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Managing fatigue at the end of life
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The National Comprehensive Cancer Network recently released the clinical practice guidelines for the treatment of cancer-related fatigue. In these guidelines, there are pharmacological and non-pharmacological treatment approaches to treating fatigue in the cancer patient. One particular feature in the guidelines is that, in general, the treatment should be customized according to the needs of the patient.
Of critical importance is to focus on the treatment of causes that can be modified or reversed (ie, hypothyroidsm, depression or anemia).
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To help improve medical status, the palliative care team must perform a comprehensive medical evaluation. All physiological causes can contribute to the presentation of hypoactive delirium. Many of these patients are diagnosed with depression and in reality they may actually have a non-agitated acute confusional state that may be treated by appropriate management of reversible medical causes.
Medications like opioids can cause sedation and fatigue. I have often used psychostimulants to counteract the side effects of the opioids. To date, there are multiple randomized placebo-controlled studies on methylphenidate with positive results. There is also promising data on L-carnitine supplementation in the treatment of this type of fatigue.
To treat sleep disorders, management should start with sleep hygiene and behavioral interventions. Progressive muscle-relaxation and imagery techniques are useful. Medications should be evaluated cautiously to prevent daytime sedation as a side effect from these medications. Sedative hypnotics should be started at low doses due to the fact that they can cause impaired cognition.
The patient may be encouraged to participate in physical activity and exercise. Mild exercise has shown in small studies to be helpful in patients with advanced cancer without causing fatigue.
Various nutritional alternatives have been proposed to optimize nutritional status, such as ensuring an adequate protein-calorie intake and using specific medications or nutrients. For instance, progestins and anabolic steroids are often used as appetite stimulants.
Energy conservation techniques provided by occupational therapy are helpful in reducing fatigue (eg, raising toilet seats). In fact, planning and prioritizing activities is crucial for these patients.
Some patients refrain from having to ask for help. In these cases, I work with the patient on exploring the causes of those beliefs and teach how to reframe them. Knowing the patients’ support system and advising them about who to ask for help often provides benefit.
Patients with advanced stage cancer often have to deal with losses. They cannot do the same things they used to do before they became ill and sometimes undervalue activities that they can perform at the present time.
Psychoeducation can minimize distress on patients caused by their fatigue. If a patient knows that the fatigue is caused by reversible factors, this in fact may decrease the patient’s suffering as well as their families’. Patients can also erroneously attribute the symptoms of fatigue to the progression of their disease.
Maria Rueda-Lara, MD, is assistant professor of psychiatry at the Cancer Institute of New Jersey, Robert Wood Johnson Medical School.
For more information:
- Breitbart W, Alici Y. J Natl Compr Canc Netw. 2010 Aug;8(8):933-42.
- NCCN Clinical Practice Guidelines in Oncology. Cancer-Related-Fatigue, 2010.