A survival analysis from this study cohort indicated that fatigue severity and fatigue‐related functional impairment were significantly associated with an increased risk of death
Psychological factors did not appear to play a significant role in fatigue severity, after controlling for sociodemographic and clinical factors.
Psychological factors being 'fear avoidance', catastrophising, 'symptom focusing', 'damage beliefs', 'embarrassment avoidance', 'all or nothing behaviours' and 'avoidance behaviours'.
So, the association of death with fatigue suggests that the patients might have been perceiving things correctly. And the lack of associations between measured psychological factors and fatigue severity suggests that changing psychological factors probably isn't the answer.
The mean CFQ numbers (lower is less fatigued; >18 is regarded as 'fatigued') were:
Baseline: 17.34
12 months: 17.37
24 months: 18.26
36 months: 16.49
Much was made of a trend to less fatigue over time, and changes in the percentages of patients who were 'fatigued'. But the cohort was changing at each measurement, with some dying, some receiving a transplant and some dropping out of the study. And the scores were hovering around that fatigue threshold of 18. Really, there is no evidence for fatigue changing over time in any systematic way.
But here's the conclusion:
In conclusion, changes in fatigue outcomes over time may be more complex than originally anticipated, varying by the length of time on dialysis, as the data suggested here. This provides some indication of when treatment for fatigue may be effectively delivered, yet the targets of treatment need to be explored further using a sample of incident dialysis patients.
So, the researchers aren't sure what psychological deficiencies in dialysis patients need to be fixed, but they suggest the study has identified when the fixing should be done - although they don't say in the conclusion when that is.
Scrolling through the study trying to find out when they think the intervention should be delivered, I could only find this:
According to the findings here, the timing of intervention delivery may be of relevance for patients on dialysis, as 24 months from dialysis initiation marked a change in the trajectory of fatigue severity. There is accumulating evidence in support of psychological interventions, such as cognitive‐behavioural therapy for the management of fatigue in physical LTCs (van den Akker
et al.,
2016) and promising preliminary evidence is available in kidney failure (Picariello
et al.,
2017). However, what modifiable cognitive and behavioural factors are associated with fatigue trajectories over the span of dialysis vintage is yet to be defined.
So, they say that at 24 months there is 'a change in the trajectory of fatigue severity'. Are they suggesting that the CBT for some yet to be identified psychological failing should be delivered at this point i.e. when the fatigue scores appear to naturally improve?
The paper is full of logical holes. And a lot of rather nasty patient blaming.
For example, once fatigue develops as a consequence of underlying disease processes, interpretations of fatigue as uncontrollable and lasting, and unhelpful thinking styles in response to fatigue, such as catastrophizing, symptom focusing, or perceiving fatigue as a sign of bodily damage (damage beliefs), may lead to increased anxiety and low mood and subsequently unhelpful behavioural responses, such as excessive rest in an attempt to control fatigue and reduce the damage perceived it is doing to their body. Excessive rest may in turn lead to deconditioning, poor sleep and physiological arousal related to anxious mood, and lead to the perpetuation of fatigue