The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 3: Assessment of Physical SymptomsAs a consequence of this complexity, the measurement of fatigue must attempt to capture thisspectrum of disturbances. Although unidimensional scales can and have been used to assessfatigue, clearly a more meaningful assessment will evaluate its temporal dimensions, physicaland psychological26 picascomponents, and associated distress.Unidimensional fatigue scales include single items in symptom checklists and the fatigue subscaleof the Profile of Mood States. 53, 54, 55 Another approach involves the assessment of specific symptomsassociated with fatigue—for example, a visual analogue scale is used to assess “drowsiness”and other scales are used to evaluate the patient’s cognitive status. Several multidimensionalscales exist, including the 41-item Piper Fatigue Self Report Scale (PFS), which addressesthe severity, distress, and impact of fatigue 56 and the Visual Analogue Scale-Fatigue measure, an18-item, multidimensional patient-rated instrument. 57 While these scales are more applicablein the research setting than in the general clinical setting, the issues involved in the assessmentof fatigue highlight the need for accurate historytaking so the dimensions of the symptom that isdistressing the patient can be clearly defined.Instruments for Assessing Symptoms That May Otherwise Be UnnoticedInstruments to detect the presence of symptoms that may otherwise go unnoticed include thoseinstruments that routinely ask patients about the presence or absence of a symptom (or multiplesymptoms) and those that assess for the presence of impaired cognition. Some symptomsmay not be reported but may nonetheless be important. Consequently, clinicians may elect toinclude routine measuring of such symptoms in clinical care. For this purpose, clinicians mayuse instruments for the assessment of a single symptom (e.g., pain) or multiple symptoms.Cognitive impairment and its associated symptoms, problems common in hospitalized patientsand those with far advanced illness, are amenable to such routine monitoring. There are manyinstruments available for cognitive assessment. 58 In the clinical setting, some clinicians includebrief cognitive screens in routine assessment to improve their ability to detect such problems.Screening tests for cognitive impairment include the Mini Mental Status Exam 59 and the BlessedOrientation-Memory-Concentration Test, 60 Figures 3-5 and 3-6, respectively. Although these toolshave been shown to be sensitive indicators of impairment, 61, 62, 63 clinicians must be cautionedthat the instruments are not specific for the diagnosis of delirium or dementia, both of whichmay occur in advanced HIV-related illness. Further assessment would be needed to make thesediagnoses. (See Chapter 10: Psychiatric Problems.)Instruments for Assessing Multiple SymptomsInstruments may be needed to assess and monitor multiple symptoms. To date, only a smallamount of research has focused on the role in routine clinical use of instruments that assessmultiple symptoms. Even less information is available that applies directly to patients with HIVinfection.In clinical settings, the main problem with instruments that assess multiple symptoms has beentheir length (which may limit their clinical utility for routine use). Nonetheless, some instrumentsare available that could be considered for use in monitoring multiple symptoms. The EdmontonSymptom Assessment Scale (ESAS) is a nine-item, patient-rated symptom visual analogue scale64U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau