Anxiety

Evidence Summary

Definition and Prevalence

Anxiety is estimated to occur in around 15 to 23 per cent of patients diagnosed with cancer, [10,11] in one third with heart disease, and two thirds of those with chronic obstructive pulmonary disease, with renal disease or with end stage cancer. [1] Anxiety rates are slightly higher in older people and increase to three quarters of older people with cognitive dysfunction. [10] It can be a response to impending death, but may result from other untreated conditions or symptoms. Death anxiety is common in patients with advanced cancer but has also been observed in older people and early stage cancer patients. [12-15] Anxiety may be a result of an underlying anxiety disorder, untreated pain, or other untreated or poorly managed symptoms, and frequently co-exists with depression [2,3,16,17]

There are many reasons why a person being cared for in palliative care setting would develop anxiety, these include poorly managed symptoms, a previous history of anxiety or as a reaction to medications. [11] Other contributing factors can include alcohol, anxiolytic or nicotine dependence, and a feeling of loss of control, either real or perceived. [11,17]

Assessment

The most widely used screening tool for anxiety is the Hospital Anxiety and Depression Scale (HADS) which has separate scales for depression and anxiety and is a useful tool for initial assessment. [18-21] There are no specific tools developed to screen for anxiety in the palliative care population. [21] Screening tools identified for use in the cancer care setting may be useful but have limited evidence for their validity in palliative care. [5,21] The Geriatric Anxiety Inventory (GAI) has been validated for use in older people in residential facilities. [6] The PROMIS Paediatric Anxiety Scale and the STAI (State-Trait Anxiety Inventory) are validated for use in paediatric cancer patients. [22] Early and ongoing screening may be beneficial to patients. A structured clinical interview is considered the ‘gold standard’ approach to diagnosing anxiety disorders. Early and ongoing consideration of psychological and psychiatric aspects of care for individuals is useful in palliative care. [21]

The Death and The Death and Dying Anxiety Scale (DADDS) has been developed specifically to measure death anxiety in advanced cancer patients but requires further validation for use in palliative settings. [23]

Treatment

Referral to specialist services may be useful if anxiety becomes severe. [9] General treatment approaches for anxiety may be useful in palliative care patients but there is limited evidence to support specific recommendations. [8,24]

Practice Implications

• Screening tools that have been validated in various settings include:
  • the Hospital Anxiety and Depression Scale (HADS) which has separate scales for depression and anxiety and is a useful tool for initial assessment [18-21,25]
  • The Geriatric Anxiety Inventory (GAI) for use in older people in residential facilities. [6]
  • The PROMIS Paediatric Anxiety Scale and the STAI (State-Trait Anxiety Inventory) for use in paediatric cancer patients [22]
• Referral to specialist services may be useful if anxiety becomes severe.
• Death anxiety is common in patients with advanced cancer but may be observed in older people and early stage cancer patients. [12-15] The Death and Dying Anxiety Scale (DADDS) has been tested in advanced cancer patients but requires further validation [23]
• Interventions targeting spiritual well-being, maintenance of hope, dignity and the sense of self were shown to have a positive effect, although high quality evidence is lacking in this area. [15]

Evidence Gaps

• Concerns as to the HADS sensitivity and specificity have been raised. [18-21] More evidence is needed to test this tool in the palliative care population.
• Anxiety screening tools identified for use in the cancer care setting, such as those mentioned above, have not been validated in a palliative care context. [5,21] Screening tools may be useful when used for benchmarking purposes or to monitor individual progress [1]
• Given there is insufficient evidence to draw a conclusion about the effectiveness of pharmacotherapy for anxiety in terminally ill patients prospective controlled clinical trials are needed. [7,8,24]
• There is limited research into the role of psychotherapeutic interventions in palliation but some evidence suggests this may be useful. [15,26,27]
• The Death and Dying Anxiety Scale (DADDS) has been tested in advanced cancer patients but requires further validation [23]