Fatigue

Key points

• Fatigue is common in advanced cancer and end-stage organ failure, as part of a constellation of constitutional symptoms which includes cachexia and anorexia. It is often associated with elevated c-reactive protein (CRF) and other inflammatory markers. In this context it is prognostically significant.
• Fatigue may also be related to treatments such as chemo- and radiotherapy, to deconditioning, and to adverse effects of medications.
• It is a frustrating symptom. Fatigue is often misinterpreted by patients and/or caregivers as depression, giving up, or unfitness.
• Maintenance of physical activity is important for wellbeing and is helpful in earlier stages of disease, but has less benefit as the disease progresses.
• 'Palliative rehabilitation' is a useful concept, which allows for optimising a patient’s function and working towards positive goals, even in the context of progressive disease and fatigue.

Assessment

• A huge variety of concepts are used by patients to describe the experience of fatigue, including words like 'exhausted', 'heavy', 'slow', 'weak', 'light-headed', or 'dizzy'.
• Use a simple performance status measure eg, Eastern Cooperative Oncology Group Performance Status (ECOG) or Australia-modified Karnofsky Performance Scale (AKPS) to quantify activity levels. Ask how much time the they spend resting each day - is it more or less than half the day?
• Look for potentially reversible comorbidities and treat as clinically appropriate. Consider the impact of any poorly controlled symptoms such as dyspnoea, depression or pain.
• Assess the psychological effect of reduced activity levels, including the extent to which it impairs the patient’s normal coping strategies (eg, ask if their relaxation usually involves sport or physical activity).

Approach to management

• Helpful strategies for managing fatigue include energy conservation, optimisation of physical activity around the most valued priorities, psychosocial interventions, and management of comorbidities (eg, pain, insomnia, depression).
• Referral to allied health (occupational therapy, physiotherapy, counselling) can greatly improve quality of life of patients with fatigue. Standard gym or exercise classes may be inappropriate.
• Pharmacological management is controversial. Short term dexamethasone may be of benefit in selected patients, while psychostimulants have been shown to be ineffective. Both have significant adverse effects.
• Transfusion may sometimes help in symptomatic anemia, but if offered should be as a therapeutic trial with a functional outcome, because it often fails to provide significant or sustained benefits.
• Reassess regularly and support patients and families to modify their goals as appropriate.