Fatigue: the signs that say more than being tired

Tiredness is a normal human state. Fatigue that does not lift with sleep, that has been present for weeks, and that is changing what a person can do, is a symptom with causes that can be found - and several of them are common, cheap to test and treatable.

What kind of fatigue it is

• Sleepy all day, falling asleep at will, and unrefreshed on waking: a sleep problem, most often sleep apnoea or chronic short sleep.
• Exhausted but wired, cannot switch off, waking at four, and tired without being sleepy: the stress and mood pattern.
• Fatigue with breathlessness on climbing stairs, or with pale skin and a fast pulse: anaemia until a blood count says otherwise.
• Fatigue with weakness that worsens through the day, double vision, or difficulty holding the head up: a neurological cause, and a specialist one.
• Post-exertional crash, where a good day is paid for with two bad ones: the pattern of chronic fatigue and of post-viral fatigue.
• Fatigue with joint stiffness, hair loss, mouth ulcers, or a rash: inflammatory and autoimmune, and worth blood work.
• Fatigue with thirst, frequent urine, blurred vision and weight loss: diabetes, and it needs testing this week rather than eventually.

The causes that get missed

• Iron deficiency, with or without anaemia. Extremely common in Indian women, in vegetarians, in anyone with heavy periods, and in frequent blood donors. Ferritin is the test, and a low ferritin with a normal haemoglobin is still iron deficiency.
• Vitamin B12 deficiency, which is epidemic here and which produces fatigue, numbness, balance trouble, mouth soreness and cognitive fog long before the blood count looks abnormal. Metformin, acid-suppressing drugs and a strict vegetarian diet all lower it.
• Vitamin D deficiency, which produces fatigue with vague aching and proximal weakness, and which is present in a majority of urban Indians in some surveys.
• Thyroid underactivity, diabetes, kidney and liver disease, coeliac disease, and chronic infection including tuberculosis, hepatitis and HIV.
• Sleep apnoea: snoring, witnessed pauses, morning headache, dry mouth, and unrefreshing sleep. It is present in a large fraction of people with high blood pressure and weight gain, and it is routinely missed.
• Medicines: beta-blockers, statins, antihistamines, some blood-pressure tablets, sedatives, some antidepressants and some nerve-pain drugs all cause fatigue as a direct effect.
• Depression and anxiety, which present as tiredness far more often than as sadness, and which are the commonest reason a long fatigue workup comes back clean.
• Pregnancy, and the months after it, including breastfeeding and a total nightly sleep of four hours.

Red flags that change the pace

• Weight loss without trying, night sweats, or a fever that has been running for weeks.
• Breathlessness at rest, chest pain, fainting, or a heart that races or skips.
• New confusion, a bad headache, double vision, facial droop, weakness on one side, or a change in speech.
• Blood in the stool, black stools, or bleeding gums and easy bruising.
• A lump, a persistent cough, or a change in bowel habit that has lasted weeks.
• Fatigue so severe that a person cannot get out of bed, with no interest in anything, or any thought of self-harm. That last one needs someone told today.
• Fatigue in someone with known cancer, kidney disease, heart disease, or on chemotherapy or immunosuppressants.

What we ask and what we test

• A sleep history: hours, timing, snoring, waking, and whether the fatigue predates the current life situation.
• A full medicine and supplement list, including anything bought online.
• Mood, appetite, weight, periods, alcohol, and how much tea or coffee is being drunk.
• Examination: pulse, blood pressure including standing, the chest, the abdomen, the thyroid, the skin, the conjunctivae and the nails, and a quick neurological screen.
• Baseline bloods, which for most people with this complaint is where the answer is: full blood count, ferritin, B12, vitamin D, sugar or HbA1c, thyroid function, kidney and liver function, and an inflammatory marker. Urine, and a pregnancy test where relevant.
• Referral onward for what we do not treat: thyroid, pituitary and adrenal disease belong with an endocrinologist, and a sleep study belongs with whoever runs one.

What we do with it

• Correct what the bloods found. Iron, B12 and vitamin D replacement are the treatment, and they are given in a proper dose for a proper length of time and then re-tested, not taken for a fortnight because the person felt better.
• Ashwagandha as the main supportive preparation, which has decent human work behind it for stress-related fatigue and sleep quality. Slow, tolerable, and not a stimulant.
• Bala and ksheerabala traditionally used for weakness and convalescence, and reasonable as support after an illness.
• Guduchi where there is a low-grade inflammatory picture, and arogyavardhini where the liver enzymes and the digestion have both crept up.
• Amla and the classical nourishing preparations as general support rather than as treatment.
• Triphala where the bowel has slowed, because a bloated, constipated person always reports fatigue as their leading symptom.
• Sleep, meal timing and workload are prescribed as concretely as a tablet, since they are the treatment in most of the cases where the bloods are clean.
• We do not give tonics for a fatigue whose cause is depression, sleep apnoea or a thyroid. Those are treated by their own pathways.

The daily part

• Sleep at a fixed time, seven to eight hours, with the phone out of the bed and no caffeine after early afternoon.
• Food at regular times with real protein at each meal, because a sugar-and-flour day produces exactly this symptom.
• Activity graded rather than heroic. The person who has a good day and does everything, then crashes for three, needs the ceiling set before the crash.
• Sunlight in the first hour of the day, which is a genuine lever on sleep rhythm.
• Alcohol reduced, because it destroys the second half of the night and people blame the tiredness on everything else.

How we judge it

• Hours of usable energy in a day, and whether the crash after activity is shorter.
• Sleep quality and the morning feeling, which is the earliest thing to change.
• The repeat blood result, since a ferritin or B12 that has not moved after a month of tablets means the dose, the diagnosis or the adherence is wrong.
• A review at four to six weeks. Fatigue that has not improved once the common causes have been excluded and treated needs the next tier of investigation rather than another bottle.