Case Study: The Short Fatigue
Fatigue is a multidimensional symptom containing a cognitive (tiredness) and Physical (weakness) element or the patient may describe it as just having a lack of energy. It has a negative impact on quality of life. If a patient complains of tiredness in end stage COPD; one just has to discern if this is cognitive, leading to listlessness, low mood, loss of concentration and sleep disturbance or a physical weakness affecting ADL’s.
The professional team starts with impeccable assessment including history, examination and laboratory testing: The Brief Fatigue Inventory is a straightforward diagnostic tool and can be used to assess the severity of the fatigue. It is important to determine the presence of potentially treatable causes eg anemia, chronic pain, thyroid disorder, infection, …show more content…
sleep disorder, anorexia, cachexia or concurrent medications’ side effects. Physical causes include the direct consequences of COPD, such as diminished oxygen-carrying capacity or oxygen transfer in the lungs and Cor Pulmonale (a sequelae of COPD). When doing Laboratory testing, the HCW needs to do the following tests in order to rule out Co-morbidities for Fatigue : FBC, Vit B12, TSH, Electrolytes and CRP.
Psychologic causes of fatigue include anxiety and depression which can be elicited with screening questionaires or obtained from collateral history. This can be addressed with medication and counseling . In this dimension it is important to view the patient and family as a unit.
The management of fatigue with an unidentified underlying treatable cause needs Patient and family education. For example, family members may interpret fatigue to mean that the patient is “giving up,” when the symptom is actually beyond the patient's control. To decrease pressure on the patient to be more energetic, the physician may need to give the patient “permission” to rest. The patient should be encouraged to try light aerobic exercise as tolerated, take short naps, eat more frequently, keep a diary of energy levels, experiment with self relaxation, and apply sleep hygiene.
The family needs to know and understand the disease process, trajectory and true limitations of the patient.
The care burden should be managed and outside resources utilized where help is needed.
Medications that could be used are corticosteroids and psychostimulants, they are sometimes beneficial adjuncts to non pharmacologic interventions directed at relieving fatigue in patients nearing the end of life. Dexamethasone (Decadron), 2 to 20 mg taken orally once daily in the morning, can bring about feelings of well-being and increased energy, although these effects may diminish after the drug has been used for four to six weeks. In the end-of-life setting, the long-term side effects of morning doses of corticosteroids are usually not an issue. Of the psychostimulants, methylphenidate (Ritalin) is most commonly prescribed, although dextroamphetamine (Dexedrine) can also be used.
Antidepressants may be considered even if there is no clinical depression when the fatigue does not respond to non-pharmacologic interventions, corticosteroids or psychostimulants. In addition to elevating mood, antidepressants (particularly selective serotonin reuptake inhibitors) can have an energizing
effect.
Treatment for fatigue may be less successful than treatment for other symptoms at the end stage of COPD and needs to be individualized and often re evaluated. The HCW needs to discern where it is applicable, and discontinue where it is detrimental. In the preterminal phase Fatigue is the body's way of shielding the patient from an otherwise traumatizing physical and psychological experience. In other words it is a protective mechanism not to be removed.
References:
• Radbruch L, Strasser F, Elsner F, Gonçalves JF, Løge J, Kaasa S, et al. Fatigue in palliative care patients -- an EAPC approach. Palliative medicine. 2008;22(1):13-32 20p.
• ROSS D, ALEXANDER C, Am Fam Physician. 2001 Sep 1;64(5):807-815.
• Mendoza TR, Wang XS, Cleeland CS, Morrissey M, Johnson BA, Wendt JK, et al. The rapid assessment of fatigue severity in cancer patients: use of the Brief Fatigue Inventory. Cancer 1999;85:1186–96.
The professional team starts with impeccable assessment including history, examination and laboratory testing: The Brief Fatigue Inventory is a straightforward diagnostic tool and can be used to assess the severity of the fatigue. It is important to determine the presence of potentially treatable causes eg anemia, chronic pain, thyroid disorder, infection, …show more content…
sleep disorder, anorexia, cachexia or concurrent medications’ side effects. Physical causes include the direct consequences of COPD, such as diminished oxygen-carrying capacity or oxygen transfer in the lungs and Cor Pulmonale (a sequelae of COPD). When doing Laboratory testing, the HCW needs to do the following tests in order to rule out Co-morbidities for Fatigue : FBC, Vit B12, TSH, Electrolytes and CRP.
Psychologic causes of fatigue include anxiety and depression which can be elicited with screening questionaires or obtained from collateral history. This can be addressed with medication and counseling . In this dimension it is important to view the patient and family as a unit.
The management of fatigue with an unidentified underlying treatable cause needs Patient and family education. For example, family members may interpret fatigue to mean that the patient is “giving up,” when the symptom is actually beyond the patient's control. To decrease pressure on the patient to be more energetic, the physician may need to give the patient “permission” to rest. The patient should be encouraged to try light aerobic exercise as tolerated, take short naps, eat more frequently, keep a diary of energy levels, experiment with self relaxation, and apply sleep hygiene.
The family needs to know and understand the disease process, trajectory and true limitations of the patient.
The care burden should be managed and outside resources utilized where help is needed.
Medications that could be used are corticosteroids and psychostimulants, they are sometimes beneficial adjuncts to non pharmacologic interventions directed at relieving fatigue in patients nearing the end of life. Dexamethasone (Decadron), 2 to 20 mg taken orally once daily in the morning, can bring about feelings of well-being and increased energy, although these effects may diminish after the drug has been used for four to six weeks. In the end-of-life setting, the long-term side effects of morning doses of corticosteroids are usually not an issue. Of the psychostimulants, methylphenidate (Ritalin) is most commonly prescribed, although dextroamphetamine (Dexedrine) can also be used.
Antidepressants may be considered even if there is no clinical depression when the fatigue does not respond to non-pharmacologic interventions, corticosteroids or psychostimulants. In addition to elevating mood, antidepressants (particularly selective serotonin reuptake inhibitors) can have an energizing
effect.
Treatment for fatigue may be less successful than treatment for other symptoms at the end stage of COPD and needs to be individualized and often re evaluated. The HCW needs to discern where it is applicable, and discontinue where it is detrimental. In the preterminal phase Fatigue is the body's way of shielding the patient from an otherwise traumatizing physical and psychological experience. In other words it is a protective mechanism not to be removed.
References:
• Radbruch L, Strasser F, Elsner F, Gonçalves JF, Løge J, Kaasa S, et al. Fatigue in palliative care patients -- an EAPC approach. Palliative medicine. 2008;22(1):13-32 20p.
• ROSS D, ALEXANDER C, Am Fam Physician. 2001 Sep 1;64(5):807-815.
• Mendoza TR, Wang XS, Cleeland CS, Morrissey M, Johnson BA, Wendt JK, et al. The rapid assessment of fatigue severity in cancer patients: use of the Brief Fatigue Inventory. Cancer 1999;85:1186–96.