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Back to Module 6: Anxiety, Delirium, Depression Assessment and Management of Anxiety

Assessment of Anxiety
Management of Anxiety

• Non-pharmacological Management of Anxiety
• Pharmacological Management of Anxiety: General Considerations
• Benzodiazepines
• Atypical Antidepressants

Assessment of Anxiety in Advanced Illness

• As anxiety may have many different origins, assessment may be complex

• Attempt to differentiate between primary anxiety and:

• Delirium
• Depression
• Bipolar disorder
• Medication side effects

• Look for reversible causes of anxiety such as:

• Insomnia
• Alcohol
• Caffeine
• Medications (e.g., increased doses of beta-agonists and methylxanthines for the management of dyspnea)

• To help clarify these issues, it is often valuable to elicit input from others who have knowledge of or contact with the patient:

• Family,
• Friends and
• Other members of the interdisciplinary team

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Management of Anxiety in Advanced Illness

Non-pharmacological Management of Anxiety

• The majority of patients will be receptive to compassionate exploration of the specific issues that are causing or exacerbating their anxiety

• Some patients may have concerns that are unlikely to resolve with medication but will benefit from counseling and supportive therapy. These include:

• Concerns about finances
• Family conflicts
• Future disability
• Dependency
• Existential concerns

• Involve other appropriate disciplines such as nursing, psychology, social work, and chaplaincy

• Complementary and alternative medical approaches may help some patients

• Issues of grief and loss are important dimensions to understand, particularly in evaluating anxiety and psychological distress. Although they are discussed in more detail in Module 12: Last Hours of Living, they are applicable earlier in the course of the illness for both patients and family members. Also, see Module 16: Social and Psychological Considerations for an in-depth discussion of the losses of the dying person and grief.

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Pharmacological Management of Anxiety: General Considerations

• When it appears that pharmacological therapy will be beneficial as part of a total plan of care for anxiety, benzodiazepines are generally the medication class of choice

• Choose an agent based on the desired half-life

• Longer half-life medications have a more sustained effect, but may accumulate
• Shorter half-life medications may have a greater risk of withdrawal and rebound anxiety

• Whichever medication is chosen, start with low doses and titrate to effect and tolerability

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Benzodiazepines

• Long half-life benzodiazepines

• diazepam 2–10 mg po q hs to q 8h
• clonazepam 0.25–1 mg po q d to bid

• Moderate half-life benzodiazepines

• lorazepam 0.25–2 mg po, sl q 6h

• Short half-life benzodiazepines

• alprazolam 0.125–0.5 mg po q 6h
• oxazepam 10–30 mg po q 4–6h

• Cautions and Side Effects

• Benzodiazepines may worsen memory, particularly in the elderly
• They may also cause confusion in patients with preexisting cognitive impairment
• When discontinuing benzodiazepines, taper them slowly

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Atypical Antidepressants

• Examples of Drugs in this Class

• mirtazipine
• nefazodone
• trazodone

• When to Use Atypical Antidepressants in the Treatment of Anxiety

• Consider using atypical antidepressants for patients with:


• Mixed anxiety and depression
• Chronic anxiety
• Panic disorder


• If only a hypnotic effect is needed, trazodone is a useful alternative (25–100 mg po q hs)

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