Ursachen und Therapie der Müdigkeit - congress

Transcrição

Fatigue
D. Aujesky & B. Kissling
Klinik für Allgemeine Innere Medizin
Overview
• Definition
• Classification
• Etiology
• Rational investigation
…intermixed with didactic case studies
2
Case 1
• 48-year-old teacher
• 2-month history of continuing tiredness
• Unremarkable medical history and no history of recent
infection, she denies unusual stress. No weight loss
• Clinical examination is normal with a blood pressure of
130/75 mm Hg, a regular pulse at 70 beats per minute, and
no lymphadenopathy
What is it?
Laboratory investigations?
What next?
3
Case 1 (con‘t)
• The patient has no red flags or suggestive symptoms and
no abnormal findings, the likely temporary nature of the
fatigue is discussed, together with some of the possible
common precipitating factors
• She is happy with a plan to return after one month for
routine blood tests (full blood count, TSH, and erythrocyte
sedimentation rate) if things have not improved
• She attends a couple of months later for a different
problem and comments that her fatigue has improved,
probably as she has resolved a difficulty at work
4
“Normal” versus “abnormal” fatigue
• Fatigue is a normal part of life and occurs in healthy persons
as a normal response to physical and mental exertion
• 20-30% of adults report that they have significant fatigue at
any given time
• However, normal fatigue may begin to become abnormal if
– chronic, extreme
– not relieved by adequate rest, adequate sleep, or removal of
stressful factors
– sudden, unexplained beginning (not due to normal physical/mental stress)
– accompanied by other, unexplained symptoms
5
Definition of fatigue
Fatigue incorporates 3 components:
-inability to initiate usual activities
(perception of generalized weakness)
-reduced capacity to maintain usual activities
(easy fatiguability)
-difficulty with concentration, memory, emotional stability
(mental fatigue)
DD: somnolence, dyspnea, and muscle weakness
6
“Müdigkeit”
•
•
•
•
•
•
•
•
•
•
•
Ermüdbarkeit
Erschöpfung, Abgeschlagenheit
Schläfrigkeit
Energielosigkeit
Antriebslosigkeit
Lustlosigkeit
Schwäche
Leistungseinbusse
Konzentrationsstörung
Atemlosigkeit
Schwindel, etc.
7
Classification of fatigue
Based on symptom duration:
-recent:
<1 month
-prolonged: 1-6 months
-chronic:
>6 months (≠chronic fatigue syndrome!)
8
Fatigue in primary care
• Fatigue is a common complaint
– 5-7% of patients have a primary complaint of fatigue
– Fatigue as additional complaint is nearly 3x as high
• Patients generally regard fatigue as important, whereas
doctors do not (because it is non-specific)
• Almost ¾ of consultations for fatigue are isolated episodes,
without follow-up consultations
– Most patients‘ fatigue improves, especially if there is a time
limited explanation, such as a recent infection
• Only 50% of practitioners perform laboratory investigations,
only few of these tests yield abnormal results
9
Identifiable cause in ~60% of patients
• 5915 Dutch primary care patients (1985-95)
• Reason for encounter: general weakness / tiredness
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
General weakness / tiredness:
Viral disease:
Upper respiratory infection:
No disease / prevention:
Iron deficiency anemia:
Acute bronchitis/bronchiolitis:
Adverse drug effect:
Depression:
Other mental disorder:
Sinusitis:
Influenza:
Acute stress reaction:
Feeling anxious/nervous/tense:
Problem working conditions:
Etc.
38%
8%
4%
4%
3%
3%
2%
2%
2%
2%
2%
2%
2%
1%
Okkes, J Fam Pract 2002
10
Etiology of fatigue- overview
• Physiological/psychological mechanisms poorly understood
•
• Fatigue as final common pathway for a variety of factors?
-Predisposing factors: female sex, history of fatigue or depression
-Precipitating factors: -acute physical stresses (e.g., infection with EBV)
-psychological stresses (e.g., bereavement)
-social stresses (e.g., working problems)
-Perpetuating factors: physical inactivity, ongoing psychological and social
stresses, sleep abnormalities
11
Diagnoses associated with fatigue
• Somatic conditions
• Psychiatric conditions
• Drugs
• Idiopathic (by exclusion, e.g. chronic fatigue syndrome)
12
Somatic conditions that may present
with apparently unexplained fatigue
• General- anemia, acute infection (viral), chronic infection (HIV),
autoimmune disease, cancer, pregnancy
• Endocrine-metabolic- diabetes, hypothyroidism, adrenal insufficiency,
hypercalcemia
• Sleep disorders- sleep apnea
• Neuromuscular- multiple sclerosis, Parkinson disease, stroke, myositis
• Gastrointestinal- chronic hepatitis, primary biliary cirrhosis, coeliac
disease
• Renal- chronic renal failure
• Cardiovascular- chronic heart failure
• Respiratory- COPD
• Rheumatic- rheumatoid arthritis, SLE
13
Psychiatric disorders commonly
associated with fatigue
• Depression
• Anxiety and panic
• Somatization disorder
• Eating disorder
• Substance misuse
Psychiatric illness is present in 60-80% of patients
with chronic fatigue
14
Drugs
• Antihypertensives (clonidine, α-methyldopa, beta-blockers)
• First generation antihistamines
• Antidepressants
• Neuroleptics
• Antiarrhythmics (amiodarone)
• Hypnotics
• Muscle relaxants
• Opioids
• Intoxications (digoxin, anticonvulsants, lead, mercury)
15
Case 2
• 34-year-old engineer
• He complains of fatigue, concentration difficulties, and
unrefreshing sleep for ca. 15 years. The fatigue is seems
somewhat periodic and stress-related
• He frequently falls asleep during meetings and when using
public transportation
• He does not get along well with his current boss. Because he
feels impaired in his professional performance, he has reduced
his working activity to 80%. In his spare time, he is involved in
vigorous physical activities
• Physical examination is normal
What next?
16
Con‘t case 2
• An extensive laboratory evaluation is normal
• A stress test confirms an above average performance
• A polysomnography does not reveal any sleeping disorder
• He comes back after 3 months. He has been prescribed an
antidepressant for the last 8 weeks, without any effect
• A diagnosis of idiopathic chronic fatigue is considered
17
Evaluation- history
•Most important step in diagnostic evaluation
•History should focus on:
– Nature of fatigue (sudden beginning, severity, duration, etc.)
– Impact on the patient’s life
– Underlying medical illness
– Underlying psychiatric illness
– Current social stresses
– Quality and length of sleep
– Medications (including drugs and alcohol)
18
Some clues from history
• Fatigue as one of several symptoms: medical or psychiatric
disorder
-organ-based: unable to complete activities
-not organ-based: tired all the time (not exertion-related, not relieved by rest)
• Loss of interest and enjoyment (ahedonia): depression
• Prominent sleepiness: sleep disorder
• Sensation of fatigue when standing up: orthostatic hypotension
• Acute beginning, periodic: chronic fatigue syndrome
19
Evaluation- physical examination
• Important to exclude specific causes, helps assure patient
that his/her complaints are worth investigating
• Physical examination
– General appearance
– Presence of lymphadenopathy
– Evidence of thyroid disease: goiter, nodule, ophthalmopathy
– Cardiopulmonary examination: signs of congestive heart
failure and chronic lung disease
– Neurologic examination: muscle bulk, tone, and strength, deep
tendon reflexes, sensory and cranial nerve evaluation
20
Value of laboratory studies
• Extensive laboratory evaluations in the absence of a
positive history or physical examination are of little utility
• In patients with fatigue >1 months, laboratory investigations
elucidate cause of fatigue in 5% of cases only
• Low pretest probability leads to false positive lab findings
21
Rational investigation of fatigue
• Aims to allow most patients to forgo testing and improve
spontaneously, while identifying the few patients with underlying
disease reasonably quickly
• Younger patients and those who consult frequently are less
likely to have underlying disease
• Recent infection or stressful events can justify deferral of testing
• Better to offer a fixed follow-up consultation than „Return if you
don‘t improve“
• Investigations are warranted in those who have not recovered
in 1 month, if presentation is atypical (e.g., older patients or
those who consult infrequently), if clinical features suggest a
specific diagnosis, or if „red flags“ are present
22
Red flags*
Hamilton, BMJ 2010
23
First line tests after 1 month
Investigations
When to consider test
Type of evidence
from primary care
Full blood count
Always
Randomizedcontrolled trial (RCT)
Thyroid function tests
Always
Random glucose
If symptoms suggest or if the
patient is obese
ESR
Always
CRP
If persistent infection is suspected
Cohort studies
Coeliac disease
Second line or if any
gastrointestinal symptoms
Cohort studies
Creatinine/electrolytes
Age>60 years or if other symptoms
such as itching or polyuria
RCT
Liver function tests
Age>60 years or with alcohol
excess or drug abuse
Calcium
If symptoms suggest hypercalcemia
Case reports
Ferritin
Women of childbearing age
RCT
EBV serology
Age<40 years with recent infection
Cohort studies
Depression score
If symptoms suggest
Cohort studies
Hamilton,
BMJ 2010
24
First line tests after 1 month
Investigations
Abnormal (%)
Full blood count
Thyroid function tests
Random glucose
When to consider test
Type of evidence
from primary care
12
Always
Randomizedcontrolled trial (RCT)
7
Always
Not known
If symptoms suggest or if the
patient is obese
32 testing
Alwaysfor infections (HIV,
Do not routine
CRP EBV, CMV, Not
known
If persistent infection is suspected
Cohort studies
Lyme),
inflammatory
diseases
Coeliac
disease RF), Not
known
Second
line or if any
(ANA,
antibody
studies
for coeliac
gastrointestinal symptoms
disease, or CK
other
features
Creatinine/electrolytes
11 without
Age>60 years
or if other
symptoms or
RCTrisks
ESR
such as itching or polyuria
Liver function tests
10
Calcium
Not known
Ferritin
9
EBV serology
Depression score
Not known
17
Age>60 years or with alcohol
excess or drug abuse
If symptoms suggest hypercalcemia
Case reports
Women of childbearing age
RCT
Age<40 years with recent infection
Cohort studies
If symptoms suggest
Cohort studies
25
Second line tests
• If first line tests are normal, a period of watchful waiting can
follow
• If tiredness has persisted for 3 months or if further
suggestive symptoms have developed, then a second line
test is reasonable
• If tiredness persists for at least 6 months without a clear
explanation, a diagnosis of chronic fatigue syndrome should
be considered (only if patient meets specific criteria!)
26
Case 3
• 39-year-old mother of 2 children (5 yrs, 15 mo)
• Feels tired, she sleeps „well but not a lot“. No
daytime sleepiness. She works at 40%
• Takes the pill, no menstruation
What next?
27
Con‘t case 3
• Lab: BSR 12, Hb 153, Lc 8‘100; PT, gGT, creat, and glucose
are normal. Vitamin B12 202, TSH 1.2, Ferritin 15
• Diagnosis: Iron deficiency
• Treatment: Ferrum Hausmann 0-0-0-1 for 3 months, which
the patient stopped because of diarrhea. Replaced by
IV Venofer 100, 200, and 200 mg
• Lab 2 months later: Hb 159, ferritin 95
• She consults one year later because she felt tired again.
Lab: BSR 10, Hb 147, Ferritin 18; PT, gGT, creat, and
glucose are normal. Treatment with IV Venofer 3 x200 mg
• 1 year later she is diagnosed Osler‘s disease with recurrent
epistaxis
28
Chronic fatigue syndrome
• 1994 CDC criteria: chronic fatigue lasting >6 months
plus at least 4 of the following:
– Subjective memory impairment
– Tender lymph nodes
– Muscle pain
– Joint pain
– Headache
– Unrefreshing sleep
– Postexertional malaise >24 h
• Found in less than 10% of patients with chronic fatigue
>75% are women, younger adults (aged 30-40 years)
• Probably has multiple causes (physical, psychological)
• Overlap with fibromyalgia (muscle pain predominant)
29
Idiopathic chronic fatigue
• Debiliating, chronic fatigue >6 months
• No medical or psychiatric condition
• Does not meet the criteria for chronic fatigue syndrome
• Disability rates and health care utilization are similar to
those with the chronic fatigue syndrome
30
Treatment chronic fatigue syndrome/
idiopathic chronic fatigue
• Cognitive behavioral therapy
• Graded excercise therapy
• Prognosis: -median recovery rate: 5%
-median improvement rate: 40%
31
Case 4
• Previously well 63-year-old woman
• She feels tired for about 1 month. She has a very mild,
inconsistent dyspnea. Smoking history: 60 py. Potential
weight loss of 2-3 kg
• Clinical examination reveals a lump in the neck (3 cm) and
a dullness over the right lung
What next?
32
Con‘t case 4
• Lab: ESR 70 mm/h, CRP 28, Hb 133, Lc 8‘600, Tc 354‘000,
D-dimer 742, the rest of the laboratory was unremarkable
• CRX: „white“ right lung, treacheal deviation to the right
• Thoracic CT: pleural effusion and atelectasis of the right
lung, occlusion of the right main bronchus, enlarged
mediastinal and supraclavicular lymph nodes
33
Summary
• Fatigue is a common principal complaint in primary care (5-7%)
• Investigations may exclude diagnosis and reassure the patient,
but they have a low rate of identifying any underlying disease
• Investigations are warranted in those who have not recovered
after 1 month, whose initial presentation points to a specific
disease or is associated with red flags
• Be alert for important but easily missed diseases, such as coeliac
disease, sleep apnea, or pregnancy
34
Literature
• Hamilton, Watson, Round. Investigating fatigue in primary
care. BMJ 2010
• Sharpe, Wilks. Fatigue. BMJ 2002
• Cornuz, Guessous, Favrat. Fatigue: a practical approach to
diagnosis in primary care. CMAJ 2006
35
Thank you for your attention!
Weary 1887 by Edward Radford (1831-1920)
36
Fatigue Severity Scale
During the past week, I have found that:
•
•
•
•
•
•
•
•
Disagree <------> Agree
My motivation is lower when I am fatigued.
Exercise brings on my fatigue.
I am easily fatigued. Fatigue interferes with my physical functioning.
Fatigue causes frequent problems for me.
My fatigue prevents sustained physical functioning.
Fatigue interferes with carrying out certain duties and responsibilities.
Fatigue is among my three most disabling symptoms.
Fatigue interferes with my work, family, or social life.
1-7
1-7
1-7
1-7
1-7
1-7
1-7
1-7
Average score >4: fatigue is present
Krupp, Arch Neurol 1989
37

Ursachen und Therapie der Müdigkeit - congress

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