PharmSmart: I'm So Stressed Out! And I’m TERRIFIED To Go To Sleep!By Seasons | March 05, 2021
BD is a 54 year old man living in a long-term care facility with an advanced illness, and a prognosis of approximately three months. The night shift nurse notices he has difficulty falling and staying asleep throughout the night. The day nurse communicates with the night nurse that she has noticed the patient is tired and irritable during the day. When she speaks with him about these issues, BD mentions that he is afraid that if he falls asleep, he will never wake up. He knows he is going to die soon, but he is terrified. He worries constantly about what will happen to his wife and family when he is gone.
Anxiety disorders affect up to 15% of the general population at any time and are among the most common of psychiatric disorders.
They are also frequently accompanied by comorbid conditions such as depression, where there is a very high concordance rate with anxiety. In the palliative care population, anxiety symptoms may be due to a variety of causes. For example, the anxiety may be “situational” – a reaction to a serious diagnosis, impending imaging, surgery, or chemotherapy, or the fear of dying. Anxiety may accompany pain and other symptoms such as dyspnea, palpitations and nausea. Medications may cause or worsen anxiety including antipsychotic agents, corticosteroids, bronchodilators, psychostimulants, thyroid replacement and withdrawing from medications (such as benzodiazepines) or substances (such as caffeine or nicotine). And as stated earlier, anxiety frequently accompanies other psychiatric disorders such as delirium, depression, panic disorders, and post-traumatic stress disorder.
Generalized anxiety disorder (GAD) typically presents as persistent worry over time with hyperarousal. Imagine you went for a hike, and a bear suddenly appeared. Your heart would race, your pupils would dilate, and your body would be ready to fight or flee. This is how hyperarousal feels - only the bear isn’t necessarily real or life threatening. Anxiety can cause emotional symptoms like edginess or a feeling of impending doom as well as physical symptoms including shortness of breath, sleep problems, muscle tension, headaches, restlessness, and GI problems. Patients can appear both fatigued and distressed. In most palliative care patients, however, the common fears and worries tend not to reach the level of a true GAD diagnosis. However, for some patients the anxiety can be unbearable and require intensive treatment.
Anxiety can be treated clinically with drug and non-drug modalities as well as self-help measures.
These measures include a healthy diet, exercise as tolerated, limiting caffeine and alcohol intake, and relaxation techniques.
Two types of psychotherapy are available as non-drug interventions: behavioral therapy and cognitive-behavioral therapy. Behavioral therapy can teach patients deep muscle relaxing when thinking about anxiety-inducing stimuli - but this only works if the stimuli are known. Cognitive-behavioral therapy adds cognitive therapy to address the worry about the self, the world, and the future which may be causing the anxiety. It does a deep dive into the root of the anxiety to change the way the patient thinks about those things which make them anxious. Group therapy sessions with the family members of the palliative care patients can also be helpful when addressing the end of life. Simpler interventions may be effective including meditation, journaling, relaxation breathing, guided imagery and using an app such as Calm. Creating a comfortable environment and mood for the patient can also make a difference. A family member or friend’s presence alone can alleviate some anxiety in a palliative care patient. BD’s doctor has the facility’s therapist and BD’s rabbi visit him to help him come to terms with what is happening in his life. He also discusses his fears with his wife.
Medications are also available to treat anxiety disorders and may be used in conjunction with non-pharmacologic interventions. If the patient has concurrent anxiety and depression, an antidepressant agent such as an SSRI (e.g., sertraline [Zoloft], paroxetine [Paxil}, escitalopram [Lexapro]) or an SNRI (e.g., duloxetine [Cymbalta] or venlafaxine [Effexor]) can be effective at treating both indications. However, it may take several weeks to see the clinical effect, so a benzodiazepine (BZD) may be used in the short-term. Tricyclic antidepressants such as amitriptyline (Elavil) are not recommended to treat depression due to the significant toxicity associated with their use.
Benzodiazepines (e.g., lorazepam [Ativan], clonazepam [Klonopin]) are often used in palliative care to treat anxiety. They are effective in treating and preventing acute anxiety episodes but are not without risk, such as added CNS and respiratory depression when combined with an opioid. The lowest dose of BZD should be used and must be tapered down if the patient experiences an adverse effect. Other therapeutic options include buspirone (BuSpar) and occasionally we will see antihistamines such as hydroxyzine used (Vistaril).
Let’s go back to BD’s case - if non-pharmacologic options do not completely resolve the patient’s anxiety, which therapeutic regimen would you recommend?
- Sertraline 25 mg po qd plus lorazepam 0.5 mg po every 6 hours as needed
- Haloperidol 2mg po twice a day
- Phenobarbital 60 mg po every 6 hours
- Amitriptyline 25 mg po at bedtime plus diazepam 10 mg po every 8 hours
BD has a prognosis of 3 months or more, therefore it would be beneficial to start an SSRI such as sertraline. While we are waiting for the sertraline to reach its maximal effect, the patient may benefit from a small dose of lorazepam. Most importantly, however, are the non-pharmacologic treatments we can offer BD such as a psychosocial/spiritual consult, relaxation techniques, journaling, and so forth.
The patient’s family can also be made aware of those techniques as well as informed about what signs to look for in the case of an anxiety attack and how to help their loved one cope.
Test Your Knowledge:
- Which of the following is true about using an antidepressant to treat a patient with anxiety?
- An SSRI (e.g., sertraline [Zoloft]) or SNRI (e.g., duloxetine [Cymbalta]) would be a preferred agent
- Most patients with anxiety have depression, and most patients with depression have anxiety
- Amitriptyline (Elavil) is a good antidepressant option, particularly if the patient has neuropathic pain
- A and B are correct
- A, B and C are correct
- What are some non-clinical ways to help manage anxiety?
- Exercise as tolerated
- Meditation or relaxation exercises
- Cognitive-behavioral therapy
- Eating junk food
- A, B and C are correct
- A, B, C and D are correct
- Which of the following could be a manifestation of anxiety?
- Shortness of breath
- Sleep problems
- Muscle tension
- Feeling of impending doom
- All of the above
- D; 2. E; 3. E
PharmSmart is a monthly article dedicated to best practices in drug management for patients nearing the end of life, with a little cheer and lightheartedness woven throughout. It is edited by Dr. Mary Lynn McPherson, PharmD. Dr. McPherson is the Executive Director of Advanced Post-Graduate Education in Palliative Care at University of Maryland. Dr. McPherson is a consultant pharmacist to Seasons, and answers complex medication questions for our clinical teams at all hours of the day or night. She is a nationally-recognized expert in medication management for hospice and palliative care patients.
This edition of PharmSmart was written by Katie Zimmerman, student pharmacist
- Lebowitz ER, King RA, Silverman WK. Anxiety Disorders. In: Ebert MH, Leckman JF, Petrakis IL. eds. Current Diagnosis & Treatment: Psychiatry, 3e. McGraw-Hill; Accessed January 28, 2021. https://accessmedicine-mhmedical-com.proxy-hs.researchport.umd.edu/content.aspx?bookid=2509§ionid=200807909
- DeBattista C. Antidepressant Agents. In: Katzung BG, Vanderah TW. eds. Basic & Clinical Pharmacology, 15e. McGraw-Hill; Accessed January 28, 2021. https://accessmedicine-mhmedical-com.proxy-hs.researchport.umd.edu/content.aspx?bookid=2988§ionid=250598963
- Irwin SA, Hirst JM. Overview of anxiety in palliative care. UpToDate, Accessed February 15, 2021. https://www.uptodate.com/contents/overview-of-anxiety-in-palliative-care
- Providing Care and Comfort at the End of Life. NIH National Institute on Aging (NIA). Accessed February 16, 2021. https://www.nia.nih.gov/health/providing-comfort-end-life