fatigue jane hartwell cumberland infirmary, carlisle
TRANSCRIPT
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.
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