There is no universal definition of tiredness/fatigue, but most experts include a lack of, or decreased, energy and physical or mental exhaustion and may be caused by one or more of the following:
Psychological or psychosocial causes — such as depression, anxiety, loss, and stress.
Physical causes — such as anaemia, diabetes mellitus, glandular fever, or malignancy.
Physiological causes — such as pregnancy, breastfeeding, inadequate rest or sleep, and excessive exercise.
In a postal survey of around 15,000 adults in the UK, 10–18% reported current tiredness/fatigue that had lasted 1 month or longer. However, the methodology of asking people directly about tiredness may lead to high self-reported rates. Annually, 1.5% of people in the UK consult their GP with a new symptom of tiredness/fatigue. Observational studies have consistently shown that 5–7% of people attending primary care have a primary complaint of fatigue.
Risk factors for tiredness/fatigue as a symptom or presenting complaint include: female sex, lower socioeconomic status — a large French study reported that people in lower social classes were less likely to be diagnosed as fatigued, but they were more likely to report symptoms of fatigue, comorbidities — both physical illness and mental health problems.
In primary care, between a third and a half of people with tiredness/fatigue as a major or concurrent symptom recover within 1 year. Almost three-quarters of people presenting with fatigue do not require further follow up, suggesting a high rate of spontaneous resolution.
Factors associated with an increased likelihood of recovery, or with faster recovery, include: deduced severity of fatigue or shorter duration of fatigue, no expectation of fatigue becoming chronic, perception of better general health, lower levels of pain, no carer responsibilities, good social support, better mental health, willingness to attribute fatigue to psychological factors, male sex.
Contents
History
Ask what the person means by tiredness or fatigue. Sleepiness is a separate issue and may indicate sleep apnoea or another sleep disorder. Weakness may suggest a neuromuscular cause. Ask about the onset, duration, severity, and precipitating factors; the effect of sleep, rest, and exercise; and the impact on activities. Onset is typically sudden with infection, myocardial ischaemia, toxins or drugs, and post-traumatic stress. Onset is usually gradual in uraemia, heart failure, liver failure, diabetes, hypercalcaemia, hypothyroidism, electrolyte abnormalities, anaemia, and depression. Persistent fatigue that is worse in the morning may suggest depression.
Take a sleep history. Ask about sleep quality, quantity, patterns, sleep hygiene measures, snoring, witnessed sleep apnoea, nocturia, and restless legs
Take a lifestyle and psychosocial history. Ask about stress and stressful life events, work, rest, recreation, exercise, quality of personal relationships, domestic violence, illicit drug use, diet, and alcohol consumption, and whether the person has carer responsibilities. Explore the possibility of carbon monoxide poisoning.
Ask about and screen for the presence of a depressive illness or an anxiety disorder.
Consider co-morbid conditions such as allergies, asthma, chronic obstructive pulmonary disease (COPD), and heart failure that may cause fatigue.
Review the person’s medication, including over-the-counter drugs, herbal remedies, and medicines purchased on the internet. Tiredness may be caused by many drugs, including sedatives/hypnotics, antidepressants, muscle relaxants, opioids, anti-hypertensives, and antihistamines.
Ask about other clinical features that may suggest an underlying condition. Weight loss or gain may suggest malignancy, Addison’s disease, diabetes mellitus, or thyroid dysfunction. Fever or night sweats may suggest malignancy, or infections such as acute hepatitis or active tuberculosis. Muscle or joint pain and/or chronic pain may suggest connective tissue disease. Muscle or joint pain, headache, sore throat, difficulty with memory or cognition, and chronic pain may suggest chronic fatigue syndrome. Travel, insect or tick bites, and skin rash may suggest tropical infections or Lyme disease.
Determine from the person’s history if they may be at risk of HIV, hepatitis B or C, or tuberculosis. Consider whether investigations are needed to exclude an underlying cause using clinical judgement.
Exclude red flag symptoms:
- Significant unintentional weight loss (5% of body weight over 6-12 months).
- Lymphadenopathy suggestive of malignancy (for example, a lymph node that is non-tender, firm or hard, larger than 2 cm, progressively enlarging, supraclavicular, or axillary).
- Any other symptoms and signs of malignancy. For example: haemoptysis, dysphagia, rectal bleeding, breast lump, postmenopausal bleeding.
- Localizing/focal neurological signs suggestive of neurodegenerative conditions such as brain tumour or multiple sclerosis.
- Carbon monoxide poisoning.
Diagnostic criteria
In adults, suspect chronic fatigue syndrome (CFS) if both of the following sets of criteria are met:
The person has fatigue that has all of the following features:
- Persistent (for 4 months or longer) or recurrent.
- New or had a specific onset (that is, not lifelong).
- Unexplained by other conditions (including body mass index greater than 40 kg/m2, although this does not rule out CFS).
- Has resulted in a substantial reduction in activity level.
- Characterized by post-exertional malaise and/or fatigue (typically delayed, for example by at least 24 hours, with slow recovery over several days).
AND the person has one or more of the following symptoms:
- Difficulty with sleeping (such as insomnia, hypersomnia, unrefreshing sleep, or a disturbed sleep-wake cycle).
- Muscle or joint pain that is multi-site and without evidence of inflammation. Headaches.
- Painful lymph nodes without pathological enlargement.
- Sore throat.
- Cognitive dysfunction (such as difficulty thinking, inability to concentrate, impairment of short-term memory, and difficulties with word-finding, planning/organizing thoughts, and information processing).
- Worsening symptoms upon physical or mental exertion.
- General malaise or flu-like symptoms.
- Dizziness or nausea.
- Palpitations in the absence of identified cardiac pathology.
The diagnosis of CFS should be reconsidered if none of the following features are present:
- Post-exertional fatigue or malaise.
- Cognitive difficulties.
- Sleep disturbance.
- Chronic pain.
Investigations
Arrange the following routine investigations, particularly if tiredness has persisted for one month or longer: FBC, ESR or CRP, LFTs, U&Es, TSH, random glucose/HbA1c, IgA. Consider additional tests depending on the history: bone biochemistry, vitamin D level if at risk of deficiency, monospot test, HIV test, hepatitis serology, CXR and sputum samples.
Consider the following investigations if the symptoms have been present for 3 or more months:
urinalysis, bone biochemistry, CK, and if the history is indicative Borreliosis (Lyme disease) and other infections such as Epstein-Barr virus or Cytomegalovirus.
Management
Treat the underlying cause if this is known. For all people with persistent unexplained fatigue, including those with suspected chronic fatigue syndrome (CFS) who have not yet received specialist assessment:
- Offer an understandable explanation for tiredness/fatigue that provides links between psychosocial and physical factors.
- Identify and address modifiable psychological, social, and general health factors, including stress, work, personal relationships, chronic pain, and alcohol/drug misuse.
- Offer advice on sleep management.
- Provide general advice on sleep hygiene.
- Discourage excessive sleep and daytime sleeping or naps.
In relation to activity, rest, and relaxation, advise limiting the length of rest periods to:
- 30 minutes at a time, introducing low level physical and cognitive activities (depending on the severity of symptoms), avoiding unsupervised, or unstructured, vigorous exercise and using relaxation techniques.
- Advise a balanced diet.
- Review medication and consider potential contribution of medications such as betablockers, antidepressants, antihistamines and opiate analgesics.
Referral
Refer adults with symptoms suggestive of chronic fatigue syndrome (CFS) to a specialist CFS service if symptoms cannot be managed in primary care:
- Within 6 months of presentation, if symptoms are mild.
- Within 3–4 months of presentation, if symptoms are moderate.
- Immediately, if symptoms are severe.
Consider referring those with persistent, unexplained tiredness/fatigue not meeting the criteria for CFS to an appropriate specialist if any of the following apply:
- There is significant uncertainty regarding the presence of an underlying physical cause.
- The person would benefit from the reassurance of a second opinion or from the thoroughness of a specialist secondary care evaluation, and referral is not likely to reinforce unrealistic beliefs in a physical cause.
- The person may benefit from access to the care delivered by a specialist CFS service, for example, cognitive behavioural therapy or graded exercise therapy.
- A secondary care opinion may be required for occupational reasons, or for assessment of eligibility for disability benefits.
References
https://www.sleepapnea.org/assets/files/pdf/ESS%20PDF%201990-97.pdf
https://cks.nice.org.uk/tirednessfatigue-in-adults https://www.nice.org.uk/guidance/cg53
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