Tired all the time? A self-help guide to managing excessive tiredness
Contents Tired all the time?.......... 3 What is excessive tiredness?......... 3 What causes excessive tiredness?......... 3 How can excessive tiredness be reduced?...... 4 Nutrition...... 4 Sleep...... 7 Exercise and activity......... 12 Stress and worries......... 13 Managing your energy............ 15 Summary............... 18 2
Tired all the time? You have been provided with this information because you experience excessive tiredness (ET). This may be in addition to other symptoms but this information is specific to ET. Sometimes, other additional symptoms can improve if ET is managed. ET is a very common symptom. Many terms are used to describe ET including fatigue, weariness, drowsiness, exhaustion or sleepiness. We have chosen the term excessive tiredness as it has the widest meaning and therefore the greatest applicability. There are many causes of ET. Your GP will assess whether you need certain specific medical investigations, which might include blood tests. Whether or not there is ultimately a specific cause and treatment for your ET, there are still effective ways in which you can manage it in the short or longer term. What is ET? Tiredness is a normal reaction to physical, mental or emotional exertion. The function of tiredness is to prompt rest which allows the body to restore its ability to undertake new tasks. Tiredness becomes excessive when: it follows only minor activity it is present most of the time it starts to interfere with everyday life it is not relieved by normal rest What causes ET? ET can result from medical conditions such as heart failure, anaemia, thyroid disease and depression or as a side effect of medication. It may also occur for unknown reasons. Whatever the origin of ET, it can be made worse by things such as sleep disturbance, deconditioning (reduction in physical fitness), chronic stress and poor diet. All of these things can be changed to improve ET. 3
How can ET be reduced? Whilst there is no quick cure, there are lifestyle changes you can make to reduce ET. It is important to find those lifestyle choices which may be contributing to your ET. Modifying these may make all the difference. To help you identify them, ask yourself the following questions: 1. Am I eating a healthy, balanced diet? 2. Am I getting enough good quality sleep? 3. Am I spending enough time being active during the day? 4. Am I taking regular exercise? 5. Am I taking rest breaks when I need to? 6. Can I stop worrying about things that I can t change? 7. Do I make decisions about what I want to do, and stick to them? 8. Am I doing things that I want to do? (rather than only doing things that I think I must do) If your answer is no to any of these questions you may benefit from the advice below. If you are unsure about any of your answers, please discuss with your GP. Nutrition One of our main sources of energy is our diet, our food is our fuel. It is important to eat a healthy, balanced diet with foods from all the different groups. Including or excluding certain types of foods is not recommended unless there is a specific medical reason. Advice on a healthy diet can be obtained from the British Dietetic Association website (www.bda.uk.org) or from your GP. If you are very overweight, this will contribute to your ET. Consult your GP or refer to the British Dietetic Association website given above for healthy weight loss. 4
Carbohydrates are essential for energy. They provide the glucose in our bodies which is needed to fuel muscles and helps our brain function. Not having enough glucose in the blood can make us feel weak, tired and fuzzy minded. This is why eating breakfast and having regular meals containing some carbohydrate is essential to enable us to participate in both mental and physical activities. If you have a high Body Mass Index (BMI), that is, if you are overweight, you may need further advice from your GP or a dietician about carbohydrate consumption. There are two main types of carbohydrates: simple carbohydrates, such as sugars, and complex carbohydrates, such as starches. Sugar is a type of carbohydrate that releases energy quickly, e.g., chocolate bars and sugary drinks. It is best to avoid these as they can lead to a crash as blood sugar levels can then drop quickly afterwards leading to further ET. Sugary drinks and snacks need not be excluded completely but should only be a very small portion of your diet. Complex carbohydrates or starches include pasta, rice, cereals, oats, bread and potatoes. These foods release energy more slowly and evenly rather than providing a rush and then a sudden drop in energy. Slow release starchy foods can take 3-4 hours for blood glucose levels to peak and then come back down again. Therefore, if you eat these kinds of foods every 3 hours, you can help keep your 5
blood glucose levels stable because you are having something to eat before your blood sugar level has become too low. This can help with your energy levels. You are not necessarily trying to change the overall amount you eat but the frequency of eating. An average man needs around 2,500 calories a day to maintain his weight. An average woman needs around 2,000 calories a day; eating more than this risks gaining weight. You therefore may wish to divide larger meals into smaller amounts and eat them at different times. (If you are diabetic please seek additional advice.) It may be worth looking at the Glycaemic Index (GI) which is a ranking of carbohydrate foods based on the rate at which they raise blood glucose levels. The Glycaemic Index can help you in identifying some foods which release energy more slowly. More information about diet and GI can be found on the British Dietetic Association website given above. It is important to limit the amount of caffeine and alcohol consumed. Too much of either can contribute to ET. They also contribute to dehydration, it is important to make sure that you drink enough water. Although there is no exact recommended daily amount, aim for around two to three litres per day. The amount you need will be dependent upon many things for example how warm it is and whether you are exercising. Certain 6
health conditions will require you to increase your fluid intake; others will require that you reduce your fluid intake. If you are unsure about how much fluid you should be drinking, check with your GP or a dietician. Action points: In order to improve my diet I will...... Sleep There is no such thing as a normal amount of sleep. Some people need more than others and the amount we need is different at different stages of our life. An average night s sleep is around 8 hours but the amount of sleep we need is dependent on many things including our age, general health etc. Some people will sleep for less than 8 hours and feel fine whereas other people will sleep for longer without it causing any problems. When the amount of sleep someone is getting (too little or too much) causes an increase in tiredness, it becomes a problem. Sometimes, sleep patterns are disturbed. The most common problems people experience with sleep are either getting to sleep or staying asleep. Because sleep is pattern based, the following tips will help to establish a good sleep pattern (sometimes called good sleep hygiene ): Have a fixed getting up time. Getting up at a set time helps the brain to establish a daily routine. Staying in bed longer can cause the brain gradually to shift from the normal night/ day pattern. Do not try to sleep longer when you feel you 7
have a bad night because it will disrupt your sleep the following night. Because our sleep goes in cycles of 90 minutes, it can sometimes help to work backwards in 90 minute slots to try to work out the best time to go to bed e.g. if you want to wake up at 7am, you could go to bed at 10pm or 11.30pm depending on how much sleep you normally have. Avoid sleeping during the day. If you feel you have to sleep during the day, restrict sleep to one regular time and reduce the amount gradually to zero over a period of weeks. Sleeping during the day reduces sleepiness at night and also confuses the brain, which needs an established day/night pattern. If you are struggling to stay awake during your rest periods, set an alarm and do not allow yourself to sleep for more than 30 minutes at a time so that you do not enter deep sleep. Some people find this kind of power nap can be beneficial. You do not have to have a rigidly fixed bedtime, although many people prefer to do so, but bedtime should be similar each night. Go to bed when you are sleepy, not because it is time for bed. Otherwise, you may have difficulties falling asleep. Think about your environment. Is your bed comfortable? Whilst it can be beneficial to have a firm mattress, if it is too firm it may not be supporting all of the curves in your back. Likewise, a very soft mattress will not provide sufficient 8
support. Think about how many pillows you need. Is the room too warm or too cold or the bed clothes too heavy or too light? Is the room dark enough? Are you being disturbed by noise? Have a wind down routine in the period before going to bed to help you relax. Avoid stimulating activities including work/studying, telephone calls, using the computer/internet, video and computer games. Instead, do something relaxing such as a hot bath, reading, listening to relaxing music or carrying out a relaxation/meditation technique. Do not exercise too vigorously in the period just before bedtime as it is stimulating and not preparing the body for sleep. However, exercise during the day improves sleep, ensuring you are physically as well as mentally tired. Establish a bedtime routine that suits you. This provides a signal to the brain that it is time to sleep. Some people benefit from a light snack or a hot milky drink. Avoid caffeinecontaining drinks later in the evening, (you should also not have more than 6 caffeinated drinks during the day). Do not eat large amounts of food near to bedtime. Smoking near bedtime or during awakenings should be avoided as nicotine is a stimulant. Alcohol is not a good idea at bedtime if you have difficulty sleeping: although you tend to feel drowsy initially following a drink, you tend to waken later in the night. 9
10 Do not use bed as a place to solve problems. If your head is full of thoughts, you will not feel sleepy although you may be physically tired. Set aside some time earlier in the day to think about things that have happened or to plan for the next day. If you still feel your mind is racing when you go to bed, try doing some relaxation exercises to quieten your mind or repeat a simple phrase to yourself e.g. this is my time to relax and sleep. A common cause for wakefulness is worry, worries can seem worse at night. It can help to write down your worry and place it away from your bed to deal with in the day. See also the section below on stress and worries. Limit your activities in bed. Bed should be a place to sleep (or have sex), not to watch television. Even reading can discourage sleep dependent on what you are reading; light material at bed time is best. Avoid working or using a computer in the bedroom. (If there is no choice but to do this, try to have a specific zone away from the sleeping area).the brain should associate bed with sleep and the rest of the house with daytime activities. Do not stay in bed if fully awake. If after about 20 minutes you have not fallen asleep, or if you are lying awake for a long time in the night, go to another room and do something relaxing in subdued lighting. Go back to bed when you begin to feel sleepy again.
Banish clocks. Watching the time can make you anxious. Turn the clock face away from the bed if an alarm is needed. Do not stay in bed if you are feeling angry or anxious about not sleeping. This will result in increased arousal and less chance of falling asleep. Again, get up and do something relaxing, returning to bed when you feel drowsy. If you wake in the night, try to keep your eyes closed to reduce the stimulation of your brain. Try to identify the cause if you are falling asleep quickly but then keep waking up again. If pain is the cause, discuss with your GP whether medication could be helpful or try applying heat. If you are getting up to go to the toilet several times a night, discuss this with your GP but also try not to have anything to drink 2 hours before going to bed. If you are taking medication, ask your GP or a pharmacist whether this could be interfering with your sleep. Smokers generally have more disturbed sleep, your GP can advise on stopping smoking. Do not worry if you do not sleep. People can survive with very little; most people sleep more than they think they do. 11
Action point: In order to improve my sleep I will...... Exercise and activity It is important to maintain some level of activity rather than over resting or doing nothing. Even if you have bad days, it is important to carry out some gentle, low level activity. People with low mood tend to feel better if they make themselves participate in some activity or exercise. Total inactivity often leads to low mood. Conversely, people can experience ET if they over exercise. If you are unsure as to whether you are exercising too much, consult your GP or a physiotherapist. It is helpful to find an activity that you can enjoy, rather than punishing yourself with exercise as a duty. It is not necessarily helpful to push through your ET in the hope of improving it, unless you have identified that your motivation or mood are very low and possibly explain your tiredness. Generally, it is better for exercise to be spread equally throughout the week rather than short, episodic bursts. If you are not used to exercising, it is important to start at very low level and slowly and gradually increase. Increases should be in the region of 10-20% per week. If you are concerned, discuss with your GP who may refer you on for specialist advice from a physiotherapist. 12
Action point: In order to improve my exercise levels I will...... Stress or worries Stress or worries can be a major contributor to ET, especially if they are experienced over a prolonged period. Therefore, it is important to identify individual stresses and consider how to deal with them. The following strategy may help: 1. Define the problem as clearly as possible 2 Think about successes (even small ones) you have had in combating the problem, or a similar problem, in the past 3. Generate a list of at least 5 possible solutions, even if some seem extreme 4. List the pros and cons of each of these 5. Decide which of the solutions is most likely to succeed and carry it out first 6. Assess whether the solution has worked, if not try another of your potential solutions. 13
For those issues which it is not possible to change, a change in the way you think about them can be helpful. In other words, sometimes you have to just accept that nothing more can be done. Talking to someone you trust about your worries can be very helpful. This could be a friend or family member or your GP can refer you to a counselor. This is particularly helpful if you start to feel depressed or anxious. Another useful technique is to imagine that someone you care about has your problem. Think about what you would say to them. Learning some relaxation techniques can be of benefit. As well as helping to cope with stress, it can also help you fall asleep at bedtime and achieve good quality rest during the day. Tai chi, yoga and qi gong are all good techniques for learning breathing exercises and relaxation techniques. Your local library may be able to help you find local classes. Finally, a lot of stress comes from indecision. Most of the choices we make every day matter very little, but it is very easy to waste a lot of mental energy deciding between them, and then wasting emotional energy wondering if we made the right choice! Try an experiment. For one day, make snap decisions about all of the little things (e.g. what soap powder to use, what magazine to buy, what order to do your work in etc). See if you find yourself feeling more energetic and confident at the end of that day. 14
Action point: In order to lessen or control my stress levels I will...... Managing your energy Energy management is used to both spread any energy a person already has throughout the day and to try to build up more energy. It is often used to stabilise symptoms of ET in order to enable a gradual increase in activity over time. One of the main aspects of energy management is taking short rests at intervals throughout the day. Although an oversimplification, in some situations it sometimes helps to imagine that you have energy very much like that of a battery. When you take part in an activity, energy will be used up. If all of your energy has been used up by the activity so that the battery is drained, it can take a long time to recharge and recover any energy even if you have a rest. However, if you take a rest at a time when you still have a little energy, not only are you helping to spread your energy out over a longer period, it is more likely that you will be able to regain some energy from that rest break. It is therefore important to rest before your ET has greatly increased, before you really feel the need to rest. 15
It is better to rest before your ET has greatly increased, because you cannot rely on your body telling you when to rest. If your body is telling you that you are feeling much more ET than before, you have left it later than you should have done to rest. The aim of the rest is to try and prevent you feeling a large increase in tiredness. The best way to ensure that you do rest regularly is at the start of each day, plan when you will take rest breaks in between carrying out specific activities. This helps to stop you from pushing yourself to do a little bit more and then experiencing a big increase in ET. However, you may need to break activities down into smaller tasks to enable you to complete a section of a task without over-exerting yourself before you take your rest e.g. people often see clean the bathroom as a task. This can be broken down to be clean the bath, clean the washbasin, clean the tiles etc, allowing for a task to be finished before taking a break. Sometimes, people may feel more energised if, for example, they can do at least part of an essential task or activity which they find is very enjoyable. Energy management also includes alternating different types of tasks. This can involve carrying out a physical activity and then carrying out a mental activity so that you are placing different demands on your body. If you carry out an activity that is energy demanding, it is important to follow this with a less demanding 16
activity, whether it is physical or mental. A certain amount of activity gives you energy, just as a car s battery is recharged by movement, not by immobility. Another way of placing different demands on your body is by thinking about your posture and alternating positions regularly. It is less tiring for your muscles if they are not held or used in the same position for a long period of time. Therefore if you are carrying out an activity where you are sitting, it is good to follow this with an activity that involves some movement. It may also help you to think about where you keep certain items, for example, are the things you use in the kitchen most frequently in the most easily accessible places? It will also help to ask yourself whether you have to do all the things that you are doing, to prioritise your necessary tasks and to delegate when possible and appropriate. When prioritising, it is important to make sure that you make the time to take part in activities that you enjoy: doing pleasurable activities helps to top your energy levels back up again. If you are very restricted, it may be that you need to break up an activity that you enjoy into small achievable steps and gradually build up the amount that you can do e.g. by setting yourself small, achievable goals with a plan of how you will achieve them. It is important to have goals, things that you would like to be able to do as this will help you to be focussed and stay motivated. Your GP can refer you to an occupational therapist for help with energy management if you require further advice. 17
Action point: In order to manage my energy I will...... Summary Excessive tiredness can be debilitating and frustrating. There is no one simple solution to excessive tiredness. However, there are many things you can do under the headings of nutrition, sleep, exercise and activity, stress and worry, and energy management to improve the overall situation. What will you do under each of these headings? If you develop any new symptoms in addition to tiredness, or if the tiredness does not improve over time having made necessary lifestyle changes, it is recommended that you return to your GP. If you are not able to access the website suggested (computers can be accessed at a local library), please ask your GP to provide you with the information referred to. 18
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Department of Rehabilitation Medicine Royal Derby Hospital Uttoxeter Road Derby DE22 3NE www.derbyhospitals.nhs.uk Trust Minicom 01332 254944 Thank you to all those professionals and patients who gave their time to help in the production of this information leaflet. Copyright 2012 Rehabilitation Medicine, Derby Hospitals NHS Foundation Trust G11624/1112