Side Effects - Fatigue

What are the causes of fatigue?

• There are many different causes for fatigue.
  • Some are due to your cancer or the treatment you are getting.
  • Others are due to your mental or emotional response to your disease or treatment.

It may also be due to any other illness you may have such as diabetes or high blood pressure.

Additionally, there are other causes, such as:

• The most common cause of fatigue in cancer patients is cancer treatment. The exact reasons for the fatigue are not totally known and are often a combination of factors.
  • Altered body chemistry (the substances in you body such as calcium, sodium, etc. are not at the levels they should be - too high or too low)
  • Emotional distress
  • Inability to sleep at night
  • Not eating well or drinking enough fluids
  • Poor muscle function due to staying in bed, being sick, having pain, or not getting any exercise
  • Having to travel to get to your treatments
  • Having to wait a long time to get your treatment
  • Side effects of treatment such as anemia (not enough red blood cells to carry oxygen to your tissues so they can work well), infection, pain, or nausea and vomiting
  • Too much calcium in the blood (hypercalcemia - can be caused by having cancer that has spread to the bone. The cancer breaks down the bone and calcium, which is used to make bones, is released from the bone into the bloodstream. This can make you fatigued; it can also cause nausea, problems with concentration and constipation)

How often does fatigue occur?

• About 80%-100% of those who have chemotherapy
• About 40%-93% of those who have radiation therapy will have fatigue
• In over 70% of all patients, fatigue affects daily life.

   

What are the symptoms of fatigue?

• Symptoms include:
  • Having a hard time climbing stairs or walking short distances
  • Having a hard time paying attention or concentrating
  • Being short of breath after walking or moving about
  • Difficulty doing simple tasks such as cooking, cleaning, taking a shower
  • Unable to do as much as usual during the day
  • A desire to sleep more
  • Slower speech
  • Feeling like crying or feeling you are sad or depressed
  • Being pale
  • Feeling very weak, weary, or listless (don't have energy to do anything or become tired very easily)
  • Having more physical complaints than usual (headache, achy joints)
  • Feeling happy one minute; crying the next; angry the next
  • Having a hard time paying attention when reading, watching TV or listening to others talking
  • Losing interest in your surroundings

What are the types of fatigue?

• There are 4 types of fatigue. They include:
  • Acute Fatigue is intermittent and can be expected
    • It has happens rapidly and lasts a short period of time.
    • It is caused by staying up too late or not getting enough sleep over a period of time.
    • It usually gets better with sleep.
  • Chronic Fatigue
    • is long-lasting
    • Is one of the types of fatigue that cancer patients get.
    • It is likely to be due to having cancer, being treated for cancer and having to deal with cancer and its treatment.
    • It does not get better with sleep or rest.
  • Attentional Fatigue
    • makes you unable to concentrate or pay attention to things you want to.
    • You may not be able to read, watch a movie or listen closely to a conversation.
    • For cancer patients who take chemotherapy, this is known as "Chemo Brain."
      • It may last up to 3 years following completion of treatment.
  • Neuromuscular Fatigue
    • is when your muscles are exhausted.
    • You get this type of fatigue if run a marathon or lift very heavy weights.
    • It goes away when you rest the muscles that are fatigued.

What is Chemotherapy-related Fatigue?

• Chemotherapy-related fatigue is an expected side-effect.
• It is noticeable within the first few days of each treatment.
• It is more obvious by 10 days after treatment.
• It slowly lessens until the next treatment.
• Over time the fatigue increases with each treatment and does not go away between treatments.
• It usually goes away in 12 to 18 months after you finish treatment.
• Some will have fatigue longer than others.

What is Radiation-related Fatigue?

• Fatigue is also an expected side-effect of radiation therapy.
• It increases over the time of therapy.
• Most patients will be feeling tired by the 3rd week of treatment.
• It continues over the course of treatment.
• The fatigue does not end immediately when treatment is over.
• It slowly goes away over time.

What is Surgery-related fatigue?

• Fatigue you experience with surgery is due to how well your heart is working, your nutritional status and how well your muscles work before and after surgery.
• It also can be caused by any fear or anxiety you may have about the surgery and the possible outcomes.
• It may be increased by medications for pain or nausea that you receive after your surgery.
• This fatigue usually goes away rapidly as you recover from your surgery.

Are there other cancer treatments that cause fatigue?

• Some treatments, called Biotherapy and including such drugs as Interferon and thalidomide, cause severe fatigue.
  • The fatigue is a likely side effect that is related to type of drug, the dose of the drug and time schedule on which the drug is given.
  • It will get worse as you continue the treatment.
  • It usually goes away 12 to 18 months after you finish your treatments.
• Combination treatment with more than one chemotherapy drug or both radiation therapy and chemotherapy also will be a cause of fatigue.
  • This fatigue can be severe and last a long time (more than a year) after treatment is done.

Patients' Comments and Concerns about fatigue

• Many patients talk about having fatigue. Comments from patients include:
  • "...I think of what I want to do and just can't get up and do it hardly unless I push myself."
  • "I could not get out of bed and walk to the bathroom and I would have to sit down... I would have to rest between each activity."
  • "...just knocked me down every 'darn' month."
• Other patients describe their fatigue as being:
  • Out of energy
  • Bone tired
  • Weary
  • Wiped out
  • Exhausted
  • Can't focus

What concerns you may have about fatigue

• Many patients have lots of concerns about feeling fatigued. Among them are that you:
• Don't feel like yourself
• Can become depressed because you can't or don't feel like doing things you usually do.
• May not realize how fatigued you were until the fatigue gets better.
• May have fatigue for a year or more after you finish your treatment.
• Don't understand that your fatigue is a side effect of treatment and not because your cancer is growing

Medical Management of Fatigue

Medical evaluation by your healthcare provider

• Your healthcare providers should be asking you about your fatigue.
• The providers should ask you if you have fatigue when you first are seen and then each time you come into the office, clinic or hospital.
• They should look at how fatigue makes you feel and what makes it better or worse.
• The provider also should ask you whether the fatigue is causing problems with concentration, your mood or your ability to do everyday things.
• Your Healthcare provider also may check to see if you are depressed, are under a lot of stress and what illnesses you have in addition to cancer

How do you measure fatigue?

• Fatigue can be measured in a number of ways.
  • A scale of some type should be used to measure your fatigue.
  • You should measure how tired you are every day and make sure to tell your provider.
  • There are a variety of scales to measure fatigue. Your provider can give you one. 
  • Your provider will also
    • Evaluate your lab values to see if you are anemic or have an infection
    • Look at the medicines you take
    • Measure the symptoms you have. 

What is the medical management for fatigue?

• There are some ways in which your healthcare provider can treat your fatigue. The most important method is to treat anything that may be causing your fatigue. Among the possible methods are for your provider to:
  • Manage your depression or pain with antidepressants or analgesics (pain medicines)
  • Treat your anemia with erythropoietin, iron supplements, folic acid and/or transfusions (see anemia)
  • Manage your sleep disorders by providing information on ways to improve rest and sleep. This may include prescribing sleeping pills.
  • Make sure that you are not dehydrated (from not drinking enough)
  • Make sure that your electrolytes and body hormones and other substances are at their normal levels
  • Give you oxygen so you are not short of breath
  • Reduce or stop any medications that are not needed
  • In some cases give you psychostimulants (such as ritalin) or low dose corticosteroids (such as prednisone) to boost you energy.
  • Suggest or let you use herbs, vitamins or other natural remedies (be sure to talk with your provider about any natural remedies you take. They may affect the way your treatment works.).

Non-Medical Management of Fatigue

There are many ways in which fatigue can be managed. These include conserving your energy; getting the right amount of sleep, rest and exercise; getting motivated and restoring attention.

How do I save energy and still do what I need and want to do?  

There are many things you can do to save the energy you have. Among them are to:

• Set Priorities
• • Write down everything you need/want to get done in a typical week. Ask yourself: Do I need to do this to survive? Is it important to my life goals?
  • Note specific things must be done.
  • Then ask if I must do this, can it be changed so that I can do it?
  • Can I do it less often? Can I break it into smaller parts? Can I delegate it to someone else?
  • Make a calendar. Place it where everyone can see it.
• Change your activities
  • Use mental vs. physical energy
  • Break an activity into component parts, only do some
  • Alternate light and heavy activities
  • Organize work areas to get more done with less energy
  • Use labor-saving devices
  • Avoid rushing/take rests
• Delegate to others
  • Be specific about what you need
  • Keep a list of what needs to be done; if someone offers, tell them immediately
  • Ask for what you need up front
  • Be open with friends/family about illness, treatment, needs and feeling (remove the taboo of topic)
  • Delegate more fatiguing or less-valued activities to others (you may want to make the birthday cake for your son's birthday, but delegate the house cleaning for the party to others or have the party at another relative's house)
• Carefully use the energy you have
  • Know when you are most tired
  • Do things when your energy is at its peak
  • Know that you can only put out as much energy as you have
  • Sit in a firm chair with arms to be better able to get out of the chair (you may need someone to hold it in place for you
  • Put on a terrycloth robe to absorb water when you get out of the tub or shower rather than drying yourself with a towel (saves a lot of energy)
  • Use a raised toilet seat in the bathroom
  • Consider a wheelchair or walker on wheels for longer distances
  • Arrange commonly used materials and supplies close to your workspace
  • Sit rather than stand
  • Use a long handled device to pick things off the floor (bending over to pick something up may be very hard and may make you dizzy when you stand back up)
  • If possible, meet with a physical or occupational therapist for energy conserving ideas
  • Keep a journal to describe your fatigue
  • Balance rest and activity
  • Postpone non-essential activities

What kinds of things can I do to regain or restore my energy?

• Get plenty of rest and sleep (good sleep hygiene)
  • Take it easy
  • Rest when you feel tired
  • Try to get more sleep at night
  • Try to rest during the day
  • Take a power nap, but no more than 30 minutes at a time
  • Do something that you enjoy that is relaxing
  • Avoid the use of caffeine (coffee, chocolate, sodas)
  • Avoid alcohol
  • Establish a regular bedtime
  • Take a warm bath
  • Sip warm milk/herbal teas
  • Listen to soothing music
  • Establish a quiet environment
  • Use your bed only for sleep; do not read or work in bed
  • Go to bed when you feel sleepy; but do not stay in bed if you do not fall asleep
  • Try to make your area for sleep quite, with fresh air and at a comfortable temperature
  • Turn down or turn off the telephone
  • Use a comfortable mattress (right firmness for you) and pillow. Use pillows for support.
  • Wear loose clothing
  • Sleep in a familiar environment whenever possible.
  • Take sleep medicines as ordered by your provider (short term or intermittent use are perfectly okay)
  • If you use herbs or other natural products for sleep, be sure to tell your provider as some herbs can affect how well your cancer treatment works.
• Get exercise daily
  • Take part in a regular exercise program (walk daily, lift weights [canned soups or vegetables can be used at weights], swim, ride a bike, run).
  • Don't exercise when it is very hot or very cold.
  • Stop exercising if you are short of breath, have pain, feel dizzy or have any other symptom.
  • Pay attention to safety; exercise with someone or have a method to reach others (Cell phone).
  • Make sure others know where you are going if you go for a walk or bike ride.
• Decrease your stress
  • Join a support group
  • Take part in activities like dancing, painting, writing poetry, making music
  • Share your thoughts and feelings
  • Focus on positive aspects of life
  • Actively participate in your treatment plan
  • Use humor
  • Change your environment
  • Share your story (life's accomplishments/events)
  • Practice
    • Deep breathing
    • Visual imagery
    • Meditation
    • Take part in ceremonies

How do I take good care of myself?

• Maintain your motivation
  • Share your thoughts and feelings
  • Focus on positive aspects of life
  • Actively participate in your treatment plan
  • Use humor
  • Change your environment
  • Share your story
• Take care of yourself
  • Take your medicines for pain and nausea (as well as all others) as your provider has told you to. Pain, nausea and any other side effects that are not relieved can increase your fatigue)
  • Continue to have a social life
  • Try to maintain a positive attitude
  • Communicate concerns about fatigue to providers
  • Learn your patterns of fatigue
  • Use a 1-10 scale to rate your fatigue (or any other routine rating); make sure to tell your provider
  • Keep a daily log, note:
  • Time of day and day of week
  • If you got any cancer treatment
  • If you got any other treatment
  • Any other illnesses
  • Highest level of energy
  • How being tired affects your life

How do I improve my ability to concentrate/pay attention?

• Walk or sit outdoors
• Tend plants
• Watch birds or wildlife
• Involve your mind by reading, doing crossword puzzles or doing math problems

Talking to your provider about feeling tired

Talking with your provider about fatigue:

• Make sure your providers ask you about fatigue
• Make sure you tell your providers about your fatigue
• Look at how long it lasts, what makes it better or worse, how bad it is
• Note if tiredness bothers your thinking, mood, and ability to perform daily activities

Be sure to call your provider if you:

• Get dizzy
• Loose your balance when walking
• Loose your balance when getting out of bed or out of a chair
• Fall or hurt yourself
• Have trouble waking up
• Have problems catching your breath
• Have a sudden increase in fatigue (you need to rest all the time)
• Have a really rapid heartbeat
• Can't go to sleep or don't stay asleep or can't go back to sleep once you wake up during the night
• Are very feeling anxious, nervous, constantly thinking about things
• Can't get out of bed for more than 24 hours

What if I am working and have fatigue?

• Trying to work while taking cancer treatments can be very hard.
• If you have fatigue, it can be even more difficult.
• There are many things you can do to make working a little easier.
  • Talking with your employer or supervisor before treatment will help.
  • It also is good to talk with at least some of your co-workers about your cancer and the treatment you are receiving. They can help you continue to work.
  • You should work with your boss to set goals for your work.
  • If you are very fatigued, see if you can work flexible hours.
  • You might ask if you can delegate some of your tasks.
  • Make sure to eat well and drink fluids.
  • You may need to plan rest periods during the day.
  • You also may want to help your co-workers to learn about your cancer so they can be more helpful.

How family/friend caregivers (those who take care of cancer patients) can prevent their own fatigue

• Taking care of someone you love who has cancer can be very tiring.
• To make sure that you don't suffer from fatigue, there are some things that you can do for yourself. Among them are to:
  • Take time for yourself and your own needs
  • Eat well and get exercise
  • Identify and use methods to reduce personal stress
  • Set limits with loved ones. Don't spend every moment with them.
  • Do things of personal value for at least 30 minutes at least 3 times per week
  • Let family and friends help. They usually would like to but need to be asked.
  • Share your feelings with others. It may help to join a support group.
  • Keep lines of communication open with all
  • Give yourself credit - "the care you give does make a difference"