1. TM The EPEC-O Project Education in Palliative and End-of-life Care - Oncology The EPEC TM -O Curriculum is produced by the EPEC TM 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 Module 3c: Symptoms – Anxiety

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

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

5. Panic attack l Sudden onset of intense terror, apprehension, fearfulness, or feeling of impending doom l Usually occurring with symptoms: o Shortness of breath o Palpitations o Chest discomfort o Sense of choking o Fear of going crazy or losing control l Lasting 15 – 30 minutes l Sudden onset of intense terror, apprehension, fearfulness, or feeling of impending doom l Usually occurring with symptoms: o Shortness of breath o Palpitations o Chest discomfort o Sense of choking o Fear of going crazy or losing control l Lasting 15 – 30 minutes

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

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

8. Key points l Pathophysiology l Assessment l Management l Pathophysiology l Assessment l Management

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

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

11. Assessment l Detailed interview o “Do you worry a lot?” o “Are you often fearful?” o “Do you feel anxious?” l Tools o Hospital Anxiety and Depression Scale o Profile of Mood States l Detailed interview o “Do you worry a lot?” o “Are you often fearful?” o “Do you feel anxious?” l Tools o Hospital Anxiety and Depression Scale o Profile of Mood States

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

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

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

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

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

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

18. Benzodiazepines... l Longer half-life: sustained effect, may accumulate o Clonazepam 30 – 40 hr o Diazepam 20 – 54 hr l Shorter half-life: o Lorazepam about 12 hr (ideal) o Alprazolam about 11.2 hr (risk of rebound) l Longer half-life: sustained effect, may accumulate o Clonazepam 30 – 40 hr o Diazepam 20 – 54 hr l Shorter half-life: o Lorazepam about 12 hr (ideal) o Alprazolam about 11.2 hr (risk of rebound)

19. ... Benzodiazepines l Very short half-life (risk of rebound is high) o Oxazepam 2.8 – 8.6 hr o Triazolam 1.5 – 5.5 hr l Ideal for procedures o Midazolam 1.8 – 6.4 hr l Very short half-life (risk of rebound is high) o Oxazepam 2.8 – 8.6 hr o Triazolam 1.5 – 5.5 hr l Ideal for procedures o Midazolam 1.8 – 6.4 hr

20. Alternatives l Gabapentin l Trazodone l Gabapentin l Trazodone

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

22. SSRIs l Paroxetine l Citalopram l Escitalopram l Paroxetine l Citalopram l Escitalopram

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

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