They are also frequently accompanied by comorbid conditions such as depression, where there is a very high concordance rate with anxiety. In the palliative care population, anxiety symptoms may be due to a variety of causes. For example, the anxiety may be “situational” – a reaction to a serious diagnosis, impending imaging, surgery, or chemotherapy, or the fear of dying. Anxiety may accompany pain and other symptoms such as dyspnea, palpitations and nausea. Medications may cause or worsen anxiety including antipsychotic agents, corticosteroids, bronchodilators, psychostimulants, thyroid replacement and withdrawing from medications (such as benzodiazepines) or substances (such as caffeine or nicotine). And as stated earlier, anxiety frequently accompanies other psychiatric disorders such as delirium, depression, panic disorders, and post-traumatic stress disorder.
Generalized anxiety disorder (GAD) typically presents as persistent worry over time with hyperarousal. Imagine you went for a hike, and a bear suddenly appeared. Your heart would race, your pupils would dilate, and your body would be ready to fight or flee. This is how hyperarousal feels - only the bear isn’t necessarily real or life threatening. Anxiety can cause emotional symptoms like edginess or a feeling of impending doom as well as physical symptoms including shortness of breath, sleep problems, muscle tension, headaches, restlessness, and GI problems. Patients can appear both fatigued and distressed. In most palliative care patients, however, the common fears and worries tend not to reach the level of a true GAD diagnosis. However, for some patients the anxiety can be unbearable and require intensive treatment.
These measures include a healthy diet, exercise as tolerated, limiting caffeine and alcohol intake, and relaxation techniques.
Two types of psychotherapy are available as non-drug interventions: behavioral therapy and cognitive-behavioral therapy. Behavioral therapy can teach patients deep muscle relaxing when thinking about anxiety-inducing stimuli - but this only works if the stimuli are known. Cognitive-behavioral therapy adds cognitive therapy to address the worry about the self, the world, and the future which may be causing the anxiety. It does a deep dive into the root of the anxiety to change the way the patient thinks about those things which make them anxious. Group therapy sessions with the family members of the palliative care patients can also be helpful when addressing the end of life. Simpler interventions may be effective including meditation, journaling, relaxation breathing, guided imagery and using an app such as Calm. Creating a comfortable environment and mood for the patient can also make a difference. A family member or friend’s presence alone can alleviate some anxiety in a palliative care patient. BD’s doctor has the facility’s therapist and BD’s rabbi visit him to help him come to terms with what is happening in his life. He also discusses his fears with his wife.
Medications are also available to treat anxiety disorders and may be used in conjunction with non-pharmacologic interventions. If the patient has concurrent anxiety and depression, an antidepressant agent such as an SSRI (e.g., sertraline [Zoloft], paroxetine [Paxil}, escitalopram [Lexapro]) or an SNRI (e.g., duloxetine [Cymbalta] or venlafaxine [Effexor]) can be effective at treating both indications. However, it may take several weeks to see the clinical effect, so a benzodiazepine (BZD) may be used in the short-term. Tricyclic antidepressants such as amitriptyline (Elavil) are not recommended to treat depression due to the significant toxicity associated with their use.
Benzodiazepines (e.g., lorazepam [Ativan], clonazepam [Klonopin]) are often used in palliative care to treat anxiety. They are effective in treating and preventing acute anxiety episodes but are not without risk, such as added CNS and respiratory depression when combined with an opioid. The lowest dose of BZD should be used and must be tapered down if the patient experiences an adverse effect. Other therapeutic options include buspirone (BuSpar) and occasionally we will see antihistamines such as hydroxyzine used (Vistaril).
Let’s go back to BD’s case - if non-pharmacologic options do not completely resolve the patient’s anxiety, which therapeutic regimen would you recommend?
BD has a prognosis of 3 months or more, therefore it would be beneficial to start an SSRI such as sertraline. While we are waiting for the sertraline to reach its maximal effect, the patient may benefit from a small dose of lorazepam. Most importantly, however, are the non-pharmacologic treatments we can offer BD such as a psychosocial/spiritual consult, relaxation techniques, journaling, and so forth.
The patient’s family can also be made aware of those techniques as well as informed about what signs to look for in the case of an anxiety attack and how to help their loved one cope.
PharmSmart is a monthly article dedicated to best practices in drug management for patients nearing the end of life, with a little cheer and lightheartedness woven throughout. It is edited by Dr. Mary Lynn McPherson, PharmD. Dr. McPherson is the Executive Director of Advanced Post-Graduate Education in Palliative Care at University of Maryland. Dr. McPherson is a consultant pharmacist to Seasons, and answers complex medication questions for our clinical teams at all hours of the day or night. She is a nationally-recognized expert in medication management for hospice and palliative care patients.
This edition of PharmSmart was written by Katie Zimmerman, student pharmacist