Energy: A Precious Natural Resource
Anne Coscarelli, Ph.D.
One of the most common problems expressed by patients is fatigue accompanied by decreased energy. These problems often begin around the time cancer is diagnosed and may continue for years afterward. In some of the early studies that I did with patients, 79% of patients diagnosed with early stage breast cancer reported a reduction in energy one-month after diagnosis. One year later, 63% of these patients continued to report a reduction in energy. A sample of disease free lung, colon, and prostate cancer survivors reported a reduction in energy by 84%, 61% and 77% respectively. Other studies report fatigue in 70-90% of all patients with cancer and 80-100% of patients on treatment. These numbers are staggering. Loss of energy is a serious problem.
Energy by definition is the capacity of acting or being active, including being intellectually active. Energy is fundamental to life and, for most people, to their ability to have a quality life. Without energy it is impossible to sustain participation in activities that are pleasurable, valuable and fruitful. Because energy is a precious commodity that is jeopardized by the diagnosis of cancer and its treatment, it is important for us to understand how the loss of energy can affect an individual and to consider strategies to preserve and restore it.
First and foremost, it is important to report symptoms of energy loss and fatigue to your physician to determine whether there may be a medically treatable cause. For example, anemia is one of those problems that contributes to fatigue yet can be treated medically. Second, it is important to understand that the loss and the restoration of energy when you have cancer is different than energy loss that most people experience with extreme exertion. With extreme exertion, rest usually replenishes the energy; in cancer, rest alone is not the answer. Rather, it is a complex behavioral and/or medical management strategy that requires organization, planning and thoughtful execution.
Psychological Impact and Treatment
Loss of energy is a psychologically demoralizing experience that can lead to increased levels of anxiety and depression. Loss of energy often means loss of pleasurable experiences and can become a key ingredient in depression. Reduced energy can affect your ability to work, physical well-being, psychological well-being, cognitive function, ability to enjoy life in the moment, intimacy with a partner, ability to care for family, and relationships with family and friends. Anxiety may be a by-product of the loss of energy and can come from the worry that you cannot perform usual tasks and the consequences of lack of performance. For example, inability to work due to reduction in energy can lead to loss of financial security or worry over this possibility.
It is important to address the anxiety and the depression. There are many effective strategies that can be tailored to the needs of each individual. Meeting with a mental health professional to evaluate these feelings and develop a plan for interventions can be an effective first step. Increased levels of anxiety and depression can further deplete energy and, thus, it is important to treat these concerns. Effective interventions may include taking time to grieve the losses brought on by the cancer experience and develop a new way of thinking about the experience. Developing cognitive based self-statements that can bolster your appraisal of the experience while providing encouragement and hope is also an effective intervention for depression and anxiety. Relaxation and meditation can also be used to reduce anxiety. In some situations, psychiatric medication such as anti-depressants may be helpful. They may not directly increase your energy, but if there is significant depression or anxiety, treating these may have a beneficial effect on energy.
Preserving Energy
Preserving energy means holding on to as much energy as possible for as long as possible. This translates into developing a strategy for the efficient expenditure of your energy. First you need to identify your priorities. I like to use the three-drawer method. Use the top drawer for the highest priority activities, the middle drawer for those that are important but not as essential and the bottom drawer for activities that can wait. Make a list of your responsibilities and pleasurable activities and then sort them into the drawers. Make sure some of your pleasurable activities end up in the top drawer. Remember that engagement in pleasure may preserve energy by improving psychological well being. Focus on the top drawer first each day.
Keep in mind that an efficient use of energy may be finding someone to whom you can delegate responsibility. When someone says to you, “Let me know if I can do something for you,” have your list ready with a response such as, “Hey, that is great. Can you pick up my laundry and get my car filled with gas?” Think in advance about delegating those high priority items that are necessary but not rewarding. Being effective at asking for assistance requires some assertion. Stating your needs and asking someone to meet them can be uncomfortable, but it is important to learn to override this discomfort. Remember, you (or your family member) have been diagnosed with cancer and this does create both empathy and sympathy. Many people have a need and desire to be helpful; capitalize on this need. You may have to change how you think just a bit. Rather than thinking of bothering or burdening others, reframe it by thinking that you are giving them a gift. Changing the way you think about things is an important psychological intervention that can facilitate your ability to do tasks that are difficult. Practice and thinking about these situations in advance makes you more skilled. If you get really good at this, you may be able to delegate someone to be in charge of organizing and orchestrating getting tasks done. Delegating tasks will preserve your energy. Furthermore, if you can let go of the more mundane activities, your energy will be preserved for more pleasurable activities. Delegating pleasurable activities is not helpful. Could you imagine saying to a friend, “Hey, could you go to a funny movie for me?” I say this in jest in the hope that it may help motivate your ability to get assistance. In my 23 years of clinical work, this issue continually comes up. It is imperative to overcome your sense of guilt and the belief that you should not give away some of your least enjoyable daily activities.
If you are financially able to hire someone to help you, consider using that as an alternative approach. Many patients and family members do not have the financial resources for this intervention; however, those who do often forget to utilize it.
If you cannot delegate something, creativity is essential in figuring out the most efficient means to do the task. Below are some tasks that most people encounter on a daily or weekly basis with ideas to modify them to preserve energy. Use these as models for thinking through other problematic situations.
WORK
It is important to work during the hours that your energy is best. Your cognitive function will be better and you will be more efficient. Consider shortening your hours, finding someone to drive you to work, utilizing energy efficient tools such as carts to move items from one place to another. Talk to supervisors about modifying job responsibilities, getting assistance and changing your physical environment. Find out about telecommuting for one or two days out of the week. Also keep in mind that you may be able to take some time off, especially during treatment. Talk with your benefits counselor at work about your options.
SHOPPING AND MEAL PREPARATION
Friends can do a great job of this, but if you have to do it yourself consider using the scooter cart. Shop during times when stores are less busy (shorter lines means less standing). Make a list organized by aisle so that you will require less time standing and thinking about what you need and where to get it. Only shop in stores you know well. Have the person bagging your groceries lift items out of the cart for the checker and have them also load your car. Grocery shop at times when someone else is home to unload.
Sit while preparing food and think about less complicated but healthful meals. Mixes and pre-packaged foods can be energy conserving. If you can afford it, take-out and delivery will save energy. Try cooking and serving in the same containers, let pans soak rather than scrubbing and sit to wash dishes. Assign loading and unloading the dishwasher to someone else if you do not live alone. Explore or have someone else determine whether you may qualify for a meal delivery program. Again, ask friends to help with meal preparation. Many people are cooking anyway. Find a handful of friends who are willing to make enough for your family one night per week. Remember, it is okay to ask for help. You are giving your friends an opportunity to be charitable. They can feel good about these efforts.
BATHING AND DRESSING
Who said that showers had to be taken standing up? Get a shower chair or put a lawn chair in the shower. Sit down and relax. Use warm rather than hot water. Wear uncomplicated clothes, things that slip on, and remember to sit down to get dressed, shave, and fix hair or make-up. Wear shoes that you can slip on or use long handled shoe horns.
CARING FOR CHILDREN
Wouldn’t it be nice if you could borrow or steal some of their energy? Children, especially young children, have an abundance of energy that makes child care assistance a must during cancer treatment. Think about neighborhood friends, teenagers or even pre-teens to assist with your children while you are home. Get them to do the active jobs such as running around, clean-ups and bathing the kids. Save your energy for the quiet peaceful times like reading books and watching a movie together. It is important to talk to your children about energy. Children can be great helpers if they understand how important their help can be. Keep in mind that raising children while having cancer treatment is just plain hard. Finding support is important for you and for them.
Restoring Energy
It is harder to restore energy during and after a cancer diagnosis, but there are specific activities that are helpful and it is important to recognize that the absence of certain behaviors will deplete energy. So, these strategies are necessary for restoration.
SLEEP
Sleep is essential and can be difficult because of the side-effects of treatment or the anxiety associated with the diagnosis. Anxiety can be managed with relaxation techniques and we have several programs at the Center that specifically teach these. Consider participating in the Meditation Group or the Mind-Body Approaches to Coping with Cancer. Both of these programs teach relaxation and guided imagery and can be used to reduce anxiety and improve sleep. Sleep hygiene is also important. Create an environment that is conducive to sleep. Do not work in the bedroom or do other anxiety provoking or activating activities there. Reduce noise and light and keep the room at a comfortable temperature. If hot flashes are a problem, try keeping the temperature lower at night.
It is important to set a specific time to go to bed and to get up. Avoid exercise too close to bedtime as this can be activating. Establish a quiet relaxing routine before bed such as reading, meditating, doing a relaxation exercise, and having a cup of herbal tea or warm milk. Don’t laugh―these simple strategies are effective when combined and may be just enough to help facilitate better sleep. Eliminate caffeine in the evening, preferably none after four in the afternoon.
When you are having difficulty getting to sleep, allow a reasonable amount of time, no more than one hour. If you do not fall asleep, then get up and do a quiet activity like watching television or reading a book or magazine. After a short time, go back to bed and start with a sleep related relaxation exercise. Remember to talk to yourself in a comforting way that reminds yourself that some nights are good, others not so good, but that you will be okay. Thinking about how awful it is that you cannot sleep and focusing on this only adds to your stress level. If this is happening to you, try to calm yourself with the thought that sleeplessness is an inconvenience but one or two nights of it will not hurt you.
If you have repeated nights of difficult sleep or if you are taking medications that are known to interfere with sleep, e.g., some steroids, consider consulting both your physician and a mental health professional. Medication may be appropriate.
REST
While rest alone will not make energy return, as it does after exertion, it can be an important strategy for some restoration. Anticipate activities that make you tired and rest before you get to the exhaustion point. When doing busy activities, plan breaks ahead of time and stick to them. It is often helpful to lie down to rest. For some people naps can be helpful, but for others, daytime sleep may interfere with nighttime sleep. Assess what works best for you.
EXERCISE AND NUTRITION
Some people think that exercise is a depleting activity, and it can be when overdone, but exercise can actually be a restorative activity. A moderate amount of exercise throughout cancer treatment has actually been shown to improve conditioning and lead to better energy levels. If you already exercise, you may need to modify your schedule, but keep some active exercise. If you are adding it to your routine, discuss it with your doctor and begin slowly. A brief walk may be the best approach. It is better to do less than overdo it. Talk to your doctor about what s/he thinks is appropriate for you. Do not forget to include some stretching, muscle strengthening and cardiovascular exercises.
Eating regular meals throughout the day that are made of healthy foods, including low fat protein, complex carbohydrates and colorful fruits and vegetables, can help you feel more energized. If nutrition is a problem, use balanced nutritional supplements. If weight maintenance is a problem, include high caloric, high energy foods. If in doubt, consult a nutritionist.
Manage Other Symptoms
Symptoms like pain and nausea can deplete energy. Seek treatment for these other problems in order to maintain your energy. When in doubt, talk to your health care team. There are some physicians who believe that activating agents may also play a role, so it is important to talk to your doctor about all of your symptoms, even though you do not think there may be an intervention. Medicine changes, so keep talking to your health care team.
Conclusion
I want to emphasize that cancer and its treatments are very powerful and that energy management is not simple. These strategies may not bring your energy levels to pre-disease treatment levels, and having this expectation may create feelings of sadness. It is important to be realistic about what you can hope to achieve and to understand that, sometimes, energy will take time to be restored. That being said, keep in mind that energy is a complex commodity and varied interventions are important for its overall management. One strategy alone may not be particularly powerful; however, using several strategies may have a cumulative effect. The combined effect of these efforts may preserve, restore, and facilitate energy and, most importantly, may have a positive effect on your quality of life.
Anne Coscarelli, Ph.D.
Wallis Annenberg Director’s Initiative in Psychosocial Oncology
© Anne Coscarelli, Ph.D. All rights reserved.
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