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Tiredness/fatigue in adults - Management
How should I assess an adult with tiredness?
- Take a full history. In particular:
- Ask the person to say what they mean by tiredness or fatigue (or a synonym).
- Sleepiness may indicate sleep apnoea or another sleep disorder — see the CKS topics on Sleep apnoea and Insomnia.
- Weakness suggests a neuromuscular cause.
- Ask about: onset, duration, severity, and precipitating factors; the effect of sleep, rest, and exercise; and the impact on activities.
- Onset is typically sudden with infection, myocardial ischaemia, toxins or drugs, and post-traumatic stress.
- Onset is usually gradual in uraemia, heart failure, liver failure, diabetes, hypercalcaemia, hypothyroidism, electrolyte abnormalities, anaemia, and depression.
- Fatigue that is worst in the morning and which never goes away suggests depression.
- Fatigue that occurs only after exercise (and not at rest) suggests a neuromuscular cause.
- Elicit the person's concerns so that reassurance and explanation can be given, if possible and appropriate.
- Elicit the person's perceptions of the cause of their tiredness, which may be important for successful management.
- Take a sleep history: ask about sleep quality, quantity, patterns, and hygiene, snoring, witnessed sleep apnoea, nocturia, and restless legs (for further information, see the CKS topics on Insomnia, Restless legs syndrome, and Sleep apnoea).
- Take a lifestyle and psychosocial history: ask about stress and stressful life events, work, rest, recreation, exercise, quality of personal relationships, illicit drug use, diet, and alcohol consumption, and whether the person is a carer for others (such as children, or elderly or disabled relatives).
- Ask about and screen for the presence of a depressive illness or an anxiety disorder. Screen for depression using the following two questions (an answer of 'yes' to either question should trigger a more detailed assessment — see the CKS topic on Depression):
- 'During the last month have you often been bothered by feeling down, depressed, or hopeless?'
- 'During the last month have you often been bothered by having little interest or pleasure in doing things?'
- Review medication, including over-the-counter drugs.
- Tiredness may be caused by many drugs, including sedative-hypnotics, antidepressants, muscle relaxants, opioids, antihypertensives, and antihistamines.
- Ask about:
- Weight loss or gain (for malignancy, Addison's disease, diabetes mellitus, and thyroid dysfunction).
- Fever or night sweats (for malignancy, and infections such as hepatitis and tuberculosis).
- Muscle or joint pain, headache, sore throat, difficulty with memory or thinking, and chronic pain (symptoms of chronic fatigue syndrome and other conditions).
- Travel, insect or tick bites, and skin rash (for tropical infections and Lyme disease).
- Allergies, such as perennial rhino-sinusitis.
- Determine if the person may be at risk of HIV, hepatitis, or tuberculosis.
- Do a complete physical examination, unless the cause is evident from the history, when a focused examination is appropriate.
- If necessary, delay this until a second, longer consultation.
- Consider whether investigations are needed.
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