Cancer-Related Fatigue: Nursing Assessment and Management

Abstract

Cancer-related fatigue (CRF), the most common side effect of cancer and cancer treatment, is unlike the acute fatigue we experience from working all day in our jobs and with our families. It is an unpredictable, intense, overwhelming sense of tiredness or energy depletion. Fatigue is also defined as exhaustion, lethargy, lack of concentration and motivation, weakness, and depression. 1 It can occur suddenly and may not end when treatment ends but last months or even years. Patients with advanced colo-rectal cancer, lung and breast cancers, and lymphoma, all of which are managed under a variety of treatment regimens, report fatigue. 2 The onset, duration, and intensity of CRF have variable patterns, most notably in people receiving chemotherapy. Many report fatigue during the first few days after treatment, with a peak in fatigue when blood counts reach their lowest (nadir) and a decrease in fatigue before the next chemotherapy cycle. 1,3 Several studies have examined patterns of fatigue from radiation. 3–5 Findings suggest that fatigue may be cumulative over four to six weeks of treatment, with an increase in the presence of other physical symptoms, mood disturbances, and changes in usual activity. 3 For people receiving biologic therapies, fatigue is cumulative and related to dose and schedule. 6,7 With more types of cancer being treated with a combination of these therapies, the number of people affected by CRF is rising. People receiving cancer treatment can best describe CRF’s effect on their quality of life and thereby provide insight into its definition. A 76-year-old woman with lung cancer stated, “The morning after my treatment I could not get out of bed. When I finally did, I could only walk as far as the bathroom, then back to bed. I did not dare walk into the kitchen to prepare breakfast. My legs felt like lead.” A 52-year-old man with colon cancer described his fatigue. “I tried to work while taking my treatments, but I was exhausted by noon. I decided to work at home with my computer, but found it hard to focus. I tried to nap, but I never felt rested.” On the initiation of her second chemotherapy regimen, a 37-year-old woman with breast cancer recalled, “The first round of treatment made me so tired. My body ached. For the last three treatments, I found myself in bed most of the time. I could not be a wife or a mother to three small children.” A variety of patterns and multiple factors influence an individual’s experience of CRF. 1,8 With the interactions of multiple physiologic and psychological factors, CRF remains difficult to describe, and subsequently, manage. 9 Cancer-related fatigue has long been a misunderstood side effect of cancer treatment, and unfortunately the message often conveyed to patients and their families is that it’s unavoidable and needs to be tolerated. ASSESSING CANCER-RELATED FATIGUE The etiology of CRF cannot always be determined. 10 Several contributing factors have been identified: cancer and cancer treatments, anemia, neutropenia, sleep disturbance, depression, nutritional disturbance, and coping with other side effects of cancer treatment such as pain and nausea. 8 Along with complaints of unusual tiredness or weakness, people with CRF have decreased physical stamina, withdrawal from social activities, and decreased motivation. They may express irritability or impatience. 2 CRF’s cognitive manifestation ranges from sluggish thought process to inability to concentrate, forgetfulness, decreased short-term memory, and shortened attention span, 11 which may interfere with the person’s ability to fully participate in work, family, and social activities. Given that the contributing factors of CRF may be multicausal, and those interrelationships are the subject of many research questions, the current approach to assessment and nursing intervention needs to be multifaceted. Fatigue may present a challenge for nursing assessment because of the inherent difficulty in measuring a subjective symptom. Here are some guidelines to consider in assessing fatigue: Assess CRF as one would pain.1 First, allow patients to describe their fatigue in their own words by using open-ended questions such as, “Tell me about your fatigue.” Afterward, it’s useful to refer to the symptom by using the patient’s own words which hold significant meaning. More specific responses may be prompted by questions related to the patient’s functional mobility and ability to participate in leisure activities. Use a scale. A 0-to-5 or 0-to-10 response scale helps determine the patient’s perception of the severity of his fatigue. Select a scale that’s familiar to other care providers in the clinical setting, and use the same scale for other subjective symptoms such as pain or nausea. Having a consistent rating system helps everyone interpret a patient’s symptom patterns more quickly. Determine aggravating and alleviating factors. Ask the patient what makes his fatigue seem more severe, and what has worked and not worked in the past to prevent or reduce fatigue. Document assessment findings. This is critical for communication among health care providers. One initial assessment strategy is to track hemoglobin counts and fatigue scores on a graph (vital signs or treatment flowsheet) so that the nurse can convey to the physician how the patient is experiencing fatigue in reference to other symptoms, treatments, and lab values. The information also may be useful for individualizing fatigue management. SUGGEST AN ACTIVE APPROACH People experiencing CRF may make adjustments in their lives long before they seek guidance from health care providers. The usual fatigue self-management strategies, such as sleep and rest, which are more appropriate for healthy persons managing acute fatigue, are passive approaches. 9 In managing CRF, strategies need to be targeted toward maintaining sufficient energy to participate in the most meaningful life activities as defined by the person experiencing fatigue. 12 Because of the multicausal and multidimensional nature of CRF, 7 more than one management strategy may be necessary to provide relief. From a review of theoretical and research literature on CRF, Emma Ream and Alison Richardson identified three core activities to reduce the effect of fatigue: effective management of associated symptoms, enhancement of activity balanced with rest, and management of emotional stress. 9 Although more investigation is necessary to identify and test successful strategies for minimizing fatigue, several approaches for managing CRF have been supported by nursing research: preparatory education, physical activity, psychosocial support resources, and attention-restoring activities. Following are self-management strategies that can be incorporated into nursing practice: Acknowledgment of fatigue. Acknowledgment of the existence of CRF is a crucial first step toward assessment and management. Its recognition by the health care provider identifies CRF to be as important as nausea and vomiting, pain, peripheral neuropathy, or other treatment-related symptoms that affect quality of life. People with cancer report that having a health care provider simply inquire about their fatigue is meaningful because it indicates that their fatigue is worthy of intervention. 13 Preparatory information. By providing patients with information on fatigue, what’s known about it, and how it can be managed, the nurse validates not only its presence, but expresses her interest in working with the patient to manage it. A study of people receiving radiation therapy reported that those who prepare themselves for impending fatigue experience it less than those who receive no preparatory information. 14 With realistic expectations, people experiencing CRF can adjust and adapt to this symptom. 2 Prioritizing and pacing activities. Discuss with your patient how to prioritize and pace activities, including rest. 15 In setting priorities, it’s important to include a family member so that the choices for rest and activity reflect the needs of patient and family. As a man receiving chemotherapy explained, “I try to work three days a week—Monday, Wednesday, and Friday. I need one day off to recuperate from eight hours of work. My wife thinks I’m lazy because I have no energy to do what she wants me to do.” Encourage the person with CRF to review his usual weekly activities and identify low, moderate, or high priorities. Eliminate the low-priority activities and negotiate the moderate-priority activities into a daily schedule. Suggest assigning low-or moderate-priorities activities that are essential to other family members. If prioritizing and planning activities are energy depleting for the patient, assign a job broker, a family member or friend who can organize and assign tasks such as grocery shopping and meal preparation. There are certain tasks that may be obligatory to the patient’s role in the family. For example, a mother of three school-age children was undergoing chemotherapy for breast cancer. She felt it was her role to complete her usual to-do list of household chores, although she knew it took much of her energy. Her nurse helped her identify realistic expectations and develop new strategies. For this family, the task of doing laundry was divided into smaller activities for each family member. Her husband brought the hamper into the living room where his wife could sort the dirty laundry. She taught the older children to use the washer and dryer in the basement. The children brought the clothes upstairs for their mother to fold and put away. By breaking down household chores, the patient was able to participate and maintain her role in the family. Balancing activity and rest. In addition to prioritizing activities, a balanced schedule of activity and rest is important. 15 One woman in a cancer support group referred to her experience with fatigue as “living with the toddler effect.” She described pushing herself like a toddler who moves from one activity to another before finally collapsing. She stated, “I didn’t know another way to manage my fatigue.” Often, the balance between activity and rest is difficult. For some people, rest means sleeping for an extended time. Whereas lying down and shutting one’s eyes may be appropriate for a short time, sleeping on and off throughout the day interrupts sleep cycles at night and creates more symptom distress. To alleviate CRF, rest is more effective when used as a respite from activity. Short, frequent periods of inactivity, such as sitting quietly or lying down, strategically planned throughout the day, are more beneficial than long periods of sleep. 15 Physical activity. The nurse may need to help a person with CRF develop an incremental plan to increase physical activity. Even normally physically active people can and do exercise during treatment. However, the intensity and duration of the activity may need to be modified. 16 Although regular physical activity is an important component of a healthy lifestyle, Anna Schwartz confirmed that many health care providers do not provide information about it or encourage people with cancer to exercise. 16 Several studies of women receiving chemotherapy or radiation therapy for breast cancer and who participated in moderately intense aerobic exercises or a walking program reported that participants had less fatigue and emotional distress than those in usual care groups. 17–19 Patients report that physical activity is most effective when symptoms like fatigue are at their worst. 20 Of all the physical activities studied that have been used by people experiencing fatigue (walking, riding a stationary bicycle, low-impact aerobics, and swimming), walking is the most convenient, low cost, and low risk, regardless of age. In addition, walking may provide distraction, socialization, and attention-restoration. One young man, after his third cycle of treatment for lymphoma, had been hospitalized for an extended period of time. Upon returning home, he needed an incremental plan for increasing his physical activity. The first few days he focused on getting out of bed, getting dressed, and moving about his house. The plan also included activities beginning with sitting on the front porch and progressing toward walking down the driveway, to the end of the street, around the block, and continuing until he was able to choose his own physical activities. When he returned to the clinic, he shared with the staff a rediscovery of what he enjoyed most in life: socializing with friends, hiking, biking, and running. More study is necessary to determine specific recommendations for the appropriate type and amount of exercise. Overall, physical activity needs to be initiated at a comfortable level. Gradually, the intensity and duration may be increased to three to four days per week. 20 Energy conservation. Encourage the person experiencing fatigue to perform tasks that expend the least amount of energy. A collaborative approach among physical therapists, occupational therapists, nurses, and physicians supports the integration of energy-conserving strategies into planning daily activities and adapting the home environment. Eileen Donovan described several energy-conserving strategies for self-care, meal preparation, housekeeping, shopping, child care, and work. 21 Simple strategies, such as sitting rather than standing, or moving items closer within reach, decrease the amount of energy used. A breast cancer survivor, who had experienced fatigue, described her energy-conservation strategy for grocery shopping to her support group. She prepared the grocery list the day before and organized it by aisle. She planned her trip to a familiar neighborhood market at a time when it was less congested. She supported herself with a grocery cart as she moved from aisle to aisle, and took a 15-minute break halfway through on a bench in front of the store. After she paid the bill, she always asked for assistance with carrying the groceries to her car. Psychosocial support resources. People receiving radiation treatment and chemotherapy find it affects many aspects of their lives: their ability to work, their physical and emotional well-being, their ability to enjoy life in the moment, and their intimacy with their partner. 22 People with a history of chemotherapy indicated that CRF made it more difficult to participate in social activities, and to maintain relationships with family and friends. 23 A nurse referral to psychosocial resources, such as support groups, can help the patient cope with the effect of fatigue on quality of life. Through support groups, patients learn new self-management strategies that they can share with others. The selection of a specific psychosocial resource needs to be individualized. 9 Some people with CRF may be open to support group activities and benefit from a group, while others may prefer one-to-one counseling. Attention-restoring activities. People with CRF are often overwhelmed by an overstimulating environment. Their attention is diverted by the many sights, sounds, and objects in the health care environment—alarms, the fast-paced movement of staff, and painful procedures. Consequently, the patient, overburdened by information and environmental distractions, may not understand what’s being said. Bernadine Cimprich pioneered research in attentional fatigue, 1 the decreased capacity to concentrate or direct attention. 24 Natural environments or scenes such as a waterfall, a garden, or a sunrise may restore the patient’s ability to concentrate and comprehend. Women newly diagnosed with breast cancer, who participated in individualized, attention-restoring activities for 30 minutes three times a week, experienced significant improvements in attentional capacity compared to a control group. 11 Following participation in attention-restoring strategies, the person with fatigue may think more clearly and participate more actively in personal care and activities. The implications of Cimprich’s research are significant for providing information and education to people with fatigue and designing more supportive environments for them. Nurses are increasingly aware that the number of people experiencing CRF is rising. Cancer-related fatigue permeates every aspect of daily life: work, family, and social activities. Although more research is required to determine the effectiveness of proposed strategies to prevent and alleviate fatigue, the profound physical, psychological, emotional, and spiritual effect of fatigue demands that nurses intervene now. Nurses can be instrumental in identifying, evaluating, and aiding patients with fatigue to make the transition from passive to more active self-care strategies. Fortunately, more than a trial-and-error approach exists for fatigue management in current clinical practice. CRF theories direct nurses to management strategies such as providing preparatory information, assisting the patient to establish a balance of activity and rest, encouraging use of psychosocial support resources, and recommending attention-restoring activities. Managing CRF effectively requires nurses to thoughtfully and thoroughly pursue strategies that prevent physical deconditioning and allow people with fatigue to continue engaging in meaningful activities.