One of the most common patient complaints that I get at my practice during an office visit is fatigue, or tiredness. Usually the patient has been dealing with fatigue for a long while before bringing it to my attention, attempting various remedies and lifestyle changes. I’m often not alerted to it until it has become debilitating for the patient. Fatigue can be a challenging symptom to evaluate and treat for a few reasons. First, fatigue is expressed differently in different people, and a careful discussion is necessary in order to get an accurate description. For instance, fatigue for some people means sleepiness, which would naturally often point to some type of sleep disorder, whether something like insomnia, sleep apnea, restless legs or a condition called periodic limb movement disorder (involuntary jerking of arms or legs during sleep). There is also a very common type of fatigue in which the individual tires more easily than they are used to, but the exhaustion is alleviated by resting for several minutes. This is commonly seen in patients with chronic heart and lung disease. Then there is the type of fatigue which is not alleviated by short-term rest. In these cases, every time the unfortunate patient happens to exert his/herself beyond his usual level of activity, they are on the couch or bed for the next few days, unable to will themselves up from sheer exhaustion. This is commonly seen in conditions like fibromyalgia, chronic fatigue syndrome and autoimmune disease. This kind of fatigue is especially complicated to treat and will be discussed separately in the near future.
Another potential challenge with fatigue, regardless of the nature of the fatigue encountered, is that there are hundreds of potential causes. Certainly, there are more common ones we encounter, but for many patients, finding the cause can be a diagnostic challenge. Many conditions can be discovered with bloodwork, a sleep study, or some type of medical imaging. Others, however, require an astute clinician to take a good history and perform an adequate physical examination. Even a seasoned diagnostician can still have trouble pinpointing the cause, because many illnesses are a diagnosis of exclusion. In other words, you arrive at that particular diagnosis only after you have ruled out other causes.
Third, there are certain disease states in which even when there is a diagnosis, there is often no good treatment for the debilitating fatigue. While it is comforting to arrive at a diagnosis, the patient is still suffering and unable to sustain a good quality of life.
Despite these challenges, not all hope is lost. Many causes of fatigue are reversible and so for any sufferers of fatigue, it is always a good idea to bring it to your physician’s attention. If your physician isn’t taking your complaint seriously, then by all means find someone who will. After a careful history and exam, there will usually be some diagnostic testing ordered and the plan proceeds from there. I will stress that in many cases, in order to treat the underlying cause of fatigue, it will require both work on the part of the medical provider and the patient. The patient may need to make meaningful lifestyle changes, such as adjusting their sleeping habits, losing weight or taking part in an exercise program.
A word about stimulants. I will sometimes have patients requesting stimulants in order to improve fatigue symptoms. The first step in addressing fatigue is to find its cause and taking stimulants will often mask the symptom while the underlying problem remains. Sometimes the underlying problem being masked is life-threatening and in many instances stimulants can make the problem worse, especially when there is heart disease involved. Stimulants also can be habit forming and thus subject to abuse. Therefore, this kind of treatment should only be considered once the underlying culprit causing the fatigue is known and that there is no concern for the stimulant to cause adverse effects. The benefit of using stimulants in these cases should far outweigh the risks associated with them, and careful discussion should be held between the patient and medical provider. Even when being used, the patient should be monitored closely for any signs of side effects. It should also be noted that there are some non-stimulant medications that can be attempted before considering stimulant therapy.
Fatigue can be a challenging and debilitating condition for those who suffer from it. By partnering with your medical provider, you manage this devastating symptom and improve your quality of life.