Always tired? A practical way to find the cause

The tell: rest does not fix it

Tiredness from a heavy week should lift with a few good nights and some time off. If you come back from vacation as drained as you left, or if you need caffeine to get through every afternoon for months, something else is likely going on.

Other clues include waking unrefreshed after what should be enough sleep, dozing off in meetings or as a passenger, needing more and more coffee, or a partner mentioning snoring or pauses in your breathing.

First: sleep and sleep-disordered breathing

The CDC recommends at least seven hours a night for adults up to 60. Many executives get less, and a backlog of short nights explains a lot of fatigue on its own.

When the hours look adequate, the quality may not be. Obstructive sleep apnea causes repeated breathing pauses that fragment sleep, often without you knowing. The NHLBI lists loud snoring, gasping during sleep and daytime sleepiness as signs, and notes that untreated sleep apnea raises the risk of high blood pressure, heart attack and stroke. It is not limited to people who are heavy or who snore loudly.

Sleep apnea is diagnosed with a sleep study. HealifyMD can screen for it with questions and refer you.

Second: the lab panel

Your clinician will decide which tests make sense. A 'normal' result does not always end the conversation, especially if a value sits at the edge of the range or has changed from an earlier test.

• Thyroid function: an underactive thyroid causes fatigue, weight gain, feeling cold and low mood, often developing slowly.
• Ferritin and iron studies: low iron stores can cause fatigue before anemia appears on a blood count.
• Vitamin B12: low levels are more likely with age, metformin, acid-reducing medicines or a plant-based diet.
• HbA1c and glucose: rising blood sugar is linked to fatigue and is common in midlife.
• Vitamin D: worth checking when there is a reason, interpreted in light of the season.
• Kidney and liver function, blood count and, where relevant, sex hormones.

Third: what is not on a panel

• Alcohol: even social drinking can break up sleep later in the night.
• Travel: crossing time zones causes sleep disturbance and daytime sleepiness that can take days to resolve.
• Mood: depression often shows up as exhaustion and poor concentration rather than sadness.
• Medicines: antihistamines, some blood pressure drugs, sleep aids and pain medicines can cause tiredness.
• Overtraining or under-eating, especially in people who exercise hard and diet at the same time.
• Perimenopause and night sweats, which disrupt sleep for many women in their 40s and 50s.

Keep a two-week fatigue log

Before your visit, jot down a few things each day for two weeks: bedtime and wake time, how rested you felt on waking, caffeine and alcohol, exercise, travel, and an energy score from one to ten in the afternoon. Women can add where they are in their cycle and any night sweats.

This takes a minute a day and often reveals patterns that are hard to recall in a visit, such as energy crashing after nights with a drink, or on days after a late flight. It also helps your clinician decide which tests are worth ordering and which are not.

What we do with the answer

Once a likely cause is found, the plan follows from it. That might mean a sleep study and treatment for sleep apnea, iron or B12 replacement, thyroid treatment with your doctor, menopause care, changes to alcohol or training, or a referral for mood. Testosterone therapy is only considered after deficiency is confirmed with repeated early-morning tests and symptoms fit.

Most changes take time to show. Your clinician will usually set a recheck about 12 weeks later, both for labs and for how you feel.

When fatigue needs prompt attention

See a clinician in person soon if fatigue comes with unexplained weight loss, fever, night sweats outside of menopause, shortness of breath, chest pain, blood in your stool or very heavy periods. Thoughts of self-harm need immediate help: call or text 988 in the U.S.