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Fatigue / Tired All The Time (TATT) Care Pathway Overview

As part of a workstream to optimise the use of Pathology in Gloucestershire, colleagues from primary care, GHFT’s Pathology department and the CCG have reviewed various areas of testing to improve quality and consistency.  One of these areas is unexplained fatigue, commonly known as ‘Tired All The Time (TATT)’.

  • Fatigue is normal for many people; between 10–18% of people in the UK report having tiredness lasting 1 month or longer and 1.5% of people consult their GP with a new symptom of tiredness each year.
  • Tiredness may be due to psychological, psychosocial, physical, or physiological causes or a combination of these.
  • 5-7% of GP consults present for fatigue – 75% of presentations are isolated episodes caused by life events or lifestyle requiring no follow up, with less than 3% of cases being caused by diseases such as anaemia or hypothyroidism.

Blood tests are often ordered immediately for TATT patients and although tests may exclude diagnosis and reassure the patient, they have a low rate of identifying any underlying disease. More serious causes need to be excluded through history, examination and consultation skills e.g. looking for red flags, is it a first presentation in an older patient.  Don’t forget to consider mental health, sleep disorders, alcohol and medication causes too as well as asking about their ideas and concerns.

Trials such as the VAgue Medical Problems IREsearch (VAMPIRE) trial found that only 17% of patients had symptoms 4 weeks later, and so initial postponement of blood test ordering may be a sound alternative (providing there are no red flags).  In their decision making, there is a need for GPs to balance up the yield of immediate, expanded test ordering with the risk of false-positive test results on one hand, and the diagnostic delay in the relatively few diagnoses when postponing blood-test ordering on the other, considering that the majority of patients do not revisit their GP for their complaints within 4 weeks.

If initial blood tests are ordered, limit testing to FBC, HbA1c, TSH and Viscosity – not B12 – then if symptoms persist for over 3 months more detailed tests may be required (UEG, LFTs, Calcium, TTG and Viscosity).  To support this practice, the following guidance has been published in parallel with introducing 2 new test collections on the ICE Requesting system – ‘Tired All The Time (1 Month)’ and ‘Tired All The Time (3 Months)’.

Please click the relevant flowchart box to be taken directly to textual information.

                             

Presentation

The patient may feel:

  • 'Tired all the time'
  • Like they have less energy than usual
  • Exhausted - either mentally, physically or both
Red Flags
  • Weight loss, drenching night sweats
  • Any features of malignancy, including haemoptysis, dysphagia, rectal bleeding, breast lump
  • Lymphadenopathy (including nodes more than 2cm)
  • Features of cardio-respiratory disease including sleep apnoea
  • Features of inflammatory arthritis, vasculitis or connective tissue disorders
  • Focal neurological signs
  • Patients 40 years and over who have smoked or have history of asbestos exposure
Differential Diagnosis

When approaching a patient with TATT, bear in mind the potential causes below and consider investigations for them either if there is good evidence that they might be the cause or if the symptoms fail to resolve after 3 months from initial presentation.

  • Lifestyle
  • Stress and anxiety
  • Alcohol/other drugs
  • Pregnancy
  • Sleep apnoea (not waking up refreshed)
  • Coeliac disease
  • Addison’s disease
  • Renal or liver failure
  • Hypothyroidism
  • Anaemia
Initial Primary Care Assessment

  • Lifestyle
  • Bleeding (menorrhagia)
  • Gastrointestinal symptoms
  • Urinary symptoms including polyuria and polydipsia
  • Medication
  • Quality and length of sleep including sleep apnoea and snoring
  • Recent infections
  • Joint pain or swelling
  • Mental health problems (stressful events, concentration and mood)
  • Alcohol intake
  • Travel history

Examination should include blood pressure and urine analysis.

Initial postponement of blood test ordering in favour of a watchful wait approach may be appropriate (providing there are no red flags), however if tests are ordered they should be limited in the first instance to FBC, HbA1c, TSH and Viscosity – not B12.  If initial testing is ordered, or if the patient returns within 4 weeks, please use the ‘Tired All The Time (1 Month)’ test collection on ICE to support your requesting.

If symptoms persist for over 3 months from initial presentation, then more detailed tests may be required using the ‘Tired All The Time (3 Months)’ test collection on ICE to support this (UEG, LFTs, Calcium, TTG and Viscosity).

Chronic Fatigue Syndrome should not be diagnosed until the symptoms have persisted for over 4 months.

Self-Management Advice

GPs should try and explain how common fatigue is, that it mainly resolves, and that providing any serious underlying causes have been considered and excluded, it can be self-managed positively by the patient and GP.  Encouragement should be given to:

  • Eat regular balanced meals and healthy snacks every 3 to 4 hours, rather than a large meal less often
  • Try and exercise regularly, even a 15 minute walk can give an energy boost.  See the Physical Activity page for local suppport information.
  • Lose some weight in order to be more active (if the patient is carrying extra weight)
  • Get up at the same time each morning, avoid naps through the day and take time to relax before bed to aid good sleep hygiene
  • Try to reduce stress levels by engaging in relaxing activities (listening to music, spending time with friends)
  • Cut out caffeine and drink less alcohol
  • Drink more water
  • Reduce their ‘screen time’
Treat the Underlying Cause/Watchful Wait
  • Treat the underlying cause if this is known.
  • For all people with persistent unexplained fatigue, including those with suspected chronic fatigue syndrome (CFS) who have not yet received specialist assessment:
    • Offer an understandable explanation for tiredness/fatigue that provides links between psychosocial and physical factors.
    • Identify and address modifiable psychological, social, and general health factors, including stress, work, personal relationships, chronic pain, and alcohol/drug misuse.
    • Provide general advice on sleep hygiene - discourage excessive sleep and daytime sleeping or naps.
When to Refer
  • Refer the person to an appropriate secondary care specialist if a serious underlying physical cause that cannot be managed in primary care is suspected or identified.
  • Chronic Fatigue Syndrome should not be diagnosed until the symptoms have persisted for over 4 months.  Refer adults with symptoms suggestive of chronic fatigue syndrome to a specialist CFS service:
    • Within 6 months of presentation, if symptoms are mild.
    • Within 3–4 months of presentation, if symptoms are moderate.
    • Immediately, if symptoms are severe.
  • Consider referring those with persistent, unexplained tiredness/fatigue not meeting the criteria for CFS to an appropriate specialist if any of the following apply:
    • There is significant uncertainty regarding the presence of an underlying physical cause.
    • The person would benefit from the reassurance of a second opinion or from the thoroughness of a specialist secondary care evaluation, and referral is not likely to reinforce unrealistic beliefs in a physical cause.
    • The person may benefit from access to the care delivered by a specialist CFS service, for example, cognitive behavioural therapy or graded exercise therapy.
    • A secondary care opinion may be required for occupational reasons, or for assessment of eligibility for disability benefits.
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