Fatigue and Interventions

RADTH 301 - RT Principles

when is fatigue’s onset

onset may occur at anytime

grade 1 faitgue

mild - relieved by rest

grade 2 fatigue

medium, not relieved by rest; limiting instrumental activities of daily living

• grocery shopping, cleaning, etc

grade 3 fatigue

severe - not relieved by rest; limits self-care activities of daily living

• changing, showering, etc

is there such thing as NCI grade 4 and 5 fatigue

no

what is cancer related fatigue?

a persistent, subjective, sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning

is CRF relieved by rest?

no, it may not be relieved by rest

there is no exact cause associated to cancer related fatigue, but what are some potential reasons

• serotonin (5-HT) dysregulation

• HPG axis dysfunction

• circadian rhythm disruption

• muscle metabolism / ATP dysregulation

• vagal afferent nerve acivation

• cytokine dysregulation

• recent medication changes

• pain

• decreased activity, bed rest, deconditioning

Serotonin (5-HT) dysregulation

cancer and cancer treatment causes upregulation of serotonin levels or receptors which can influence appeitie, sleep, memory, CV function, muscle contraction, endocrine function, and depression which in turn affect fatigue

• tumor necrosis factor (TNF) may also dysregulate 5HT3 feedback loop, causing increase of serotonin release

HPG axis dysfunction

decreased serum cortisol levels

circadian rhythmn disruption

changes in circadian rhythm are infleunced by psychosocial, genetic, environmental, and behavioural components

muscle metabolism / ATP dysregulation

regeneration of ATP in skeletal muscle can be compromised by cancer and or treatment. ATP replacement may be lessensed by decrease in fluid or nutrient intake. anorexic or cachexic patients may have greater changes in muscle protein metabolism

vagal afferent nerve activation

stimulation of vagal afferent nerves via somatic muscle activity inhibition and ‘sickness’ behaviour may contribute to decrease in skeletal muscle tone, weakness, fatigue, and decreased concentration

cytokine dysregulation

increase in plasma levels of proinflammatory cytokines from TME or tx result in increased fatigue (TNF and IFN-a have been linked to lethargy, anoxrexia, and fatigue)

what medications may cause increased fatigue in patients

opiods, antidepressants, antihistamines, beta blockers, anticonvulsants, benzodiazepines, antiemetics

what comorbidities result in decrease activity and deconditioning, leading to CRF

anemia, nutritional deficits, emotional distress, sleep disorders, extent of disease, heart disease, diabeters, etc

what are some interventions for non-urgent (grade 1) fatigue

low to moderate excercise, energy conservation, sleep hygiene, psychological and wellness support, dietary management, pharmacologic management, patient education

what should we tell our patients about low or moderate excercise to combat fatigue

• include mechanism of action

5 days a week, walks, yoga, gardening, start with slow sessions (5-10) and build up to 30 mins, be sure to individualize for capabilities

• results in more physical energy, improved appetite and increased ability to perform activities of daily living

what should we tell our patients about energy conservation to combat fatigue

• MoA

place, planning, priority setting, posture

• conserving energy will allow patient to participate in more ADLs

what should we tell our patients about sleep hygiene to combat fatigue

• MOA

encourage comfortable surroundings, relaxation before bed time and limit naps while discouraging lying in bed when not trying to sleep, distracting noises, and caffeine near bedtime

• prevents disruption of circadian rhythm to reduce fatigue

what should we tell patients about pyschological and wellness support to combat fatigue

• MoA

referral to support groups/therapists, encourage games, reading, music, socializing, CAM

• also prevents disruption of circadian rhythm to reduce fatigue

what should we tell patients about dietary management to combat fatigue

• MoA

hydrate (8-10 cups of water per day), adequate nutrition with balanced diet: encourage small frequent meals and eating protein first (boost, ensure). give dietary referrals or pamphlets as required

• provides energy to body and replenish ATP levels

what should we tell patients about pharmacological management to combat fatigue

• MoA

avoid medications that may cause or exacerbate fatigue (in collab with doctor), iron supplements may need to be prescribed or recommended

• iron supplements ensure iron levels are sufficient to provide adequate oxygen for red blood cells

what is it important to educate the patient on about cancer related fatigue

CRF is normal, education and follow-up ensures the patient understands what fatigue is and ways of coping with it

• ask patient to track times of day and activities that are more fatigue inducing to help manage day better

• log book to track fatigue levels

• follow-up with patient daily

If a patient presents with urgent (grade 2-3) fatigue, what must be done?

patient requires medical attention within 24 hours

why is physican collaboration important for Grade 2-3 fatigue?

rules out other causes / concomitant causes (immunotherapy)

why is it important for vital signs to be monitored and lab tests to be ran for grade 2-3 fatigue

monitor patient status and investigate for causes

what lab tests may be ordered for patients with grade 2-3 fatigue

CBCD, urinalysis, thyroid function

what medications may be prescribed for grade 2-3 fatigue

iron supplements, psychostimulants/corticosteroids, sleep enhancing medications

why is it important to try and understand the true cause of each patient’s fatigue

as this will impact appropriate patient interventions

what other assessments could we do to figure where patient’s fatigue is coming from

pain, emotional distress, anemia, sleep disturbances, nutritional status, activity level, medication side effects, substance use, comorbidities

what symptoms / side effects should we watch for with patients with fatigue

blood loss, labored breathing, cachexia, chest pain, cognitive impairment, poor posture, altered mobility, and pallor