What is Anxiety?

Definition

A subjective sensation of apprehension, tension, insecurity and/or uneasiness that can affect attention, learning and adaptation. The cause of the anxiety may or may not be known to the person experiencing the anxiety. Understanding its causes, prevention, and treatment will help most people find relief.

Causes

• Medication
• Psychological
• Post Traumatic Stress Disorder (PTSD)
• Delirium
• Advanced disease
• Dyspnea
• Withdrawal
• Constipation
• Urinary retention
• Infection
• Pain
• Brain mets
• Electrolyte imbalance

Assessment

History

• Onset, acute or chronic anxiety
• Precipitating/relieving factors
• Timing of anxiety
• Specific fears and phobias
• What diseases/illness does this person have that may cause the anxiety
• Medications
• Reactions to medications, interventions
• Associated symptoms (palpitations, panic, restlessness, chest pain, irritability, jitteriness, headache, anorexia, apprehension)
• Sleep disturbances
• History of mental illness
• Previous coping mechanisms
• Psychosocial concerns
• Spiritual concerns
• Caregiver concerns
• Impact on functionality
• Quality of life.

Physical Exam

• Appearance of patient
• Cardiopulmonary system
• GI/GU system
• Signs of infection

Non Pharmacological Interventions

• Active listening
• Emotional support
• Supportive psychotherapy
• Patient/family education to alleviate fear of unknown
• Continuous updated communication
• Ample time for patient to ask questions and discuss fears
• Subdued, comforting environment to reduce stimuli
• Encourage use of cognitive/behavioral therapies such as relaxation, visualization, distraction
• Palliative Arts therapy including (but not limited to) massage, music, therapeutic touch
• Prayer
• Religious rituals

Pharmacological Interventions

Pharmacological treatment should be based on relieving cause of anxiety whenever possible. Resolution of underlying factor(s) should be primary goal whenever possible. Utilize team collaboration in assessment, intervention and education with the patient and family.

• Treat precipitating pain or other symptom appropriately
• Ativan (Lorazepam) 0.5 – 2 mg po/sl q 6h PRN (MDD = 12 mg/day)

Evaluate and Document symptom at each visit until resolved. Evaluate discontinuing medications as symptoms resolve. Collaborate with psychosocial and spiritual professionals to confirm that symptoms are managed with the most effective combination of non-pharmacological and pharmacological interventions.

References

Breibart W, Chochinov HM & Passik SD. Psychiatric symptoms in palliative medicine. In: Doyle D, Hanks G, Cherny N, Calman K eds Oxford Textbook Palliative Medicine. 3rd ed. pp. 748 -750, Oxford University, 2005.

Clinical Practice Guidelines: The Hospice of the Florida Suncoast (2008).

Grauer P, Shuster J & McCrate-Protus B. (2008). Palliative Care Consultant: A reference guide for palliative care 3RDed. Kendall/Hunt Publishing Co.

Kuebler KK, Davis MP & Moore CD. (2005). Palliative Practices: An Interdisciplinary Approach. Elsevier/Mosby: Missouri.

Pasacreta JV, Minarik PA & Nield-Anderson L. Anxiety and Depression. In: Ferrell B & Coyle N, eds Textbook of Palliative Nursing 2nd ed, pp 375 – 399. Oxford University Press, 2006.

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