Are you tired of feeling tired all the time?


MEDICAL MATTERS:More than 10 per cent of GP patients complain of tiredness, writes MUIRIS HOUSTON

AS I write this week’s column the sound of Bob Dylan performing live at the O2 remains fresh. For over 90 minutes, the 68-year-old icon played non-stop. With no “chat” between songs and with a full-on blues-based performance of many favourites, Dylan showed amazing energy.

It is a fair bet that most of his audience, whose average age was 45 plus, felt more tired than Dylan did. Which is not to suggest that there was anything medically wrong with any of them or that age is a factor in either Dylan’s impressive energy or the fatigue felt by any audience member.

Rather it reminded me how often people attending doctors in primary care complain of tiredness. Known in the business as TATT – tired all the time – research has shown more than 10 per cent of patients attending a doctor’s surgery described being substantially fatigued for at least a month.

Of course, most of these people will not go on to develop chronic fatigue syndrome (CFS), but the immediate challenge for a doctor is to ensure that any physical causes are diagnosed and appropriately treated. Unlike many other problems presented by patients, TATT does not fit into a ready diagnostic algorithm.

However, research in the current issue of the British Journal of General Practice (BJGP) offers doctors and patients a little more certainty than before.

Doctors from the universities of Amsterdam and Maastricht in the Netherlands recruited more than 300 patients who came to see their doctors with new unexplained fatigue.

Almost one in 10 had an illness that was diagnosed following a series of blood tests. Interestingly, when a broad range of blood tests were performed, the results were less accurate than when a limited set of four investigations were undertaken.

The study shows that carrying out just four blood tests in patients who reported fatigue – ESR, glucose, haemoglobin level and TSH – was sufficient to maximise the opportunity of diagnosing a physical illness.

ESR stands for erythrocyte sedimentation rate and is a general measure of whether an inflammatory process is under way in the body. An elevated glucose level suggests the possibility of diabetes, while a decreased haemoglobin reading indicates the person has anaemia (low blood count).

TSH stands for thyroid stimulating hormone; when it is raised, it suggests the person may have an underactive thyroid, a key symptom of which is profound tiredness.

In the study, blood tests were done four weeks after the patients were initially seen and the number of positive tests reflects the small number of patients who returned as instructed to have blood taken.

Notwithstanding the low number of patients with fatigue who re-consulted after four weeks, the authors say general practitioners should “try to postpone blood test ordering in patients with initially unexplained fatigue, and if blood tests are ordered, limit the tests to haemoglobin, ESR, glucose and TSH”.

Many doctors, however, may take the view that it is reasonable to carry out this limited range of blood tests immediately in most patients in whom a thorough history and examination suggests they have established fatigue.

In a separate research paper, other Dutch researchers attempted to predict the outcome for patients who present TATT in primary care. It found that both the severity of fatigue and a patient’s expectation that it would become a chronic problem were the strongest predictors that the fatigue would be prolonged.

Men, those who had a good perception of their health, and individuals who were not caring for others were more likely to recover within a shorter timeframe. Of the 525 people enrolled in the study, 11 per cent had a chronic condition such as asthma or diabetes.

Some 3 per cent had a previous history of cancer. “Patient perceptions are associated with the prognosis of fatigue in primary care. Negative thoughts regarding symptoms are potentially modifiable in patients,” the authors conclude and are backed up by an editorial in the Journalreinforcing the value of cognitive behavioural therapy in treating people with CFS.

Meanwhile, for those whose energy levels today make them feel closer to “knocking on heaven’s door”, Dylan’s energetic performance offers hope that tomorrow offers hope of feeling “forever young”.