Fatigue

Causes of fatigue

Generally, fatigue is caused by the combination of all of the physical and emotional burdens of advanced illness. These burdens may include:

• pain
• poor sleep
• worry
• depression
• treatment side effects
• complications of the illness, such as infections and anemia.

Serious illness itself – even without specific complications or side effects of treatments – tends to be draining on the body’s energy.

TIP: Recognize that fatigue is real. Fatigue experienced by someone with an advanced illness is different from the fatigue experienced by a healthy person. People who are seriously ill may feel exhausted even after staying in bed for hours at a time.

Sometimes fatigue is mostly related to a specific problem, which may be corrected fairly easily. These corrections may include:

• medications being changed
• an infection being treated
• a blood transfusion being given.

There are other times when the fatigue is mostly due to the overall energy drain of the illness itself. Resolving this type of fatigue with new treatments or a change in medication is not always possible.

Sorting out symptoms

To determine possible causes of fatigue, the health care team will often ask questions, conduct a physical examination, or order some tests.

Questions from the health care team

Describing fatigue is an important step in figuring out its cause and working towards possible treatment. These questions can help you prepare to discuss your fatigue or help you better describe the fatigue of someone you know.

• How bad is the fatigue?
  • Mild, moderate, or severe?
  • Rating fatigue on a scale from 0 to 10 can be helpful. Zero means no fatigue, while a 10 means the fatigue is so bad it cannot get any worse.
• Is the fatigue overall tiredness, or is it more specifically a weakness of the arms and/or legs?
• What does the fatigue feel like…what words describe it?
  • Tired, exhausted?
  • Sore, stiff, heavy or weak muscles?
  • Trouble thinking clearly?
  • Feeling irritable or impatient?
  • Short of breath?
• When did the fatigue start?
• How long does it last?
  • Always there?
  • Off and on?
  • Specific amount of time?
• What makes it worse?
  • Certain physical activities, movement, medication, conversations?
• What makes it better?
  • Certain positions, relaxation, sleep, food or drink, being active?
• Has fatigue been experienced before?
  
  • If so, when?
  • What happened then?
• What are the effects of fatigue?
  • What kinds of things are difficult or impossible because of fatigue?
  • Has there been a loss of interest or motivation to do things?
  • Are there feelings of depression, sadness or loss of hope?
• What medications are being taken for fatigue?
  • When are they taken?
  • How long have they been used (days, months)?
  • Are there any side effects?
  • Does the medication improve the fatigue?
• Are there any other methods being used to help deal with fatigue (herbal remedies, relaxation techniques)?
• How does the fatigue change with treatment?

Physical examination

Since fatigue is such a general symptom that can be caused by many different problems, it is usually helpful for the health care provider to do a general physical exam. This may provide some clues about what might be causing the fatigue, and will help guide decisions about tests that may be needed and treatments that might be suggested.

Tests

It may be helpful to take blood samples and possibly conduct other tests to sort out the cause of fatigue.

What you can do

Talk to your health care team

Tell your health care team about your exhaustion.  While fatigue is common among people with terminal illness, there are things you and your health care team can do to try to improve your energy levels.

Plan your day

Develop a plan to make the most of available energy. Careful planning of the day’s activities can prevent fatigue from becoming worse. Planning will also help you to take full advantage of high-energy times during the day.

• Plan activities for when energy levels are best. Save energy for doing the activities that are most important.
• Save energy by spreading activities throughout the day. Try not to do too many things in a short period of time.
• Try to include some activities in the day instead of resting all the time. A total lack of activity can make the body feel even more tired.
• Try mild exercise like walking to help the body feel more energized. An exercise routine should be unique for each individual and should take all medical conditions into account. Even people who are on bed rest or have a limited range of movement can exercise.
• Establish good sleep habits. Go to bed at the same time and try to keep noise out and lights down when sleeping.
• Avoid stimulants such as coffee and alcohol before bed.

Try relaxation strategies

If you’re worried about your fatigue, try these or other relaxation strategies.

• Deep breathing
  Breathe deeply, listening carefully to the sounds of breath going in and out. Concentrate on slow, regular breathing.
• Imagery
  Imagine a scene that is relaxing to you, such as a quiet beach with the waves lapping on the shore. Imagery is like a deliberate daydream that can reduce stress and anxiety.
• Counselling
  Consider seeking counselling for feelings of depression or anxiety. These feelings can make the fatigue feel worse. The health care team should be able to help arrange for counselling.

What your health care team can do

Ask your medical team to help develop a plan to manage the fatigue in the best way possible.

Treating the cause of the fatigue

Generally, the most effective way to relieve a symptom is to fix the problem that is causing it. After sorting out the possible causes of fatigue, there may be some treatment options that might help improve a person’s energy level. People may find they have more energy after they are treated for such things as:

• anemia (low red blood cell count)
• infections
• chemical imbalances (such as high calcium levels in the blood)
• depression.

Sometimes trying different approaches and evaluating the response is the only way to find out whether treating a specific problem will help the overall feeling of fatigue.

Medications that may help improve energy

Psychostimulants
For example, methylphenidate (Ritalin®). Stimulant medication can sometimes give a feeling of more energy and alertness, particularly if the patient’s mood is depressed. Potential side effects of psychostimulants include anxiety, restlessness, and trouble sleeping. These medications have a tendency to lose their effectiveness after a few weeks, perhaps as the body becomes used to them.
 

Low dose corticosteroids
For example, prednisone or dexamethasone. Although the way in which these medications work to affect a person’s energy level is not fully understood, some people may feel more energy when taking corticosteroid medications. Side effects of long-term use of steroids may include confusion, muscle weakness, high blood sugars and harm to bones.
 

Your treatment plan may include changing the dose of a medication or adding new medications.

A note about depression

It is important not to overlook the significant impact that depressed mood can have on overall energy, and how much improvement can be seen if depression is recognized and properly treated. Too often, depression is considered to be an expected and normal part of serious illness, and is therefore ignored. Very often, improvements in mood and energy can be obtained through working with the health care team to talk about worries and concerns, planning changes in lifestyle and living situation, and if appropriate, starting medication to treat depression.
See also: Depression

Content reviewed January 2023