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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Back to Module 6: Anxiety, Delirium, Depression
    Assessment and Management of Anxiety

    Assessment of Anxiety
    Management of Anxiety

    Assessment of Anxiety in Advanced Illness

    • As anxiety may have many different origins, assessment may be complex
    • Attempt to differentiate between primary anxiety and:
      • Delirium
      • Depression
      • Bipolar disorder
      • Medication side effects
    • Look for reversible causes of anxiety such as:
      • Insomnia
      • Alcohol
      • Caffeine
      • Medications (e.g., increased doses of beta-agonists and methylxanthines for the management of dyspnea)
    • To help clarify these issues, it is often valuable to elicit input from others who have knowledge of or contact with the patient:
      • Family,
      • Friends and
      • Other members of the interdisciplinary team

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    Management of Anxiety in Advanced Illness

    Non-pharmacological Management of Anxiety

    • The majority of patients will be receptive to compassionate exploration of the specific issues that are causing or exacerbating their anxiety
    • Some patients may have concerns that are unlikely to resolve with medication but will benefit from counseling and supportive therapy. These include:
      • Concerns about finances
      • Family conflicts
      • Future disability
      • Dependency
      • Existential concerns
    • Involve other appropriate disciplines such as nursing, psychology, social work, and chaplaincy
    • Complementary and alternative medical approaches may help some patients
    • Issues of grief and loss are important dimensions to understand, particularly in evaluating anxiety and psychological distress. Although they are discussed in more detail in Module 12: Last Hours of Living, they are applicable earlier in the course of the illness for both patients and family members. Also, see Module 16: Social and Psychological Considerations for an in-depth discussion of the losses of the dying person and grief.

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    Pharmacological Management of Anxiety: General Considerations

    • When it appears that pharmacological therapy will be beneficial as part of a total plan of care for anxiety, benzodiazepines are generally the medication class of choice
    • Choose an agent based on the desired half-life
      • Longer half-life medications have a more sustained effect, but may accumulate
      • Shorter half-life medications may have a greater risk of withdrawal and rebound anxiety
    • Whichever medication is chosen, start with low doses and titrate to effect and tolerability

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    • Long half-life benzodiazepines
      • diazepam 2–10 mg po q hs to q 8h
      • clonazepam 0.25–1 mg po q d to bid
    • Moderate half-life benzodiazepines
      • lorazepam 0.25–2 mg po, sl q 6h
    • Short half-life benzodiazepines
      • alprazolam 0.125–0.5 mg po q 6h
      • oxazepam 10–30 mg po q 4–6h
    • Cautions and Side Effects
      • Benzodiazepines may worsen memory, particularly in the elderly
      • They may also cause confusion in patients with preexisting cognitive impairment
      • When discontinuing benzodiazepines, taper them slowly

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    • Examples of Drugs in this Class
      • mirtazipine
      • nefazodone
      • trazodone
    • When to Use Atypical Antidepressants in the Treatment of Anxiety
      • Consider using atypical antidepressants for patients with:

        • Mixed anxiety and depression
        • Chronic anxiety
        • Panic disorder

      • If only a hypnotic effect is needed, trazodone is a useful alternative (25–100 mg po q hs)
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