ASCPRO 2
Conceptual Definitions of Fatigue
Concepts used to
describe the
experience of fatigue
1 Subjective
2 Behavioral
3 Physical
4 Emotional experience
5 Cognitive
6 Temporal
7 Unusual
Author(s)
("The Cancer-Related
Fatigue Guidelines
(Version 2.2007),"),
NCCN
(NCI, 2007) –
professional version
(NCI, 2006) – patient
Terms in the definition that are indicative of a concept
Self-report; self-perception
↓ function; ↓ capacity for work; ↓ QOL; difficulty completing tasks; ↓ sleep quality; withdrawal
from activities; debilitation
severity; sensations (exhaustion; ↓ energy; weakness; malaise; tiredness; lassitude)
helplessness; vulnerability; distress; reactivity; impatience; anxiety, emotional numbness;
unpleasant experience; emotional lability
↓ attention; ↓ concentration; ↓ motivation; ↓ memory; ↓ mental capacity; ↓ capacity for mental
work
pervasive; chronic; acute; persistent
unrelieved by rest; unusual; abnormal; not proportional to activity; unusual need for rest;
unpredictable
Fatigue Description/Definition
Cancer-related fatigue is a distressing persistent, subjective sense of
tiredness or exhaustion related to cancer or cancer treatment that is not
proportional to recent activity and interferes with usual functioning.
Professional definition: “… a condition characterized by distress and
decreased functional status related to a decrease in energy. The
specific manifestations may be physical, mental, or emotional.”
Concepts
1 2 3 4 5 6 7
X X X X
X X
X X
X
Author(s)
version
(NCI) – patient dictionary
version
(ONS)
(Dalakas, Mock, &
Hawkins, 1998)
(Schwartz, 1998)
(Piper, 1998)
Fatigue Description/Definition
Patient definition: “… can be described as a condition that causes
distress and decreased ability to function due to a lack of energy.
Specific symptoms may be physical, psychological, or emotional.”
Patient dictionary definition: A condition marked by extreme tiredness
and inability to function due (to) lack of energy. Fatigue may be acute or
chronic.
“Fatigue is defined as a persistent and subjective sense of tiredness that
interferes with usual functioning.”
CRF: Chronic experience of “an overwhelming sense of exhaustion and
decreased capacity for physical and mental work, regardless of
adequate sleep or rest, that may persist for months or years after the
end of treatment. Their fatigue is highly correlated with anxiety,
depression, and emotional stress” (p. 48).
Neuromuscular fatigue is “fatigue caused by impairment of elements
within the motor unit… comprised of the motor neuron, the axon, the
neuromuscular junction, and the muscle fibers supplied by the motor
neuron” (p. 49).
Schwartz Cancer Fatigue Scale: Self-perceived state with four
dimensions: physical, including neurophysiologic aspects (e.g., muscle
weakness, exhaustion, pain) possibly leading to impaired physical
function; emotional – loss of ability and feelings of helplessness and
vulnerability; cognitive dimension – decline in direct attention, leading to
distraction and impaired concentration; temporal: chronic fatigue
(versus acute fatigue) – has no function (e.g., protective), generalized
effect on mind and body, associated with unpredictable onset and not
quickly remedied, major impact on QOL, rapid changes – temporal
pattern (p. 712). Conceptualization consistent with NANDA definition.
Revised Piper Fatigue Scale: Notes that there is no universally
recognized definition of fatigue but that most definitions allude to:
Concepts
1 2 3 4 5 6 7
X X X
X
X X X X X X
X X X X X X X
X X X X X X
Author(s)
(Cella, Peterman, Passik,
Jacobsen, & Breitbart,
1998)
Fatigue Description/Definition
multidimensionality, behavioral or work/performance decrement,
physical/physiologic or biochemical dimension, subjective or
symptom/sensory dimension. Other dimensions proposed are:
situational, cognitive/mental or attention, affective, personality, severity,
and temporal/timing (p. 678).
Subjective dimensions of fatigue (measured by scale): timing of fatigue
(temporal dimension), mental, physical and emotional symptoms of
fatigue (sensory dimension), emotional meaning (affective dimension),
impact and distress on ADL (intensity/severity dimension).
Objective dimension of fatigue: signs that can be validated by
physiologic, biochemical and behavioral means (p. 678).
[The revised Piper Fatigue scale (22 items) – behavioral/severity,
affective meaning, sensory, and cognitive/mood—does not include
temporal dimension due to lack of support by factor analysis.]
Proposed ICD-10 Criteria for CRF (1998 draft)
A. Six (or more) of the following symptoms have been present every
day or nearly every day during the same 2-week period in the past
month, and at least one of the symptoms is (A1) significant fatigue:
1. Significant fatigue, diminished energy, or increase need to
rest, disproportionate to any recent change in activity level;
2. Complaints of generalized weakness or limb heaviness;
3. Diminished concentration or attention;
4. Decreased motivation or interest to engage in usual activities;
5. Insomnia or hypersomnia;
6. Experience of sleep as unrefreshing or nonrestorative;
7. Perceived need to struggle to overcome inactivity;
8. Marked emotional reactivity (e.g., sadness, frustration, or
irritability) to feeling fatigued;
9. Difficulty completing daily tasks attributed to feeling fatigued;
Concepts
1 2 3 4 5 6 7
X X X X X X
Author(s)
(Mendoza et al., 1999)
(Portenoy & Itri, 1999)
(Meek et al., 2000)
(Curt et al., 2000)
Fatigue Description/Definition
10. Perceived problems with short-term memory;
11. Post-exertional malaise lasting several hours;
B. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
C. There is evidence from the history, physical examination, or
laboratory findings that the symptoms are a consequence of cancer or
cancer therapy.
D. The symptoms are not primarily a consequence of co-morbid
psychiatric disorders such as major depression, somatization disorder,
somatoform disorder, or delirium.
Development of Brief Fatigue Inventory. No real definition of fatigue
given but states that assessment is usually based on conceptualization
of fatigue as a subjective experience, which can then be compared to
pain: “It is what the person experiencing it says it is” (p. 1187).
(CRF) “Fatigue is an inherently subjective and multidimensional
condition. It may be described in terms of a variety of characteristics
(e.g., severity, distress, temporal features) and specific impairments
(e.g., lack of energy, weakness, somnolence, difficulty concentrating)…
Fatigue may be characterized as a multidimensional phenomenon that
develops over time, diminishing energy, mental capacity, and the
psychologic condition of cancer patients. Fatigue is also linked with
lethargy, malaise, and asthenia in the revised National Cancer Institute
(NCI) Common Toxicity Criteria (CTC)” (p. 1-2).
Brief discussion (beyond scope of article to discuss construct, etc.):
Fatigue is a sensation, with self-report for assessment. Self-perceived
“state” rather than characteristic or trait due to fluctuation in severity.
Second survey in formulation of diagnosis of cancer-related fatigue
was made (for ICD-10 above). In questionnaire, fatigue was “defined as
a general feeling of debilitating tiredness or loss of energy” (p. 354).
Concepts
1 2 3 4 5 6 7
X
X
X X X X
X
X
X X
Author(s)
(Krishnasamy, 2000)
(Okuyama et al., 2000)
(Nail, 2002)
(Sadler et al., 2002)
Fatigue Description/Definition
(CRF) “… [F]atigue relates to a subjective, unpleasant, often
overwhelming feeling of loss of energy, which interferes with an
individual’s ability to function to a degree which they consider to be
abnormal or unacceptable” (Carpenito, 1995, Ream & Richardson,
1996) (p. 403). Also see paradigm in figure 1.
(CRF) “Fatigue is defined as a condition characterized by a subjective
feeling of a decrease in energy, and it has both physical and
psychological aspects (p. 5).”
(CRF) States that the most common definition without including
responses to fatigue “is a sensation of tiredness (citing Winningham et
al., 1994).” She also states that the sensation should be in terms of selfperception.
Used ICD-10 Criteria. “…, [R]esearch suggests that fatigue in cancer
patients has physical, cognitive, emotional, and behavioral
manifestations. Consistent with this view, we observed that the
presence of a general symptom of fatigue (i.e., significant fatigue on a
daily basis) was accompanied in a majority of patients by perceived
impairments in the physical domain (e.g., generalized weakness or limb
heaviness), cognitive domain (e.g., diminished attention and
concentration), behavioral domain (e.g., decreased motivation to
engage in usual activities), and emotional domain (e.g., marked
emotional reactivity to feeling fatigued)” (p. 411).
(CRF) “Fatigue in humans may be defined as a ‘subjective state of
overwhelming, sustained exhaustion and decreased capacity for
physical and mental work that is not relieved by rest’” (p. 389). No
citation given for this quote in text.
(Morrow, Shelke, Roscoe, (CRF) Multidimensional condition characterized by subjective feelings
(Morrow, Andrews,
Hickok, Roscoe, &
Matteson, 2002)
Concepts
1 2 3 4 5 6 7
X X X X
X
X
X X
X
X
X X X X
X X X
X X
X
X
X X
Author(s)
Hickok, & Mustian, 2005)
(Ahlberg, Ekman,
Gaston-Johansson, &
Mock, 2003)
(Wu & McSweeney,
2004)
(Wu & McSweeney,
2007)
(Iop, Manfredi, & Bonura,
2004)
Concepts
Fatigue Description/Definition
1 2 3 4 5 6 7
should include: pervasiveness, persistence, detrimental effect on quality
of life and ability to function and inability to be relieved by rest or sleep.
They quote NCCN definition but note that it does not mention inability to
be relieved by rest.
Uses NCCN definition, then states “can be described in terms of
X X X
X
perceived energy, mental capacity, and psychological status. It arises
over a continuum, ranging from tiredness to exhaustion… cancerrelated fatigue is perceived as being of greater magnitude,
disproportionate to activity or exertion, and not completely relieved by
rest, leaving the patient with an overwhelming and sustained sense of
exhaustion” (p. 1).
Four characteristics of CRF: (1) physical sensation of fatigue, including
X X X X
severity and intensity of its indicators, (2) mood, emotion, or affective
feelings, (3) cognitive or mental dimension of fatigue, and (4) temporal
components, including the frequency and duration of fatigue.
They state that manifestations of fatigue should be distinguished from
consequences of fatigue (e.g., functional performance and quality of
life).
(CRF) No definition provided, just characteristics. For cancer patients,
fatigue involves 4 physical changes: “decreased physical performance,
unusual, extreme tiredness, feeling of weakness, and unusual need for
rest (Glaus et al., 1996; Patarca-Montero, 2004)… CRF is more rapid in
onset, more intense, more severe, more energy draining, and longer
lasting than typical fatigue, and often is unexpected” (p. 118).
(CRF) “[Fatigue] can be described using a range of general
characteristics (severity, negative sensations, temporal features) and
specific weaknesses (lack of energy, weakness, somnolence, difficulty
in concentrating). Fatigue can be defined as a multidimensional
X X
X X
X X X X X
Author(s)
(Spazzapan, Bearz, &
Tirelli, 2004)
(Van Belle et al., 2005)
(Mitchell & Berger, 2006)
Olson (2007)
Concepts
Fatigue Description/Definition
1 2 3 4 5 6 7
phenomenon which evolves over time, compromising physical energy,
mental capacity and the psychological condition of the patient with
cancer” (p. 712).
Editorial comment to Iop, et al., 2004: “… [C]ancer-related fatigue is a
X X X X
non-specific, multidimensional construct characterized by debilitating
lassitude unrestored by rest, decreased capacity in maintaining
performance, generalized weakness defined as the anticipatory
sensation of difficulty in starting a new activity, mental fatigue defined as
the presence of impaired mental concentration, loss of memory and
emotional lability. Sleep disorders are also frequently reported” (p.
1576).
(CRF) “Fatigue is to be taken as a chronic form of tiredness, which is
X
X
X X
perceived by the patient as being unusual or abnormal, absolutely
disproportionate with respect to the amount of exercise or activity he/she
has carried out, and not alleviated by resting or sleeping. It often
persists after treatment is concluded” (p. 247).
“… [A] persistent and subjective sense of tiredness that interferes with
X X X
X
usual functioning” (p. 375). Refers to ICD-10 Criteria for cancer-related
fatigue for criteria of diagnosis. Components in assessing are:
intensity, persistence or pervasiveness, interference with function, and
distress. Consequences include: decrements in physical, social and
vocational functioning, mood, sleep disturbances, and emotional and
spiritual distress in patient and family members (p. 374).)
(CRF) See Table 1.
Table 1. Key Domains of Adaptation in Relation to Tiredness, Fatigue, and Exhaustion
Term
Sleep Quality
Tiredness
Normal sleep pattern,
Feel rested
Forgetful
Fatigue
Chronic disrupted
sleep pattern, do not
feel rested
Inability to
concentrate
Exhaustion Erratic sleep pattern,
including periods of
insomnia and periods
of hypersomnolence
Cognition
Confusion
Stamina
Emotional
Reactivity
Control Over
Body
Processes
Gradual loss of energy
in proportion to energy
expended
Gradual loss of energy
out of proportion to
energy expended
Impatient
Body and mind
work together
Anxious
Mind over body
Sudden loss of energy
out of proportion to
energy expended
Emotionally
numb
Body over mind
Social
Interaction
Engage in
normal social
activities
Saves energy
for
participation
in enjoyable
activities
Withdraws
from all social
activities
Note. From “A New Way of Thinking About Fatigue: A Reconceptualization,” by K. Olson, 2007, Oncology Nursing
Forum, 34(1), 96. Copyright 2007 by the Oncology Nursing Society.
References
Ahlberg, K., Ekman, T., Gaston-Johansson, F., & Mock, V. (2003). Assessment and management of cancer-related fatigue in adults.
Lancet, 362(9384), 640-650.
The Cancer-Related Fatigue Guidelines (Version 2.2007). In The Complete Library of NCCN Clinical Practice Guidelines in
Oncology [CD-ROM] (June 2006). Jenkintown, Pennsylvania: © 2006 National Comprehensive Cancer Network, Inc.
Cella, D., Peterman, A., Passik, S., Jacobsen, P., & Breitbart, W. (1998). Progress toward guidelines for the management of fatigue.
Oncology (Huntingt), 12(11A), 369-377.
Curt, G. A., Breitbart, W., Cella, D., Groopman, J. E., Horning, S. J., Itri, L. M., et al. (2000). Impact of cancer-related fatigue on the
lives of patients: New findings from the Fatigue Coalition. The Oncologist, 5(5), 353-360.
Dalakas, M. C., Mock, V., & Hawkins, M. J. (1998). Fatigue: definitions, mechanisms, and paradigms for study. Seminars in
Oncology, 25(1 Suppl 1), 48-53.
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37(5), 401-414.
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12(5), 374-387.
Morrow, G. R., Andrews, P. L., Hickok, J. T., Roscoe, J. A., & Matteson, S. (2002). Fatigue associated with cancer and its treatment.
Supportive Care in Cancer, 10(5), 389-398.
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http://www.cancer.gov/cancertopics/pdq/supportivecare/fatigue/healthprofessional
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http://www.ons.org/outcomes/volume1/fatigue/def_fatigue.shtml
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Krishnasamy (2000)
Fig. 1 Subjective and objective manifestations of fatigue. After: Granjean (1970); Hart et al
(1990); Rhoten (1982); Piper (1986); Ream et al (1996); Glaus et al (1996); Krishnasamy
(1997a).
Subjective
descriptions
General appearance
Weary, worn out, tired, listless,
lethargy, weak, no energy, heaviness,
strong desire to sleep, exhausted,
awfulness
Pale, shallow respiration,
relaxed facial muscles and
decreased smiling
Attitude
Sleep-seeking behavior,
decreased interest, decreased
motivation, irritability, ignoring
things, tearful episodes
Fatigue
Speech
Slow responses, short answers,
dull tone, no desire to talk
Concentration
Impaired thinking, decreased
attention, inability to concentrate,
slowed and impaired perception
Activity
Minimal activity initiated on
own, decreased performance in
physical and mental activities
Note: From “Fatigue in Advanced Cancer – Meaning Before Measurement?” by M. Krishnasamy, 2000.
International Journal of Nursing Studies, 37, p. 402. Copyright 2000 by Elsevier Science Ltd.