How to Identify and Treat Fatigue in Our Patients with Serious Illness

As palliative care clinicians, we are so focused on helping our patients and their families navigate the choppy waters of a serious illness that we might overlook an important symptom that most patients experience: fatigue.

Fatigue is the subjective feeling of tiredness, weakness, or lack of energy that can affect one’s physical, emotional, and cognitive state. It is the most common symptom in serious illness, affecting more than 80 percent of patients—regardless of their diagnosis. We also know from literature on cancer-related fatigue (CRF) that fatigue has a high prevalence rate and lasts much longer in patients with chronic illnesses.

It’s tricky because fatigue is one of the most underreported and undertreated symptoms—exceeding even pain­—perhaps since it’s difficult to recognize in one’s self. Therefore, fatigue is often undertreated and can take a significant toll on quality of life.

Fatigue has substantial adverse physical, psychosocial, and economic consequences for patients. But, it’s difficult for clinicians to get an accurate assessment of fatigue due to its combined subjective and objective nature. A wide range of factors—biochemical, physiological, psychological, and behavioral—can be responsible, including:

• Direct effects of an illness and/or treatments
• Deconditioning
• Medications (e.g., opioids, benzodiazepines, antihistamines, hypnotics)
• Psychiatric comorbidities (e.g., depression, anxiety)
• Sleep disturbances (e.g., insomnia, sleep apnea)
• Uncontrolled pain, and more

Often the causes are multidimensional, making specific treatment strategies more difficult.

As mentioned, your patient might not report fatigue because it’s hard to recognize (“Of course I’m tired, I’m going through cancer treatment!”). If fatigue isn’t already part of your clinical assessment, we recommend performing a comprehensive history and physical examination to make a diagnosis. If the fatigue is out of proportion with their level of physical activity, it’s a pretty clear sign that it’s present.

In some cases, the cause might not be so clear. You may run labs to identify potential contributing factors (e.g., anemia, electrolyte imbalance), or use scales or assessment tools to index the severity of the fatigue. This helps distinguish it from other common conditions like depression or delirium.

Several scales measure severity based on the physical symptoms of fatigue; a higher score indicates more severe fatigue. Note that they were not developed specifically for seriously ill patients. If you use a scale, choose one that’s most appropriate for your clinical setting and comfort level.

This nine-item questionnaire gauges the severity of a patient’s fatigue; a higher score indicates more fatigue.

This 10-item scale evaluates symptoms of chronic fatigue by asking patients to agree with statements about their experiences ranging from “never” to “always.”

This 20-item scale evaluates five dimensions: general fatigue, physical fatigue, reduced motivation, reduced activity, and mental fatigue.

There are no widely accepted guidelines to help manage fatigue in seriously ill patients. The wide range of causes and association with other comorbidities means we don’t have a solid body of evidence on the most effective interventions.

However, national guidelines from the National Comprehensive Cancer Network (NCCN) and National Institute for Health and Care Excellence (NICE) maintain that clinicians should focus on non-pharmacological interventions, reserving medication for select patients. A Cochrane systematic review confirmed a lack of evidence to support the use of medications for fatigue in patients with CRF.

When starting treatment, evaluate which options are most appropriate for your patient and their specific needs, given other comorbidities. You may divide treatments into two categories: specific and non-specific treatments.

Specific treatments target an identifiable and modifiable cause (e.g., discontinuing the use of a sedating drug, correcting an electrolyte imbalance). Meanwhile, non-specific treatments can help reduce fatigue, optimize function, and promote adaptation when there’s no obvious cause. Current literature suggests employing several of the techniques below to improve quality of life:

By educating your patients and their families about fatigue, you can normalize it to promote acceptance and adaptation. Talk about setting realistic goals, modifying activities, and planning around energy levels.

Exercise can improve fatigue in patients with cancer. Low to moderate aerobic exercise (e.g., walking) has the strongest evidence, and there may be benefits to resistance training. (Aim for 20-30 minutes of per day, at least three days per week).

CBT has been shown to help fatigue in cancer survivors, although there is a lack of randomized-controlled trials. However, some evidence suggests that CBT can interrupt and redirect dysfunctional thoughts and behaviors, which may reduce distress related to poor sleep.

Fatigue can be effectively managed with acupuncture.

Pharmacological therapy should be reserved for specific patients (those who have failed non-pharmacological therapies) due to limited evidence for efficacy. Possible options include a psychostimulant (e.g., methylphedinate and modafinil); corticosteroids; megestrol acetate; antidepressants (e.g., bupropion and paroxetine); or dietary supplements (e.g., ginseng). Make sure there are no interactions with other medications.

Once you have recognized symptoms of fatigue in your patient, conducted a thorough examination, ruled out other comorbidities, and decided on treatments, consider strategies to address potential barriers:

Treatment for fatigue takes time and often requires an interdisciplinary management plan. Be clear with your team about roles and responsibilities.

If your patient is feeling exhausted, it may be hard to motivate them to stick with a fatigue management plan. Motivational interviewing can help.

They may feel too unwell from their primary diagnosis to follow your recommendations about fatigue. Carefully consider the benefits of your fatigue management recommendations, tailoring your plan to the individual patient.

Your patient and their family may not know what fatigue is, or may feel that fatigue is inevitable, questioning why they should address it. Emphasize that fatigue is a symptom—like pain—and strategies exist that can improve quality of life.

Your patient’s illness, or the fatigue, may cause them to feel a loss of self and lack of meaning in their experience. Dignity therapy can help.

You may feel uncomfortable with your knowledge about fatigue and non-pharmacological management strategies.

You may have trouble distinguishing fatigue as a stand-alone symptom compared with other issues (e.g., drowsiness from other treatments, medications, psychological distress). A comprehensive history and physical can help.

Fatigue is prevalent among patients, but often goes underreported, and is difficult to assess and treat. But we can’t let this stand in our way of providing the best possible care—and helping patients live with the best possible quality of life.

Edited by Melissa Baron. Clinical review by Andrew Esch, MD, MBA.