Anxiety

A comprehensive review of anxiety disorders may be found in

Chapter 40.
»» Palliative Care Considerations
•• Anxiety is “a state of fearfulness, apprehension, worry,
emotional discomfort, or uneasiness resulting from an
unknown internal stimulus, is excessive, or is otherwise
inappropriate to a given situation.”15
•• Anxiety is closely related to fear, but fear has an identified
cause or source of worry (eg, fear of death). Fear may be
more responsive to counseling than anxiety that the patient
cannot attribute to a particular fearful stimulus. Anxiety
disorders are the most prevalent class of mental disorders, so
it is not surprising that anxiety is a common cause of distress
at life’s end.
In addition to anxiety disorders, a variety of conditions can
cause, mimic, or exacerbate anxiety.16,17 Delirium, particularly
in its early stages, can easily be confused with anxiety. Physical
complications of illness, especially dyspnea and undertreated
pain, are common precipitants. Significant anxiety is present in
most patients with advanced lung disease and is closely related
to periods of oxygen desaturation. Medication side effects,
especially akathisia from older antipsychotics and antiemetics
(including metoclopramide), can present as anxiety. Interpersonal,
spiritual, or existential concerns can mimic and exacerbate
anxiety. Patients with an anxious or dependent coping
style are at high risk of anxiety as a complication of advanced
illness. Short of making a diagnosis of a formal anxiety disorder,
differentiating normal worry and apprehension from pathologic
anxiety requires clinical judgment.
Behaviors indicative of pathological anxiety include intense
worry or dread, physical distress (eg, tension, jitteriness, or
restlessness), maladaptive behaviors, and diminished coping and
inability to relax.
Pathological anxiety may be complicated by insomnia, depression,
fatigue, GI upset, dyspnea, or dysphagia. Anxiety can also
worsen these conditions if they are already present. Untreated
anxiety may lead to numerous complications, including withdrawal
from social support, poor coping, limited participation in
palliative care treatment goals, and family distress. Reassess the
patient for anxiety with any change in behavior or any change in
the underlying medical condition. Assessment for formal anxiety
disorders or other contributing factors is key to management. A
comprehensive review of insomnia may be found in Chapter 41.
»» Nonpharmacologic Treatment
Regardless of treatment approach chosen, the following principles
apply. Ask questions and listen to patients’ concerns and
fears. Offer emotional support and reassurance when appropriate.
Err on the side of treatment—be willing to palliate anxiety.
Assess treatment response and side effects frequently. Aim to
provide maximum resolution of anxiety and educate patients and
families about anxiety and its treatments.
Psychotherapies can help manage anxiety, although availability
of trained therapists willing to make home visits, and limited
stamina and attention span of seriously ill patients, typically
make such therapies impractical in the hospice setting. Cognitive
and behavioral therapies can be beneficial, including simple
relaxation exercises or distraction strategies (ie, focusing on
something pleasurable or at least emotionally neutral). Encourage
pastoral care visits, especially if spiritual and existential concerns
predominate.
When an underlying cause of anxiety can be identified, treatment
is initially aimed at the precipitating problem, with monitoring
to see if anxiety improves or resolves as the underlying
cause is addressed.
»» Pharmacotherapy
In most cases, management of pathological anxiety in the hospice
setting involves pharmacologic therapies. Benzodiazepines are
the standard for treatment; however, selective serotonin reuptake
inhibitors (SSRIs), typical and atypical antipsychotics, may be
appropriate based on the patient’s life expectancy.18 The primary
goal of therapy for anxiety in hospice is patient comfort. Aim
to prevent anxiety, not just treat it with as needed medications.
Think of pain management as an analogy. As with all medications
that act in the central nervous system (CNS), anxiolytics
such as benzodiazepines should be dosed at the lower end of
the dose range to prevent unnecessary sedation, particularly in
the frail and elderly. However, recognize that standard or higher
doses may be required. Avoid use of bupropion and psychostimulants
for anxiety. Although effective for depression, they
are ineffective for anxiety and may make anxiety worse. Many
patients have difficulty swallowing as they approach the end of
life. Lorazepam, alprazolam, and diazepam tablets are commonly
crushed and placed under the tongue with a few drops of water if
the liquid formulations are not readily available. Low-dose haloperidol
is also used to treat anxiety in palliative care, particularly
if delirium is present. Chapter 40 provides more detailed information
on appropriate use of anxiolytic agents.