Condition

Anxiety in Palliative Care Patients

Editors: Kristina M. Conner MD; Zbigniew Fedorowicz PhD, MSc, DPH, BDS, LDSRCS; Alexander Rae-Grant MD, FRCPC, FAAN

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Background Information

Description

  • In patients receiving palliative care for serious illness, anxiety can manifest as intense and persistent feelings of distress, fear, worry, apprehension, fatigue, and/or tension. It includes but is not limited to clinical anxiety disorders.
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Also Called

  • Distress.
  • Stress.

Definitions

  • Palliative care is an interdisciplinary medical specialty that addresses the physical, emotional, spiritual, and cultural needs of persons with serious illness to reduce symptom burden and improve quality of life for the patient and family. Palliative care is not based on prognosis, can be provided alongside directed/curative treatment, and can be appropriate during any stage of a serious illness (Center to Advance Palliative Care).
  • Key concepts and terms used in palliative care more generally:
    • Advance care planning - A decision-making process in which patients learn about their prognosis and treatment options and outline preferences for future medical care in the event of incapacitation (BMJ 2013 Oct 21;347:f6064).
    • Comfort care - Care interventions that provide symptom relief for patients who are close to death (N Engl J Med 2015 Dec 24;373(26):2549).
    • Hospice - A component of palliative care that provides nondirected/noncurative comfort-focused care to people at the end of life. Like palliative care, hospice focuses on managing symptoms (such as pain, nausea, delirium, fatigue, anorexia, anxiety, depression, and others) and offers psychosocial and other support for the patient and family. Different from palliative care, hospice may or may not be delivered concurrently with disease-directed treatment, depending on specific eligibility requirements and public insurance repayments (J Aging Soc Policy 2015 Oct-Dec;27(4):364).
    • Informal caregiver - A family member or other person with a close relationship to the patient who provides care, typically unpaid, that includes help with daily activities and monitoring for safety (The Role of Human Factors in Home Health Care: Workshop Summary 2010.
  • Anxiety disorders generally refer to a group of mental disorders whose common symptoms include excessive anxiety, worry, fear, apprehension, and/or dread, and may include:
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  • Other concepts important for anxiety in the palliative care setting include:
    • Adjustment disorder - reactions to an identifiable psychosocial stressor (such as, a diagnosis) with a degree of psychopathology that is less severe than diagnosable mental disorders such as major depressive disorder or generalized anxiety disorder and yet are "in excess of what would be expected" or result in "significant impairment in social or occupational functioning"
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    • Psychosocial distress (in adults with cancer) - an unpleasant experience of an emotional, psychological, social, or spiritual nature that interferes with the ability to cope with cancer treatment
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Epidemiology

Incidence/Prevalence

  • anxiety reported in up to 60% of patients in palliative care settings and may depend on underlying condition and assessment criteria
    • for cancer, 22%-58%
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    • for heart failure, 50% (estimated from figure)
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    • for chronic obstructive pulmonary disease, 60% (estimated from figure)
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    • for chronic kidney disease, 45% (estimated from figure)
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    • for HIV infection, 38% (estimated from figure)
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    • for stroke, 20%-36% (Am J Occup Ther 2015 Jan-Feb;69(1):6901180050p1)
  • STUDY SUMMARY
    clinically relevant anxiety reported in 22% of patients hospitalized with cancer and 36% of patients receiving symptom-directed palliation only
    CROSS-SECTIONAL STUDY: J Pain Symptom Manage 2020 Sep;60(3):522

Risk Factors

  • risk factors for anxiety in patients with cancer or HIV infection
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      DynaMed Commentary

      The following risk factors for anxiety are in reference to patients with cancer or HIV infection, but patients in the palliative care setting in general may have similar risk factors for anxiety.

    • factors related to underlying condition
      • severe distress about physical symptoms
      • severe pain
      • functional limitations
      • diagnosis (especially if young age) and subsequent stages of disease
      • advancing disease
      • if infectious, fear of transmission (such as with HIV infection)
    • social concerns including social stigma and fear of disclosure (such as with HIV infection)
    • existential issues
    • history of anxiety disorders (stress of disease and/or treatment may also trigger relapse)
    • lack of social support
    • fear of social isolation and abandonment
    • history of trauma or severe illnesses
    • poor communication with others
    • financial burden
    • fear of dependency
    • female sex
  • for general distress in patients with cancer
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    • lung, pancreatic, and brain cancer (but risk for distress is only modestly greater compared to other cancers)
    • in women with early-stage breast cancer
      • mental disorder
      • demographic factors
        • younger age
        • non-White racial status
        • less formal education
      • disease-specific factors
        • mastectomy rather than lumpectomy
        • receiving hormonal treatment
        • treatment-related physical symptoms and adverse events
  • see anxiety disorder topics for additional information
  • STUDY SUMMARY
    self-reported symptoms/concerns and demographic factors associated with increased risk of depression or anxiety among patients with terminal cancer
    CROSS-SECTIONAL STUDY: J Pain Symptom Manage 2007 Feb;33(2):118

Factors not Associated With Increased Risk

  • communications regarding goals of care and end-of-life issues not associated with increased risk of depression, anxiety, or hopelessness (JAMA Intern Med 2014 Dec;174(12):1994)
  • STUDY SUMMARY
    end-of-life discussion not associated with increased risk of depression or anxiety in patients with advanced cancer and terminal prognosis
    COHORT STUDY: JAMA 2008 Oct 8;300(14):1665

Associated Conditions

Etiology and Pathogenesis

Causes

  • in adults with cancer
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      DynaMed Commentary

      The following potential causes for anxiety are in reference to patients with cancer, but many of these potential causes may also apply to patients in the palliative care setting in general.

    • reactivation of memories of previous traumatic illness
    • fears of
      • uncontrolled pain
      • isolation
      • abandonment
      • dependency
    • nonpsychiatric medical conditions
      • causes of poorly controlled pain such as insufficient or as-needed pain medication
      • central nervous system metastases
      • conditions that lead to hypoxia, dyspnea, or other breathing difficulties such as primary lung tumors and lung metastases
      • causes of abnormal metabolic states such as
      • hormone-secreting tumors such as
        • pheochromocytoma
        • thyroid adenoma or carcinoma
        • parathyroid adenoma
        • corticotropin-producing tumors
        • insulinoma
      • nonhormone secreting pancreatic cancers
    • anxiety-producing medications such as
      • corticosteroids
      • neuroleptics used as antiemetics
      • thyroxine, bronchodilators
      • beta-adrenergic stimulants
      • antihistamines
      • benzodiazepines (paradoxical reactions are often seen in older persons)
    • withdrawal from
      • opioids
      • benzodiazepines
      • barbiturates
      • nicotine
      • alcohol
    • see anxiety disorder topics for additional information
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