Contents
Introduction
Tiredness is a very common presenting complaint to general practice, with a wide range of differentials. It is not a diagnosis, rather it is a symptom. It is commonly referred to by the acronym TATT – tired all the time.
The most common reason for tiredness is “psychological distress” – which may manifest as a true psychiatric diagnosis – such as anxiety or depression, or in many cases, no specific psychiatric diagnosis can be made, but there may be many “life stressors” – e.g. long working hours, an illness in the family, a large load of family and home life responsibilities.
It is still important to take a comprehensive history and examination and assess for other possible differentials. The list of differentials is extremely long and can include endocrine causes (most commonly hypothyroidism), sleep apnoea, anaemia, or other chronic diseases such as heart failure or diabetes.
Epidemiology and Aetiology
- Accounts for about 1% of all general practice consultations
- 25% of patients admit to feeling “chronically fatigued” when questioned directly
- In up to 50-80% of cases, no organic cause can be identified. Most are due to “psychological distress”. A large proportion of the remainder are due to depression
- Be wary of patients who physically fall asleep in the day time or who report they fall asleep very easily
- This is not typical of a TATT presentation and suggests organic pathology – particularly sleep apnoea
- Risk factors for chronic tiredness include:
- Low socioeconomic status
- Female gender
- Fewer total years of education
- Psychological distress
- Lack of physical exercise
- Poor diet
- Obesity
- Sleep deprivation
Differential diagnoses
This list is very long, and quite difficult to properly strategise. History taking is an extremely important part of narrowing down the TATT differential.
- Endocrine and metabolic
- Hypothyroidism
- Diabetes
- Addison’s disease
- Electrolyte disturbance – particularly hypokalaemia and hypomagnesia
- Malignancy
- Sleep apnoea
- Chronic infection
- HIV
- Hepatitis B and C
- Malaria
- Lyme disease
- Post-infectious fatigue – e.g. after influenza or EBV
- Bacterial endocarditis
- TB
- Anaemia
- Drugs
- Prescribed
- Analgesia
- Anticonvulstants
- Antidepressants
- Anhistamines
- Antiemetics
- B-blockers
- Digoxin
- NSAIDs
- Alcohol
- Prescribed
- Renal failure
- Gynaecological
- Neurological disorders
- Parkinson’s disease
- Head injury
- Gastrointestinal
- Liver failure
- Coeliac disease
- Other malabsorption or food intolerance
- Haemochromatosis
- Neuromuscular disorders
- Cardiovascular
- Heart failure
- Cardiomyopathy
- Arrythmia
- Psychiatric
- Depression
- Anxiety
- “Psychological distress”
- Somatisation disorder
- Poorly understood disorders
- IBS
- Fibromyalgia
- Chronic fatigue syndrome
- Rare
- Hyperparathyroidism
- Narcolepsy
- Autoimmune disorders
- Excessive physical activity – e.g. athletes, manual job with long hours
Most likely causes
- Psychological distress, anxiety
- Depression
- Lifestyle and psychosocial factors
- Viral or post-viral illness
- Sleep disorder
Serious but rare
- Malignancy
- HIV
- Other chronic infections (TB, infective endocarditis)
History
Red flags for tiredness
- Unexplained weight loss
- Sleep disturbance
- Other symptoms of depression
- Fever
Sleep
- Ask detailed questions – not just “do you sleep well?”
- What time to you go to bed?
- What to do you go to sleep?
- Do you wake during the night?
- What time do you wake in the morning?
- What time do you get out of bed in the morning?
- What do you do just before bed?
- Do you fall asleep during the day?
- Consider the Epworth sleepiness score if sleep apnoea is suspected
Social history
- Work – how is work? Do you work long hours? Do you enjoy your job? What are your career plans? Bullying at work?
- Home life – how is home life? Do you have any children? Do you have a supportive partner? How are your children / partner / parents?
- Recent bereavement?
- Recent relationship breakdown?
- Recently retired?
- Why do you think you are tired?
Diet
- Don’t just ask “what is your diet like?” Or “do you have a good diet?” Be specific
- “Are you following a particular specialist diet?”
- Take me through a typical day from when you get up to when you go to bed – tell me everything you eat and drink”
Medical questions
- Menstrual history
- Sexual activity / sexual dysfunction
- Any regular medications? Any OTC medications?
- Recent history of trauma or surgery
- Any recent infections?
- Any fevers?
- Any chronic pain?
- Bowel habit
- Specific illness questions (if suspected), e.g.:
- Hypothyroidism – weight gain, skin changes, hair changes, mood changes
- Sleep apnoea – falling asleep during the day, awaking with a headache, aka wing feeling untested, history of snoring
- Heart failure – SOB on exertion, ankle swelling, history of heart disease, cough
Psychological
- Do you feel depressed?
- Any history of mental health disorders
- Ask yourself – Is this patient depressed?
Examination
- Vital signs
- Weight and height for BMI
- Basic respiratory and cardiovascular examination
- Abdominal examination – particularly for masses and in guitar lymphadenopathy
Investigations
Below are the recommended investigations when screening for chronic fatigue syndrome (NICE guidelines 2007).
That doesn’t necessarily mean that every patient whom presents with TATT should have every single test, but in a but based on the presentation, a selection or all of these would be appropriate. In cases where no cause (either organic or lifestyle) can be identified, then over the course of several consultations and follow-ups, all of these tests would likely be performed.
- FBC
- U+E
- Blood sugar
- Electrolytes – calcium and magnesium
- LFTs
- Iron studies
- Coeliac serology
- FOBT
- TSH
- CXR
- Urine – dipstick and MC+S
If all these investigations are normal, and a psychiatric disorder has been ruled out, then a diagnosis of chronic fatigue syndrome (CFS) can be made.
Others to consider based on risk factors and history
- HIV serology
- Sleep study
References
- Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
- Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
- Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy