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Fatigue Background Fatigue is defined by Aaronson et al as “a decreased capacity for physical and/or mental activity due to an imbalance in the availability, utilization, and/or restoration of resources needed to perform activity.” Fatigue is one of the most common and debilitating complaints of HIV-infected people, with an estimated prevalence of 20-69%. The consequences of severe fatigue may include curtailment of work and other activities, need for frequent breaks, limitations in involvement with family and friends, and difficulty completing even the simplest household chores. In HIV-infected individuals, fatigue may be caused by several comorbid conditions or by HIV itself. HIV-related fatigue is a broad term referring to fatigue that begins or significantly worsens after the patient is infected with HIV and that has no other identifiable causes. HIV-infected people with fatigue should be evaluated carefully for reversible causes, such as depression, anemia, hypogonadism, insomnia, and medication adverse effects, and should be treated aggressively if these are found. In some patients, fatigue may be related to advanced immunosuppression (with low CD4 cell counts) or to high levels of circulating HIV virus. Unfortunately, a specific cause of fatigue is not identified in many patients. Research to date suggests that fatigue in many HIV-infected individuals may result from a complex interplay between physiologic and psychosocial variables, and ongoing studies are being conducted to define factors related to the onset or worsening of fatigue. S: Subjective The patient complains of tiredness, easy fatigability, a need for frequent rest or naps, or waking in the morning feeling unrefreshed. The patient may complain of difficulty working, difficulty concentrating, inability to exercise without experiencing profound fatigue, or impairment in social relations because of fatigue. Consider the following during the history: ♦ No objective clinical indicators exist for fatigue; thus, the diagnosis of fatigue rests on subjective data. ♦ ♦ ♦ ♦ ♦ ♦ ♦ Section 5—Complaint-Specific Workups | 5–21 Fatigue assessment tools may help to diagnose and estimate the severity of fatigue. One such tool, the HIV-Related Fatigue Scale, was developed specifically for use with seropositive individuals (see Barroso and Lynn reference below). The scale includes 56 items that assess the intensity of fatigue (on the day of the assessment and during the previous week), the circumstances surrounding fatigue (including patterns), and the consequences of fatigue. Take a thorough history of the fatigue symptoms, including onset, duration, exacerbating and alleviating factors, and associated symptoms. Evaluate for symptoms of other conditions that cause fatigue (eg, hypothyroidism, hypogonadism, anemia, heart failure, poor nutrition). Depression can cause significant fatigue and is common in HIV-infected patients with fatigue. Screen the patient for depression. A single question—“Are you depressed?”—has been shown to be as valid and reliable as most depression instruments. See the chapter Depression for further information. Evaluate the patient’s sleep patterns. HIV infection can interfere with sleep architecture early in the illness. Inquire about substance use or abuse. Obtain a list of all current medications, including herbal and over-the-counter preparations. Conduct a nutritional assessment. O: Objective Check vital signs and orthostatic blood pressure and heart rate measurements, if indicated. Perform a physical examination including evaluation of nutritional status, affect, conjunctivae and skin (for pallor), thyroid, lungs and heart, and deep tendon reflexes.
5–22 | Clinical Manual for Management of the HIV-Infected Adult/2006 A: Assessment The differential diagnosis includes the following: ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ Anemia Hypothyroidism Hypogonadism Depression Insomnia or poor-quality sleep Substance use or abuse Malnutrition Medication adverse effects (eg, zidovudine, interferon) Opportunistic infections, malignancy, chronic hepatitis B or C, other illnesses P: Plan Diagnostic Evaluation To rule out reversible causes of fatigue, perform laboratory tests, including: ♦ ♦ ♦ Hemoglobin and hematocrit Thyroid function tests Testosterone (in both men and women) Fatigue assessment tools, as mentioned above, may be used to assess the intensity of fatigue, the circumstances surrounding fatigue, and the consequences of fatigue. Treatment If testing reveals a specific cause of fatigue, treat appropriately. For example: ♦ ♦ ♦ ♦ ♦ ♦ Treat anemia, hypothyroidism, or hypogonadism, as indicated. (See chapter Anemia.) Treat depression with antidepressant medication, psychotherapy, or both. (See chapter Depression.) Treat insomnia and review good sleep-hygiene practices with the patient. (See chapter Insomnia.) Refer for treatment of substance use or abuse, if possible. Treat malnutrition, ideally in conjunction with a nutritionist. Treat opportunistic infections and other illnesses. (See section Disease-Specific Treatment.) ♦ ♦ Control other symptoms that could be causing fatigue (eg, diarrhea). If fatigue seems to be related to antiretroviral medication(s), weigh the benefits of the medication(s) against the possible adverse effects, and discuss these with the patient. If, after appropriate evaluation, the fatigue is thought to be related to HIV infection or no specific cause is identified, consider the following: ♦ ♦ ♦ ♦ ♦ ♦ ♦ If HIV infection is inadequately controlled, particularly if the CD4 count is low or the HIV viral load is high, consider antiretroviral therapy (ART), if otherwise appropriate. Patients taking effective ART may still experience HIV-related fatigue. Providers should not dismiss these symptoms or tell these patients that, because their CD4 counts are high or HIV viral loads are low or undetectable, they should be feeling fine. Encourage patients to track their patterns of fatigue with a fatigue diary if necessary. Once patients recognize their individual patterns, they can better cope with fatigue by planning their daily activities accordingly (eg, performing the most strenuous tasks during times of peak energy or staggering activities to avoid excessive fatigue). Recommend moderate exercise and frequent rest. Refer the patient to community-based agencies for assistance with housekeeping. Evaluate the need for occupational therapy (eg, energy conservation techniques) or physical therapy (eg, reconditioning and strengthening exercises). Medications, such as stimulants, may be helpful for some patients with severe or debilitating fatigue.
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Table of Contents Clinical Manual f
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Preface—About this Manual | Clini
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Previous Editions Atlanta Contribut
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♦ ♦ ♦ ♦ ♦ | Clinical Manu
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Initial Physical Examination Backgr
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Genitals/Rectum • Inspect the gen
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Initial and Interim Laboratory and
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Section 1—Testing and Assessment
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Patient Education ♦ ♦ ♦ ♦ D
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Section 2—Health Maintenance and
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References ♦ ♦ ♦ ♦ ♦ ♦
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Occupational Postexposure Prophylax
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P: Plan Laboratory Testing Provide
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For hepatitis C, no recommended pro
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as hepatitis C or another sexually
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for treatment is appropriate, and b
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contact with the patient. Patients
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tablet daily of trimethoprim-sulfam
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Opportunistic Infection Prophylaxis
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Discontinuing Primary Prophylaxis P
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Latent Tuberculosis Background Late
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INH may cause liver toxicity and it
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Patient Education ♦ ♦ ♦ ♦
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Reducing Maternal-Infant HIV Transm
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Some states require written informe
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contraindicated during pregnancy be
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Section 3—Antiretroviral Therapy
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Nelfinavir (Viracept) Adequate drug
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Gonorrhea and Chlamydia Background
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Treatment of Gonorrhea Treatment op
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Hepatitis B Infection Background He
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Hepatitis C Infection Background He
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pregnancy. Ribavirin is teratogenic
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Herpes Simplex, Mucocutaneous Backg
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References ♦ ♦ ♦ ♦ ♦ Cent
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Kaposi Sarcoma Background Kaposi sa
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Treatment Treatment of KS is not co
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Molluscum Contagiosum Background Mo
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Mycobacterium avium Complex Backgro
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Table 1. Interactions between Rifab
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Mycobacterium tuberculosis: Treatme
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P: Plan Diagnostic Evaluation Durin
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Table 1. Regimens for Treatment of
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Rifabutin may be substituted for ri
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Non-Hodgkin Lymphoma Background Non
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Patient Education ♦ ♦ ♦ ♦ S
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Toxoplasmosis Background Toxoplasma
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♦ Atovaquone 1,500 mg orally twic
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Linear Gingival Erythema Background
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Background Necrotizing ulcerating p
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Oral Health Background Examination
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Maxillary Tori; Mandibular Tori S:
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Periodontal Disease Background The
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Oral Hairy Leukoplakia Background O
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Oral Ulceration Background Oral ulc
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Oral Warts Background Oral warts ar
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Anxiety Disorders Background Anxiet
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Patient Education ♦ ♦ Behaviora
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Insomnia Background Insomnia is a c
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Suicidal Ideation Background Transi
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Section 8—Neuropsychiatric Disord
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P: Plan ♦ ♦ ♦ ♦ ♦ Check t
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Correctional Settings Background Ca
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Adherence Adherence is one of the m
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Karnofsky Performance Scale Backgro
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