Tiredness and fatigue

Introduction

Tiredness and fatigue are among the most common symptoms reported in primary care. While the terms are often used interchangeably, they represent slightly different phenomena. Tiredness usually refers to the subjective feeling of needing rest or sleep, while fatigue is a more persistent lack of energy that may not improve with rest. Fatigue can be physical (reduced muscle capacity), mental (difficulty concentrating), or both.

Because these symptoms may result from lifestyle factors, psychological conditions, or underlying medical illnesses, proper evaluation is critical.

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Types of Fatigue

• Acute fatigue: short-term, usually due to sleep loss, overwork, or acute illness.

• Chronic fatigue: lasting more than 6 months, often associated with chronic conditions such as endocrine disorders, autoimmune diseases, or chronic fatigue syndrome (CFS).

• Central fatigue: related to brain and nervous system signaling (e.g., depression, sleep disorders).

• Peripheral fatigue: related to muscles or neuromuscular junction (e.g., anemia, electrolyte imbalance, neuromuscular disease).

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Common Causes

1. Lifestyle Factors

• Poor sleep quality or insufficient sleep

• Overwork and stress

• Sedentary lifestyle

• Poor diet (low in essential nutrients)

• Excessive caffeine or alcohol

2. Psychological Causes

• Depression (often accompanied by low mood and loss of interest)

• Anxiety (fatigue from constant hyperarousal)

• Stress-related burnout

• Post-traumatic stress disorder (PTSD)

3. Medical Conditions

• Endocrine: Hypothyroidism, diabetes, adrenal insufficiency

• Hematologic: Iron-deficiency anemia, vitamin B12 or folate deficiency

• Infectious: Chronic infections (e.g., HIV, hepatitis, tuberculosis, mononucleosis)

• Cardiac or respiratory: Heart failure, COPD, sleep apnea

• Rheumatologic/autoimmune: Rheumatoid arthritis, lupus, chronic fatigue syndrome (myalgic encephalomyelitis)

• Cancer: Fatigue is a common early symptom and may also be treatment-related

• Medication-related: Sedatives, antihypertensives (beta-blockers), antihistamines, chemotherapy agents

4. Sleep Disorders

• Insomnia

• Obstructive sleep apnea (OSA)

• Restless legs syndrome

• Narcolepsy

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Diagnostic Evaluation

History

• Onset and duration of fatigue

• Associated symptoms (weight change, fever, pain, mood changes)

• Sleep quality and duration

• Diet and exercise patterns

• Medication use and substance history

Physical Examination

• Vital signs (blood pressure, heart rate, temperature, oxygen saturation)

• Thyroid gland examination

• Cardiopulmonary assessment

• Neurological exam

• Signs of anemia or nutritional deficiency (pale skin, glossitis, brittle nails)

Investigations

• Full blood count (FBC) – anemia, infection

• Thyroid function tests – hypothyroidism

• Blood glucose and HbA1c – diabetes

• Renal and liver function tests

• Serum ferritin, vitamin B12, folate

• ESR/CRP – inflammation or autoimmune disease

• Sleep studies (if sleep apnea suspected)

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Treatment Strategies

1. Lifestyle Modifications

• Sleep hygiene: consistent sleep schedule, avoiding screens before bedtime, limiting caffeine.

• Balanced diet: adequate protein, fruits, vegetables, and hydration.

• Exercise: moderate activity 30 minutes most days, which boosts energy long-term.

• Stress management: relaxation techniques, mindfulness, cognitive-behavioral therapy.

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2. Treating Underlying Medical Conditions

Anemia

• Iron-deficiency anemia:

  • Ferrous sulfate: 325 mg orally once to three times daily with vitamin C.

• Vitamin B12 deficiency:

  • Cyanocobalamin: 1000 mcg intramuscular injection weekly for 4–6 weeks, then monthly maintenance.

  • Oral therapy: 1000–2000 mcg daily.

• Folate deficiency:

  • Folic acid: 1 mg orally daily.

Hypothyroidism

• Levothyroxine: usual starting dose 25–50 mcg orally daily, adjusted according to TSH levels every 6–8 weeks.

Diabetes

• Lifestyle modification (diet, exercise) plus medications if required:

  • Metformin: 500 mg orally once or twice daily, titrated to 1500–2000 mg daily as tolerated.

Sleep Apnea

• Weight reduction, avoidance of alcohol at night.

• Continuous Positive Airway Pressure (CPAP) therapy.

• In some cases, mandibular advancement devices or surgery.

Depression/Anxiety

• Antidepressants (if indicated):

  • SSRIs (fluoxetine 20 mg daily, sertraline 50 mg daily).

• Psychotherapy: cognitive-behavioral therapy (CBT) is highly effective.

Chronic Fatigue Syndrome (CFS)

• No specific cure; management includes:

  • Graded exercise therapy (GET) under supervision.

  • Cognitive-behavioral therapy (CBT).

  • Symptom relief (pain management, sleep aids).

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3. Symptomatic and Supportive Management

• Pain relief (if fatigue linked to chronic pain):

  • Paracetamol (acetaminophen): 500–1000 mg every 6 hours as needed.

  • Ibuprofen: 200–400 mg every 6–8 hours as needed.

• Stimulants (specialist use in refractory cases such as CFS or narcolepsy):

  • Modafinil: 100–200 mg orally once daily in the morning.

  • Methylphenidate: 10–20 mg orally in divided doses daily.

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Red Flags (Urgent Medical Attention Needed)

• Unexplained weight loss

• Persistent fever or night sweats

• Severe breathlessness or chest pain

• New neurological deficits (weakness, confusion)

• Fatigue persisting >3 weeks despite lifestyle changes

• Oral ulcers, sore white tongue, or recurrent infections with fatigue (possible immune deficiency or malignancy)

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Prognosis

• Fatigue due to lifestyle factors often improves with rest, diet, and sleep hygiene.

• Correctable medical causes (anemia, hypothyroidism, diabetes) respond well to targeted therapy.

• Chronic fatigue linked to autoimmune or cancer-related conditions may require long-term management.

• Psychological causes respond best to combined therapy (psychological + pharmacological).