Anxiety in dying patients tends to look very much like anxiety in patients who are not dying. Patients tend to be agitated. They may pace, call out, fidget, or moan. Anxiety is relatively easy to recognize. It is more difficult to understand why the patient is anxious. Anxiety can result from fears, grief reactions, or altered states of consciousness. It may be associated with physical symptoms, especially dyspnea and pain. Depression may also present with anxiety as a prominent feature.
Anxiety commonly arises in the dying. Although anxiety tends to respond to the usual anxiolytics, the clinician is cautioned not to jump to medications too quickly. Anxiety in most patients seems to be a transient state, and to reflect some deeper distress that we should try to identify and address. For most people dying is very scary. The images we have of dying, largely derived from movies and television, are ones of violence and pain. The fear of loss of self in dying is something people who know they are dying wrestle with, some more successfully than others. While there is no easy fix for such existential distress, many fears are very concrete and can be addressed, thereby relieving fear and associated anxiety. How will I die? Will it hurt? We can do much to reassure patients and families that most dying people who receive good palliative care die peacefully and that pain can be controlled. Identifying and addressing these fears, which are so scary to some that they have trouble verbalizing them, can go far toward relieving anxiety.
Anxiety related to grief may respond to grief facilitation (see section on grief below). Anxiety related to depression or physical symptoms often responds to treatment for depression or to relief of the physical symptom. Anxiety associated with altered states, such as sundowning in dementia, may improve if the sensorium is cleared using an agent such as haloperidol or by using reorienting activities such as pointing out clocks and familiar objects.
Benzodiazepines are the mainstay of pharmacotherapy for anxiety.8 These medications can be very efficacious but should be used with caution, especially in the elderly when anxiety or agitation is thought to arise from dementia or delirium, because a "paradoxical response" may occur. Benzodiazepines can disinhibit patients, especially if they are prone to confusion. Benzodiazepines function rather like alcohol; one drink, and some people are swinging from the rafters, four drinks, and they are asleep. Lorazepam is most commonly used, as it is relatively short acting. If anxiety is responsive to benzodiazepines and is persistent throughout the day, a longer-acting agent, such as diazepam, may be chosen, much as we use long-acting opioids for basal pain.
Three other agents bear mentioning. Buspirone is a nonbenzodiazepine anxiolytic agent that can be helpful in certain cases. Its greatest disadvantage is its delayed onset of action, approximately two weeks. It may be considered for people with persistent anxiety who have a life expectancy of at least several weeks. Gabapentin is an anticonvulsant commonly used in the treatment of neuropathic pain. It also has anxiolytic properties and may be a useful agent for patients with anxiety who also have seizures or neuropathic pain.12,13 Certain SSRI antidepressants such as paroxetine and mirtazapine have anxiolytic effects and may be of particular help in panic disorders.14,15 Anxiety may also exist as a part of a continuum with terminal distress or delirium. The goal of standard anxiolytic therapy is to relieve anxiety without undue sedation. Unfortunately, in patients close to death, sometimes we have little choice but to advance to frank sedation if anxiety or agitation is unresponsive to standard anxiolytic doses. (See the discussion of treatment options in the section on altered states below.)
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Palliative Care Perspectives
James L. Hallenbeck, M.D.
Copyright © 2003 by Oxford University Press, Inc.
The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.