Show Summary Details
Page of

Anxiety 

Anxiety
Chapter:
Anxiety
Author(s):

Maria Gatto

, Patricia Thomas

, and Ann Berger

DOI:
10.1093/med/9780190204747.003.0031
Page of

PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford University Press, 2015. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Medicine Online for personal use (for details see Privacy Policy).

Subscriber: null; date: 16 October 2017

Key Points

  • Anxiety is a universal subjective and objective life experience that crosses all eight palliative care domains of the National Consensus Project (NCP) Clinical Practice Guidelines.

  • Anxiety and chronic diseases are interchangeable in their causal relationship; chronic diseases can exacerbate symptoms of anxiety, and anxiety disorders can lead to chronic diseases.

  • Assessment and treatment of anxiety by the advanced practice registered nurse (APRN) is essential since it affects all four whole-person dimensions of suffering: physical, psychological, social, and spiritual.

Introduction

Anxiety, an aspect of our history that spans the evolutionary process, is inherent in all the domains of the National Consensus Project for Quality Palliative Care’s Clinical Practice Guidelines. Anxiety is present in the everyday lives of humans, whether patient or clinician. Anxiety is unique and specifically identified within NCP Domain 3 under Psychological and Psychiatric Aspects of Care: “The interdisciplinary team assesses and addresses psychological and psychiatric aspects of care based on the best available evidence to maximize patient and family coping and quality of life”.1 Due to the physical, affective, behavioral, and cognitive responses that anxiety may escalate, it can be clinically implicated in NCP Domain 1, Physical Aspects of Care; NCP Domain 2, Physical Aspects of Care; NCP Domain 4, Social Aspects of Care; and NCP Domain 7, Care of the Patient at the End of Life.

Anxiety is a multidimensional subjective and objective experience with manifestations of physical, affective, behavioral, and cognitive responses.2 As such, it can be considered both positive and negative. The experience is the physiological reaction that occurs in response to a perceived harmful attack or threat to survival. These include feelings of worry, apprehension, tension, and nervousness that are unpleasant and distressful, but they are a common response for patients and family members when faced with a serious diagnosis.

Anxiety is a natural and expected part of the coping process that helps us adapt to everyday concerns. However, extreme distressful anxiety can impair daily function, causing disability and disruptions in quality of life for patients, family, and caregivers.3 Specific differentiation between anxiety as a normal response and a specific diagnostic criterion that requires professional intervention and treatment is outlined according to the fifth edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR).4 The experience of apparent uncontrollable physical, affective, behavioral, and cognitive symptoms having no specific stimulus warrants consideration of a pathological disorder. Anxiety disorders are categorized according to criteria and range in complexity and severity from panic attacks, acute stress disorder, generalized anxiety disorder, social anxiety disorders, phobias, obsessive–compulsive disorder, post-traumatic stress disorder, anxiety secondary to a medical condition, and substance-induced anxiety disorders.4

Common situations, medical conditions, medications, and substances are associated with and can cause nonspecific anxiety symptoms.5,6 Existential and psychosocial concerns increase anxiety when a person is faced with mortality, long-term or permanent disability, loss of control, family and financial crisis, loss of meaning, hope, and purpose, and religious or spiritual crisis. There is also considerable overlap and confusion among the anxiety, depression, and delirium that commonly arise as part of an illness trajectory and that can either lead, progress to, or continue in a vicious downward cycle when not recognized and treated appropriately (Table 31.1).

Table 31.1 Associated Causes and Mimics of Anxiety

Acute emotional disruption

Interpersonal stresses

Anger

Legitimate worries and concerns

Anxiety disorders

Loss of control

Coping style (poor pattern)

Pain

Delirium

Physical symptoms

Fear

Side effects of medications

Financial concerns

Spiritual and existential crisis

Grief and bereavement

Withdrawal states

From references 2, 5, 7.

Despite the importance of mental health and the increasing prevalence of mental health disorders, U.S. healthcare delivery systems are complex and fragmented, and patients and families are offered little guidance in navigating these systems to manage medical conditions effectively. The result is that anxiety is underestimated, untreated or undertreated, and unrecognized by healthcare professionals. Furthermore, intensified financial stress and social economic burden contribute to anxiety. Given this, anxiety is a contributory factor for caregiver burden, chronic distress, mortality, and comorbidity of the family and caregivers.7,8 Barriers to appropriate professional intervention are also created by the lack of an integrated palliative care curriculum, inadequate professional resources, personal experiences, limited assessment skills and clinical knowledge, and personal biases associated with the stigma and stereotypes related to diagnosis. This often leads to acceptance of not treating anxiety or its physical, emotional, and psychosocial manifestations.

This chapter presents palliative care from the APRN’s perspective, focusing on APRN competencies as an effective team member or leader for patient-family centered care. Assessment and management of anxiety are based on national quality clinical practice guidelines, evidence-based research, and recommendations by national professional organizations.

Definitions and the Distress Continuum

Any serious illness, such as cancer, is a life-altering experience. In the 1970s, Weissman and Worden identified the first 100 days after the diagnosis of cancer as an “existential plight” in which patients suddenly confront their mortality. This is an extremely fragile period filled with fear and anxiety. Information, communication, and overall psychosocial support are priority needs for the patient’s mental well-being.

How anxiety is defined, when an individual is diagnosed with a serious illness, ranges from normal adjustment issues to syndromes that meet the diagnostic criteria for mental disorders. It occurs on a continuum of increasing levels and severity of psychosocial distress, ranging from normal adjustment to adjustment disorders, and subthreshold mental disorders to diagnosable mental disorders (Fig. 31.1).9,10,11 As healthcare professionals, APRNs must appreciate the variety of related concepts and distinctions of normal adjustment issues from mental disorders along the distress continuum to anticipate potential or actual needs, treatments, and interventions (Table 31.2).

Table 31.2 Summary of Psychosocial Distress Definitions

Normal adjustment

Ongoing life processes and coping responses associated with living with cancer to:

  • Manage emotional distress

  • Solve specific cancer-related problems

  • Gain mastery or control over cancer-related life events

Psychosocial distress

  • Extends along a continuum ranging from:

    • Common normal feelings of vulnerability, sadness, and fears to problems that are disabling (i.e., depression, anxiety, panic)

    • Feeling isolated

    • Spiritual crisis

  • Unpleasant experience of:

    • Emotional, psychological, social, or spiritual nature that interferes with the ability to cope with cancer treatment

Adjustment disorders

A diagnostic category of the fifth revised edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR):

  • Reactions to an identifiable psychosocial stressor with a degree of psychopathology

  • Less severe than diagnosable mental disorders yet in excess of what would be expected

  • Result in significant impairment in social or occupational functioning (i.e., major depressive disorder, generalized anxiety disorder)

Anxiety disorders

  • Group of mental disorders whose common symptoms include excessive, unwarranted, often illogical anxiety, worry, fear, apprehension, and/or dread.

  • The DSM-V-TR examples include generalized anxiety disorder, panic disorder, agoraphobia, social anxiety disorder, specific phobia, obsessive-compulsive disorder, and post-traumatic stress disorder.

From reference 11.

Normal adjustment or psychosocial adaptation is not defined as a single event or in a specific moment in time. Adjustment and adaptation are constant and represent an ongoing process. Coping behaviors are continuous as the individual learns to manage life and relationships that incorporate and integrate a serious illness into daily activities. As personal, professional, and family relationships change, the individual is confronted with solving and mastering cancer-related emotions, issues, and situations.12,13,14 Psychosocial distress has been defined as:

an unpleasant experience of an emotional, psychological, social, or spiritual nature that interferes with the ability to cope with cancer treatment. It extends along a continuum, from common normal feelings of vulnerability, sadness, and fears, to problems that are disabling, such as depression, anxiety, panic, and feeling isolated or in a spiritual crisis.9,10,11,12,13,14

Adjustment disorders are a diagnostic category in DSM-V-TR. For some, the psychosocial stressors associated with a cancer diagnosis are identifiable with a reactive psychopathology less severe than diagnosable mental disorders that impair social or occupational behavior significantly. The DSM-V-TR anxiety disorders are a group of mental disorders whose common symptoms include excessive, unwarranted, often illogical anxiety, worry, fear, apprehension, and/or dread.4

Prevalence and Incidence: Anxiety and Chronic Disease Connection

There is a close relationship between the prevalence of anxiety and the incidence of mental illnesses and chronic diseases. According to the Centers for Disease Control and Prevention (CDC), the National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health, recognized that chronic diseases can exacerbate symptoms of depression, and depressive disorders can lead to chronic diseases.15 Anxiety, when unrecognized, unassessed, and undertreated, with other comorbid conditions potentiates adjustment disorders. The CDC report Mental Illness Surveillance Among Adults in the United States, which supplements the CDC’s Morbidity and Mortality Weekly Report (MMWR), compiled the first national data to measure the prevalence and effect of anxiety and other mental health conditions for adults in the United States. It underscored the correlation between mental illness and chronic illness.16 Executive highlights pertaining to chronic disease and anxiety/mental illness are as follows:

  • 25% of all U.S. adults have a mental illness and nearly 50% of U.S. adults will develop at least one mental illness during their lifetime.

  • Mental illness is associated with increased occurrence of chronic diseases, such as cardiovascular disease, diabetes, obesity, asthma, epilepsy, and cancer.

  • Treatment of mental illnesses associated with chronic illness reduces the effects of both and supports better outcomes.

  • Chronic diseases can coexist in people who have suffered from depression8 (Table 31.3).

Table 31.3 Anxiety and Chronic Disease Prevalence

Medical Conditions

Examples

Cardiovascular

Angina, congestive heart failure, hypovolemia, mitral valve prolapse, myocardial infarction, paroxysmal atrial tachycardia

Endocrine

Carcinoid syndrome, Cushing’s disease, hyperglycemia, hypoglycemia, hyperthyroidism, hypothyroidism, pheochromocytoma

Immune

AIDS

Metabolic

Anemia, hypercalcemia, hyperkalemia, hypoglycemia, hyponatremia, hyperthermia

Respiratory

Asthma, chronic obstructive pulmonary disease, hypoxia, pneumonia, pulmonary disease, pulmonary edema, pulmonary embolus

Neurological

Akathisia, encephalopathy, brain lesion, seizure disorders, post-concussion syndrome, vertigo, cerebral vascular accident, dementia

Neoplasms

Islet cell adenomas, pheochromocytoma

Cancer

Hormone-producing tumors, pheochromocytoma

From references 2, 5, 7.

Anxiety and the Other Side of the Distress Continuum: Adjustment, Integration, and Life Transformation

Anxiety, whether positive or negative, occurs throughout life. It is a continual process with many revolving cycles, not a linear progression. When a patient is diagnosed with a serious illness, anxiety is often identified and separated into categories based on different life experiences. Palliative care practice differs because it embraces and incorporates the integrative nature and multidimensional holistic human needs approach to care, which challenges the assumption that anxiety and disease are separate processes. Anxiety needs to be viewed as a multidimensional experience within an integrated whole.

Cancer and serious illness are experienced within a continuum ranging from positive to negative in terms of adjustment. Positive adjustment is the patient’s psychosocial adaptation process or increased ability to cope. Negative adjustment is the patient’s inability to cope or the presence of anxiety and mental disorders that may require professional treatment.17,18

Life and serious illness need to be understood as a whole, not as separate entities. The role of the APRN is to understand and address anxiety from an interdisciplinary team perspective and to support adjustment from a medical and holistic perspective.

Integration of Chronic Illness

Palliative care professionals encourage patients and families to focus on living rather than on their illness. The patient’s life and illness are not separate but coexist in a way that can be balanced, meaningful, and purposeful, integrating the illness into a whole that also includes the patient’s many roles, responsibilities, personal identity, and life experiences.19 Integration is not just a matter of incorporating disease management into one’s daily activities but rather integrating the disease experience physically, mentally, emotionally, and spiritually.18

The clinical courses of cancer are prediagnosis, diagnosis, treatment, post-treatment, remission, reoccurrence/palliative care, and survivorship.18 Within each clinical course there is an anxiety experience, normal adjustment and support, and an adjustment period.20 Anxiety and adjustment are natural parts of the illness experience. The clinical courses should not be considered as separate entities but rather as an ongoing experience of anxiety, challenges, and adjustment (Tables 31.4, 31.5, and 31.6).

Table 31.4 Summary of Adjustment Stages When Diagnosed with Cancer: Pre-Diagnosis and Diagnosis

Pre-Diagnosis

Diagnosis

Diagnostic process

  • Phase 1

  • Initial response

  • Phase 2

  • Dysphoria

  • Phase 3

  • Adaptation (long term)

  1. 1) Anxiety experience:

    • Normal levels of anxiety and concern

    • Crisis: Psychological and existential

  1. 1) Anxiety experience:

    • Disbelief

    • Denial

    • Shock

    • High level of distress, emotions

    • Inability to remember, understand

  1. 1) Anxiety experience:

    • Distress ranges:

    • Illness-death

    • Depression, anxiety,

    • insomnia, anorexia

    • Poor concentration

    • Inability to function in daily roles

    • Hope: increased with understanding and awareness of treatment

  1. 1) Anxiety experience:

    • Coping strategies:

    • Problem-focused

    • Emotion-focused

    • Meaning-focused

  1. 2) Normal adjustment & support:

    • Support systems, personal, religious, spiritual

  1. 2) Normal adjustment & support:

    • Compassionate communication skills to deliver “bad news,”

  1. 2) Normal adjustment & support:

    • Education and information

  1. 2) Normal adjustment & support:

    • Personalized coping styles and strategies

  1. 3) Adjustment period:

    • 1 week

  1. 3) Adjustment period:

    • Variable, 1–2 weeks

  1. 3) Adjustment period:

    • Variable, 1–2 weeks

  1. 3) Adjustment period:

    • Variable, 1–2 weeks

From reference 21.

Table 31.5 Summary of Adjustment Stages When Diagnosed with Cancer: Treatment, Post-treatment, Remission

Treatment

Post-treatment

Remission

  1. 1) Anxiety experience:

    • Treatment fears and focuses:

    • Side effects

    • Disruptions in daily life

    • Effectiveness

    • Survival

  1. 1) Anxiety experience:

    • Ranges: positive anticipation, ambivalence, vulnerability

    • Fear: lack of physician and medical care

  1. 1) Anxiety experience:

    • Normal anxiety regarding recurrence

  1. 2) Normal adjustment & support:

    • Understanding

    • Short-term discomforts outweigh long-term gains

  1. 2) Normal adjustment & support:

    • Balance of positive expectations, reality of fears, apprehensions

  1. 2) Normal adjustment & support:

    • Coping strategies

    • Expression of emotions (i.e., honesty, nonjudgmental acceptance)

3) Adjustment period: Variable

3) Adjustment period: Variable

3) Adjustment period: Variable

Table 31.6 Summary of Adjustment Stages When Diagnosed with Cancer: Palliative Care & Survivorship

Palliative Care

Survivorship

  1. 1) Anxiety experience

    • Disbelief, denial, shock, crying, withdrawal, isolation, spiritual/religious anger

    • Shift: palliative curing to healing

  1. 1) Anxiety experience

    • Greater appreciation, reprioritizing of life values, strengthening of spiritual or religious beliefs

  1. 2) Normal adjustment & support:

    • Palliative care: hope through what is meaningful

  1. 2) Normal adjustment & support:

    • National organizations (i.e., programs, tools, resources)

    • Physical, emotional well-being support

  1. 3) Adjustment period: Weeks

  1. 3) Adjustment period: Gradual over many years

From reference 21.

Anxiety adjustment goes beyond the natural state of adaptation, coping, and integration. Adjustment outcomes have been identified in different categories, such as healing, psychosocial and spiritual pain in palliative care, posttraumatic growth, stress- related growth, benefit-finding resilience, subjective well-being, and self-actualization.21,22,23

Life-Transforming Change

Life-transforming change can result from the illness experience. Some patients experience a total paradigm shift, where unanticipated discovery of personal abilities and untapped resources helps the patient overcome the challenges of cancer and life challenges outside of cancer. With this shift, the patient’s life is taken to a previously unknown level where he or she experiences a more fulfilling, purposeful, and meaningful life, with greater depth psychosocially and spiritually (Fig. 31.2).

Figure 31.2 Cancer-related life transformation change process

Figure 31.2 Cancer-related life transformation change process

Some patients describe a reduction in negative experiences; others identify an increase in positive experiences. These changes can occur in the areas of self-care, relationships, spirituality, being true to oneself, personal strength, and priorities or purpose. The “domains” of this change are pre-cancer, cancer, adaptive beliefs and attributes, pragmatic actualization, and transformation. Each domain has its own categories and process themes.19

Pre-cancer’s category is trauma and healing. The process theme focuses on the pre-cancer state and diagnosis as a challenging event.

The domain of cancer has three subcategories: debilitation, challenges to normal life, and coping. The debilitation subcategory focuses on the process themes of cancer symptoms and treatment side effects. The challenges to normal life subcategory focuses on the process themes of uncertainty, heightened awareness, and loss. The major view expressed by patients in this subcategory is, it’s not just about the cancer. Support comes in the form of education and lowering distress.

The adaptive beliefs and attributes domain has two subcategories: personal life and hope. Personal life focuses on the process themes of maintaining a personal life, tolerance, and the expectation that life could be improved, mastery of life skills, and improved situational challenges. The hope category’s process themes focus on motivation, protection, surrounding oneself with people who provide support, and offer grounding in personal truth and what is found as meaningful.

The domain of pragmatic actualization entails turning hope into reality. It has two subcategories: exploring and resources. Exploring focuses on the process themes of proactive learning, research, personal decisions and choices, and active experimentation. The resources subcategory focuses on gathering and giving in a wide range of meaningful relationships, unexpected resources, expanded spirituality, and conservation of resources in times of greater need.

The domain of transformation focuses on a recurrent process theme, it’s not just about the cancer, in terms of applying newly discovered personal resources and heightened skills to non-cancer issues. Applying these new-found personal resources and abilities ultimately leads to a greater sense of gratitude, life appreciation, and empathy and a higher interest in life-fulfilling pursuits.19

Screening and Assessment

The sequential screening, evaluation, and referral process is undertaken when anxiety or psychosocial issues arise. A variety of screening tools are available based on the patient’s presentation. Screening may include a brief, self-report questionnaire method. The patient’s score establishes the level and severity of distress to guide the next steps. If the distress is high, a referral for an in-depth psychosocial assessment by an appropriate mental health professional is made.24

Screening and assessment are not just patient-focused but are also family-focused based on the standards of the National Consensus Project for Quality Palliative Care Clinical Practice Guidelines.25 Family members are the most common caregivers and their needs often go unaddressed. Many are easily overwhelmed physically, mentally, socially, and financially. Caregiver stress and burden can lead to increased health risks in terms of heart disease, hypertension, immune impairment, and cognitive functioning that may meet DSM-V criteria for a psychiatric condition.26 When assessing caregivers, the APRN should identify the specific problems, needs, strengths, and resources they have for themselves and those that affect the patient’s care.27

Communication with patients and family members and their participation as partners in care are key. By partnering with them, the APRN can identify their needs and set out the next steps. The patient and family are part of the process, since assessment is a combination of self-report and evaluation by members of the professional team. This approach to assessing caregivers’ needs and strengths can improve the overall health and quality of life for both the patient and caregivers.28 The five major components of the caregiver experience that provide insight into caregiver stress are caregiver context, primary stressors, secondary stressors, resources, and outcomes.29

Caregiver context addresses sociodemographic information, history of illness, and caregiving and living arrangements. Primary stressors from the patient experience are symptoms, impairments, activities of daily living, behavioral and cognitive issues, and the caregiver’s subjective burden. Secondary stressors are tension and conflicts of employment, relationships, and maintaining roles and responsibility. Resources are social, financial, emotional, and gains from experience. Outcomes are either positive or negative health outcomes related to the caregiver.8

The National Caregiver Alliance sponsors the National Center on Caregiving, which provides support and guidance in the development of policy, resources, and programs. It serves as a central source on caregiving and long-term care issues.30

The expression of, assessment for, and interventions for anxiety are placed in the cultural and spiritual domains of the National Consensus Project Clinical Practice Guidelines. Domain 5 addresses spiritual, religious, and existential aspects of palliative care. Domain 6 addresses cultural aspects of care.1 Inappropriate or incomplete awareness of cultural, religious, and spiritual beliefs or needs can lead to inappropriate and unacceptable plans of care, resulting in unnecessary and undue anxiety and distress.

To complete the comprehensive anxiety assessment processes and psychosocial spiritual screening and assessments, a physical examination is appropriate; it could reveal anxiety-associated medical conditions, emergent pathophysiology, and medications and substances whose side effects mimic anxiety.

Treatment

The palliative care approach to treatment, occurs across a continuum with many different and simultaneous dependent, independent, and collaborative team approaches and interventions.

Pharmacologic Management

Common medications and substances that can cause nonspecific anxiety symptoms are listed in Table 31.7. Pharmacologic agents used to manage anxiety are listed in Table 31.8.

Table 31.7 Anxiety-Causing Medications and Substances

Alcohol and nicotine withdrawal

Bronchodilators and sympathomimetics

Analgesics

Caffeine (stimulants)

Anticholinergic

Cannabis

Anticonvulsants

Cocaine

Antidepressants

Corticosteroids and anabolic steroids

Antiemetics

Digitalis toxicity

Antihistamines and decongestants

Epinephrine

Antihypertensives

Hallucinogens

Antiparkinsonian drugs

Sedatives (hypnotic withdrawal and paradoxical reaction)

Antipsychotics

Anesthetics and analgesics

Benzodiazepines (and their withdrawal)

From references 2, 5, 7.

Table 31.8 Common Pharmacologic Treatment Options of Anxiety

Generic Name

Approximate daily dose/ranges (mg)

Comment

Benzodiazepines

Alprazolam

0.25–2 tid–qid

Short-acting

Clonazepam

0.5–2 bid–qid

Long-acting

Diazepam

5–10 bid–qid

Long-acting; rapid onset with single PO dosage

Lorazepam

0.5–2 tid–qid

Short-acting; multiple routes, PO, SL, IV, IM, no metabolites

Azapirones

Buspirone

5–20 tid

Extended time to peak effect similar to antidepressants

Antidepressants

Serotonin Reuptake Inhibitors

Citalopram

20–40 daily

New warning from U.S. Food & Drug Administration about doses above 40 mg

Fluoxetine

10–80 daily

Longest half-life among serotonin reuptake inhibitors

Paroxetine

10–60 daily

Sertraline

50–200 daily

Tricyclics

Desipramine

12.5–150 daily

Least sedating tricyclic antidepressant

Imipramine

12.5–150 daily

Other Antidepressants

Duloxetine

40–60 daily

Venlafaxine

75–375 daily

Mirtazapine

15–60 daily

  • Promotes sleep and appetite at low doses;

  • oral disintegrating tablets available

Antipsychotics

Olanzapine

5–15 dailya

Oral disintegrating tablets available

Quetiapine

25–200 dailya

Preferred for patients with Parkinson’s disease

Risperidone

1–3 dailya

Haloperidol

0.5–5 q2–12h

Inexpensive and multiple routes of administration (IV, PO, and IM)

Antihistamines

Hydroxyzine

25–50 q4–6h

Risk of anticholinergic side effects and delirium

a In divided doses

From reference 5.

Most antidepressants are effective for treating anxiety, but full benefit may take several weeks, and lower doses are tolerated best. Many clinicians treating anxiety disorders use selective serotonin reuptake inhibitors (SSRIs) as their first choice due to these agents’ reliability and effectiveness for panic, generalized anxiety disorders, post-traumatic stress disorder, and obsessive-compulsive disorder. Common side effects are managed with low dose titration, and SSRIs have no adjuvant therapeutic effect on pain unlike serotonin-norepinephrine reuptake inhibitors.5 Tricyclic antidepressants are effective and inexpensive, and serve as an adjuvant for neuropathic pain. Tricyclics can promote sleep and appetite but have a high side-effect burden.

Benzodiazepines are commonly used for the relief of acute anxiety. They have a rapid onset and can reduce nausea, but they are toxic if overdosed, and can suppress respirations, especially in patients with lung disease, and can cause cognitive impairment.31 There are risks for abuse and addiction with benzodiazepines, but they are effective in the long term. Use of long-acting agents can prevent the loss of efficacy that can occur with shorter-acting agents.

Antipsychotics are reliable, but long-term use can produce the side effect of movement disorders. This risk makes them a second-line treatment. They are valuable when a rapid anxiolytic effect is needed and if patients cannot tolerate benzodiazepines or have respiratory compromise.32

The geriatric population has special considerations, and medication adjustments are required. Treatment of anxiety often reflects the balance between goals and the length of time remaining in life. This is especially true in geriatric palliative care evaluation and treatment. For patients with less than a few months to live who are minimally ambulatory, the APRN can prescribe benzodiazepines for rapid relief of symptoms or brief treatment. They are considered a second-line drug based on their longer half-life, which causes adverse drug effects. Benzodiazepines overall have a paradoxical effect that may actually cause more anxiety, especially in the elderly, and are not recommended because they can increase confusion. Typically, tricyclic antidepressants and beta-adrenergic agents are not well tolerated. The most common side effects in the elderly are ataxia, cognitive impairment, and excessive sleepiness. Opioids are indicated for treatment of anxiety secondary to dyspnea in terminally ill patients.33 Antidepressant therapies are often indicated, and cholinesterase inhibitors may be beneficial.

Nonpharmacologic Treatment

Nonpharmacologic therapies used for anxiety are outlined in Table 31.9.

Table 31.9 Nonpharmacologic Anxiety Treatment

Mind-Body Therapy

Posture & Mobility

Touch & Body Work Energetic Therapies

Sense Therapy

  • Biofeedback

  • Psychotherapy

  • Guided Imagery

  • HypnosisMeditation

  • Cognitive Therapy

  • Behavioral Therapy

  • Reminiscence/Life Review, Centering

  • Creating Intention

  • Journaling

  • Movement therapy

  • Tai ChiYoga

  • Massage, Reflexology

  • Acupressure, Healing Touch, Reiki, Therapeutic Touch

  • Polarity Therapy

  • Aromatherapy

  • Music therapy

  • Kinesthetics

From references 34, 35, 36, 37.

Palliative care includes holistic integrative therapies as well as conventional therapies. Holism and palliative care philosophy are inseparable since they both focus on the total person, with the belief that the mind, body, and spirit are inseparable and interdependent and that health, illness, and dying are manifestations of the life processes of the whole person.33,34,35,36,37,38 In both holistic and palliative care, the partnership among the patient, family, and provider generates a sense of empowerment and enables healing (if not necessarily a cure) and transcendence.

There are many integrative holistic therapies that can be used to decrease anxiety. They can improve the overall quality of life for patients and families. Maximum benefits with minimal risk can be achieved when complementary/alternative medicine and therapies are integrated with conventional treatments. This can be accomplished through collaborative interdisciplinary team processes as a component of the overall plan of care (Table 31.10).

Table 31.10 Integrative Holistic Treatment of Anxiety

Nutritional Therapy

Eastern Therapies

Integrative Holistic Providers

  • Herbology/Herbal Medicine

  • Nutritional Supplements

  • Traditional Chinese Medicine

  • Acupuncture

  • AMMA Therapy

  • Shiatsu

  • Jin Shin Jyutsu

  • Ayurveda Medicine

  • Naturopathic Medicine

  • Homeopathic Medicine

  • Integrative Holistic Medicine

From references 34, 35, 36, 37.

Conclusion

Palliative care is a comprehensive, evidence-based specialty, provided by a supportive interdisciplinary team, that addresses patient- and family-centered needs. Whether the illness is life-threatening, chronic, progressive, advanced, or terminal, the identification and the management of anxiety are central to effective treatment. Anxiety is a common response in patients and family members and is manifested in various physical, affective, behavioral, and cognitive responses. Palliative care incorporates anxiety in professional practice standards with the goal of anticipating, identifying, assessing, and addressing it via core and interdisciplinary team approaches.

Case Study

Mr. S was a married 61-year-old male Russian immigrant who was self-employed in the construction industry. He had no children and enjoyed traveling with his wife. He was a practicing Catholic but did not have an identified community church. He engaged in mind–body practices and coped with hardship using rituals and clear next steps. The palliative care team followed Mr. S for 2 years from his diagnosis of cancer to his death. At diagnosis, he underwent a thoracotomy, with subsequent pain and anxiety resulting from his new diagnosis of cancer. After the palliative APRN did a thorough palliative care evaluation, his anxiety was initially treated with lorazepam 0.5 mg q6h PRN and acupuncture for pain and anxiety. He also engaged in spiritual ministry.

Several months after diagnosis, Mr. S developed metastatic mesothelioma and was placed on an experimental protocol. His chest pain and dyspnea had increased significantly, and he was extremely anxious when hospitalized for hypercapnic respiratory failure. He was significantly fatigued due to lack of sleep. He was intubated and then sent home on BiPAP, which he remained on for the rest of his life. Duloxetine was started and lorazepam was discontinued by the palliative APRN. Hypnosis was started for the anxiety and acupuncture was continued for pain, anxiety, and fatigue. Several months later, Mr. S discontinued chemotherapy and continued aggressive palliative care.

Two months before his death, Mr. S presented to the ED with severe respiratory distress and was admitted to the ICU with hypercapnia. At this time, the settings on his BiPAP were changed. The palliative APRN visited Mr. S in the ICU to assess how he was doing. He said, “Physically, I am weak because I am dying. But emotionally and spiritually I am great.” When the nurse asked what happened, the patient said, “Dying people should not be in an ICU, but I have been transformed.” That day he was clearly not anxious and was able to speak to his wife, telling her how much he loved her. He received acupuncture and spiritual ministry. His wife received counseling for her anxiety until his death.

One month before his death, Mr. S was seen in the pain and palliative care outpatient clinic. He was very weak and fatigued and could not sleep. When he stated he was scared to use his BiPAP, the palliative APRN explored this with him. When asked if he was scared he would die at night, he said yes. At this time, the team provided Mr. S with information about the dying process, after which he felt comforted, less frightened, and less anxious. The APRN knew he liked rituals so she framed the conversation about BiPAP as a ritual. Mr. S devised a nightly ritual in which his wife would help him put the machine on his face and then kiss him goodnight. Mr. S and his wife found this meaningful and the ritual continued until his death. Mr. S died at home with his wife at his side. Mrs. S was followed by the bereavement program.

The case study summarizes the APRN’s integrated and collaborative role within the palliative care team. In her roles as clinician and educator, this palliative APRN employed expertise in clinical treatment interventions, communication, listening, and compassion to initiate and maintain a trusting relationship with this patient and family. After conducting a comprehensive assessment, the APRN developed a holistic and purposefully aligned treatment plan. As the patient’s and family’s needs changed, the treatment plan was adjusted. The continuity of care was coordinated over time in multiple care settings from diagnosis until death. The palliative APRN and her palliative care colleagues were successful in managing the patient’s anxiety, pain, and respiratory distress, honoring the wishes of the patient and his wife for information and taking advantage of their past success with rituals. They created an opportunity for transformation at the end-of-life by directing care and treatment toward spiritual healing rather than disease cure. Palliative APRNs, as members of the interdisciplinary team, are prepared to deal with physical, psychological, social, and spiritual suffering using both pharmacologic and complementary approaches to the management of anxiety.

References

1.National Consensus Project. Clinical Practice Guidelines for Quality Palliative Care. 3rd ed. Pittsburgh, PA: National Consensus Project for Quality Palliative Care; 2013. Accessed July 20, 2014, from https://www.hpna.org/multimedia/NCP_Clinical_Practice_Guidelines_3rd_Edition.pdf; ISBN 1-934654-35-3.Find this resource:

    2.Dahlin CM. Anxiety, depression and delirium. In: Matzo M, Sherman D.Palliative Care Nursing: Quality Care to the End of Life. 4th ed. New York, NY: Springer Publishing; 2015:509–39.Find this resource:

      3.Thalén-Lindström A, Larsson G, Glimelius B, Johansson B. Anxiety and depression in oncology patients: A longitudinal study of a screening, assessment, and psychosocial support intervention. Acta Oncol. 2013; 52(1): 118–27. doi: 10.3109/0284186X.2012.707785.Find this resource:

      4.American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. Accessed June 1, 2013, at dsm.psychiatryonline.org.

      5.Shuster J. Anxiety. In: Berger A, Shuster J, Von Roenn J.Palliative Care and Supportive Oncology. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013:552–61.Find this resource:

        6.Pasacreta JV, Minarik PA, Nield-Anderson L, Paice J. Anxiety and depression. In: Ferrell B, Coyle N, Paice J, eds.Oxford Textbook of Palliative Nursing. 4th ed. New York, NY: Oxford University Press; 2015:366–84.Find this resource:

          7.Borneman T, Brown-Saltzman K. Meaning in illness. In: Ferrell B, Coyle N, Paice J, eds.Oxford Textbook of Palliative Nursing. 4th ed. New York, NY: Oxford University Press; 2015:554–63.Find this resource:

            8.Witt-Sherman D, Cheon J. Family caregivers. In: Matzo M, Sherman D, eds. Palliative Care Nursing: Quality Care to the End of Life. 4th ed. New York, NY: Springer Publishing; 2015:147–63.Find this resource:

              9.National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN©). Distress management Ver 3.2015. http://www.nccn.org/professionals/physician_gls/pdf/distress.pdf. Accessed December 10, 2015.

              10.Brennan J. Adjustment to cancer: Coping or personal transition? Psychooncology. 2001; 10(1): 1–18.Find this resource:

              11.Adjustment to Cancer: Anxiety and Distress (PDQ®). Accessed July 16, 2014, at http://www.cancer.gov/cancertopics/pdq/supportivecare/adjustment/HealthProfessional/page2

              12.Folkman S, Greer S. Promoting psychological well-being in the face of serious illness: when theory, research and practice inform each other. Psychooncology. 2000; 9(1): 11–9.Find this resource:

              13.Nicholas DR, Veach TA. The psychosocial assessment of the adult cancer patient. Prof Psychol. 2000; 31(2): 206–15.Find this resource:

              14.Fashoyin-Aje LA, Martinez KA, Dy SM. New patient-centered care standards from the commission on cancer: Opportunities and challenges. J Support Oncol. 2012; 10(3): 107–11.Find this resource:

              15.Chapman DP, Perry GS, Strine TW. The vital link between chronic disease and depressive disorders. Prev Chronic Dis. 2005; 2(1): A14. Epub December 15, 2004.Find this resource:

              16.Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report (MMWR): Mental Illness Surveillance Among Adults in the United States. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/su6003a1.htm?s_cid=su6003a1.

              17.Centers for Disease Control and Prevention. Mental Health and Chronic Disease Expert Workgroup. Accessed July 14, 2014, at http://www.cdc.gov/mentalhealth/about_us/expert-wg.htm.

              18.Whittem R, Dixon J. Chronic illness: the process of integration. J Clin Nurs. 2008; 17: 177–87. doi: 10.1111/j.1365-2702.2007.0224Find this resource:

              19.Skeath P, Norris S, Katheria V, et al. The nature of life-transforming change among cancer survivors. Qual Health Res. 2013; 23(9): 1155–67.Find this resource:

              20.Holland JC, Gooen-Piels J. Principles of psycho-oncology. In: Holland JC, Frei E, eds. Cancer Medicine. 5th ed. Hamilton, Ontario: B.C. Decker Inc.; 2000:943–58.Find this resource:

                21. National Cancer Institute: PDQ® Adjustment to Cancer. Bethesda, MD: National Cancer Institute. Available at http://cancer.gov/cancertopics/pdq/supportivecare/adjustment/HealthProfessional/page5. Last modified May 29, 2014. Accessed July 28, 2014.

                22.Tartaro J, Roberts J, Nosarti C, et al. Who benefits?: Distress, adjustment and benefit finding among breast cancer survivors. J Psychosoc Oncol. 2005; 23(2-3): 45–64.Find this resource:

                23.Johnson J. An overview of psychosocial support services: Resources for healing. Cancer Nurs. 2000; 23(4): 310–3. doi:10.1097/00002820-200008000-00009Find this resource:

                24.Zabora JR. Screening procedures for psychosocial distress. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds. Psycho-oncology. New York, NY: Oxford University Press; 2010:653–61.Find this resource:

                25.Nicholas DR, Veach TA. The psychosocial assessment of the adult cancer patient. Prof Psychol. 2000; 31(2): 206–15.Find this resource:

                26. Family Care Giver Alliance. Caregiver assessment: Principles, guidelines, and strategies for change. Report from a national consensus development conference, 2006. Vol 1. San Francisco, CA: Family Caregiver Alliance. Available at http://www.caregiver.org/caregiver/jsp/content/pdfs/v1_consensus.pdf.

                27.Vanderwerker LC, Laff RE, Kadan-Lotick NS, McColl S, Prigerson HG. Psychiatric disorders and mental health services use among caregivers of advanced cancer patients. J Clin Oncol. 2005; 23(28): 6899–907.Find this resource:

                28.Fineberg L, Houser A. Assessing family caregiver needs: Policy and practice considerations. Washington DC: AARP Public Policy Institute. Available at http://www.caregiving.org/wp-content/uploads/2010/11/AARP-caregiver-fact-sheet.pdf.

                29.Kutner KS, Kilbourn KM. Bereavement: Addressing challenges faced by advanced cancer patients and their caregivers, and their physicians. Prim Care. 2009; 36(4): 825–44.Find this resource:

                30.National Alliance for Caregiving. Care for the family: A place to start. Available at http://www.caregiving.org/data/Emblem_CfC10_Final2.pdf.

                31.Nutt DJ. Overview of diagnosis and drug treatments of anxiety disorders. CNS Spectr. 2005; 10(1): 46–59.Find this resource:

                32.Ravindran LN, Stein MB. The pharmacologic treatment of anxiety disorders: A review of progress. J Clin Psychiatry. 2010; 71: 839–54.Find this resource:

                33.Morrison RS, Meier D.Geriatric Palliative Care. New York, NY: Oxford University Press; 2014; 286–298.Find this resource:

                  34.Freeman L.Mosby’s Complementary and Alternative Medicine: A Research-Based Approach. 3rd ed. St. Louis, MO: Mosby Elsevier; 2008.Find this resource:

                    35.Dossey B, Keengan L, eds. Holistic Nursing, A Handbook for Practice. 6th ed. Burlington, MA: Jones and Bartlett Learning; 2013.Find this resource:

                      36.Snyder M, Lunquist R, eds. Complementary and Alternative Therapies in Nursing. New York, NY: Springer Publications; 2010.Find this resource:

                        37.Matzo M, Sherman D.Palliative Care Nursing: Quality Care to the End of Life. 4th ed. New York, NY: Springer; 2010.Find this resource:

                          38.Quinn J. Transpersonal human caring and healing. In: Dossey B, Keengan L, eds. Holistic Nursing: A Handbook for Practice. 6th ed. Burlington, MA: Jones & Bartlett, 2013:107–16.Find this resource: