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
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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.
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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.
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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
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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
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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
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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
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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
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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.
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• 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.
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• 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.
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Action point:
In order to improve my sleep I will
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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.
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Action point:
In order to improve my exercise levels I will
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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.
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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.
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Action point:
In order to lessen or control my stress levels I will
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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.
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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
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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.
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Action point:
In order to manage my energy I will
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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.
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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