The

TM

EPEC-O

Education in Palliative and End-of-life Care - Oncology

Project

The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

E P E C O EPEC – Oncology Education in Palliative and End-of-life Care – Oncology

Module 3c Symptoms – Anxiety

Anxiety



A state of feeling apprehension, uncertainty or fear



May lead to some level of dysfunction

Generalized anxiety disorder



A state of excessive anxiety or worry



Lasting ≥ 6 months



Impacting day-to-day activities

Panic attack



Sudden onset of intense terror, apprehension, fearfulness, terror or felling of impending doom



Usually occurring with symptoms Shortness of breath Chest discomfort Palpitations Sense of choking Fear of going crazy or losing control



Lasting 15 – 30 minutes

Prevalence



Up to 21% of cancer patients



Often no previous anxiety



Often un- or under-diagnosed



Many develop PTSD symptoms

Prognosis



No specific implications



Sequelae can limit prognosis Anorexia Insomnia Harmful behaviors

Key points

1.

Pathophysiology 2.

Assessment 3.

Management

Pathophysiology . . .



Maladaptive neurotransmitter-based response to stimuli, involving Norepinephrine Serotonin GABA



Modest genetic component

. . . Pathophysiology



Anxiety can be generated by Symptoms Hypoxia Pain Sepsis Adverse reactions Akathisia Medication withdrawal

Assessment



Detailed interview Do you worry a lot?

Are you often fearful?

Do you feel anxious?



Tools Hospital Anxiety and Depression Scale Profile of Mood States

. . . Assessment



Look for Insomnia Alcohol, caffeine Adverse effects of medications Medical conditions Delirium Depression Pain Metabolic states Withdrawal from alcohol, nicotine, opioids

Management



Supportive counseling



Complementary therapies



Pharmacotherapy



Combinations are best

Supportive counseling . . .



Weave into routine care Include family when possible



Improve understanding



Create a different perspective



Identify strengths, coping strategies

. . . Supportive counseling



Re-establish self-worth



New coping strategies



Educate about modifiable factors



Consult, refer to experts

Complementary therapies



Muscle relaxation



Massage



Guided imagery



Hypnosis



Meditation



Aromatherapy



Avoid caffeine, alcohol



Treat insomnia

Acute anxiety



Benzodiazepines – ideal for short term management Anxiolytics, muscle relaxants, amnestics, antiepileptics Contraindicated in elderly (amnesia) Choose base on half life ( t½ ) Never more than one at a time Taper slowly

Benzodiazepines . . .



Longer t½ - sustained effect, may accumulate Clonazepam 30 – 40 hr Diazepam 0.83 – 2.25 days



Shorter t½ Lorazepam ≈ 12 hr (ideal) Alprazolam ≈ 11.2 hr (risk of rebound)

. . . Benzodiazepines



Very short t½ (risk of rebound is high) Oxazepam 2.8 – 8.6 hr Triazolam 1.5 – 5.5 hr



Ideal for procedures Midazolam 1.8 – 6.4 hr

Alternatives



Gabapentin



Trazodone

Chronic anxiety



SSRIs Latency 2 –4 weeks Well tolerated Once-daily dosing Start with lower doses in advanced illness, titrate to therapeutic dose Check for medication interactions

SSRIs



Paroxetine



Citalopram



Escitalopram

Severe anxiety



Start simultaneously Benzodiazepine SSRI



Taper benzodiazepine once SSRI effective in 4 – 6 weeks



Consult a psychiatrist if therapy ineffective

E P E C O

Summary

Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience