THE PARKINSON’S PERSPECTIVE Newsletter Volume 36, Issue 4
SEPTEMBER/OCTOBER 2016
Serving OR and S. WA
UNDERSTANDING FATIGUE Contributed by Tony Borcich, LCSW
With the advent of the World Parkinson Congress (September 20-23 in Portland) we’ve been hearing from clients with questions about how to manage their desire to participate in the full days while acknowledging that Parkinson’s disease has taken a toll on stamina and energy levels. Experienced people with Parkinson’s (PwP) know to prioritize each day with focus on those events and activities that will bring the greatest reward. Since distressing fatigue effects anywhere from 1/3 to ½ of PwP, we thought we would take the opportunity to dig a little deeper into this challenging PD symptom. Fatigue is one of the earliest symptoms to manifest in Parkinson’s disease, with one study suggesting it can appear as early as five years before a Parkinson’s diagnosis(1). Fatigue in PD can be chronic and incapacitating often leading the person to reduce enjoyable activities and pull back from social situations. Fatigue is not the same as feeling sleepy, though sleepiness may be a symptom of PD as well. It is a lack of mental as well as physical energy displayed as a lack of motivation and/ or poor concentration. It is not helped by rest.
neurologist to connect fatigue to PD because of other diagnoses the PwP may be dealing with and the combination of medications they may be taking. Other issues such as sleep apnea or poor nutrition may exacerbate the fatigue. Fatigue in PD assumes a couple of forms. There is peripheral fatigue which can occur due to tremor, dyskinesia and/ or rigidity. Peripheral fatigue might be described by “I cannot do it, I’m exhausted.” Central fatigue, however, is more about motivation and may in fact be more debilitating. Central fatigue can be described as “I do not feel like doing it, it is not worth it.”(2)
CBT has been shown to be effective for depression and insomnia. Mindfulness based interventions (MBI) have shown efficacy in small trials for fatigue in neurological disorders(7). Further research is warranted for both CBT and MBI. Fatigue is complicated and challenging to manage. If you are feeling the effects of fatigue, please discuss with your neurologist and follow his/her guidance. Anecdotally, other PwP have found that the following tips might help in managing fatigue – particularly peripheral fatigue.
What causes central fatigue? Some is known about co-occurring symptoms, but less is known about a direct cause. Neuroinflammatory markers found in PD are higher in PwP exhibiting severe fatigue(5). Sex, age, disease duration, clinical stage, motor complications, prior psychiatric disorders, and treatment were not significantly associated with the presence of fatigue(3).
Fatigue cannot be diagnosed by a physician other than via a detailed narrative from the PwP and those close to them. It’s also difficult for the
What might help? Two systematic reviews of the literature find little help for fatigue in PD. One stated there is insufficient evidence to support treatment of fatigue in PD with any drug or non-drug treatment(4). The other suggested that doxepin, used for depression, may help reduce fatigue(5).
SEPT/OCT 2016
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Proper night time sleep. Regular exercise. Managing depression if present. Keeping your weight controlled. Eating on time and not skipping any meals. Allowing enough time to finish daily activities. Taking a short nap daily in the afternoon. Rest periods also help. Not shying away from asking for help. Staying mentally active. References 1. Schrag, A., Horsfall, L., Walters, K., Noyce, A., & Petersen, I. (2015). Prediagnostic presentations of Parkinson’s disease in primary care: a casecontrol study. Lancet Neurology, 57-64 2. Dantzer, R., Heijnen, C., Kavelaars, A., & Laye, S. C. (2014). The Neuroimmune Basis of Fatigue. Trends in Neuroscience, 39-46. 3. Saez-Francas, N., Hernandez-Vara, J., Roso, M. C., Martin, J. A., & Brugue, M. C. (2013). The association of apathy with central fatigue perception in patients with Parkinson’s disease. Behavioral Neuroscience, 237-244. 4. Franssen, M., Winward, C., Collett, J., Wade, D., & Dawes, H. (2014). Interventions for fatigue in Parkinson’s disease: A systematic review and meta-analysis. Movement Disorders, 1675-1678. 5. Lindqvist, D., Hall, S., Surova, Y., Nielsen, H., Janelidze, S., Brundin, L., & Hansson, O. (2013). Cerebrospinal fluid inflammatory markers in Parkinson’s disease - Associations with depression, fatigue, and cognitive impairment. Brain, Behavior and Immunity, 183-189. 6. Elbers, R., Verhoef, J., van Wegen, E., Berendse, H., & Kwakkel, G. (2015). Interventions for fatigue in Parkinson’s disease. Cochrane Database of Systematic Reviews. 7. Immink, M. (2014). Fatigue in neurological disorders: a review of selfregulation and mindfulness-based interventions. Fatigue: Biomedicine, Health & Behavior, 202-218.
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