Tired all the time (TATT)

 

• Differential diagnosis

  TIRED CHAP:

  • Tumour
  • Infection: HIV, infective endocarditis, TB.
  • Rheumatological: RA, PMR, GCA.
  • Endocrine: Addison's, thyroid disease, diabetes.
  • Depression
  • CHF
  • Anaemia
  • Pulmonary: COPD, IPF.

• Chronic fatigue syndrome

  Aka myalgic encephalomyelitis (ME).

  Epidemiology

  • 0.5% prevalence.
  • Commonest in young and middle-age women.

  Definition and clinical features

  There are no definitive, internationally agreed upon criteria. The following is based on UK (NICE) guidance.

  Fatigue with following features:

  • Persistent (>4 months) or recurrent.
  • New onset i.e. not lifelong.
  • Unexplained.
  • Follows exercise with a delay of >24 hrs.
  • Leads to reduced activity.

  Plus any 1 of:

  • Poor sleep.
  • Cognitive dysfunction.
  • Pain: muscle, joints, head, lymph nodes, throat.
  • General malaise, flu-like, dizziness, or nausea.
  • Palpitations.

  Investigations

  • Rule out other causes: FBC, urinalysis and U&E (CKD), LFT (liver disease), glucose (diabetes), TFT (hypothyroidism), ESR/CRP (autoimmune disease), coeliac serology.
  • Many report that symptoms developed following an infection; however, only test if the history points to something specific e.g. hepatitis B/C, HIV.

  Management

  Education and advice:

  • Sleep hygiene.
  • Relaxation techniques.
  • Rest periods up to 30 minutes at a time.

  Specific therapy:

  • Cognitive behavioural therapy.
  • Graded exercise therapy, which includes one-to-one therapy encouraging gradually increased periods of physical activity.
  • Activity management: involves diary keeping and planning steady, consistent level of daily activities (as opposed to bursts and troughs), with gradual increases if possible.

  Social support:

  • Encourage and support continued education and work where possible.
  • Equipment may be needed for those with severe disease e.g. wheelchair, stairlift.

  Prognosis

  • Most patients will improve, especially children and young people.
  • A minority with severe disease may be housebound long-term.