We wish to thank Matilda Hale for her important article about the difficulties of living with severe fatigue. Whilst clinicians tend to focus on the primary textbook diagnosis, it is actually the so-called secondary symptoms that constitute the greatest burden of disease for patients and impact severely on quality of life. As discussed by Professors Newton and Jones, inflammation is increasingly implicated in the pathogenesis of fatigue; especially in the context of younger people with chronic disease such as Matilda. Its relevance and seriousness has recently been acknowledged in the consensus diagnostic criteria for cachexia where fatigue is one of five sub-criteria [1]. However fatigue is also an overlooked but important condition causing considerable burden to older people. Aetiology in this group is more likely to be multi-factorial; a consequence of the rise in inflammatory milieu that occurs with age [2], chronic multi-morbidity, poor nutrition and physiologic anorexia of old age [3] as well as psychiatric pathology including depression. Indeed, fatigue is one of the five diagnostic criteria for physical frailty and via this definition has been linked with multiple adverse outcomes [4].

We characterised fatigue amongst 148 patients admitted in a prospective manner to a medicine for older people unit in a large university teaching hospital (mean age 86 years). We asked two simple questions based on the CES-D depression scale: ‘Over the past week do you think that everything was an effort?’ and ‘Over the past week do you feel you could not get going for at least three days?’ 79% of patients answered yes to one or both of these questions. The questions were repeated six months later in those who had returned to their usual residence in the community (n=103, 16% lost to follow up and 12% mortality); 48% answered yes to one or both questions.

This small study has demonstrated a high prevalence of fatigue in older people not only during their acute hospital admission but also 6 months later once they have been discharged home. We agree that increasing recognition of fatigue as a major disabling condition must be accompanied by the use of standardised tools for diagnosis and exploration of the most appropriate approaches to treatment in different patient groups. This is a fertile area for future research.

Reference List

(1) Evans WJ, Morley JE, Argiles J, Bales C, Baracos V, Guttridge D et al. Cachexia: a new definition. Clin Nutr 2008; 27(6):793-799.

(2) Franceschi C, Capri M, Monti D, Giunta S, Olivieri F, Sevini F et al. Inflammaging and anti-inflammaging: a systemic perspective on aging and longevity emerged from studies in humans. Mech Ageing Dev 2007; 128(1):92-105.

(3) Morley JE. Anorexia of aging: a true geriatric syndrome. J Nutr Health Aging 2012; 16(5):422-425.

(4) Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56(3):M146-M156.

Competing interests: None declared