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Palliative care: Overview of fatigue, weakness, and asthenia

Eduardo Bruera, MD
Sriram Yennurajalingam, MD
Section Editor
Deputy Editor
Diane MF Savarese, MD


Fatigue is the most common symptom in palliative care patients who have advanced cancer or other serious and/or life-threatening illnesses. It is also one of the most under-reported and undertreated symptoms in such patients, as well as in other palliative care populations, including those with end-stage heart failure. Fatigue has substantial adverse physical, psychosocial, and economic consequences for both patients and caregivers. However, due to its subjective nature and multidimensional causes, assessment and treatment of fatigue in the palliative settings can be complex.

This topic review will provide an overview of the clinical evaluation and treatment of fatigue in palliative care. Although the focus is on fatigue in cancer patients receiving palliative care, the principles of assessment and management are similar in other end-stage disease states. A more extensive discussion of fatigue in patients with cancer and of the assessment and management of chronic fatigue syndrome (CFS), also known as systemic exertion intolerance disease (SEID), are presented elsewhere. (See "Cancer-related fatigue: Prevalence, screening and clinical assessment" and "Cancer-related fatigue: Treatment" and "Clinical features and diagnosis of chronic fatigue syndrome (systemic exertion intolerance disease)" and "Treatment of chronic fatigue syndrome (systemic exertion intolerance disease)".)


It is important to distinguish fatigue from other common presentations in palliative care, including depression, delirium, drowsiness, demoralization [1], psychomotor retardation, and weakness. Demoralization is a frequent syndrome of existential distress in patients with cancer (13 to 18 percent). Early identification of this syndrome using a demoralization scale would be helpful to distinguish it from fatigue [1,2]. Psychomotor retardation involves a slowing down of thought and a reduction of physical movements in an individual, while weakness is a term commonly used to describe a state of lack of physical, muscle, or motor strength.

Fatigue in palliative care settings can be broadly defined as “a subjective state characterized by feelings of tiredness and a perception of decreased capacity for physical or mental work” [3]. The National Comprehensive Cancer Network (NCCN) defines cancer related fatigue as a “distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to activity and that interferes with usual functioning”. (See "Cancer-related fatigue: Prevalence, screening and clinical assessment", section on 'Definition'.)

In the past, the terms “asthenia” and “weakness” were used to describe a subjective sensation of tiredness, while the specific term “fatigue” was used to describe a symptom of tiredness precipitated by effort. However, the terms are currently often used in the same context. The term “fatigue” has gained widespread acceptance in the medical literature and is preferentially used in the National Cancer Institute toxicity grading scale that covers fatigue, asthenia, and malaise (table 1).

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Literature review current through: Nov 2017. | This topic last updated: Sep 14, 2017.
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