Anxiety in Palliative Care Patients

Background

• Palliative care is interdisciplinary care (including medicine, nursing, social work, chaplaincy, and other specialties) that seeks to improve the quality of life in patients with serious, often incurable illness, and with their families.
• The majority of patients receiving palliative care have some degree of anxiety or distress which further impacts their quality of life above and beyond their underlying chronic illness or disease process.
• Anxiety in palliative care patients and/or distress in patients receiving palliative care may be triggered or exacerbated by factors related to the underlying illness (such as uncontrolled pain or symptoms), existential concerns, advancing disease, lack of social support, and prior history of anxiety.
• Different types of anxieties may manifest including generalized anxiety disorder, panic disorder, posttraumatic stress disorder, acute stress disorder, social anxiety disorder, phobias, obsessive-compulsive disorder, and death anxiety.

Evaluation

• Screen all patients being considered for palliative care for anxiety and other mood disorders.
• When assessing patients for anxiety, consider avoiding words which suggest the stigma of major mental illness and instead use more common words such as concerns, distress, worries, uncertainties, and stressors.
• Obtain a detailed medication history to assess for medications which might:
  • produce anxiety
  • interact with other medications leading to symptoms
  • be inadequately dosed for symptom control
  • produce symptoms if recently discontinued due to withdrawal
• Ask about the duration and other characteristics of distress to differentiate normal worry from symptoms that raise suspicion of anxiety disorders.
• If anxiety is suspected, use a validated instrument to assess the severity and to inform treatment decisions.

Management

• Provide adequate information and support.
• For situational anxiety with an identifiable cause (such as due to pain, underlying condition, medication adverse event, or hormone-secreting tumor), treat the underlying cause.
• Consider psychological support for general distress and anxiety disorders such as relaxation training, cognitive and behavioral coping strategies, disease-specific education/information sessions, group social support, and formal cognitive behavioral therapy.
• Consider exercise to alleviate symptoms of depression and anxiety.
• If symptoms are severe, or if counseling does not reduce (or is not expected to reduce) anxiety, consider anxiolytics such as benzodiazepines, antidepressants, or other medications.
  • Benzodiazepines are the main class of anxiolytics (especially if immediate relief id required), but may not be appropriate or effective for some patients.
  • Medication selection should take into account the patient's severity of symptoms, degree of functional impairment, underlying disease process, psychiatric history, and potential side effects and adverse reactions.
• Continually reassess the patient's symptoms and:
  • if anxiety symptoms subside, consider tapering and discontinuing medications
  • if side effects develop or treatment is inadequate, change, augment, or discontinue medications
• If the patient becomes more debilitated and less able to interact, consider including the family.