CHAPTER 17. ANXIETY
Debra E. Heidrich and Peg Esper
DEFINITION AND INCIDENCE
Anxiety is an experience of diffuse apprehension or uneasiness, often accompanied by feelings of uncertainty and helplessness and activation of the autonomic nervous system (Carpenito, 2000). In nursing diagnosis terminology, the source of anxiety is either nonspecific or unknown, contrasting with fear, which occurs when the source of the uneasiness is known (Carpenito, 2000). Since these two nursing diagnoses overlap in terms of defining characteristics and appropriate interventions, the term anxiety is used here to describe a symptom associated with apprehension and uneasiness. Everyone feels anxious at times, especially when facing new situations, and particularly when facing a new medical diagnosis of an advanced, progressive disease. Anxiety may be mild, moderate, severe, or extreme. Although mild anxiety can be beneficial, leading people to seek appropriate information and support, increased or sustained anxiety can be detrimental both physiologically and psychologically (Shoemaker, 2005).
Studies of prevalence rates of anxiety are difficult to interpret since the term is neither defined nor measured consistently. Mild to moderate anxiety is common and expected when facing the physical, psychosocial, emotional, and spiritual issues associated with cancer and terminal illnesses (Breitbart, Chochinov, & Passik, 2004; Dinoff & Shuster, 2005; Noyes, Holt, & Massie, 1998; Vachon, 2004). Family caregivers of patients with advanced, progressive illnesses also experience anxiety and at higher levels than the general population (Grov, Dahl, Moum et al., 2005). Most people possess the necessary coping skills to manage lower levels of anxiety. However, in those with borderline coping skills, mild anxiety may progress to severe anxiety. Thus, even mild anxiety, although expected, must be assessed and addressed. Contrary to some beliefs, a high level of anxiety is not inevitable during the terminal phase of illness and should not be expected or tolerated (Breitbart, Chochinov, & Passik, 2004).
Anxiety disorders are syndromes characterized by anxiety that is beyond the norm in intensity, duration, or behavioral manifestations (Noyes, et al., 1998). There are several DSM-IV anxiety disorder diagnoses, including acute stress disorder, anxiety disorder due to general medical condition, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobias, and posttraumatic stress disorder (American Psychiatric Association, 1994). Anxiety disorders affect approximately 19 million Americans, or about 6% of the general population (National Institute of Mental Health, 2001). The incidence of anxiety disorders is higher in patients with cancer and those at the end of life than the general population. Studies examining the prevalence of pathological anxiety in patients with early to advanced stages of various cancer diagnoses show a range from 1% to 44% (Noyes et al., 1998). In addition, Olfson, Shea, Feder et al. (2000) reported that 14.8% of patients seeking primary care in an urban general medicine practice met the criteria for generalized anxiety. So, it appears appropriate to conclude that the prevalence of anxiety is higher in people seeking medical attention than the general, healthy population. Psychiatric disorders, including anxiety, often are unrecognized and untreated in the terminally ill, as a result of several factors (Academy of Psychosomatic Medicine, 1999):
▪ Difficulty in differentiating symptoms of physical disease from a psychiatric problem
▪ Belief that many of the symptoms of psychiatric illnesses are normal in the dying process
▪ Belief that patients at the end of life do not respond to treatment of psychiatric problems
▪ Barriers associated with accessing trained psychiatrists
▪ Stigma associated with a psychiatric diagnosis by professionals, family, and patient
▪ Formal diagnosis of psychiatric complications is not sufficiently emphasized in palliative care
Patients with higher anxiety scores are more likely to request a hastened death and less likely to have a peaceful death (Georges, Onwuteaka-Philipsen, van der Heide et al, 2005; Mystakidou, Rosenfeld, Parpa et al., 2005). This emphasizes the importance of assessing and aggressively managing, Rosenfeld, Parpa anxiety in the palliative care setting.
ETIOLOGY AND PATHOPHYSIOLOGY
Anxiety has many causes—physical, psychosocial, emotional, and spiritual. Anxiety can be a manifestation of a medical problem (e.g., hypoxia) or a symptom of physical discomfort (e.g., dyspnea, pain, nausea). Many practitioners have observed that physical discomfort is often perceived as being worse in the presence of anxiety, creating a snowball effect of a symptom, anxiety, worsening of symptom, and worsening of anxiety.
Anxiety is sometimes a side effect of medications or a symptom of medication or substance withdrawal. Patients with cognitive dysfunction, such as those with Alzheimer’s disease or delirium, commonly exhibit anxiety or agitation. Indeed, anxiety can also be an early sign of delirium, so it must be assessed carefully (Caracini, Martini, & Simonetti, 2004).
A host of psychological or emotional concerns may lead to anxiety. Concerns or fears about control of symptoms, addiction to medicines, self-concept and role changes, the dying process, and unresolved family or financial issues are examples of potential issues that may contribute to anxiety in both patients and caregivers. And certainly, anxiety may be a symptom of spiritual distress. Box 17-1 illustrates the wide-ranging causes of anxiety.
Box 17-1
ANXIETY AS A SYMPTOM OF A PHYSICAL PROBLEM
• Any unrelieved distressing symptom such as pain or dyspnea
• Underlying somatic process (hypoxia, sepsis)
• Adverse drug reaction such as akathisia (haloperidol), psychosis (corticosteroids), or toxicity (meperidine)
• Medication or substance withdrawal (alcohol, anticonvulsants, benzodiazepines, nicotine, and opioids)
• Actual or impending delirium
MEDICAL PROBLEMS ASSOCIATED WITH ANXIETY SYMPTOMS
• Cardiovascular: angina, arrhythmias, valvular disease, congestive heart failure, myocardial infarction
• Fluid and electrolyte imbalances: dehydration, hyponatremia, hyperkalemia, hypercalcemia, or hypocalcemia
• Endocrine: hyperthyroidism, hypothyroidism, Cushing’s syndrome, Addison’s disease, hyperparathyroidism, abnormal glucose levels
• Pulmonary: asthma, chronic obstructive pulmonary disease (COPD), dyspnea, hypercapnia, hypoxia, pneumothorax, pulmonary embolism, sleep apnea, pneumonia
• Neurologic: encephalopathy, vertigo, delirium, cerebrovascular accident, multiple sclerosis, transient ischemic attacks, hematoma
• Hematologic/malignancy: any brain metastasis, anemia, pheochromocytoma
• Nutritional: anemia, folate deficiency, vitamin B 12 deficiency
• Drug or medication side effects: for example, bronchodilators, phenothiazines, corticosteroids, digitalis preparations, anticholinergics, central nervous system stimulants used to counteract the sedative side effects of opioids: caffeine, methylphenidate (Ritalin), amphetamine
• Any infectious process, for example, pneumonia and urinary tract infections
ANXIETY AS A SYMPTOM OF A PSYCHOSOCIAL, EMOTIONAL, OR SPIRITUAL CONCERN
• Normal reaction to a threatening situation
• Indication of an anxiety disorder as defined by DSM-IV criteria
• Expression of existential or spiritual suffering
Data from Breitbart, W., Chochinov, M., & Passik, S. (2004). Psychiatric aspects of palliative care. In D. Doyle, G. Hanks, N. Cherny, et al. (Eds.), Oxford textbook of palliative medicine (3rd ed., pp. 746-771). New York: Oxford University Press; Hinshaw, D.B., Carnahan, J.M., & Johnson, D.L. (2002). Depression, anxiety, and asthenia in advanced illness. J Am Coll Surg, 195(2), 271-277; Shoemaker, N. (2005). Clients with psychosocial and mental health concerns. In J.M. Black & J.H. Hawks (Eds.), Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 523-536). St. Louis: Elsevier Saunders; and Vachon, M.L.S. (2004). The problems of the patient in palliative medicine. In D. Doyle, G. Hanks, N. Cherny, et al. (Eds.), Oxford textbook of palliative medicine (3rd ed., pp. 961-985). New York: Oxford University Press.
Anxiety activates the sympathetic branch of the autonomic nervous system, eliciting the stress or fight-or-flight response. The physiological changes that occur with the stress response are initially adaptive, enhancing the body’s ability to perform physically and mentally. However, a sustained stress response can lead to complications due to continued overstimulation of the sympathetic nervous system and physiological exhaustion, including hypertension, palpitations and stress on cardiac functioning, nausea, tissue breakdown, hyperglycemia, impaired psychological functioning, increased blood coagulation (leading to potential complications like pulmonary emboli), and immunosuppression (Guyton & Hall, 2005).
ASSESSMENT AND MEASUREMENT
Anxiety is manifested in many ways—subjective experiences, observable signs, and physiological changes. These symptoms vary with the intensity of the patient’s anxiety (Carpenito, 2000; Dinoff & Shuster, 2005; Shoemaker, 2005). The clinician must use a combination of patient and family interviews, astute observation of anxiety-associated behaviors, anxiety assessment tools, and physical assessment to evaluate the presence and severity of anxiety. It is important to have one-on-one discussions between the clinician and patient and between the clinician and caregiver to elicit subjective experiences associated with anxiety, assess coping styles, and identify changes in behavior that indicate anxiety.
Subjective Experiences Associated with Anxiety
▪ Apprehension, uneasiness, fear
▪ Tension or nervousness
▪ Irritability
▪ Restlessness
▪ Loss of control (feelings of helplessness, angry outbursts)
▪ Increased attention with mild anxiety, difficulty concentrating with increasing anxiety
▪ Physical discomforts: headaches; pains in neck, back, or chest; nausea; hot or cold flashes
Observable Signs of Anxiety
▪ Tense posture
▪ Fidgeting with fingers or clothing
▪ Frequent sighing
▪ Dryness and licking of dry lips
▪ Trembling
▪ Insomnia
▪ Changes in communication: quieter or more talkative than usual
▪ Changes in speech: pitch higher than normal, voice tremors
▪ Clenched jaw or grinding of teeth
Physiological Signs of Anxiety
▪ Changes in vital signs: increase in heart rate, respiratory rate, and systolic blood pressure
▪ Diaphoresis
▪ Flushing or pallor
▪ Dry mouth
▪ Dilated pupils
▪ Urinary frequency or urgency
▪ Diarrhea
▪ Fatigue
The appropriate treatment of anxiety is guided by its severity. The level of anxiety is inferred on the basis of the severity of the patient’s subjective feelings, observable signs, and physical symptoms associated with anxiety. As with other subjective symptoms, asking individuals to rate their anxiety on a numeric scale may be helpful. One well-researched tool used in the palliative care setting is the Edmonton Symptom Assessment System (Edmonton Regional Palliative Care Program, 2001). This tool includes a visual analogue scale for rating anxiety from 0 (not anxious) to 10 (worst possible anxiety). Observable signs and physical symptoms of anxiety may also be used to identify the severity of this symptom (Table 17-1).
| Anxiety Level | Physical Manifestations | Emotional Manifestations | Cognitive Manifestations |
|---|---|---|---|
| Mild | Increased pulse and blood pressure | Positive affect | Alert, can solve problem, prepared to learn new information |
| Moderate | Elevated vital signs, tense muscles, diaphoresis | Tense, fearful | Attention focused on one concern, may be able to concentrate with directions |
| Severe | Fight-or-flight response, dry mouth, numb extremities | Distressed | Decreased sensory perception, can focus only on details, unable to learn new information |
| Panic | Continued as in severe level | Totally overwhelmed | Ignores external cues, focused only on internal stimuli, unable to learn |
Individuals with severe or panic levels of anxiety and those with prolonged anxiety require further screening for the presence of clinical anxiety disorders. Consultation with a psychologist or psychiatrist is recommended for patients or caregivers with anxiety disorders.
HISTORY AND PHYSICAL EXAMINATION
Because anxiety is characterized by a variety of subjective feelings, observable behaviors, and physiologic changes and has multiple causes, the history and physical examination must include assessment of physical, psychological, emotional, and spiritual issues.
▪ General appearance: dress, hygiene, motor activity, facial expression, and speech pattern
▪ Primary and secondary medical diagnoses, noting those with a potential for complications with anxiety symptoms; for example, bone metastasis and hypercalcemia, lung disease and hypoxia, syndrome of inappropriate antidiuretic hormone (SIADH) and hyponatremia
▪ Systems review
Cardiovascular: tachycardia, increased systolic pressure, angina, facial flushing or pallor, diaphoresis
Respiratory: dyspnea, tachypnea, signs of hypoxia
Musculoskeletal: muscle tension, trembling
▪ Presence of pain from any source
▪ Use of any medications associated with anxiety
▪ Psychoemotional status
Patient and family’s understanding of the advanced illness
Present concerns or worries, including those about the illness itself, the symptoms, or the management of symptoms
Stresses affecting the patient or family: any change in health, marital status, family unit, living arrangements, responsibilities, employment, or financial status
Self-appraisal of patient and family adjustment to these changes
▪ History of substance abuse: alcohol, nicotine, prescription medications, or illicit drugs
▪ History of an anxiety disorder, depression, or other mental health disorder, including time since diagnosis, treatments, ongoing interventions, and current status
▪ Presence and severity of anxiety at this time
Feelings of uneasiness, tension, or restlessness
Presence and severity of observable signs or physiologic changes associated with anxiety
▪ Resources available to manage anxiety: social support, religion, recreational or social activities, support groups, professional assistance
▪ Spiritual belief system, including spiritual meaning of experiences, beliefs about an afterlife, and existential concerns and questions
DIAGNOSTICS
The appropriate use of diagnostic tests is determined by the suspected underlying cause of the anxiety. If a medical complication is suspected, appropriate diagnostics may include pulse oximetry to assess oxygen saturation; blood chemistries to evaluated abnormalities, such as hyponatremia, hypokalemia, hypercalcemia, or hypocalcemia; chest radiograph to diagnose pneumonia; or urine cultures to verify urinary tract infection. If an anxiety disorder is suspected, the patients may be referred to a psychiatrist for further evaluation and diagnosis.
INTERVENTION AND TREATMENT
Appropriate treatment depends on the underlying cause and level of anxiety. Because anxiety is typically multidimensional, it is helpful to use multiple approaches to manage this symptom.
Treat Physical Causes
▪ Aggressively treat uncomfortable symptoms, such as pain, dyspnea, and nausea.
▪ Manage, as feasible and appropriate, medical conditions contributing to anxiety, such as anemia, hypercalcemia, SIADH, and pulmonary compromise.
▪ Treat symptoms related to withdrawal.
Medications such as benzodiazepines or opioids must be tapered if no longer necessary for symptom control to prevent withdrawal. Be aware that caregivers sometimes stop giving these medications when the patient is no longer alert.
Consider using a nicotine patch for patients with a history of smoking who stop smoking, whether by choice or due to physical condition.
Consider adding a benzodiazepine to manage the symptoms of alcohol withdrawal for patients with physical dependence on alcohol who are no longer able to swallow. Evaluate the benefits versus potential complications of continuing alcohol via nasogastric or gastrostomy.
Enhance Coping Skills
For mild-to-moderate anxiety
▪ Listen actively to concerns and fears.
▪ Encourage to express feelings.
▪ Convey respect for the individual and acceptance of feelings (e.g., “feelings are neither right nor wrong—they just are”).
▪ Provide information to clarify misconceptions, answer questions, and alleviate concerns. For example, discussing the facts about the extremely low incidence of addiction when opioids are used for pain management may significantly decrease anxiety and pain.
▪ Clarify information and reinforce teaching frequently.
▪ Teach relaxation techniques.
▪ Use complementary therapies, such as music, art, imagery, and massage.
▪ Assist the individual to identify anxiety-provoking stimuli.
▪ Assist in developing strategies to prevent or modify an anxiety-provoking situation, if possible.
▪ Encourage the patient to recognize the onset of anxiety early and intervene before it escalates.
▪ Refer to counseling services, as appropriate, such as medical social services, pastoral counseling, and financial and estate planning.
▪ Consider referral to a support group, as appropriate.
▪ Encourage the patient and caregiver to accept assistance to reduce stress:
Make lists of tasks that can be delegated.
Delegate these tasks to available extended family, worship community, and neighborhood or civic group members.
For severe anxiety
▪ Provide a safe, calm environment.
Remove as many stressors as possible, including limiting number of people in the room.
Avoid moving the patient from familiar surroundings, if possible.
Encourage the physical presence of a trusted person.
▪ Communicate in short, simple sentences in a calm tone of voice.
▪ Do not overload the patient and caregiver with information; the ability to concentrate and learn is impaired.
▪ Allow expression of feelings, without probing or confrontation.
▪ Consider consultation with a clinical psychiatrist.
Pharmacological Interventions
Although the interventions to enhance coping skills are effective for mild and, to some degree, moderate anxiety, anxiolytic medications are very important in the treatment of prolonged or severe anxiety. If anxiety is interfering with quality of life, a short course of anxiolytic medication may reduce the unpleasant symptoms associated with anxiety and enable the individual to learn new coping skills. Severe anxiety and anxiety disorders often require ongoing pharmacological treatment in addition to psychotherapy. Table 17-2 provides dosage ranges for the medications discussed later.
| *Avoid the IM route of administration whenever possible. |
||||
| Data from Esper, P. & Heidrich, D.E. (2005). Symptom clusters in advanced illness. Semin Oncol Nurs, 21(1), 20-28; Goldberg, L. (2004). Psychological issues in palliative care: Depression, anxiety, agitation, and delirium. Clin Fam Pract, 6(2), 441-470; Hinshaw, D. B., Carnahan, J.M., & Johnson, D.L. (2002). Depression, anxiety, and asthenia in advanced illness. J Am Coll Surg, 195(2), 271-277; Thomson Micromedex. (2005). Micromedex® healthcare series. Retrieved September 1, 2005, from http://micromedex.med.umich.edu/mdxcgi/quiklocn.exe?CTL=E:\mdx\mdxcgi\MEGAT.SYS&SET=1C64C5D24F042200&SYS=19&T=799&D=1&Q=26; and USP DI. (2005). USP DI® drug information for the health care provider (25th ed.). Retrieved September 1, 2005, from http://online.statref.com/Document/Document.aspx?DocId=3449&FxId=6&Scroll=1&Index=0&SessionId=65E26DIZLYGKCYJY. | ||||
| Drug | Dosage Range (mg/day) | Available Routes* | Half-life (hr) | Comments |
|---|---|---|---|---|
| Benzodiazepines | ||||
| Very short acting | ||||
| Midazolam | 10-60 | IV, subcutaneous | 2-7 | Used when quick relief is needed |
| Short acting | ||||
| Alprazolam | 0.75-4 | Oral, SL | 9-27 | Used in anxiety and panic disorders |
| Lorazepam | 2-4 | Oral, SL, IV, IM | 10-20 | Readily absorbed, moderate price |
| Intermediate acting | ||||
| Chlordiazepoxide | 15-100 | Oral, IM, IV | 24-48 | Useful with comorbid seizure disorders |
| Long acting | ||||
| Diazepam | 4-40 | Oral, IM, IV, PR | 24-120 | Useful with comorbid seizure disorders |
| Clonazepam | 1.5-20 | Oral | 30-40 | Adjuvant for neuropathic pain |
| Nonbenzodiazepine | ||||
| Buspirone | 15-30 | Oral | 2-11 | Will not block withdrawal effects from discontinuation of benzodiazepines |
| Neuroleptics | ||||
| Haloperidol | 1-15 | Oral, IV, subcutaneous, IM | 12-38 | Not as sedative as chlorpromazine |
| Chlorpromazine | 50-100 | Oral, IM, IV | 30 | Also useful in hiccups |
| Olanzapine | 5-10 | Oral, IM | 30-38 | Not recommended in Parkinson’s disease |
| Risperidone | 1-2 | Oral, IM | 20 | May cause significant hypotension |
| Antihistamines | ||||
| Hydroxyzine | 50-100 | Oral, IM | 3-20 | Useful in management of pruritus |
| Promethazine | 12.5-100 | Oral, IM, IV, PR | 5-14 | Also useful to control nausea and vomiting; IV is not the preferred route |
Benzodiazepines
The benzodiazepines are the most commonly prescribed anxiolytics. These medications work by potentiating gamma-aminobutyric acid, an inhibitory neurotransmitter in the central nervous system (CNS). The result is CNS suppression, especially at the level of the limbic system (Hodgson & Kizior, 2004). The benzodiazepines with a short half-life (e.g., lorazepam) are generally preferred in elderly patients and for short-term management of anxiety. Alprazolam has an intermediate half-life (approximately 14 hours) and is also an effective, widely used anxiolytic. A potential problem with the short-acting benzodiazepines is end-of-dose failure; the medications with a longer half-life, such as clonazepam, may be preferred if breakthrough anxiety is present (Goldberg, 2004). Clonazepam is also a recommended choice in individuals with neurological disorders (Hinshaw, Carnahan, & Johnson, 2002).
Diazepam, clorazepate, flurazepam, and other benzodiazepines with active metabolites should be avoided due to the risk of escalating blood levels, inducing side effects such as slurred speech, somnolence, and confusion. Those individuals exhibiting both anxiety and depression may benefit from the use of an antidepressant. Patients with compromised respiratory function or who are on large doses of opioid analgesics should be evaluated carefully prior to prescribing benzodiazepines secondary to their potential for central respiratory suppression (Hinshaw et al., 2002).
Neuroleptics
The neuroleptic medications are used when the benzodiazepines are not effective or when confusion or hallucinations accompany the anxiety. Be aware that the combination of anxiety with a mental status change is a sign of delirium. Haloperidol is often used to manage severe anxiety on a short-term basis or for treating psychotic episodes. It is not as sedative as agents such as chlorpromazine (Montagnini & Moat, 2004; Paice, 2002). Neuroleptic medications work by suppressing the cerebral cortex, limbic system, and hypothalamus and by blocking CNS dopamine receptors (Hodgson & Kizior, 2004).
Other Anxiolytics
Buspirone is a nonbenzodiazepine anxiolytic. Inhibition of serotonin appears to be the mechanism of action (Thomson Micromedex, 2005). This medication may take 1 to 2 weeks to reach maximal effectiveness and is generally used for chronic anxiety. The clinician must be cautious when switching to buspirone from a benzodiazepine since buspirone does not block benzodiazepine withdrawal (USP DI, 2005).
Antihistamines have also been used for their anxiolytic properties (Goldberg, 2004; Montagnini & Moat, 2004). Hydroxyzine appears to depress the CNS more than diphenhydramine, but both have been used. Some practitioners prefer to use antihistamines if the patient’s respiratory status is extremely compromised and there is a concern about respiratory depression from benzodiazepines (Breitbart, Chochinov, & Passik, 2004). However, as the antihistamines tend to have a relatively mild anxiolytic effect, a benzodiazepine or neuroleptic may be required for moderate to severe anxiety even in the presence of a compromised respiratory system (Goldberg, 2004). Antihistamines such as promethazine have been used in patients with chronic obstructive pulmonary disease. Their effect on anxiety is mild and additional agents may be required (Runo & Ely, 2001).
Special Considerations
Patients on longer-term anxiolytics, in particular, benzodiazepines, need to be tapered off of these medications slowly if it appears they are no longer needed. However, many patients require treatment until death to avoid withdrawal symptoms. If stopped abruptly, terminal agitation can occur. This can be treated, if needed, by using rectally administered diazepam, sublingual lorazepam, or subcutaneous midazolam for those patients unable to swallow (Periyakoil, Skultety, & Sheikh, 2005).
Midazolam is an appropriate choice for patients with anxiety and agitation in the final days of life if they are unable to take oral agents or if other agents have not been successful. Initial dosing is generally 0.5 to 1 mg per hour by continuous subcutaneous or intravenous infusion; the dosage may be increased by 25% to 50% hourly as needed to effect comfort (Hanks-Bell, Paice, & Krammer, 2002).
PATIENT AND FAMILY EDUCATION
Providing information is extremely important in the management of anxiety, including explaining aspects of symptom management to alleviate the source of the anxiety, when possible, and discussing the recognition and management of anxiety itself. Both the patient and the family are at risk, because anxiety in one person can exacerbate that in another. Thus, it is important to include both patients and caregivers when providing information.
▪ Teach accurate symptom assessment and management.
▪ Correct misconceptions and fears regarding medications (e.g., addiction, respiratory depression, sedation).
▪ Assist the individual to identify his or her own signs of anxiety.
▪ Teach relaxation and other stress management techniques.
▪ Emphasize that anxiety is a symptom that requires treatment (versus a sign of weakness).
▪ Teach the potential benefit of using many approaches to manage anxiety, including counseling.
▪ Teach patients and caregivers to consult a clinician before stopping any medication.
EVALUATION AND PLAN FOR FOLLOW-UP
Successful intervention for anxiety leads to a resolution or, at least, a decrease in the subjective and objective signs of anxiety. Evaluating the subjective aspects of anxiety includes asking the individual about feelings of uneasiness, apprehension, and helplessness. Use of a numeric scale or anxiety assessment tool as part of initial and ongoing assessments assists in documenting the subjective experience of anxiety and in monitoring for changes over time. Objective signs of anxiety are also monitored to determine the effectiveness of the interventions. In addition to evaluating the effectiveness of medications ordered for anxiety, the patient should be monitored for side effects of these medications.
The potential for anxiety is always present in patients with advanced illness and their caregivers, making ongoing evaluation a necessity. And, since anxiety can change from day to day, the ongoing evaluation process should include not only present anxiety but any anxiety in the past 24 hours or since the last visit or appointment. Be sure to consider that meeting with health care professionals may increase or decrease anxiety, depending on the individual’s degree of comfort with his or her clinician. Remember that a high level of anxiety is not inevitable during the terminal phase of illness and should not be expected or tolerated; it must be anticipated, carefully assessed, and appropriately managed.
Mr. K. is a 52-year-old man with a new diagnosis of metastatic non–small-cell lung cancer. He lives at home with his wife; his children are married and live out of state. Mr. K. had a history of panic attacks in his late 20s but has not been on any medication for this in over 10 years. His lung cancer was diagnosed after he began coughing up blood. Following two standard and one investigational treatment regimens, he has continued to show progressive disease. He has become weaker and has increasing anorexia. His wife has had to continue her employment in order to maintain their insurance coverage. Mr. K. expressed that he is starting to have difficulty sleeping at night because he “can’t stop [his] mind from going in 100 different directions.” He is exhausted during the day but states he doesn’t like to sleep when his wife is away at work. During his clinic appointment, the clinician has a chance to speak with Mr. K. alone. In reviewing his current problems, it is noted that Mr. K. is quite fidgety and has difficulty maintaining eye contact. As the discussion continues, the clinician explores with Mr. K. the “thoughts” that he has at night that keep him awake. In doing this, the clinician identifies that Mr. K. is afraid of going to sleep and not waking up again. He is also afraid that he’ll cough up blood in his sleep and not be able to breathe.
Mrs. K. is able to obtain a family medical leave. Mr. K. begins the lorazepam and initially finds that it allows him to sleep better at night, and he even takes an occasional nap during the day. As his disease progresses, however, Mr. K. begins to experience more problems with dyspnea and is coughing up more blood. His anxiety level is not being controlled with lorazepam. Based on his rapidly declining condition, the clinician decides to initiate a subcutaneous infusion of midazolam at 1 mg/hr. Mr. K. is able to obtain good relief of anxiety within 24 hours of initiation of this therapy. As his condition deteriorates he ultimately requires titration up to 4 mg/hr but is without perceptible restlessness or anxiety at the time of his death.
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