding and identification of triggers (i.e., lifestyle, social and environmental factors)
66
what type of symptom presentation makes patients think dr are more responsive to
Many patients perceive that medical practitioners and staff are more responsive to them when they describe physical symptoms
67
what is important for dr to do
Important to provide a supportive environment where patients are validated in their experience and can openly discuss their condition
-follow ups and regular viists
68
best treatment
* Patients benefit from a comprehensive multidisciplinary approach to provide psychological support and focused treatment on comorbid symptoms (insomnia, mood disorders, pain, memory and concentration difficulties)
* The clinician’s attentiveness in listening and providing explanatory responses can be extremely important to reassure the patient
* All patients should be encouraged to engage in normal activities as much as able to, and be reassured that full recovery is eventually possible in most cases
69
when to refer in systemic intolerance disease
* Secondary organic causes of fatigue to be managed at the specialist level
* Infections that are not responsive to standard treatment
* Difficult to control hyper- or hypothyroidism
* Severe psychological illness
* Malignancy
70
detailed health history for fatigue
* Develop a clear picture of the patient’s fatigue, including
onset, duration, and exacerbating factors
* Inquire about associated symptoms to explore possible undiagnosed medical illness(es)
* Obtain a thorough medication history
* Obtain a detailed sleep history
71
what to screen for in fatigue?
* Screen for underlying psychiatric disorders (e.g., depression, anxiety, substance abuse)
* Explore psychosocial issues (e.g., home life, occupation)
* Rule out any “must not miss” diagnoses (e.g., anemia, hypothyroidism, diabetes mellitus)
72
what opened ended questions to ask in the case of fatigeu
* Tell me about your fatigue. What do you mean when you say you are fatigued?
* Tell me about your energy level. Has the fatigue changed your lifestyle?
* Tell me about any new or unusual circumstances in your life when you first noted the fatigue.
73
effective interviewing with fatigue
* Distinguish fatigue from other symptoms, such as excessive somnolence (daytime sleepiness) or shortness of breath
* Determine the impact of the patient’s fatigue on the patient’s lifestyle and social and occupational function
* Identify possible precipitating events
74
quality of the fatigue?
* Has your fatigue affected your ability to perform responsibilities at work or at home?
* Have you stopped exercising?
* Do you become more weak or tired with exertion?
* Do you become short of breath with exercise?
75
time course of fatigue
* Can you remember exactly when your fatigue started? * How long have you been experiencing fatigue?
* Do you feel more fatigued in the morning?
* Do you feel tired all day?
* Do you feel more fatigued at the end of the day? * Did your fatigue begin following surgery?
* Have you ever had radiation therapy?
76
alarm symptoms in fatigue
* Fever, night sweats
* Weight loss
* Sore throat
* Lymph node enlargement * Shortness of breath
* Palpitations
* Joint pain, stiffness
* Back pain; diffuse bony pain * Excessive thirst, urination
* Abdominal pain * Jaundice
* Chest pain
* Diarrhea
* Rectal bleeding
* Double vision, difficulty speaking or chewing, pain with chewing
* Sleep disturbance
77
modifying factors in fatigue
* Does your fatigue only happen with exertion?
* Is your fatigue unrelated to physical effort?
* Do you feel better on the weekends?
* Does your fatigue improve after a good night’s rest?
78
personal/social issues to ask in case of fatigue
* Have you had more stress in your life lately? Have there been any problems in your family? Have you had more pressure at work? Have you experienced a death of a close friend or relative?
* When is the last time you had a vacation?
* Do you use alcohol (CAGE screening)?
* Do you use illicit drugs?
* Do you have more than one sexual partner?
* Have you recently traveled to developing countries?
* What medications do you take on a regular basis (prescribed/OTC)? Have you recently started taking any new medications?
79
psychogenic illness questions to ask fro fatigue
* How would you describe your mood?
* Have you been feeling sad, blue, or down? Have you lost interest in or avoided social activities? Have you experienced loss of self- esteem?
* Have you been more irritable or angry?
* Do you often feel agitated? Are you constantly worried about something?
* Do you experience sudden episodes of intense anxiety? If so, have you experienced chest pain, palpitations, and sweating?
* Has your appetite been affected? Have you had more difficulty with sleep?
80
differentials for fatigue chart SLIDE 63 ****Very important
psychological (depression, anxiety, eating disorder)
gastrointestinal (IBD)
pharmacological (opioids, antidepressants)
neurologic (parkinsons, multiple sclerosis)
sleep apnea
endocrine (diabetes, hypothyroids, cushing)
infection (HIV, hepatitis)
cardiopulmonary (COPD, CHF)
rheymatoligc (Lyme, SLE)
hematologic (anemia, leukemia
oncologic
ETTCCCCCC
81
what does differential diagnosis so for SEID
its a diagnosis of exclusion
82
lab findings for chronic fatigue
labs are normal
83
physical exams for fatigue
* Vitals (BP, T, HR, RR)
* Oropharyngeal Exam
* Lymph node assessment
* *Additional physical exams based on patient intake and your top diagnoses and must-not-miss diagnoses
84
how much do lab results for fatigue affect management
Lab results affect management in only 5% of patients; if the initial results are normal, then repeat testing is generally not indicated
85
if initial labs for fatigue are normal should you repeat
no
86
labs for fatigue
* CBC
* ESR
* Thyroid function
* Pregnancy test for women of childbearing age
* Urinalysis
* Chemistry panel (glucose, electrolytes, blood urea nitrogen BUN, creatinine, calcium), including kidney and liver function tests
87
algorithm for fatigue SLIDE 70
history and physical exams --> mental status exam --> lab testing --> if longer than 6 months and have 4 symptoms (pharyngitis, tender lymphs, myalgias, polyarthralgia, new headaches, bad sleep, postexertional malaise, memory or concentration impairment)
88
most additional tests aren't useful unless think specific medical condition; what tests to do if indicated
* Serum cortisol
* Antinuclear antibody, Rheumatoid factor, Immunoglobulin levels
* Lyme serology
* HIV antibody, Tuberculin skin test
* Toxicology screen
* Chest radiography
* Brain MRI
* Echocardiography
* Electrodiagnostic testing
* Polysomnogram
89
2 types of electrodiagnostic testing
* Nerve Conduction Study
* Electromyography
90
what to do to assess for nerve disorders
* Peripheral nerve disorder
* Myopathy
* Motor neuron disease (MND)
* Neuromuscular junction disorders
* Muscle pain, numbness, cramps, spasm, and abnormal twitching * Traumatic injury affecting nerves and muscles
91
fatigue algorithm on slide 77
x
92
common causes of fatigue
* Psychological/psychosocial causes are very common, as are sleep disturbances and medication impacts
93
how common is SEID
SEID is a rare cause of persistent fatigue; other explanations should be carefully excluded
