In 1796 Thomas Ball submitted a dissertation to the Philadelphia Medical Society on "the causes and effects of sleep." Ball (who was about to become a doctor) suggested a number of remedies to "produce sedative effects." First on his list was bloodletting (a formerly popular procedure in which a small incision is made in a vein and some blood is removed from the sick person), which he stated "should be preferred to all other depleting remedies; because we have it more under command than any other." He elaborated by saying, "I have seen it necessary to bleed as oft as four, five, or even six times, before the excitement would be sufficiently reduced to admit of sleep." Other remedies he discussed included purging, vomiting, taking a cold bath, and inducing blisters. Although Dr. Ball's remedies are well left in the past, we can commend him for recognizing the importance of sleep in health and disease.
Today the medical and pharmacological treatment of fatigue depends on the underlying reasons for the symptom. For instance, insomnia (caused by pain) and anemia are two common problems that cancer survivors face which contribute to fatigue. These problems, once identified, are usually easily resolved. Cancer treatments that cause hormonal fluctuations may lead to insomnia. So, for example, women with breast or endometrial cancer and men with prostate cancer may be affected by hot flashes, which can keep them awake at night. The cancer treatment may need to be continued, in order to alter the estrogen or testosterone levels, despite this bothersome side effect. However, medications that don't affect these hormones may work to decrease the incidence and intensity of the hot flashes (for example, the antidepres-sant medication Effexor [venlafaxine] has been shown to relieve hot flashes in women with breast cancer).
Pharmacological treatment of fatigue can be divided into several categories. In the first category are medications to promote sleep, including the classes of benzodiazepines (such as Valium) and non-benzo-diazepines (such as Ambien, Lunesta, and Rozerem). Ambien is best used for a short-duration sleep issue; however, Ambien CR (which is relatively new on the market) is approved for long-term use. Another new non-benzodiazepine drug, Lunesta (eszopiclone) can be used for "sleep maintenance"; it works to keep people asleep through the night, in addition to helping people fall asleep. Lunesta can also be used to treat chronic insomnia over the long term. Finally, another new medication for insomnia is Rozerem (ramelteon), which affects melatonin in the brain and is indicated for use in people who have difficulty falling asleep initially.
The second category includes drugs that help to control pain. Pain is depleting and the relief of pain is energizing. In addition, medications that help control pain often have a sedating effect (examples are narcotic pain medications, muscle relaxants, and antidepressants), so they can help relieve sleep problems in two ways. The third category consists of mood stabilizers such as antidepressants (these also can help reduce pain and are included in the second category as well). Alleviating depression helps people to feel more energetic and vigorous. Reducing anxiety and mood fluctuations can promote sleep as well. The fourth category comprises psychostimulants, substances that improve alertness and energy. Medications in this category include methylphenidate (Ritalin), modafinil (Provigil), and pemoline (Cylert). Psychostimulants should be prescribed with caution because they may produce significant side effects such as insomnia, anxiety, decreased appetite, confusion, and a racing heart rate.
Here is a stepwise plan for addressing the symptom of fatigue:
Step 1. Make an appointment with your doctor to discuss your symptoms. Be sure to talk to her about how fatigue is affecting you on a daily basis. Describe any pain that you have and what your mood is like. Talk to her about your sleep pattern. Mention how often you exercise, what you are doing for exercise, and the intensity and duration of your fitness program. Describe your diet—how often you eat and what you eat. Tell her about your use of alcoholic beverages. Make a list of all of your medications and any over-the-counter supplements you are taking, so that she can easily review it. Your doctor may order tests to further investigate your symptoms, or she may suggest that you change your exercise regimen, bedtime routine, diet, and so forth. Book a follow-up appointment for one to two months later. At that time repeat this same process and note any changes you have made to improve your symptoms. Report how these changes have helped (or not). Specifically ask for further advice about treating your fatigue. Continue this pattern every couple of months until your symptoms improve and you are feeling more energetic.
Step 2. Exercise most days of the week; focus on aerobic (cardiovascular) exercise to improve your endurance and overall fitness level. Exercise has been shown to relieve fatigue in people with different kinds of cancer and is an easy way to both increase your energy and help your body to heal in other ways. While this may not seem intuitive, resting too much has been shown to contribute to cancer-related fatigue rather than lessen it. Therefore, if you are tired, try increasing your activity level instead of resting more.
Step 3. Exercise is important, but so is pacing yourself. Keep in mind that running errands and doing "busy work" is not very helpful when it comes to physical healing. Therefore, even as you focus on pursuing an appropriate exercise program, avoid overdoing it with chores that are energy-depleting. Chapter 4 covers this topic in much greater detail.
Step 4. Eat a healthy diet and include frequent snacks as energy boosters. Maintaining your blood sugar level throughout the day is important. See Chapter 8 for tips on how to eat to heal.
Step 5. Reduce your stress, anxiety, and depression. If you are feeling worried or sad, you can do things on your own or with the help of your doctor or mental health professional to improve your mood. Read Chapter 11 for more about mood management.
Step 6. Sleep well. This may seem obvious, but it is important to remember: you will never feel energetic if you don't sleep well. Sleep is the way your body refreshes itself. If you don't sleep well in terms of quality and quantity, you'll feel tired. It's as simple as that. If you aren't sleeping well, talk to your doctor, who can help identify the problem and find possible solutions.
One way to evaluate your sleep is to keep a log for a week. What time do you go to bed and when do you wake up? Do you sleep all night? If not, what interferes with your sleep? Is your sleep restless? Do you feel refreshed in the morning? Also record how active you are during the day and whether you stop to rest or nap. The log will help you to determine whether what you do during the day affects your ability to sleep at night.
Fatigue can range from extremely debilitating to simply annoying. It is a frequent complaint in the general population—most people would like to have more energy. A cancer survivor's fatigue may be worse than what is experienced by others, and it can impair physical recovery because energy is a critical component in healing well. This is why proper rest is the third essential healing component in my list in Chapter 2. Taking the time to evaluate and treat the troubling symptom of fatigue is worthwhile. The more energy you have, the better you will be able to heal.
Cancer-Related Fatigue and Anemia: Treatment Guidelines for Patients (Jenkin-town, PA: National Comprehensive Cancer Network /American Cancer Society, 2003), p. 5. International Classification of Disease-10 (ICD-10) (Albany, NY: World Health Organization, 2003).
D. Cella et al., "Progress toward Guidelines for the Management of Fatigue," Oncology 12 (1998): 369—377.
R. J. Reiter, "Melatonin: Clinical Relevance," Best Practice and Research Clinical Endocrinology and Metabolism 17 (2003): 273—285.
S. Ancoli-Israel, "Sleep Is Not Tangible or What the Hebrew Tradition Has to Say about Sleep," Psychosomatic Medicine 63 (2001): 778—787.
D. E. Theobold, "Cancer Pain, Fatigue, Distress, and Insomnia in Cancer Patients," Clinical Cornerstone 6 (2004): S15—S21.
P. A. Bryant et al., "Sick and Tired: Does Sleep Have a Vital Role in the Immune System?" Nature Reviews Immunology 4 (June 2004): 457—467.
T. Ball, "An Inaugural Dissertation on the Causes and Effects of Sleep" (MD diss., University of Pennsylvania, 1796), p. 2.
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