Fatigue Jane Hartwell Cumberland Infirmary, Carlisle.

FatigueFatigue

Jane Hartwell

Cumberland Infirmary, Carlisle

Fatigue Fatigue

The Syndrome that wears you out!

Fatigue should receive the same attention as other symptoms associated with advanced cancer such as pain.

However, to develop effective strategies to control fatigue we must first gain a greater understanding of what fatigue is.

It is a BIG PROBLEM for patients

Fatigue is multidimensionalFatigue is multidimensional

In its cause In its treatment It is subjective: how a patient perceives and feels

about their weakness. It is measurable: measurable decrease in physical

or mental performance

Effect on PatientsEffect on Patients

Physiological (acute)

Positive effect on body allowing recuperation

Pathological (chronic)

Negative effects on body- associated with chronic conditions

5 5 Dimensions to Subjective FatigueDimensions to Subjective Fatigue

Cognitive sensations• reduced concentration• memory loss• difficulty thinking clearly

Affective sensations• low mood• low motivation• anticipatory sensation of difficulty initiating any activity• Low energy

Physical sensations•feeling tired

• easy tiring

• reduced capacity to maintain performance

Advanced Stage of Fatigue

Fatigue of dying

Secondary Fatigue

The wearying effect of

living with fatigue

OverviewOverview

Reported as the most prevalent and disturbing symptom of cancer and its treatment

Up to 80-96% of patients receiving chemotherapy, (Richardson (2000) 65-95% of patients receiving radiotherapy experience fatigue (Nail 1993)

60% of patients with cancer claim that fatigue had a major effect on their lifestyle ( Cella, 1993, Vogelzang, 1997)

Is fatigue an effect of cancer, Is fatigue an effect of cancer, cancer treatment or both? cancer treatment or both?

Difficult to research, ethically unable to give cancer treatment to patients unless

they have cancer.

However, survivors of nuclear fallout all experienced fatigue as a major problem..

Causes of fatigueCauses of fatigue

Radiotherapy

Accumulation of metabolites as a result of normal tissue damage (Greenberg, 1992)

High anabolic processes involved in molecular and cellular repair ( Beach, 2001)

? Linked to anaemia where large fields or marrow producing bones are included in treatment area

ChemotherapyChemotherapyNeurotoxic drugs e.g. vinca-alkaloids

Immunosuppression- release of cahectin 14

Magnesium depletion (Piper, 1981)

SurgerySurgery

AAnaesthesianaesthesiaAnalgesiaAnalgesiaDecreased ventilatory capacityDecreased ventilatory capacityAltered sleep patternsAltered sleep patterns

Causes of cancer related fatigueCauses of cancer related fatigue

Physiological factorsA. Cytokines

tumours release chemicals known as cytokines- which affect the bodies metabolism.

tumours also secrete macrophages and other immune cells, which produce and secrete cytokines

CNS effectsCNS effects The reticular activating system is believed to be The reticular activating system is believed to be the area of the brain controlling fatigue.the area of the brain controlling fatigue.

Muscular Skeletal EffectsSeveral abnormalities in muscle structure and function occur in cancer patients, even in the absence of cachexia/malnutrition.

Cytokines are believed to have a major role in the development of these changes in muscle tissue.

Biochemical and Endocrine AbnormalitiesHypocalcaemia Diabetes HypothyroidismHypomagnesia

Polypharmacy

Haematological AbnormalitiesAnaemia: Controvesial

How is Hb mechanically associated with fatigue?

Chemotherapy

numbers of red

blood cells are

depleted

Reduced O2 capacity

damage/changes to the actual cell

(Andrews, 2003)

Quality as well as quantity affected

Pain

Insomnia

Nausea

Constipation

Dyspnoea

Studies have shown a link between the severity of physical symptoms and fatigue.

Dyspnoea is associated with the greatest

fatigue. In a study by Thatcher (2001) looking at

QOL in patients with lung cancer,all questionnaire

respondents said that fatigue was their major

debilitating symptom.

These patients have a short survival time, therefore,

they deserve more intense recognition and treatment

of their worst symptom.

Fatigue is often accepted as “part of the illness” but it has a huge and often underestimated impact on patient’s quality of life

Fatigue

Leisure

Social activities

Relationships

Self imageSelf care

Psychological factorsPsychological factors

Depression

Personality type

Stress:

Cancer patients experience extreme physical, mental

and environmental stresses.

Social and Environmental factors

Gradual decline in social performance experienced by many patients may induce fatigue if not replaced by meaningful activities.E.g

loss of social contacts/activities.

Perceived inability to fulfil former role.

Increased reliance on others.

AssessmentAssessment

Listen to the patient Family support Patient information and education

“ Meaning before measurement”

Assessment toolsAssessment tools

Piper Fatigue Scale (Piper, 1988)

The multidimensional fatigue scale (Smets et al, 1996)

Fatigue assessment questionnaire (Glaus, 1998)

Brief Fatigue inventory (Mendoza, 1996)

Also

QOL tools which contain a measurement of fatigue e.g. EORTC QLC C30

Fatigue ManagementFatigue Management

Nursing Support and advice in hospital

and community reinforcing

advice from other

team members.

Medical

correct any physiological causes

e.g. Anaemia

Allied professionals

Social worker help in maintaining independence

Dieticianassistance/advice with

maintaining good nutritional intake

Assessment and MonitoringAssessment and Monitoring

Correct the CorrectableCorrect the Correctable

EstablishTheir understanding of their illness, prognosis/treatment

The nature of their fatigue

Their coping mechanism

How it affects their lives

Their pre-morbid personality/lifestyle

What they want to achieve

TreatmentTreatmentBalance of activity

Pacing (5 minute more syndrome)

Prioritisation

Delegation of tasks

Ergonomics

Medication

Analysis of current activity and fatigue levels e.g. use a simple fatigue inventory.

Planning Goal setting Adaptation of environment/energy

conservation advice Support re managing family relationships Relaxation Advice and support re managing

sleeplessness Graduated exercise programme/ regular

exercise Advice re nutrition intake

ExerciseExercise

• Balance between exercise and rest• Try to maintain a routine• Regular light exercise if possible.

Exercise has been shown to decrease fatigue as well as nausea and can improve sleep

• Drink fluids before and after exercise

Fatigue ManagementFatigue ManagementExercise

Physical activity may improve the QOL and physical performance of cancer patients during and after treatment. (British Journal of Sports Medicine,2001)

Moderate intensity walking showed a significant improvement in physical functioning – no increase in fatigue Windsor et al, 2004)

Results from Porock’s Study in 2000 showed walking programme for patients with advanced cancer

Increased Decreased

Activity levels Anxiety

QOL scores

Remember Fatigue is:

A Syndrome not a symptom Correct what you can Any intervention is a therapeutic trial keep monitoring Keep listening Keep Positive