Susan K. Smith of Louisville was caught off-guard by the relentless fatigue that hit her after her stage 4 lung cancer diagnosis in early 2020.
Initially, Smith, now 77, considered it might be depression. It was a herculean task just to get dressed every morning. On some days, even getting out of bed seemed impossible.
But as she started to organize her affairs, Smith realized something else was at play. No matter how much she slept, she woke up feeling drained. She was exhausted, even if she didn't do much during the day.
"When people told me, 'It's just old age.' it didn't help at all. It made me feel there was nothing I could do mentally or physically to manage this," she explained.
Fatigue is a frequent symptom of many diseases that afflict the elderly, such as heart disease, cancer, rheumatoid arthritis, lung disease, kidney disease, and neurological conditions like multiple sclerosis. According to a 2021 review by researchers at the University of Massachusetts, it's one of the primary symptoms associated with chronic illness, affecting 40% to 74% of older people living with these conditions.
This goes beyond the tiredness after an extremely busy day or a sleepless night. It's a persistent feeling of exhaustion that envelopes the whole body, even without physical exertion. "I feel like a spent battery almost all the time," said a user named Amanda in a Facebook group for people with polycythemia vera, a rare blood cancer. "It's like being a thoroughly squeezed-out sponge."
Dr. P., a research scientist at the Regenstrief Institute in Louisville and a professor at the University of Louisville School of Medicine, said that fatigue isn't about being tired for a day; it's about weeks or even months of tiredness.
When he and his team surveyed nearly 3,500 older patients at a primary care clinic in Louisville about distressing symptoms, 55% mentioned fatigue — second only to musculoskeletal pain (65%) and more than back pain (45%) and shortness of breath (41%).
Meanwhile, a 2010 study in the Journal of the American Geriatrics Society estimated that 31% of people aged 51 and older had experienced fatigue in the past week.
The consequences can be severe. Fatigue is the leading cause of limited activity in people aged 70 and above, according to a 2001 study by Yale researchers. Other studies have associated fatigue with impaired mobility, limitations in performing daily activities, the onset or exacerbation of disability, and premature death.
Often, older adults with fatigue reduce their activity level and become deconditioned, leading to muscle loss and weakness, which intensifies fatigue. "It creates a vicious cycle that can lead to things like depression, which further increases fatigue," said Dr. Amy Harmon, a professor of medicine and chief medical officer at the University of Colorado Hospital.
To break this cycle, Smith developed a strategy after learning her lung cancer had returned. Every morning, she set small goals. One day, she would get up and wash her face. The next, she would take a shower. Another day, she would go grocery shopping. She would rest after each activity.
In the three years since her cancer recurrence, Smith's fatigue has been relentless. But she said, "I'm doing better now" because she has learned to pace herself and find things that drive her, like teaching a virtual class to aspiring teachers and exercising under a personal trainer's supervision.
When should elderly individuals be concerned about fatigue? "If a person was doing fine but now feels constantly tired, it's crucial to get an evaluation," advised Dr. Jennifer Wilson, a physician at Scripps Mercy Hospital in San Diego and the incoming board president of the American Academy of Hospice and Palliative Medicine.
"Fatigue is a warning signal that something is off in the body, but it's seldom one thing. Typically, several issues need addressing," noted Dr. Rohit Patel, section chief of the Center for Geriatric Medicine at the Cleveland Clinic.
He listed several factors doctors should investigate: Are thyroid levels normal? Is sleep a problem? Are underlying medical conditions well managed? Is there an underlying infection? Is there chronic dehydration? Is there anemia or an electrolyte imbalance? Are testosterone levels low? Is protein intake sufficient? Have feelings of anxiety or depression increased? Could current medications be causing fatigue?
"Even if the medications and dosages haven't changed, your body's ability to process those medications and remove them from your system might have," Patel said, pointing out that such metabolic changes are common as people age.
Many potential fatigue contributors can be addressed. However, often, fatigue can't be attributed to an underlying medical condition.
This was the case for Lydia Gonzalez, 64, a retired nurse living just outside of Portland, Oregon. On a December trip to Arizona, she suddenly found herself winded and extremely tired during a hike, despite being fit. After being diagnosed with an asthma flare-up at an urgent care facility and prescribed steroids, she didn't find any relief.
Soon, Gonzalez was spending most of her day in bed, overwhelmed by intense tiredness and weakness. Even minor activities exhausted her. But none of the medical tests she received in Arizona or back in Portland — including a chest X-ray and CT scan, blood work, and a cardiac stress test — revealed anything abnormal.
"It's hard for anyone to believe you're ill when there's no objective evidence of disease," she shared with me.
Gonzalez began frequenting long covid websites and chat rooms for chronic fatigue syndrome sufferers. She now believes she has post-viral syndrome from an infection. The Centers for Disease Control and Prevention report fatigue that hinders daily life as one of the most frequent symptoms of long covid.
Several strategies exist for managing persistent fatigue. For cancer patients, Dr. Jason Fowler, an associate professor of palliative medicine at the University of Kansas Health System, said, "the best evidence supports physical activities like tai chi, yoga, walking, or low-impact exercises." The goal is to "gradually expand patients' stamina," he mentioned.
For long Covid, though, overdoing it too soon can result in "post-exertional malaise." It's often advised to pace activities: do only what's most important when energy levels are at their peak, and rest afterward. "You learn how to set realistic goals," said Dr. Mark Ashton, senior education advisor at the Center to Advance Palliative Care.
Cognitive behavioral therapy can help the elderly with fatigue learn to adjust expectations and tackle intrusive thoughts like, "I should be able to do more." At the University of Texas MD Anderson Cancer Center, plans for managing fatigue in older patients typically include strategies to address physical activity, sleep health, nutrition, emotional health, and support from family and friends.
"Much of managing fatigue is about developing new habits," pointed out Dr. Sarah Green, a palliative care and integrative medicine physician at MD Anderson. "It's crucial to understand that this doesn't occur instantly: It takes time."
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