Module 11

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The
EPEC-O
TM
Education in Palliative and End-of-life Care -
Oncology
Project
The EPEC-O Curriculum is produced by the EPECTM
Project with major funding provided by NCI, with
supplemental funding provided by the Lance
Armstrong Foundation.
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EPEC Oncology Education in Palliative and
End-of-life Care Oncology

• Module 3c
• Symptoms Anxiety

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Anxiety

• A state of feeling apprehension, uncertainty or
  fear
• May lead to some level of dysfunction

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Generalized anxiety disorder

• A state of excessive anxiety or worry
• Lasting 6 months
• Impacting day-to-day activities

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Panic attack

• Sudden onset of intense terror, apprehension,
  fearfulness, terror or felling of impending doom
• Usually occurring with symptoms
• Shortness of breath Palpitations
• Chest discomfort Sense of choking
• Fear of going crazy or losing control
• Lasting 15 30 minutes

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Prevalence

• Up to 21 of cancer patients
• Often no previous anxiety
• Often un- or under-diagnosed
• Many develop PTSD symptoms

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Prognosis

• No specific implications
• Sequelae can limit prognosis
• Anorexia
• Insomnia
• Harmful behaviors

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Key points

1. Pathophysiology
2. Assessment
3. Management

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Pathophysiology . . .

• Maladaptive neurotransmitter-based response to
  stimuli, involving
• Norepinephrine
• Serotonin
• GABA
• Modest genetic component

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. . . Pathophysiology

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

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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

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. . . Assessment

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

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Management

• Supportive counseling
• Complementary therapies
• Pharmacotherapy
• Combinations are best

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Supportive counseling . . .

• Weave into routine care
• Include family when possible
• Improve understanding
• Create a different perspective
• Identify strengths, coping strategies

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. . . Supportive counseling

• Re-establish self-worth
• New coping strategies
• Educate about modifiable factors
• Consult, refer to experts

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Complementary therapies

• Muscle relaxation
• Massage
• Guided imagery
• Hypnosis
• Meditation
• Aromatherapy

• Avoid caffeine, alcohol
• Treat insomnia

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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

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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)

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. . . 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

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Alternatives

• Gabapentin
• Trazodone

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Chronic anxiety

• SSRIs
• Latency 24 weeks
• Well tolerated
• Once-daily dosing
• Start with lower doses in advanced illness,
  titrate to therapeutic dose
• Check for medication interactions

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SSRIs

• Paroxetine
• Citalopram
• Escitalopram

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Severe anxiety

• Start simultaneously
• Benzodiazepine
• SSRI
• Taper benzodiazepine once SSRI effective in 4 6
  weeks
• Consult a psychiatrist if therapy ineffective

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Summary

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