Managing Anxiety in Hospice Patients

Anxiety is a common and normal response to terminal illness in hospice patients. Symptoms of anxiety, listed below, may be related to physical, psychological, social, spiritual, practical, and issues of loss that are prevalent at the end-of-life.

Although many hospice patients will experience fear and other manifestations of anxiety, a formal anxiety disorder, manifested by intense, excessive, and persistent worry and fear about everyday situations, is not common. Some patients, however, may experience severe anxiety related to serious illness; others may even express a desire to hasten dying as a means of avoiding anxiety.

Anxiety is estimated to affect 70% of patients at the end of life and is more common among women, physically impaired patients, and younger patients. Severe anxiety is less common, affecting less than 10% of patients.

Symptoms and Signs of Anxiety

General Emotional/Psychiatric Symptoms

• Feelings of impending doom, terror, edginess, apprehension, dread, obsession, worry.

Emotional/Psychiatric Symptoms at the End of Life

• Feeling helpless or a sense of losing control.
• Fearing what death will look like and feel like, and what events will lead up to it.
• Concerns about religious beliefs, spirituality, existential matters (such as the fear of no afterlife, questions about the meaning of one's life), and how to achieve a good death.

Behavioral Symptoms

• Avoidance, compulsions (such as repeated checking locks and doors, excessive hand washing).
• Psychomotor agitation (e.g., pacing back and forth, wringing hands, tapping fingers or feet, talking quickly, moving objects around for no reason).

Autonomic Symptoms

• Sweating, diarrhea, nausea, dizziness, rapid heart rate, rapid breathing.

Cognitive and Decision-Making Symptoms

• Trouble focusing or receiving information.
• Appearing confused, asking the same questions repeatedly, difficulty making decisions or making inconsistent decisions, expressing suspicion toward family and hospice staff.

Identifying and Screening for Anxiety

Although patients with serious illness commonly experience anxiety, they may not express these feelings, making it important for caregivers to listen for key words that can be a sign of underlying anxiety. Commonly, these words include “worried,” “scared,” “nervous,” and “concerned.”

Formal Screening Methods

Clinicians may also screen patients more formally for anxiety (and depression), using validated scales such as the brief Patient Health Questionnaire for Depression and Anxiety (PHQ-4) and the General Anxiety Disorder scale (GAD-7). Patients testing positive may need to be more formally assessed for major depression requiring pharmacologic treatment and monitoring over time for response.

Anxiety Due to Underlying Symptoms

Anxiety may also be due to an unmanaged underlying symptom, especially in patients without a personal or family history of anxiety, and those who do not respond to medications commonly used for its relief (reviewed below). Patients with shortness of breath, for example, can experience severe anxiety, which is relieved with the appropriate use of opioids.

Anxiety Overlapping with Delirium

In addition to depression, symptoms of anxiety may overlap with delirium, making careful assessment for this condition important. Patients with delirium, for example, can show poor sleep and inattention or difficulty focusing, which may also be seen in anxiety. Unlike people with anxiety, however, delirious patients typically also have disordered thought (such as hallucinations and delusions), disturbed consciousness (excessive lethargy, hyper-alertness, or both), and altered cognition – which are rarely seen in anxiety.

Treatment Approaches for Anxiety in Hospice Patients

Therapeutic Support

Once anxiety is identified, treatment begins with sitting with an anxious patient and exploring his or her concerns. Support may be needed from a variety of health professionals:

• A physician may reassure a patient concerned about pain or other unpleasant symptoms as death approaches.
• A social worker may address concerns about finances or completing important documents such as a will.
• A chaplain may help with spiritual concerns.

Adjunctive Therapies

• Exercise, reduction in alcohol and caffeine intake, massage, and improved sleep may also help relieve anxiety.

Medications for Anxiety Relief

Antidepressants

In patients with anxiety and depression – or those whose anxiety is a manifestation of depression – antidepressant therapy may provide some relief. These include SSRIs such as escitalopram (Lexapro ©) and other agents. Because antidepressants typically require several weeks to take effect, prognosis is relevant to the decision to initiate therapy.

Benzodiazepines

Benzodiazepines such as lorazepam (Ativan ©), clonazepam (Klonopin ©), alprazolam (Xanax ©), and diazepam (Valium ©), are commonly used for the rapid relief of anxiety in hospice patients and can be very effective. The choice of which to use is driven by variations in potency, duration of action, and the presence of active metabolites.

• Lorazepam: Frequent choice due to its short 4-hour duration of action and lack of active metabolites.
• Diazepam: Longer duration of action (12–24 hours) with cumulative effects due to active metabolites.

The effects of these drugs can vary greatly between individuals. Lorazepam may also paradoxically increase anxiety or cause agitation and delirium, requiring a switch to another agent.

Conclusion

In summary, anxiety is common in hospice patients. Fortunately, hospice staff are skilled at helping relieve anxiety, using a variety of techniques from counseling to behavioral and lifestyle interventions, to the use of medications. If your hospice-enrolled loved one is – or may be – suffering from anxiety, be sure to notify your hospice team so they can help.