The EPEC-O Project Education in Palliative and End-of-life Care - Oncology

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

2. EPEC– Oncology Education in Palliative and End-of-life Care – Oncology Module 3c: Symptoms – Anxiety

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

4. Generalized anxiety disorder • A state of excessive anxiety or worry • Lasting greater than or equal to 6 months • Impacting day-to-day activities

5. Panic attack • Sudden onset of intense terror, apprehension, fearfulness, or feeling 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

6. Prevalence • Up to 21% of cancer patients • Often no previous anxiety • Often undiagnosed or underdiagnosed • Many develop PTSD symptoms

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

8. Key points • Pathophysiology • Assessment • Management

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

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

11. 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

12. . . . Assessment • Look for: • Insomnia • Alcohol, caffeine use • Adverse effects of medications • Medical conditions: • Delirium • Depression • Pain • Metabolic states • Withdrawal (from alcohol, nicotine, opioids)

13. Management • Supportive counseling • Complementary therapies • Pharmacotherapy • Combinations are best

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

15. . . . Supportive counseling • Re-establish self-worth • Develop new coping strategies • Educate about modifiable factors • Consult, refer to experts

16. Complementary therapies • Muscle relaxation • Massage • Guided imagery • Hypnosis • Meditation • Aromatherapy • Avoid caffeine, alcohol • Treat insomnia

17. Acute anxiety • Benzodiazepines – ideal for short- term management • Anxiolytics, muscle relaxants, amnestics, antiepileptics • Contraindicated in elderly (amnesia) • Choose based on half-life (t½) • Never use more than one at a time • Taper slowly

18. Benzodiazepines . . . • Longer half-life: sustained effect, may accumulate • Clonazepam 30 – 40 hr • Diazepam 20 – 54 hr • Shorter half-life: • Lorazepamabout 12 hr (ideal) • Alprazolamabout 11.2 hr (risk of rebound)

19. . . . Benzodiazepines • Very short half-life (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

20. Alternatives • Gabapentin • Trazodone

21. Chronic anxiety • Selective Serotonin Reuptake Inhibitors (SSRIs) • Latency 2–4 weeks • Well tolerated • Once-daily dosing • Start with lower doses in advanced illness, titrate to therapeutic dose • Check for medication interactions

22. SSRIs • Paroxetine • Citalopram • Escitalopram

23. Severe anxiety • Start simultaneously: • Benzodiazepine • SSRI • Taper benzodiazepine once SSRI effective in 4 – 6 weeks • Consult a psychiatrist if therapy ineffective

24. Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience.