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Anxiety

Chapter 20 - Psychological Problems in Older Cancer Patients

Anxiety disorders in older cancer patients are common. As with depression, there needs to be greater attention on understanding and recognising anxiety disorders in older adults with cancer.

Anxiety in Geriatric Patients with Cancer

Prevalence rates of anxiety vary between 1% and 23% in studies of patients with cancer. In patients with advanced cancer, rates of anxiety have been found to be close to 30%. Older adults with cancer often have multiple medical conditions and complex polypharmacy issues that may blur the clinical presentation of anxiety. The diagnosis of anxiety in older patients with cancer is usually determined by questions about ongoing worry, restlessness, pacing, apprehension, and hypervigilance. Several factors that can complicate the diagnosis of anxiety in older patients with cancer include pain, respiratory distress, sepsis, endocrine abnormalities, hypoglycaemia, hypocalcaemia, hormone-secreting tumours, and pancreatic cancer. A change in metabolic state or an impending medical catastrophe may be heralded by symptoms of anxiety. Suddenly occurring symptoms of anxiety with chest pain, respiratory distress, restlessness, and a feeling of “jumping out of my skin” may indicate a pulmonary embolus. Patients who are hypoxic often appear anxious and fear that they are suffocating or dying.

The use of steroids, anti-emetics, and withdrawal from narcotics, benzodiazepines, and alcohol can all cause anxiety. Akathisia, a common side effect of neuroleptic drugs used to control nausea, may often manifest as anxiety and restlessness. These symptoms can be controlled by the addition of a benzodiazepine or a beta-blocker.

Withdrawal states from alcohol, opioids, and benzodiazepines are often overlooked as causes of anxiety and agitation even in older patients. Patients in the palliative care setting may have been prescribed shorter- acting benzodiazepines (e.g., lorazepam, alprazolam, and oxazepam) to control both anxiety and nausea. With inadequate dosing or tapering regimens, these patients often have rebound anxiety or withdrawal between doses.

Panic disorder often presents as a sudden, unpredictable episode of intense discomfort and fear with thoughts of impending doom. Patients who have already compromised respiratory function may have cyclical exacerbations of their anxiety and breathing problems. Symptoms of a pre-existing panic disorder may intensify during the palliative care phase when patients are confronting increasing physical symptoms and disability and their own mortality.

Treatment for Anxious Older Patients with Cancer

Psychotherapeutic and pharmacological approaches have been shown to successfully treat anxiety disorders in older adults. Individual and group cognitive-behavioural interventions and supportive therapy, IPT, problem- solving therapy, and insight-oriented therapy have been used successfully with older patients to relieve anxiety.

  • For patients with mild to moderate anxiety, the use of psychological techniques alone may be sufficient to assist them in managing anxiety. Psychoeducational interventions are particularly useful for anxious patients who have difficulty understanding medical information about their prognoses and symptoms. Explaining the predictable emotional phases through which patients pass as they face new and frightening information may also alleviate their anxiety. Providing information to patients’ families enables them to cope more effectively, which in turn enhances patients’ sense of support. Cognitive-behavioural interventions include reframing negative, irrational thought processes, progressive relaxation, distraction, guided imagery, meditation, biofeedback, and hypnosis. Other psychotherapeutic techniques such as supportive and insight-oriented therapy may be helpful to reduce anxiety symptoms and allow for better coping with the cancer. When working with older cancer patients, having the flexibility to adjust the length of sessions, intervals between sessions, and use of the telephone for those who have difficulty coming into your office is imperative.
  • One quarter to one-third of patients with advanced cancer receive antianxiety medication during their hospitalisations. In deciding whether a pharmacological approach may be useful, the severity of the patient's anxiety symptoms and the degree to which they interfere with overall well-being are the most reliable guides. Given the possibility of compromised hepatic and renal functioning, as well as increased sensitivity to pharmacological interventions, drugs are to be used with caution in older patients. Starting with lower doses than would be used with younger, physically healthy patients, and increasing these doses more cautiously will lead to more successful outcomes.
    • The first-line antianxiety drugs are benzodiazepines. In older patients however, these medications may result in mental status changes such as confusion or impaired concentration or memory. These changes are more often seen in those with advanced disease and those with impaired hepatic or brain function. Dose-dependent side effects such as drowsiness, confusion, and decreased motor coordination must be monitored carefully in elderly patients. Benzodiazepine use represents an important iatrogenic risk factor for falls in older adults. One must keep in mind the synergistic effects of the benzodiazepines with other medications that have central nervous system (CNS) depressant properties such as narcotics and some antidepressants. Elderly patients with dementia or brain injury who are administered benzodiazepines may experience paradoxical behavioural disturbances such as aggressiveness, irritability, and agitation.
    • For insomnia, the benzodiazepine temazepam as well as the non-benzodiazepine hypnotics zolpidem, zaleplon, eszopiclone, or ramelteon may be effective. In addition, sedating antidepressants such as trazodone or mirtazapine may also help patients with persis- tent anxiety and insomnia. A sedating atypical neuroleptic such as olanzapine or quetiapine may be effective for the patient who is anxious or has trouble sleeping and is confused or has respiratory compromise. Neuroleptics may also be useful for the patient whose anxiety is substance induced (e.g. steroids) or in anxious patients with severely compromised pulmonary function. Buspirone is useful for patients with generalised anxiety disorder and for those in whom there is the potential for abuse. Buspirone is not effective on an as-needed basis, and its effects are not apparent for one to two weeks.
    • In the oncology setting, the SSRIs are effective in the management of generalised anxiety and panic disorder.

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