Drug therapy for symptoms associated with anxiety in adult palliative care patients Stable (no update expected for reasons given in 'What's new')

Abstract

Abstract
Background

This is an update of a Cochrane Review first published in 2004 (Issue 1) and previously updated in 2012 (Issue 10). Anxiety is common in palliative care patients. It can be a natural response to the complex uncertainty of having a life‐limiting illness or impending death, but it may represent a clinically significant issue in its own right.

Objectives

To assess the effectiveness of drug therapy for treating symptoms of anxiety in adults with a progressive life‐limiting illness who are thought to be in their last year of life.

Search methods

We ran the searches for this update to May 2016. We searched the CENTRAL, MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), PsychLIT (Silver Platter) and PsycINFO (Ovid). We searched seven trials registers and seven pharmaceutical industry trials registers. We handsearched the conference abstracts of the European Association of Palliative Care.

Selection criteria

Randomised controlled trials which examined the effect of drug therapy for the treatment of symptoms of anxiety in adult palliative care patients, that is, people with a known progressive life‐limiting illness that is no longer responsive to curative treatment, including advanced heart, respiratory and neurological diseases (including dementia). Comparator treatments included placebo; another drug therapy or different dose schedule; or a non‐drug intervention such as counselling, cognitive behaviour therapies or relaxation therapies.

Data collection and analysis

Two review authors independently screened titles and abstracts to identify potentially relevant papers for inclusion in the review. We sought full‐text reports for all papers retained at this stage and two reviews authors independently assessed these for inclusion in the review. We planned to assess risk of bias and extract data including information on adverse events. We planned to assess the evidence using GRADE and to create a 'Summary of findings' table.

Main results

In this update, we identified 707 potentially relevant papers and of these we sought the full‐text reports of 10 papers. On examination of these full‐text reports, we excluded eight and two are awaiting classification as we have insufficient information to make a decision. Thus, in this update, we found no studies which met our inclusion criteria. For the original review, we identified, and then excluded, the full‐text reports of six potentially relevant studies. For the 2012 update, we sought, and excluded, two full‐text reports. Thus, we found no studies that assessed the effectiveness of drugs to treat symptoms of anxiety in palliative care patients.

Authors' conclusions

There is a lack of evidence to draw a conclusion about the effectiveness of drug therapy for symptoms of anxiety in adult palliative care patients. To date, we have found no studies that meet the inclusion criteria for this review. We are awaiting further information for two studies which may be included in a future update. Randomised controlled trials which assess management of anxiety as a primary endpoint are required to establish the benefits and harms of drug therapy for the treatment of anxiety in palliative care.

Author(s)

Susan Salt, Caroline A Mulvaney, Nancy J Preston

Abstract

Plain language summary

 Drugs to help reduce anxiety in people nearing the end of life due to illness 

 Review question 

We aimed to answer the question "how good are drugs at treating anxiety and worry in adults who have an illness which is getting worse and are in the last year of their life?"

 Background 

Anxiety or worry is a common problem for people who have an illness which is getting worse and are in the last year of their life. People may be anxious for many reasons. These reasons include being worried about pain and treatment, having to rely on other people to help them and having to face death. Anxiety can make it difficult for people to cope with their illness. Anxiety can make other problems worse and harder to manage, problems such as pain or feeling short of breath. For people who are nearing the end of their life due to illness, it is important to reduce their worry if possible. The use of some medicines may help to reduce anxiety. However, anxiety in people who are nearing the end of life has not be studied very much. People with anxiety often do not have their anxiety properly treated.

We searched for studies which looked at how good medicines were at reducing worry in adults nearing the end of their life. We were interested in studies that compared use of a medicine to no medicine, another medicine or a different dose of that medicine, or treatments such as talking to someone or relaxation therapy. We were interested in studies that measured anxiety. We were interested in trials designed to ensure that participants had an equal chance of receiving any of the treatments being tested in each trial. This review was first done in 2004 and updated in 2012. This is the second update. We searched to May 2016 for studies to include in this review.

 Key results 

We found no studies to include in this review. No studies were found for the original 2004 review or for the 2012 update. There is a lack of studies assessing the effect of drugs on reducing anxiety in adults who are nearing the end of their life. We found two relevant studies which may be included in a future update, but we need more information before we can make a judgement. Anxiety can have a big impact on how a person can cope with their illness, and we therefore need to know how to reduce their anxiety. Good‐quality studies on how to reduce anxiety are needed.

Author(s)

Susan Salt, Caroline A Mulvaney, Nancy J Preston

Reviewer's Conclusions

Authors' conclusions

Implications for practice

Due to the lack of evidence on the role of drug therapy for treating anxiety in palliative care patients, this review cannot draw any conclusions specific to any medications or drug classes in this patient population. To the best of our knowledge, clinical guidelines from the main health organisations across the world recommend non‐drug therapy treatments for anxiety in palliative care patients such as psychological support and intervention (NICE 2004), in preference to drug treatment except in the last days of life (NICE 2015). In the case of severe anxiety, guidelines recommend referral to a psychiatrist (National Consensus Project 2009). In addition, there is evidence for the effectiveness of cognitive behavioural therapy as a psychological intervention (Moorey 2009).

Until there is evidence indicating harms caused by the drugs currently used in palliative care to manage anxiety, their use is likely to be continued. However, their administration should be based on the severity of symptoms and an assessment of the risk of increased sensitivity to drugs. As addressed in the review, underlying causes for anxiety should be thoroughly evaluated to determine if the cause of a person's anxiety is related to other symptom management or the use of other medications or substances. If appropriate, treating another symptom (e.g. pain) or eliminating an agent that is causing or exacerbating anxiety (e.g. caffeine) may pre‐empt the need for another medication to treat anxiety. If drugs are started, they should be at a lower dose than would be prescribed for physically healthy people and any increase should be attempted cautiously and with consideration of other drugs the person may be taking (Roth 2007). The drug group of choice commonly stated in the literature for palliative care patients (prior to the final dying phase) is short‐acting benzodiazepines, such as lorazepam or midazolam (Henderson 2006; Klein 2011; Roth 2007).

Implications for research
General implications

As there is a lack of evidence of the effectiveness of drug therapy for treating anxiety in people with a life‐limiting illness there is a need for research in this topic.

Design

Randomised controlled trials (RCTs), adequately powered and involving more than 200 participants per arm are needed.

Measurement (endpoints)

Depression and anxiety are often measured using the same scale, thus it is necessary that future trials specifically assess and report measures of anxiety. The diagnosis of anxiety should be clearly defined and be a discrete endpoint for the trial. Outcomes need to be assessed using validated tools.

Other

RCTs should follow the CONSORT Statement (Schulz 2010).

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