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Symptomatology, assessment, and treatment of anxiety in older adults with cancer

2020; Elsevier BV; Volume: 12; Issue: 2 Linguagem: Inglês

10.1016/j.jgo.2020.06.011

1879-4076

Kelly M. Trevino, Rebecca M. Saracino, Andrew Roth,

Health, psychology, and well-being

Anxiety is a normal response to a perceived threat and is characterized by worry that is difficult to control, restlessness, difficulty concentrating and sleeping, fatigue, and muscle tension [1American Psychiatric Association Diagnostic and statistical manual of mental disorders.5th ed. 2013Crossref Google Scholar]. The objective threat posed by cancer likely accounts for the high rates of anxiety in cancer patients and survivors [2Stark D.P. House A. Anxiety in cancer patients.Br J Cancer. 2000; 83: 1261-1267Crossref PubMed Scopus (300) Google Scholar]. In fact, many studies indicate that rates of anxiety are higher than rates of depression in cancer patients across age groups [3Mitchell A.J. Ferguson D.W. Gill J. Paul J. Symonds P. Depression and anxiety in long-term cancer survivors compared with spouses and healthy controls: a systematic review and meta-analysis.Lancet Oncol. 2013; 14: 721-732Abstract Full Text Full Text PDF PubMed Scopus (543) Google Scholar,4Puigpinos-Riera R. 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Sterns S. Wagner L.J. Kahana B. Cancer-related health worries and psychological distress among older adult, long-term cancer survivors.Psycho-Oncology. 2006; 15: 306-320Crossref PubMed Scopus (384) Google Scholar]. This finding suggests that anxiety may be chronic, existing even after older adults complete cancer treatment. Further, anxiety increases in the context of additional threats such as surgery and disease progression [2Stark D.P. House A. Anxiety in cancer patients.Br J Cancer. 2000; 83: 1261-1267Crossref PubMed Scopus (300) Google Scholar]. The role of additional threats is particularly important to consider in the context of the COVID-19 pandemic. COVID-19 has unique negative implications for patients with cancer due to delays in diagnosis and initiation of cancer treatment, disruption of ongoing treatment and supportive care, and reduced patient access to support networks and coping strategies, resulting in high rates of COVID-19 distress [22Büntzel J. Klein M. Keinki C. Walter S. Büntzel J. Hübner J. Oncology services in corona times: a flash interview among German cancer patients and their physicians.J Cancer Res Clin Oncol. 2020; : 1-3PubMed Google Scholar]. For older adults, the higher rates of infection and mortality from COVID-19 are additional and significant stressors that further increase the importance of addressing the mental health needs of older adults with cancer [23Mohile S. Dumontier C. Mian H. et al.Perspectives from the Cancer and aging research group: caring for the vulnerable older patient with cancer and their caregivers during the COVID-19 crisis in the United States.J Geriatr Oncol. 2020; 11: 753-760Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. Anxiety is clearly prevalent in older adults with cancer, influenced by the aging process, and exacerbated by external stressors such as COVID-19. Oncologists are often tasked with treating this anxiety, including in settings with no or limited mental health resources. Up to half of distressed older adults with cancer do not receive psychosocial services [24Zebrack B. Kayser K. Bybee D. et al.A practice-based evaluation of distress screening protocol adherence and medical service utilization.J Natl Compr Canc Netw. 2017; 15: 903-912Crossref PubMed Scopus (67) Google Scholar,25Trevino K.M. Nelson C.J. Saracino R.M. Korc-Grodzicki B. Sarraf S. Shahrokni A. Is screening for psychosocial risk factors associated with mental health care in older adults with cancer undergoing surgery?.Cancer. 2020; 126: 602-610Crossref PubMed Scopus (13) Google Scholar]. One reason for this undertreatment may be a lack of provider knowledge of the prevalence and importance of anxiety and strategies for anxiety assessment and treatment tailored for older adults with cancer [26Trevino K.M. Healy C. Martin P. et al.Improving implementation of psychological interventions to older adult patients with cancer: convening older adults, caregivers, providers, researchers.J Geriatr Oncol. 2018; 9: 423-429Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. Therefore, the purpose of this paper is to provide a brief overview of anxiety in older adults with cancer with recommendations that can be integrated into oncology care in order to reduce rates of untreated anxiety and improve the psychological well-being of older adults with cancer. The topics to be addressed are: (1) problems associated with anxiety; (2) considerations for anxiety screening; and (3) considerations for anxiety treatment. Anxiety warrants treatment not only because of its inherent distress but also because of its association with other problems in older patients. Patients with elevated anxiety report worse physical symptoms, including greater fatigue, nausea, pain, shortness of breath, worse social and cognitive function [27Fujii M. Ohno Y. Tokumaru Y. et al.Manifest anxiety scale for evaluation of effects of granisetron in chemotherapy with CDDP and 5FU for head and neck cancer.Support Care Cancer. 2001; 9: 366-371Crossref PubMed Scopus (11) Google Scholar, 28Brown L.F. Kroenke K. Cancer-related fatigue and its associations with depression and anxiety: a systematic review.Psychosomatics. 2009; 50: 440-447Crossref PubMed Scopus (0) Google Scholar, 29Reddy S.K. Parsons H.A. Elsayem A. Palmer J.L. Bruera E. Characteristics and correlates of dyspnea in patients with advanced cancer.J Palliat Med. 2009; 12: 29-36Crossref PubMed Scopus (114) Google Scholar, 30Salvo N. Zeng L. 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Validated cut-off scores have been developed for mild (score: 5–9), moderate (score: 10–14), and severe anxiety (score: 15–21). Other anxiety screening measures have been developed for older adults (e.g., Geriatric Anxiety Inventory [45Pachana N.A. Byrne G.J. Siddle H. Koloski N. Harley E. Arnold E. Development and validation of the geriatric anxiety inventory.Int Psychogeriatr. 2007; 19: 103-114Crossref PubMed Scopus (562) Google Scholar], Geriatric Anxiety Scale [46Segal D.L. June A. Payne M. Coolidge F.L. Yochim B. Development and initial validation of a self-report assessment tool for anxiety among older adults: the geriatric anxiety scale.J Anxiety Disord. 2010; 24: 709-714Crossref PubMed Scopus (134) Google Scholar], Memorial Anxiety Scale for Prostate Cancer [47Roth A.J. Rosenfeld B. 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Screening measures with less emphasis on the somatic and cognitive symptoms of anxiety may more accurately differentiate anxiety from cancer and aging-related processes and minimize erroneous referrals to mental health treatment. Anxiety in response to a threat can be adaptive by motivating patients to take action to address problems and meet their needs. However, if the severity of the anxiety is disproportionate to the threat, it can be maladaptive and problematic. Determining whether anxiety in older adults with cancer is disproportionate to the threat is difficult due to the challenge of quantifying the threat posed by cancer and aging, change in that threat over time, and lack of clarity regarding the normal course of anxiety during cancer [2Stark D.P. House A. Anxiety in cancer patients.Br J Cancer. 2000; 83: 1261-1267Crossref PubMed Scopus (300) Google Scholar,53Andersen B.L. Tewfik H.H. Psychological reactions to radiation therapy: reconsideration of the adaptive aspects of anxiety.J Pers Soc Psychol. 1985; 48: 1024-1032Crossref PubMed Scopus (66) Google Scholar]. One benchmark for identifying maladaptive anxiety is the degree to which anxiety symptoms impair function. For example, anxiety-driven behaviors such as avoidance and frequent reassurance seeking can interfere with relationships and patients' ability to engage in daily tasks [2Stark D.P. House A. Anxiety in cancer patients.Br J Cancer. 2000; 83: 1261-1267Crossref PubMed Scopus (300) Google Scholar]. Strategies for screening for functional impairment due to anxiety are available. For example, the GAD-7 includes a final item that assesses the impact of anxiety symptoms on the patient's ability to "do your work, take care of things at home, or get along with other people." [44Spitzer R.L. Kroenke K. Williams J.B. Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7.Arch Intern Med. 2006; 166: 1092-1097Crossref PubMed Scopus (17534) Google Scholar] Defining maladaptive anxiety based on this type of functional impairment allows for a patient-centered approach that considers the threat posed by both cancer and aging and the unique characteristics and situation of each older adult. Older adults have higher rates of medical comorbidities and frailty than younger patients [54Roth A.J. Modi R. Psychiatric issues in older cancer patients.Crit Rev Oncol Hematol. 2003; 48: 185-197Crossref PubMed Scopus (49) Google Scholar]. Therefore, consideration of underlying physiological conditions that may present as anxiety (e.g., pain, dyspnea, delirium) is particularly important in this population [54Roth A.J. Modi R. Psychiatric issues in older cancer patients.Crit Rev Oncol Hematol. 2003; 48: 185-197Crossref PubMed Scopus (49) Google Scholar,55Winell J. Roth A.J. 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Benzodiazepines are often first line of treatment for anxiety in younger adults due to their positive impact on ongoing and high intensity anxiety and panic attacks. Additional benefits include decreased restlessness, improvements in sleep initiation and insomnia, reduced irritability and chemotherapy-induced nausea, and enhanced muscle relaxation. However, the calming effects of benzodiazepines can overextend to cause sedation, problems concentrating, forgetfulness, dizziness and muscle relaxation, which can lead to problems with ambulation, driving, focusing and working. Individually or combined, these side effects make falls and other accidents more likely in vulnerable populations. Further, benzodiazepines are prescribed as controlled substances due to the potential for misuse and subsequent harm. It is important to discuss the distinctions between dependence, tolerance, and addiction with patients and be aware of concomitant substance use or abuse. Antidepressants can be alternative medications for anxiety and may be a more appropriate initial preventive treatment for generalized anxiety or panic attacks in older people with cancer [82Shimizu K. Treatment of anxiety and stress-related disorders.in: Grassi L. Riba M.B. Psychopharmacology in Oncology and Palliative Care A Practical Manual. Springer, 2014: 129-144Crossref Google Scholar]. If a benzodiazepine is prescribed, consider using lower doses depending on patient frailty. As always, evaluate drug–drug interactions and liver, kidney and cardiac function; gradually increase the dose; and closely monitor for side effects. For older adults, it is particularly important to check liver function tests and conduct a baseline cognitive screen to allow for evaluation of the impact of the medication on cognitive function. The use of low-dose antipsychotics is common clinical practice for short-term treatment of severe anxiety when benzodiazepines cannot be used because of frailty or respiratory compromise. However, in older adults, clinicians should consider the risks and benefits of antipsychotics carefully, especially in patients with underlying dementia, due to reports of increased mortality and risk of cardiovascular and cerebrovascular events in this population. Older adults with cancer face the dual threat of aging and cancer. Anxiety is prevalent in older adults with cancer and associated with poor quality of life and cancer treatment response. External stressors such as COVID-19 further exacerbate this anxiety and heighten the importance of identifying and treating anxiety in older adults with cancer. The evaluation and treatment of anxiety in older adults must consider the overlap of symptoms of anxiety, disease and treatment effects, and aging processes. Screening for anxiety using measures validated in older adults promotes referral to evidence-based psychotherapy and pharmacologic interventions effective for anxiety. Reducing anxiety symptoms with these treatments has the potential to improve the quality of life, physical symptoms, and engagement in cancer care of older adults with cancer. The authors have no conflicts of interest to disclose. Trevino: Manuscript Writing, Approval of Final Article. Saracino: Manuscript Writing, Approval of Final Article. Roth: Manuscript Writing, Approval of Final Article. This research is funded in part by grants from the National Institute on Aging and American Federation for Aging Research (Trevino, K23AG048632) and the National Cancer Institute (P30 CA008748). The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies. Sponsors did not have a role in study design; the collection, analysis and interpretation of data; the writing of the report; or the decision to submit the article for publication. We would like to thank the MSK Psycho-oncology in Aging and Cancer research laboratory (PAC MSK) for providing feedback on this paper.