Approach to the adult patient with fatigue
- Kevin M Fosnocht, MD
Kevin M Fosnocht, MD
- Chief Medical Officer
- Associate Executive Director
- Penn Presbyterian Medical Center
- University of Pennsylvania Health System
- Jack Ende, MD
Jack Ende, MD
- Professor of Medicine
- University of Pennsylvania School of Medicine
Fatigue is a common complaint, with a prevalence in population-based surveys in Britain and the United States of between 6.0 and 7.5 percent [1,2]. A cross-sectional survey of United States workers found the two-week period prevalence of fatigue to be 38 percent, with an estimated annual cost to employers exceeding $136 billion in lost productive work time . In addition, an estimated 21 to 33 percent of patients seeking attention in primary care settings report significant fatigue [4-8], resulting in approximately seven million office visits per year in the United States .
The overall approach to the patient who complains of fatigue is presented here. Systemic exertion intolerance disease (SEID), also known as chronic fatigue syndrome (CFS), is discussed separately. (See "Clinical features and diagnosis of systemic exertion intolerance disease (chronic fatigue syndrome)" and "Treatment of systemic exertion intolerance disease (chronic fatigue syndrome)".)
Fatigue can be manifested as difficulty or inability initiating activity (perception of generalized weakness); reduced capacity maintaining activity (easy fatigability); and difficulty with concentration, memory, and emotional stability (mental fatigue) .
Fatigue should be distinguished from somnolence, dyspnea, and muscle weakness, although these symptoms may also be associated with fatigue. Patients may use the terms fatigue, tiredness, lack of energy, and excessive sleepiness interchangeably. (See "Approach to the patient with excessive daytime sleepiness" and "Approach to the patient with dyspnea" and "Approach to the patient with muscle weakness".)
Duration of fatigue can be recent (less than one month), prolonged (more than one month), or chronic (over six months). The presence of chronic fatigue does not necessarily imply the presence of systemic exertion intolerance disease (SEID), also known as chronic fatigue syndrome (CFS), which is discussed separately. (See "Clinical features and diagnosis of systemic exertion intolerance disease (chronic fatigue syndrome)".)
- Lawrie SM, Manders DN, Geddes JR, Pelosi AJ. A population-based incidence study of chronic fatigue. Psychol Med 1997; 27:343.
- Walker EA, Katon WJ, Jemelka RP. Psychiatric disorders and medical care utilization among people in the general population who report fatigue. J Gen Intern Med 1993; 8:436.
- Ricci JA, Chee E, Lorandeau AL, Berger J. Fatigue in the U.S. workforce: prevalence and implications for lost productive work time. J Occup Environ Med 2007; 49:1.
- Bates DW, Schmitt W, Buchwald D, et al. Prevalence of fatigue and chronic fatigue syndrome in a primary care practice. Arch Intern Med 1993; 153:2759.
- Kroenke K, Arrington ME, Mangelsdorff AD. The prevalence of symptoms in medical outpatients and the adequacy of therapy. Arch Intern Med 1990; 150:1685.
- Fuhrer R, Wessely S. The epidemiology of fatigue and depression: a French primary-care study. Psychol Med 1995; 25:895.
- Kroenke K, Wood DR, Mangelsdorff AD, et al. Chronic fatigue in primary care. Prevalence, patient characteristics, and outcome. JAMA 1988; 260:929.
- Buchwald D, Sullivan JL, Komaroff AL. Frequency of 'chronic active Epstein-Barr virus infection' in a general medical practice. JAMA 1987; 257:2303.
- Schappert SM. National Ambulatory Medical Care Survey: 1989 summary. Vital Health Stat 13 1992; :1.
- Markowitz AJ, Rabow MW. Palliative management of fatigue at the close of life: "it feels like my body is just worn out". JAMA 2007; 298:217.
- Chen MK. The epidemiology of self-perceived fatigue among adults. Prev Med 1986; 15:74.
- Cathébras PJ, Robbins JM, Kirmayer LJ, Hayton BC. Fatigue in primary care: prevalence, psychiatric comorbidity, illness behavior, and outcome. J Gen Intern Med 1992; 7:276.
- Ridsdale L, Evans A, Jerrett W, et al. Patients with fatigue in general practice: a prospective study. BMJ 1993; 307:103.
- Prins JB, van der Meer JW, Bleijenberg G. Chronic fatigue syndrome. Lancet 2006; 367:346.
- Buchwald D, Umali P, Umali J, et al. Chronic fatigue and the chronic fatigue syndrome: prevalence in a Pacific Northwest health care system. Ann Intern Med 1995; 123:81.
- Wessely S, Chalder T, Hirsch S, et al. Psychological symptoms, somatic symptoms, and psychiatric disorder in chronic fatigue and chronic fatigue syndrome: a prospective study in the primary care setting. Am J Psychiatry 1996; 153:1050.
- Manu P, Lane TJ, Matthews DA. Chronic fatigue and chronic fatigue syndrome: clinical epidemiology and aetiological classification. Ciba Found Symp 1993; 173:23.
- Okkes IM, Oskam SK, Lamberts H. The probability of specific diagnoses for patients presenting with common symptoms to Dutch family physicians. J Fam Pract 2002; 51:31.
- IOM (Institute of Medicine). Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness. Washington, DC: The National Academies Press; 2015 http://www.iom.edu/mecfs (Accessed on February 12, 2015).
- Lane TJ, Matthews DA, Manu P. The low yield of physical examinations and laboratory investigations of patients with chronic fatigue. Am J Med Sci 1990; 299:313.
- Conti F, Priori R, De Petrillo G, et al. Prevalence of chronic fatigue syndrome in Italian patients with persistent fatigue. Ann Ital Med Int 1994; 9:219.
- Nijrolder I, van der Windt D, de Vries H, van der Horst H. Diagnoses during follow-up of patients presenting with fatigue in primary care. CMAJ 2009; 181:683.
- Fukuda K, Straus SE, Hickie I, et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group. Ann Intern Med 1994; 121:953.
- Bombardier CH, Buchwald D. Chronic fatigue, chronic fatigue syndrome, and fibromyalgia. Disability and health-care use. Med Care 1996; 34:924.
- Ridsdale L, Evans A, Jerrett W, et al. Patients who consult with tiredness: frequency of consultation, perceived causes of tiredness and its association with psychological distress. Br J Gen Pract 1994; 44:413.
- Darbishire L, Ridsdale L, Seed PT. Distinguishing patients with chronic fatigue from those with chronic fatigue syndrome: a diagnostic study in UK primary care. Br J Gen Pract 2003; 53:441.
- Price JR, Couper J. Cognitive behaviour therapy for adults with chronic fatigue syndrome. Cochrane Database Syst Rev 2000; :CD001027.
- Whiting P, Bagnall AM, Sowden AJ, et al. Interventions for the treatment and management of chronic fatigue syndrome: a systematic review. JAMA 2001; 286:1360.
- Deale A, Wessely S. Patients' perceptions of medical care in chronic fatigue syndrome. Soc Sci Med 2001; 52:1859.
- O'Malley PG, Jackson JL, Santoro J, et al. Antidepressant therapy for unexplained symptoms and symptom syndromes. J Fam Pract 1999; 48:980.
- Smith RC, Lyles JS, Gardiner JC, et al. Primary care clinicians treat patients with medically unexplained symptoms: a randomized controlled trial. J Gen Intern Med 2006; 21:671.
- Huibers MJ, Beurskens AJ, Van Schayck CP, et al. Efficacy of cognitive-behavioural therapy by general practitioners for unexplained fatigue among employees: Randomised controlled trial. Br J Psychiatry 2004; 184:240.
- Ridsdale L, Darbishire L, Seed PT. Is graded exercise better than cognitive behaviour therapy for fatigue? A UK randomized trial in primary care. Psychol Med 2004; 34:37.
- Bombardier CH, Buchwald D. Outcome and prognosis of patients with chronic fatigue vs chronic fatigue syndrome. Arch Intern Med 1995; 155:2105.
- Straus SE, Dale JK, Tobi M, et al. Acyclovir treatment of the chronic fatigue syndrome. Lack of efficacy in a placebo-controlled trial. N Engl J Med 1988; 319:1692.
- Rimes KA, Chalder T. Treatments for chronic fatigue syndrome. Occup Med (Lond) 2005; 55:32.
- Joyce J, Hotopf M, Wessely S. The prognosis of chronic fatigue and chronic fatigue syndrome: a systematic review. QJM 1997; 90:223.
- Smith WR, Noonan C, Buchwald D. Mortality in a cohort of chronically fatigued patients. Psychol Med 2006; 36:1301.
- Nijrolder I, van der Windt DA, van der Horst HE. Prognosis of fatigue and functioning in primary care: a 1-year follow-up study. Ann Fam Med 2008; 6:519.
- Clark MR, Katon W, Russo J, et al. Chronic fatigue: risk factors for symptom persistence in a 2 1/2-year follow-up study. Am J Med 1995; 98:187.
- EPIDEMIOLOGY AND ETIOLOGY
- Systemic exertion intolerance disease (chronic fatigue syndrome)
- Idiopathic chronic fatigue
- Physical examination
- Laboratory studies
- Cognitive behavioral therapy
- Graded exercise therapy
- Other measures
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS