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CMS200 > Week 6 Non-organic fatigue > Flashcards

Week 6 Non-organic fatigue Flashcards

1
Q
A
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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.

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3
Q

time line of fatigue? cause?

A

Fatigue is common, usually short-lived, and often related to some identified cause

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4
Q

what does fatigue effect?

A

Fatigue can impact an individual’s work performance, and family and social relationships

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5
Q

how many patients in family medicine present with fatigue

A

1/5

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6
Q

sex differences in describing fatigue

A
  • Men typically say they feel “tired”
  • Women say they feel “depressed” or “anxious”
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7
Q

what is the lifetime prevalence of fatigue (>2 weeks)

A

25%

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8
Q

common causes of fatigue

A

overexertion, deconditioning, viral illness, upper respiratory tract infection, anemia, lung disease, medications, cancer, depression, and surgery

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9
Q

fatigue from recovering from surgery

A

6-12 weeks of fatigue is not unusual during recovery from even minor surgery

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10
Q

what is idiopathic fatigue

A

unknown cause

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11
Q

how many patients with psychaitric symptoms have fatigue

A

75%

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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
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13
Q

fatigue and sleep

A

Sleep disorders, especially Obstructive Sleep Apnea and insomnia
syndromes, are common in patients with fatigue

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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)

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15
Q

Acute fatigue

A

lasts ≤ 1 month and is relieved with rest

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16
Q

subacute fatigue

A

lasts between 1 to 6 months

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17
Q

chronic fatigue

A

lasts ≥ 6 months and is not relieved with rest

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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

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19
Q

secondary fatigue

A

due to an underlying medical condition; may last ≥ 1 month but generally lasts < 6 months

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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

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21
Q

secondary vs physiologic fatiguer

A

secondary- from underlying medical condition

physiologic- lifestyle imbalance

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22
Q

3 major components of fatigue

A
  1. Generalized weakness (difficulty in initiating activities)
  2. Easy fatigability (difficulty in completing activities)
  3. Mental fatigue (difficulty with concentration and memory)
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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

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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?
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25
Q

epworth sleepiness scale

fatigue severity scale

A

xx

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26
Q

chronic fatigue

A

> 6 months

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27
Q

prevalence of chronic fatigue

gender or age?

A

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

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28
Q

groups with highest prevalence of chronic fatigue

A

women, minorities, low SES

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29
Q

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

A

2/3

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30
Q

resolution and improvement in chronic fatigue

A
  • 64% of patients have limited improvement
  • Only 2% of patients report complete long-term resolution of symptoms
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31
Q

poor prognosis in chronic fatigue

A
  • Patients whose symptoms worsen for longer than 24 hours after physical exertion have a poor prognosis
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32
Q

what % of patients with chronic fatigue have a medical
or psychological explanation

A

70%

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33
Q

predominant causes of chronic fatigue

A
  • 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
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34
Q

causes of chronic fatigue

A

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
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35
Q

referral and management of chronic fagtigu

A

treat underlying condition

adjust meds

follow ups

co-management referral

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36
Q

chronic fatigue syndrome is aka

A

systemic intolerance disease

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37
Q

systemic intolerance disease aka

A

Systemic Exertion Intolerance Disease (SEID), Chronic Fatigue Syndrome (CFS), or Myalgic Encephalomyelitis (ME)

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38
Q

why dont use chronic fatigue syndrome label

A

term “Chronic Fatigue Syndrome” affects patients’ perceptions of their illness, can diminish its seriousness, and promote a misunderstanding of the condition

39
Q

what’s wrong with myalgic encephalomyelitis term

A

misleading because of the lack of evidence for brain inflammation, and myalgia is not a core symptom of the disease

40
Q

why use the term systemic exertion intolerance disease

A

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
Q

cause of systematic intolerance disease? what do labs show?

A
  • A complex syndrome of uncertain etiology, causing profound unexplained fatigue
  • No physical finding or lab test can be used to confirm the diagnosis
42
Q

how many people does systemic intolerance disease effect globally

A

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
Q

women vs men for systemic intolerance disease

A

Higher rate in women (1.5 to 2x) verses men

44
Q

highest age group prevalence for systemic intolerance disease

A

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
Q

ethnicity for systemic intolerance disease

A

Most patients currently diagnosed in the White population – though some studies suggest that the condition is actually more common in minority groups

46
Q

income and systemic intolerance disease

A

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
Q

systemic intolerance disease and all cause mortality

A

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
Q

epidemiology of chronic fatigue? early life events?

A

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
Q

employment and systemic intolerance disease

A

Associated with a poorer quality of life, with over half of patients being unemployed

50
Q

emotions and systemic intolerance disease

A

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
Q

what type of disorder is systemic intolerance disease

A

biological (NOT psychological)

52
Q

pathogenesis of systematic intolerance disease

A
  • 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
Q

genetics and systemic intolerance disease

A
  • 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
Q

infections and systemic intolerance disease

A
  • 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
Q

immune systemic dysrgeulation and systemic intolerance disease

A
  • 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
Q

other possible etiological factors of systemic intolerance disaese

A
  • 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
Q

diagnostic criteria for systemic intolerance disease

A

lack of standard criteria

58
Q

primary symptom in systemic intolerance disease as by Oxford

A

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
Q

4 major criteria and 3 physical and many minor diagnostic criteria of systemic intolerance disease via CDC, 1994

A

—-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
Q

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

A
  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
Q

criteria of systemic intolerance disease 2015

A
  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
Q

prognosis of systemic intolerance disease

A

unknown; recovery unknown, treatment is more to manage (no cure)

63
Q

hypothesis for cause of systemic intolerance disease

A
  • 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
Q

better prognosis in systemic intolerance disease

A
  • 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
Q

goals of treatment for systemic intolerance disease

A

-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
Q

what type of symptom presentation makes patients think dr are more responsive to

A

Many patients perceive that medical practitioners and staff are more responsive to them when they describe physical symptoms

67
Q

what is important for dr to do

A

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
Q

best treatment

A
  • 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
Q

when to refer in systemic intolerance disease

A
  • 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
Q

detailed health history for fatigue

A
  • 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
Q

what to screen for in fatigue?

A
  • 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
Q

what opened ended questions to ask in the case of fatigeu

A
  • 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
Q

effective interviewing with fatigue

A
  • 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
Q

quality of the fatigue?

A
  • 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
Q

time course of fatigue

A
  • 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
Q

alarm symptoms in fatigue

A
  • 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
Q

modifying factors in fatigue

A
  • 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
Q

personal/social issues to ask in case of fatigue

A
  • 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
Q

psychogenic illness questions to ask fro fatigue

A
  • 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
Q

differentials for fatigue chart SLIDE 63 **Very important

A

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
Q

what does differential diagnosis so for SEID

A

its a diagnosis of exclusion

82
Q

lab findings for chronic fatigue

A

labs are normal

83
Q

physical exams for fatigue

A
  • 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
Q

how much do lab results for fatigue affect management

A

Lab results affect management in only 5% of patients; if the initial results are normal, then repeat testing is generally not indicated

85
Q

if initial labs for fatigue are normal should you repeat

A

no

86
Q

labs for fatigue

A
  • 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
Q

algorithm for fatigue SLIDE 70

A

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
Q

most additional tests aren’t useful unless think specific medical condition; what tests to do if indicated

A
  • 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
Q

2 types of electrodiagnostic testing

A
  • Nerve Conduction Study
  • Electromyography
90
Q

what to do to assess for nerve disorders

A
  • 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
Q

fatigue algorithm on slide 77

A

x

92
Q

common causes of fatigue

A
  • Psychological/psychosocial causes are very common, as are sleep disturbances and medication impacts
93
Q

how common is SEID

A

SEID is a rare cause of persistent fatigue; other explanations should be carefully excluded

CMS200 (19 decks)

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