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Overview

Anxiety is estimated to occur in up to four fifths of patients diagnosed with cancer or AIDS, one third with heart disease, and two thirds of those with chronic obstructive pulmonary disease or with renal disease. [1] It can be a natural response to impending death, but may result from other untreated conditions or symptoms.

Anxiety: the palliative context

• Untreated pain
• Untreated or poorly managed symptoms
• An underlying anxiety disorder (e.g. panic disorder, phobia)
• Fear of death
• Family distress
• Drug induced

Important contributing factors

• Previous psychiatric history
• Alcohol and nicotine dependence
• Long term benzodiazepine use
• Loss of control – real or perceived

Key messages

• Anxiety may be a result of an underlying anxiety disorder, untreated pain, or other untreated or poorly managed symptoms. [2, 3] 
• Anxiety and anxiety disorders frequently co-exist with depression. [4, 5] 
• A structured clinical interview is considered the ‘gold standard’ approach to detecting anxiety disorders.
• Related concerns at the end of life include:
  • a sense of burden
  • loss of dignity
  • a desire for death. [6]
• There are pharmacological agents in use for patients at the end of life. [6] However, as yet there is no evidence from randomised controlled trials as to their effectiveness in a palliative population. [7] Some evidence indicates that massage confers a short term benefit for anxiety. [8]

Active research areas / controversies

• 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 enables the course of anxiety symptoms to be monitored over time. Concerns as to its sensitivity and specificity have been raised. [9-11]
• 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. [12] 
• Death anxiety in older adults is shedding insight into the relationship of anxiety at the end of life. [13-15] Findings to date indicate that lower ego integrity, more physical problems, and more psychological problems are predictive of higher levels of death anxiety in elderly people.

Finding out more

• Drug therapy for anxiety in palliative care. Jackson KC, Lipman AG. Cochrane Database Syst Rev. 2004;(1):CD004596.
• Anxiety and its management in advanced cancer. Roth AJ, Massie MJ. Curr Opin Support Pall Care. 2007 Apr;1(1):50-6.

Related CareSearch Pages

Depression
Existential Distress

References

1. Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage. 2006 Jan;31(1):58-69.
2. Stiefel F, Razavi D. Common psychiatric disorders in cancer patients. II. Anxiety and acute confusional states. Support Care Cancer. 1994 Jul;2(4):233-7.
3. Miller K, Massie MJ. Depression and anxiety. Cancer J. 2006 Sep-Oct;12(5):388-97.
4. Massie MJ, Holland JC. Depression and the cancer patient. J Clin Psychiatry. 1990 Jul;51 Suppl:12-7.
5. McCarthy M, Lay M, Addington-Hall J. Dying from heart disease. J R Coll Physicians Lond. 1996 Jul-Aug;30(4):325-8.
6. Block SD. Psychological issues in end-of-life care. J Palliat Med. 2006 Jun;9(3):751-72.
7. Jackson KC, Lipman AG. Drug therapy for anxiety in palliative care. Cochrane Database Syst Rev. 2004;(1):CD004596.
8. Fellowes D, Barnes K, Wilkinson S. Aromatherapy and massage for symptom relief in patients with cancer. Cochrane Database Syst Rev. 2004;(2):CD002287.
9. Lloyd-Williams M. Screening for depression in palliative patients: a review. Eur J Cancer Care (Engl). 2001 Mar;10(1):31-5.
10. Faull CM, Johnson IS, Butler TJ. The Hospital Anxiety and Depression (HAD) Scale: its validity in patients with terminal malignant disease. Palliat Med. 1994 Jan;8(1):69. No Abstract Available.
11. Kramer JA. Use of the hospital anxiety and depression scale (HADS) in the assessment of depression in patients with inoperable lung cancer. Palliat Med. 1999 Jul;13(4):353-4. No Abstract Available.
12. Fortner BV, Neimeyer RA. Death anxiety in older adults: a quantitative review. Death Stud. 1999 Jul-Aug;23(5):387-411.
13. Adelbratt S, Strang P. Death anxiety in brain tumour patients and their spouses. Palliat Med. 2000 Nov;14(6):499-507.
14. Lauderdale SA, Sheikh JI. Anxiety disorders in older adults. Clin Geriat Med. 2003 Nov;19(4):721-41.

Last updated 09 July 2010*