Symptoms and Management of End-of-Life Anxiety

Anxiety is a common symptom in patients nearing death. Some patients may experience mild anxiety, but for others, full-blown panic attacks can occur. Regardless of the cause, anxiety needs to be treated promptly.

Symptoms

Reactions to anxiety can vary. Some may be able to verbalize what they are feeling and others may not. It's important to know what anxiety looks like so you can easily recognize it when it happens.

Anxiety is driven by adrenaline, and its symptoms indicate that the body's "flight or fight" response has been initiated.

Anxiety has cognitive, emotional, behavioral, and physical manifestations ranging from mild to severe.

Cognitive Symptoms

• Mild anxiety: The patient may be hyper-alert and have narrowed focus.
• Moderate anxiety: She may have difficulty concentrating and be easily distracted.
• Severe anxiety/panic: The patient may not be able to focus, even when clear directions are given. Severe anxiety may lead to a disconnected state.

Emotional and Behavioral Symptoms

• Mild anxiety: The patient may be irritable or mildly upset. She might be short-tempered or easily annoyed.
• Moderate anxiety: The patient may be restless, visibly upset, and have increasing irritability. She may be tearful and express feelings of worry or uneasiness.
• Severe anxiety: The patient may be crying uncontrollably, appear greatly agitated, and even yell and scream. She may express feelings of doom, dread, or terror, or exhibit irrational or repetitive self-soothing behaviors.

Physical Symptoms

Many of the physical manifestations of anxiety listed below are similar to those caused by the underlying illnesses and treatments.

• Mild anxiety: The patient may have insomnia and difficulty resting.
• Moderate anxiety: She may have an increased heart rate or palpitations. Her breathing may be faster, and she might complain of feeling nauseated or have diarrhea.
• Severe anxiety: The patient may have all the above symptoms, but more severe. She may vomit or soil herself. She might hyperventilate or have chest pains. Her pupils will dilate and she may sweat profusely.
• Other physical symptoms of anxiety include dry mouth, muscle twitching or trembling, and abdominal pain.

Management

If your loved one is beginning to show signs of anxiety, the first thing you should do is try to calm him down. Sometimes simple distraction could be enough to reduce anxiety level and keep him calm. Try discussing something other than their illness or symptoms — perhaps the latest ball game or celebrity gossip.

Simple interventions that can be done at home to help with anxiety include:

• Distraction: Be careful with this, however, as patients nearing end of life will experience normal anxiety that needs to be validated and not only replaced with different thoughts.
• Deep breathing: The power of mindful breathing is endless. Making the simple effort of gathering up your breath and allowing your exhalation (breathing out) to be longer than your inhalation, will increase the activity of your vagal nerve, which will help you relax.
• Naming: Simple naming games—e.g., name five things you can see in the room, four things you can feel, three things you can hear, etc. These allow the patient to feel grounded in the moment, which is usually not as overwhelming as the mind can make it appear. Once we are more present, anxiety naturally dissipates.

Whether the anxiety passes or continues to increase, it's important to call the treating doctor to report the symptom and get medical advice. If your loved one is in hospice care, contact the hospice agency and report to the nurse that he is showing signs of anxiety. The hospice nurse will give you specific instructions and may send a nurse out to evaluate the situation.

Most hospice agencies supply their at-home patients with a special kit of medications to be used in case of emergency. These kits, sometimes called comfort kits or emergency kits, most often contain at least one medication to treat anxiety. The hospice nurse may give you instructions to start one of the medications and record it on a medication log.

If your loved one isn't on hospice care, you'll need to get instructions from the treating doctor or the doctor on-call. She may call in a prescription to the pharmacy or request to see the patient in the office.

Medications

When it comes to medications for anxiety at end of life; there are usually two lines of care;

Benzodiazepines: These are used intermittently for episodes of anxiety severe enough to interrupt a patient's day-to-day life and that have not responded to relaxation measures. The type of medications used will usually belong to the benzodiazepine family and include:

• Ativan (lorazepam)
• Klonopin (clonazepam)
• Xanax (alprazolam)
• Valium (diazepam)

Antidepressants: By regulating brain chemistry, antidepressants like Prozac (fluoxetine), Remeron (Mirtazapine), Effexor (Venlafaxine) and many others, can be used when patients have recurrent episodes of anxiety.

Even thought their label as "antidepressants" points to their use for depression instead of for anxiety, these medications can have a powerful effect on chronic anxiety. By regulating brain chemistry these agents help further prevent episodes of anxiety, and might help patients rely on benzodiazepines less. Since excessive use of benzodiazepines can cause sedation and steal valuable moments of with a loved one nearing end of life, taking a preventative medication may be a better option. The limitation to the use of antidepressants for chronic anxiety at the end of life, is that they need time to work, taking up to six weeks for full clinical effect . Some patients reaching the end of their lives might not have this much time, and should rely solely on as needed medications like benzodiazepines.

Treating Underlying Causes

Two of the most common causes of anxiety are pain and shortness of breath (​dyspnea). If your loved one is experiencing one of these symptoms, it's important that it be treated along with the anxiety.