Anxiety

F40.0-2/F40.8-9F41.3/ F41.8-9/F42.0-2/F42.8-9 + (Z51.1)

DESCRIPTION

Anxiety is defined as the apprehensive anticipation of future danger or misfortune accompanied by a feeling of dysphoria or somatic symptoms of tension. Anxiety is characterised by excessive feelings of fear apprehension and worry. Anxiety may be associated with symptoms of depression, poor concentration, insomnia, irritability, panic attacks, sweating, tremor and nausea. It is a common symptom in Palliative Care and the complex multi-causative nature of anxiety in patients with life threatening illnesses always require a multimodal approach.

GENERAL MEASURES

Address any contributing factors such as pain and dyspnoea. Consider other underlying conditions that may mimic anxiety e.g. electrolyte imbalance, hyperthyroidism, hypoxia, arrhythmias and many medicine side effects.

Assess for depression or any other previous psychiatric illness.

Include the caregivers

Ensure the patient and caregivers have received the desired amount of information around the nature of the disease, treatment, side-effects and outcomes.

MEDICINE TREATMENT

A multi-disciplinary team approach is recommended (including a spiritual carer).

Acute management of anxiety:

For an acute episode or intense prolonged anxiety:

  • Benzodiazepine, e.g.: LoEIII [9]
  • Diazepam, oral, 2.5–5 mg as a single dose.
    • Repeat if required up to 12 hourly.
    • Duration of therapy: up to 2 weeks, taper off to zero within 6 weeks.
    • Avoid if liver function impaired

LoEIII [10]

OR

  • Lorazepam, oral, 0.5–1 mg, immediately.
    • Repeat as necessary to control symptoms.
    • Tablets may be crushed and administered sublingually.

LoEIII [11]

LoEIII [12]

Patient unable to take oral medication/ terminal sedation required:

See Sedation in palliative care.

CAUTION

Benzodiazepines, especially diazepam IV, can cause respiratory depression. Patients with liver dysfunction require lower doses. LoEIII [13]

Monitor patients closely.

In the short-term, benzodiazepines can aggravate delirium.

  • In frail and elderly patients or where respiratory depression is a concern, reduce the dose by half.

LoEIII [14]

  • The safest route of administration is oral with the IV route having the highest risk of respiratory depression and arrest. Use the safest route wherever possible.
  • Monitor vital signs closely during and after administration.
  • Use haloperidol instead of benzodiazepines in patients with respiratory insufficiency.
  • To avoid inappropriate repeat dosing allow at least 15–30 minutes for the medication to take effect. Repeated IM doses of benzodiazepines may result in toxicity owing to accumulation.

  • SSRI e.g.: LoEI [15]
  • Citalopram, oral.
    • Initiate at 10 mg daily for 2 weeks.
    • Then increase to 20 mg daily.

LoEI [16]

OR

  • Fluoxetine, oral.
    • Initiate at 20 mg every alternate day for 2 weeks.
    • Increase to 20 mg daily after 2–4 weeks.
    • Delay dosage increase if increased agitation/panicked feelings occur.

LoEIII [17]

Note: Effect of SSRIs are only apparent after 2–3 weeks of treatment, so they should be reserved for patients where end-of-life is not imminent.

REFERRAL

Poor response to treatment.