Fatigue
Fatigue is one of the most prevalent symptoms of myeloma affecting almost all patients during the course of their myeloma, particularly those undergoing treatment.
It is defined as a persistent sense of tiredness or exhaustion typically resulting from physical or mental exertion that interferes with normal daily activities. Whereas fatigue in healthy individuals can be improved by rest, fatigue in myeloma and other cancer patients is much more severe and not relieved by sleep and rest.
For patients, fatigue is regarded as being one of the most pervasive and debilitating consequences of myeloma. Patients report having difficulty achieving the most fundamental activities such as eating, concentrating, working, socialising, taking exercise, performing chores, and maintaining intimate relationships with partners.
There are many possible causes of fatigue in myeloma patients which can be grouped into disease-related, treatment-related or psychological factors. Anaemia either as a result of the myeloma itself, or a side effect of treatment, both disrupting normal red blood cell production, is common. Other causes or contributing factors include: pain; sedating properties of some anti-myeloma treatments or supportive treatments such as painkillers, sleep disturbances, nutritional deficits, emotional distress, anxiety and depression, and infection.
Fatigue is subjective and the level varies enormously from patient to patient. Some patients report only mild fatigue which has little impact on their daily activities whereas others report severe debilitating fatigue that profoundly affects their quality of life. It is vital therefore that nurses take a proactive approach to help patients and their families reduce the impact of this debilitating symptom and help improve quality of life and outcomes for patients.
Watch the following video clip of Prof Sam Ahmedzai, Consultant in Palliative Care, explaining how fatigue can affect patients:
Assessment of fatigue
There are no laboratory tests that can be used to diagnose fatigue although blood tests such as full blood count, thyroid function, renal function and calcium/iron/vitamin B12/folate, vitamin D and CRP checks can identify causes of fatigue. Instead, it relies on patients being asked about their levels of fatigue during consultations. This may simply involve asking patients some questions about their energy levels and how they are feeling in general.
It is important that good history is taken to assess functional interference, emotional state, mental capacity and sleep pattern. Nurses should assess for muscle wasting, specific weakness, anxiety/depression, infection, anaemia and level of physical activity. Current drug regimens for co-morbidities should also be reviewed paying particular attention to cardiac medication. Blood counts, electrolytes, liver function and calcium levels should be checked so that any metabolic disturbances can be corrected where appropriate.
If fatigue is suspected, a more formal assessment should be included; several tools exist but there is no single recommended one. Examples include:
- Myeloma Patient Outcome Scale (myPOS)
- Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F)
- Multiple item scales embedded in other tools e.g. European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30
- Multiple item multi-dimensional scales, such as Brief Fatigue Inventory (BFI)
Treatment for fatigue
Medical causes of fatigue can be treated directly. For instance, anaemia may be treated with blood transfusions or EPO. Fatigue as a result of dehydration may be alleviated by fluid and electrolyte replacement and similarly anorexic patients may be dietary supplements to boost caloric intake.
Pain management should be reviewed to determine if they are effective or whether they may be contributing to mood and cognitive impairment. Where depression is suspected, anti-depressant treatment may help improve mood and fatigue.
For patients who have severe fatigue, they may be offered psychostimulants such as methylphenidate (Ritalin®), pemoline (Cylert®) or dextroamphetamine (Dexedrine®). The MDT should also consider changes to a patients’ treatment e.g. dosage if fatigue is severely impacting quality of life. As always, there is a cost/benefit balance to consider.
Prevention and management of fatigue
Nurses play a centre role in the management of fatigue particularly by openly talking about it with their patients and offering strategies to help both patients and families cope with it. Read more in our Myeloma Nurse Guide: Fatigue.
Nurses should help patients make adjustments to their life if fatigue is impacting on their activities of daily living such as bathing, eating, dressing and mobility. They should help patients devise plans to modify their activities and make relevant lifestyle changes. Where appropriate, referrals to occupational therapy or physiotherapy should be made.
The following are recommendations to suggest to patients to help them cope with fatigue.
Diet
- Eat enough food and ensure that their diet is well balanced and includes food from all food groups, with plenty of fresh fruit and vegetables. Carbohydrates (such as pasta) are a good source of quick energy.
- Eat little and often
- Stay hydrated
- Prepare meals in advance where possible for times when energy may not be as high
- Avoid stimulants such as coffee, tea, green tea, chocolate and fizzy drinks in the evening and avoid excessive alcohol intake
Lifestyle
- Include a little physical activity every day and continue with social activities where possible to help boost mood and feeling of normality
- Sleep for just long enough to feel refreshed
- Go to bed and get up at the same time every day so the body gets into a routine
- Allow rest periods during the day. Take short naps, if needed, but not if they interfere with sleeping at night
- Use relaxation techniques such as breathing exercises or yoga, to induce sleep or help with feelings of anxiety
- Prioritise tasks at the start of the day. Use limited energy wisely, coordinate specific activities to coincide with greater energy levels
- Keep a diary to help identify what exacerbates or alleviates symptoms
Support
- Ask for help and delegate tasks to others
- Keep a diary e.g. of what makes your fatigue worse or better, to help guide clinic appointments
Fatigue can be difficult to manage and an element of it can remain for patents throughout their disease. Early intervention can improve functional capacity and quality of life and requires patients and nurses to work in partnership to improve outcomes. It is easy to underestimate the impact of fatigue and therefore it is important that its assessment is part of regular clinical reviews e.g. through holistic needs assessments.
Watch a video of a myeloma patient describing fatigue.
Fatigue is a common challenge of living with myeloma and Lynn describes it as “like wading through mud” and having a “porridge/marshmallow head”. Lynn also discusses receiving her diagnosis of myeloma and how she focuses on making the most of every single day.