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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 that results from an unknown internal stimulus, is excessive, or is other-

wise inappropriate to a given situation."

• Anxiety is closely related to fear, but fear has an identified cause or source of worry (e.g., fear of death). Fear may be more responsive to counseling than an anxiety state that the patient cannot attribute to a particular fearful stimulus. Anxiety disorders are the most prevalent class of mental disorders overall, so it is not surprising that anxiety is a common cause of distress at life's end.14

• In addition to anxiety disorders, a variety of conditions can cause, mimic, or exacerbate anxiety15,16:

• 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 the majority of 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 and especially metoclopramide), can present as anxiety.

• Interpersonal, spiritual, or existential concerns can mimic 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 (e.g., tension, jitteriness, or restlessness)

• Maladaptive behaviors (e.g., treatment nonadherence, social withdrawal, or avoidance)

• Diminished coping and inability to relax

• Pathologic 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.

• Search for probable etiologies

• Assess for formal anxiety disorders

• Assess for other contributing factors

• Appropriate assessment of anxiety is key to its management.

Nonpharmacologic Treatment in Palliative Care

Regardless of what treatment approach is chosen, the following principles apply:

• 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.

• Educate patients and families about anxiety and its treatments.

• Psychotherapies can help in the management of anxiety, though the 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 (i.e., focusing on something pleasurable or at least emotionally neutral).

• Encourage chaplain 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 Palliative Care

• In most cases, management of pathological anxiety in the hospice setting involves pharmacologic therapies. Benzodiazepines are the gold standard for treatment;

however, selective serotonin reuptake inhibitors (SSRIs), typical and atypical anti-

psychotics, and tricyclic antidepressants may also be appropriate.

• The primary goal of therapy for anxiety in hospice is patient comfort. Aim to prevent anxiety, not just treat it with as needed medications when it flares. Think of pain management as an analogy.

• Start at the lower end of the dose range of a given anxiolytic agent to prevent unnecessary sedation, but recognize that standard or higher doses may be required.

• Avoid use of bupropion and psychostimulants for anxiety. While effective for depression, they are ineffective for anxiety and may make anxiety worse.

• Lorazepam, alprazolam, and diazepam are commonly crushed and placed under the tongue with a few drops of water for patients who have difficulty swallowing.

• 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.

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