Anxiety, Depression, and Delirium PDF

Nicole G. Loving & Constance M. Dahlin 22 Anxiety, Depression, C H A P T E R and Delirium KEY POINTS...

Nicole G. Loving & Constance M. Dahlin 22 Anxiety, Depression, C H A P T E R and Delirium KEY POINTS Anxiety, depression, and delirium are common symptoms experienced by patients with serious illness. Anxiety manifests itself in four ways: physical symptoms, affective symptoms, behavioral responses, and cognitive responses. The patient and the family should be reassured that symptoms of depression and anxiety are effectively treated most of the time with pharmacological and nonpharmacological interventions. Effective treatment of anxiety, depression, and delirium necessitates a collaborative effort between the patient, family, and the health team. CASE STUDY Paul was a 62-year-old male artist, married to Ellen for 30 years and father of three. He was an avid bicyclist, and he enjoyed reading fiction and helping in his local community garden. Eleven years ago, he was diagnosed with Stage II colorectal cancer, for which treatment included resection and chemotherapy. Two years after treatment and follow-up, Paul was found to be cancer free after treatment and continued to regularly receive cancer screen- ings with no sign of disease recurrence. In the past month, Ellen noticed that Paul spent less time at work in his studio and more time at home in bed. She initially thought that he was experiencing grief over the loss of the family dog. However, his exhaustion did not seem to improve with rest. Initially, Paul denied that he was feeling anything other than his usual self. However, when he experienced persistent bloating and new abdominal pain, he finally admitted he had not been feeling well for the past 3 months. A follow-up appointment was scheduled with his oncologist. Imaging revealed that the colorectal cancer had returned and had spread to his liver. Paul immediately received weekly chemotherapy infusions that left him feeling ill and exhausted. Ellen worried about Paul’s low spirits and social withdrawal. He spent most of the day sleeping in bed, resulting in night wakefulness. Usually surrounded by people, Paul no longer answered the phone, nor responded to texts or emails. Near to his bed, stacks of books and magazines went unread alongside partially eaten plates of food. In addition to Copyright Springer Publishing Company. All Rights Reserved. From: Palliative Care Nursing: Quality Care to the End of Life, Fifth Edition DOI: 10.1891/9780826127198.0022 Matzo_27129_PTR_22_545-580_05-24-18.indd 545 5/24/18 7:38 PM  546 IV. PHYSICAL HEALTH: SYMPTOM MANAGEMENT his poor appetite, he experienced intermittent abdominal pain, but he refused to take any opioids and would take only ibuprofen. Paul requested that Ellen not share the news of his recurrence with their children or their friends. Ellen felt increasingly helpless, worried and unsure what to do. T he response to a serious, life-threatening diagnosis results in individual coping methods and adaptive behaviors. Often, a person may develop psychiatric symp- or delirium may be the first sign of a medical problem, particularly in older adults (Hosker & Bennett, 2016). Moreover, these symptoms may be interwoven, making toms, including anxiety, depression, and delirium. These it difficult to differentiate among the three diagnoses. symptoms range from mild to severe in nature. There Anxiety may precede depression in the diagnosis of is a strong correlation between symptoms of anxiety, certain medical conditions such as myocardial infarc- depression, and delirium in patients receiving pallia- tion or dementia. Anxiety and depression may be seen tive care for a life-limiting illness (Pasacreta, Minarik, together, perhaps in the setting of a diagnosis of a seri- Nield-Anderson, & Paice, 2015). As common transient ous illness such as heart disease, pulmonary disease, or symptoms, anxiety, depression, and delirium may be advanced cancer. Delirium may cause anxiety stemming acute but self-limiting. However, in more chronic and from altered consciousness, confusion, and disorienta- severe diagnoses, these psychiatric issues may inhibit a tion. This is particularly true if the delirium waxes and person’s ability to have meaningful communication with wanes and the patient has a sense of his or her cogni- family and friends as part of life closure, cause suffering, tive impairment. Anxiety may result in delirium if the and affect quality of life. patient’s anxiety escalates, and he or she either does Palliative care includes attention to psychiatric not have proper nutrition or overmedicates himself or symptoms and physical symptoms by the interdisciplin- herself. Additionally, depression may result if a patient ary team. The attention to these symptoms is specified understands his or her cognitive deficits. Diagnosis and in Domain 3 of the National Consensus Project for treatment may be challenging when the person is able to Quality Palliative Care, Clinical Practice Guidelines, compensate for the cognitive deficits, thereby decreasing Psychological and Psychiatric Aspects of Care Guideline the likelihood of detection and treatment. 3.1, which states, “The interdisciplinary team assesses Historically, it was thought that children experience and addresses psychological and psychiatric aspects of fewer psychosocial symptoms from a diagnosis of serious care based upon the best available evidence to maximize illness. However, this has been a grave misperception and patient and family coping and quality of life” (National their symptoms have been significantly underestimated. Consensus Project for Quality Palliative Care, 2013). More important, it may be difficult to distinguish anxiety Nurses are often the first direct care provider to identify and depression from sadness or grief in children. To add these symptoms and collaborate with other disciplines to to the complexity, there are fewer available mental health promote positive coping strategies. The specialty palliative specialists to treat children and pediatrics (Goldsmith, care team can diagnose, manage, and treat symptoms of Ortiz-Rubio, Staveski, Chan, & Shaw, 2011; Pao & depression, anxiety, delirium, and cognitive impairment. Wiener, 2011). Other populations whose symptoms Such symptoms may be a consequence of the serious ill- are underestimated include older patients, who may ness itself or, among patients with comorbid psychiatric not be forthcoming with their psychological concerns; illness, accompany their serious or life-threatening ill- patients with preexisting mental health issues; patients ness (National Consensus Project for Quality Palliative with financial or insurance issues; and patients from Care, 2013). Moreover, treatment and management is other cultural backgrounds. done in partnership with the patient and family using Once a diagnosis is made, treatment issues for psy- interventions informed by evidence-based practice and chiatric symptoms related to a specific patient must be may include pharmacological, nonpharmacological, and considered. In particular, the clinician must consider complementary therapies. the patient’s age. Older adults and young children In primary care, anxiety and depression may arise may have more pronounced and adverse effects from as the presenting precursor to another illness such as medications. In addition, older adults may experience heart disease or neurological conditions. In palliative diminishing functional and physiological processes, care, anxiety and depression commonly arise from fear as well as social supports. Successful treatment often of death, loss of independence, fear of being a burden includes pharmacological medications, complementary to others, hopelessness, and loneliness, in addition to therapy, and mobilization of social support of the patient concern about symptom burden and disease progres- and family. This chapter addresses the comprehensive sion (Nelson, 2016). Delirium may develop during the patient-centered and family-focused care necessary for course of serious illness, particularly at the end of life, effective diagnosis, assessment, and treatment of anxiety, and it is important to remember that anxiety, confusion, depression, and delirium in the palliative care patient. Matzo_27129_PTR_22_545-580_05-24-18.indd 546 5/24/18 7:38 PM  22. Anxiety, Depression, and Delirium 547 ANXIETY strangers, injuries, and loud noises, while teens may have issues regarding personal appearance, self-worth, and Definition competence (Pao & Wiener, 2011). In addition, worries about being hospitalized, treatment sessions, or the side Anxiety is defined as feelings of distress, worry, and effects of these activities may occur as well. tension from a known or unknown stimulus (American Psychiatric Association [APA], 2013). It is a necessary Incidence aspect of life as a stimulus for our actions. Anxiety manifests itself in multiple ways, and is either acute or Anxiety symptoms may develop in any individual diagnosed chronic in duration. Acute anxiety is comprised of cogni- with a life-limiting illness. The diagnosis, itself, is stress and tive, physiological, and behavioral manifestations that anxiety provoking. An increased incidence of anxiety has are relatively self-limiting and respond to treatment or a been associated with female gender, young age, and low change in circumstance. Chronic anxiety is characterized socioeconomic status, as well as with cancer and chronic by low-grade distress that interferes with psychosocial diseases (Gatto, Thomas, & Berger, 2016; Zvolensky, Garey, functioning due to restlessness or being on edge, difficulty & Bakhshaie, 2017). Furthermore, as a serious illness pro- in concentration, irritability, muscle tension, and sleep gresses and a person’s physical status declines, anxiety may alterations (APA, 2013). The Diagnostic and Statistical increase. Cancer-related anxiety is a natural response to Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013) the crisis precipitated by such a diagnosis, the threat to life, includes the diagnosis, Anxiety Disorder Due to Another and the future (Traeger, Greer, Fernandez-Robles, Temel, Medical Condition, which relates to a patient with a & Pirl, 2012). Within the pediatric population, there are chronic, progressive, or serious life-threatening illness or no prevalent studies related to anxiety at the end of life. injury. This diagnosis states that anxiety in patients with serious illness is related to the circumstances of the direct pathophysiological consequences of a medical condition, Etiology not a mental disorder. Furthermore, anxiety can affect the patient’s social interactions, occupation, and general Anxiety in patients with a life-limiting illness is common functioning (APA, 2013). Patients may also experience and may have a multitude of causes, including adjust- anticipatory anxiety, an episode of anxiety prior to an ment disorder, panic disorder, GAD, phobia, or agitated event or a procedure, resulting in acute manifestations depression (Gatto et al., 2016). The etiology of anxiety and can be very distressing to the patient. includes medical conditions such as poorly managed pain, Generalized anxiety disorder (GAD) is defined as chronic endocrine disorders including hypo- and hyperglycemia, uncontrollable nervousness, fearfulness, and sense of worry hypo- and hyperthyroidism, Cushing’s disease, and carcinoid lasting for 6 months or longer (APA, 2013). Patients may syndrome. Cardiovascular conditions include myocardial describe a sense of worry, fear, concern, or even foreboding. infarctions, angina, congestive heart failure, mitral valve Although anxiety is a very subjective experience, it is often prolapse, and hypovolemia; respiratory conditions include accompanied by somatic complaints such as tachycardia, asthma, chronic obstructive pulmonary disease (COPD), fatigue, restlessness, difficulty concentrating, muscle tension, pneumonia, pulmonary edema, dyspnea, and hypoxia. headaches, palpitations, sweating, abdominal discomfort, Neoplasms and neurological conditions such as akathisia, dizziness, urinary frequency, and sleep disturbances. To encephalopathy, seizure disorder, and post-concussion confirm a diagnosis of GAD, any of the aforementioned disorders can also contribute to or exacerbate anxiety symptoms must be present for at least 6 months and should disorders (Fournier, 2013a; Pasacreta et al., 2015). cause impairment in social or occupational functioning. In Stimulant substances may contribute to anxiety. the older adults with GAD, there may be a concomitant The most common substance is caffeine. The stimulant symptom of agoraphobia, or fear of outside the home, ephedrine, stimulant-type drugs such as methylphenidate, which leads to more social isolation (Irwin & Hirst, 2017). and withdrawal from medications such as benzodiaz- Anxiety within the pediatric population is common. The epines, alcohol, and barbiturates may cause anxiety. challenge is twofold: the anxiety of the child and the child’s Psychological distress, including worries about family reaction to the stress and anxiety of the parents, family, relationships, family strife, and financial issues, can and caregivers around him or her (Kane & Himelstein, contribute to feelings of anxiety in seriously ill patients. 2007; Pao & Wiener, 2011). This may be common for These worries may be exacerbated by concerns about children and parents of children with chronic illness or being or becoming a burden to family members during congenital conditions. The symptoms that children experi- the course of their illness. Lastly, a previous history or ence are related to behavioral issues and the change in their family history of anxiety may be a contributory factor functional abilities, specifically irritability, resistance, and resulting in more pronounced anxiety in older patients refusal of tests and procedures. Anxiety may affect their as they lose physical functioning. See Table 22.1 for routines such as in school or other activities (APA, 2013). further summary of causative factors and Table 22.2 Younger children may have worries related to separation, for emergent conditions disguised as anxiety. Matzo_27129_PTR_22_545-580_05-24-18.indd 547 5/24/18 7:38 PM  548 IV. PHYSICAL HEALTH: SYMPTOM MANAGEMENT TABLE 22.1 Potential Conditions That Produce or TABLE 22.2 Emergent Conditions Disguised as Anxiety Mimic Anxiety Hypoxia System/Condition Examples Sepsis Uncontrolled pain Cardiovascular Angina, congestive heart failure, Pulmonary embolus conditions hypovolemia, mitral valve prolapse, myocardial infarction, paroxysmal Impending cardiac or respiratory arrest atrial tachycardia Electrolyte imbalance Endocrine disorders Carcinoid syndrome, Cushing’s Dehydration disease, hyperglycemia, Sources: Adapted from Breitbart, W., & Dickerman, A. L. (2017, hypoglycemia, hyperthyroidism, and May 10). Assessment and management of depression in palliative hypothyroidism care. Retrieved from https://www.uptodate.com/contents/­assessment -and-management-of-depression-in-palliative-care; Fournier, D. Immune conditions AIDS, infections (2013a). Anxiety disorders. In T. Buttaro, J. Trybulski, P. Bailey, & J. ­Sandberg-Cook (Eds.), Primary care: A collaborative approach Metabolic conditions Anemia, hyperkalemia, (4th ed., pp. 1344–1351). St. Louis, MI: Elsevier Mosby. hyperthermia, hypoglycemia, and hyponatremia Respiratory Asthma, chronic obstructive TABLE 22.3 Four Types of Anxiety Manifestation conditions pulmonary disease, hypoxia, Classification Manifestations pneumonia, pulmonary edema, and pulmonary embolus Physical symptoms Autonomic responses such as tachycardia, tachypnea, Neurological Akathisia, encephalopathy, brain diaphoresis, light-headedness, conditions lesion, seizure disorders, post- tremors concussion syndrome, vertigo, cerebral vascular accident, and Affective symptoms Nervous or restless behaviors dementia such as pacing, picking, frequent movement Cancer Hormone-producing tumors: pheochromocytoma Behavioral responses Avoidance, compulsions Medication and Withdrawal of alcohol, Cognitive responses Edginess, worry, panic, terror, substances benzodiazepines, nicotine, apprehension, obsession, thoughts or sedatives. Use of steroids, of physical or emotional damage stimulants, and neuroleptics to self such as metoclopramide or Source: Adapted from Irwin, S. A., & Hirst, J. M. (2017, May 10). prochlorperazine ­Overview of anxiety in palliative care. In D. M. F. Savarese & R. ­Hermann (Eds.), UpToDate. Retrieved from http://www.uptodate Pain Uncontrolled or poorly controlled.com/contents/overview-of-anxiety-in-palliative-care Sources: Adapted from Breitbart, W., & Dickerman, A. L. (2017, May 10). Assessment and management of depression in pallia- tive care. R­ etrieved from https://www.uptodate.com/contents/­ anxiety (Rosen, Koretz, & Reuben, 2010). Patients may assessment-and-management-of-depression-in-palliative-care; Fournier, D. (2013a). Anxiety disorders. In T. Buttaro, J. Trybulski, be observed to experience anxiety-related behaviors P. Bailey, & J. Sandberg-Cook (Eds.), Primary care: A collaborative such as a tense posture and frequent sighing. Older ­approach (4th ed., pp. 1344–1351). St. Louis, MI: ­Elsevier Mosby; adults are more likely to minimize emotions and feel- Pasacreta, J. V., Minarik, P. A., Nield-Anderson, L., & Paice, J. A. ings and report somatic complaints (Tabloski, 2014). (2015). Anxiety and depression. In B. Ferrell & N. Coyle (Eds.), ­Oxford textbook of ­palliative nursing (4th ed., pp. 366–385). New York, NY: Moreover, older adults are particularly vulnerable to Oxford U­ niversity Press. suicide due to the potentially multiple burdens of pain and suffering, poor prognosis, depression, delirium, loss of control, and lack of social support (Breitbart, Cardinal Signs Chochinov, & Passik, 2010). In differentiating anxiety from fear, evaluation should explore the known pres- Anxiety has four types of manifestations: physical ence of an external threat versus anxiety stemming symptoms, affective symptoms, behavioral responses, from an unknown internal stimulus (Traeger et al., and cognitive responses (Pollack, Otto, Wittmann, & 2012). The diagnosis of Anxiety From Another Medi- Rosenbaum, 2010), as outlined in Table 22.3. Gener- cal Condition is helpful to consider as there are many alized anxiety can be accompanied by symptoms of “unknowns” in chronic progressive conditions and/ depression, panic, and phobias. In the older patient, or serious life-threatening illnesses that cause anxiety depression is the most common symptom accompanying including, but not limited to, continued surveillance of Matzo_27129_PTR_22_545-580_05-24-18.indd 548 5/24/18 7:38 PM  22. Anxiety, Depression, and Delirium 549 the disease, concerns over test results, and the rapidity overemphasized. There are many aspects of care that of the disease progression, particularly into advanced incur anxiety for patients (whether an adult or child) conditions. Finally, the loss of control and the multitude with a serious diagnosis, including the anxiety about of significant losses throughout the course of serious the unknown illness trajectory, consultations with spe- illness may become major stressors. cialists, diagnostic procedures, changes in care needs, moving from one care setting to the next, or changing Severity the care provider. For children, a skilled assessment based on children’s concerns and worries may help Anxiety, in its mildest form, is a positive form of stress reveal both parent and child anxiety (­ Mullaney, 2011; that serves as a motivation to perform various functions Pao & Wiener, 2011). in learning, working, and adapting to the ongoing changes in life. Levels of anxiety can be mild (which is considered Physical Examination normal), moderate, severe, and panic (Pasacreta et al., 2015). In its most severe form, anxiety becomes panic, A physical examination may reveal tachycardia, tachypnea, which may result in a form of psychological paralysis skin changes, tongue changes, rapid speech, restlessness, and isolation. The person may become paralyzed by fear and tremors. Complete blood panels and metabolic screens and be confined to his or her immediate surroundings, can delineate other processes such as infection, cardio- such as his or her home or room. Table 22.4 outlines pulmonary conditions, and so on. Further assessment the characteristics of mild anxiety to panic. includes ruling out associated conditions. For example, if the patient has tachycardia, a thyroid function panel Assessment can rule out hyperthyroidism, an electrocardiogram can rule out dysrhythmias, and a glucose test can rule A history and review of medical conditions for potential out hypoglycemia. If the patient is found to have a sore causes of anxiety are central to the initial evaluation. tongue along with anxiety, testing folate levels can rule The evaluation of the serious illness and its symptom out nutritional deficiencies. Pulmonary function tests and burden is important as well as other comorbid conditions. arterial blood gases can rule out hypoxia and pulmonary Predisposing factors should be examined, including a disease (Fournier, 2013a). Finally, there may be situations previous history of anxiety or trauma, social isolation, where drug toxicology screening is necessary to rule out and coping style (Traeger et al., 2012). A thorough for cocaine or amphetamine use, or other medications discussion of psychosocial situations including living from which the patient may be in withdrawal. conditions, recent changes in the patient’s life, and anticipated life changes is warranted. This conversa- Assessment Tools tion can sometimes be more revealing if it includes both the patient and his or her family or friends, as The Anxiety Sensitivity Index (ASI) is a 16-item self-report permitted by the patient. An open discussion of fears tool in which responses are rated from 0 to 4. A mean and concerns of an uncertain illness trajectory may score of 20 and below indicates no anxiety. A mean score be helpful. This may help in determining whether the in the 20s is common for those with GAD, and a mean anxiety is a secondary response to the following: an score of 35 and above indicates panic disorder (Reiss, organic factor, a primary psychiatric disorder, or reac- Peterson, Gursky, & McNally, 1986). Another commonly tive or situational-related stress (Traeger et al., 2012). used tool is the brief Patient Health Questionnaire for Situational-related stress is common and cannot be Depression and Anxiety (PHQ-4). If the patient screens positive for the PHQ-4, it is suggested that he or she be assessed for major depression or dysthymia using the TABLE 22.4 Mild to Severe Anxiety and Its Effects American Psychiatric Association DSM-5 criteria for Mild Awareness, alert attention for problem solving the disorders, and if major depression is present, the Patient Health Questionnaire (PHQ-9) can be used to Moderate Perceptual field narrowed, decreased monitor depression severity over time (Irwin & Hirst, observation, and selective attention 2017). Other tools include the Hospital Anxiety and Severe Reduced perceptual field, scattered, escalated Depression Scale, which is a self-report measure of anxiety with inability to attend 10 questions, and the Visual Analog Scale or the Distress Inventory Scale (Sheldon, Swanson, Dolce, Marsh, & Panic Feelings of awe, dread, fear, panic; inability to focus; no perceptual field Summers, 2008). There are several tools to assess anxiety in well chil- Source: Adapted from Pasacreta, J. V., Minarik, P. A., Nield-­ dren; however, none have been tested in chronically ill Anderson, L., & Paice, J. A. (2015). Anxiety and depression. In B. Ferrell & N. Coyle (Eds.), Oxford textbook of palliative nursing or terminally ill children. Two self-report measures are (4th ed., pp. 366–385). New York, NY: Oxford University Press. the Spence Children’s Anxiety Scale and the Screen for Matzo_27129_PTR_22_545-580_05-24-18.indd 549 5/24/18 7:38 PM  550 IV. PHYSICAL HEALTH: SYMPTOM MANAGEMENT Child Anxiety–Related Emotional Disorders. One inter- benzodiazepine of choice with older populations. It has view that may help is the Anxiety Disorders Interview a double result in both relief of nausea and reduction Schedule for Children (Kersun & Shemesh, 2007). The of panic attacks. Very short-acting benzodiazepines, questionnaire is comprised of a series of semi-structured like oxazepam or alprazolam, are not recommended questions answered by child and parent self-report. and should be avoided because of the association with These questions review lifetime and current anxiety, a significant risk for rebound anxiety and withdrawal as well as mood. For children younger than 8 years, syndromes (Irwin & Hirst, 2017). Generally, tricyclics the questions are usually answered by their caregivers; and beta-adrenergic agents are not well tolerated in older however, developmentally appropriate assessments in populations, though a trial may be warranted if other younger children have been reported. medications do not offer relief. If insomnia and anxiety together are symptoms, temazepam 15 to 30 mg at bed- Management time may be helpful, and patients with decreased hepatic function may do better with temazepam and lorazepam Nurses may be the first to identify anxiety for many as these medications do not have active metabolites. patients. A collaborative interdisciplinary team ­approach Drug-induced anxiety may be caused by neuroleptic is helpful in the treatment of anxiety for patients medications such as haloperidol, and hydroxyzine can experiencing serious life-limiting illness. Treatment cause anticholinergic side effects and delirium. For of anxiety is most successful when psychosocial and ­patients with generalized anxiety and a history of sub- psychoeducational interventions are combined with stance abuse, buspirone may be useful. For patients with pharmacological interventions (Blatt, 2012; Braun, severe respiratory function, low dose antihistamines may Pirl, & Greenberg, 2010). Often a medication and dietary be helpful, and for terminally ill patients with dyspnea, review may reveal substances and medications used to opioids are indicated. For patients for whom anxiety manage disease-related symptoms, such as steroids or mostly affects the ability to go to sleep and/or stay asleep, stimulants, which increase anxiety, but are essential but not their daily routine, there may be situations where to disease management. In this situation, the times of hypnotics are used to help them either on a short-term or medication administration may need to be changed to long-term basis. The use of these medications should be promote sleep. carefully monitored (Gatto et al., 2016). See Table 22.5 for drugs and dosages. Pharmacological. In general, there is a lack of evi- In children, benzodiazepines are the medication of dence to draw a conclusion about the effectiveness of choice. The short-acting agent lorazepam is helpful drug therapy for symptoms of anxiety in adult palliative for procedures. Clonazepam and diazepam are help- care patients (Salt, Mulvaney, & Preston, 2017). In a ful long-acting agents, although diazepam’s half-life younger, healthier population, selective serotonin reup- may affect other medications (Mullaney, 2011; Pao & take inhibitors (SSRIs) are the first drug of choice for the Wiener, 2011). Dosing is based on weight (Mullaney, treatment of anxiety disorders as this class of medication 2011; Pao & Wiener, 2011). Lorazepam is calculated at has proven to be effective in addressing panic, GAD, 0.025 mg/kg/24-hr dose with a maximum of 2 mg/dose. posttraumatic stress disorder, and obsessive–compulsive Diazepam is calculated at 0.01 to 0.02 mg/kg/24 hr disorder (Gatto et al., 2016). Tricyclic antidepressants with a maximum dose of about 10 mg/d. Clonazepam is (TCAs) can also be effective and have the benefit of being calculated at 0.01 mg/kg/24 hr with a maximum initial inexpensive and serving as an adjuvant for neuropathic dose of 0.05 mg/kg/d. pain. Because benzodiazepines have a rapid onset, they are commonly used to treat acute anxiety. However, Nonpharmacological. To manage anxiety, a range this class of medication has been associated with many of psychosocial strategies are beneficial. When possible, adverse events in the medically ill and caution is advised it is helpful to work with patients over time to pro- in their use (Irwin & Hirst, 2017). mote the acknowledgment of their anxiety about their In older and geriatric populations, it is important to disease, treatment, symptoms, and future. The nurse consider medication, dosages, and dose titrations because can reduce general anxiety by offering the patient and of the potential of paradoxical responses to certain family information about the clinical encounter. This medications. In addition, it is important to be mind- includes the process or procedure of home visits, office ful of the patient’s prognosis and his or her insurance visits, or the schedule of the day on an acute care or coverage for medications. Antidepressant therapies are facility unit; preparation and information about tests indicated if prognosis extends beyond 2 months. If time and procedures; and identification of health procedures. is shorter, benzodiazepines can be prescribed for rapid Patients diagnosed with a serious illness may have fears relief of acute anxiety symptoms. However, due to their and concerns about dying and the dying process. The long half-life, these medications can cause adverse drug process of inquiring about such fears helps to normalize effects, including confusion and worsening anxiety. Due their presence, and addressing them is helpful, particularly to its shorter half-life, lorazepam is the recommended in developing an individualized care plan. Discussion of Matzo_27129_PTR_22_545-580_05-24-18.indd 550 5/24/18 7:38 PM  22. Anxiety, Depression, and Delirium 551 2012). Providing structure and predictability can help TABLE 22.5 Medications to Treat Anxiety to allay fears and can take place in the form of future Medication Class Range appointments and symptom management (Bakitas, Dah- Adults lin, & Bishop, 2017). Offering summary information at the end of every visit about progress and future events Benzodiazepines may alleviate any surprises and assure the patient and Short acting: provider share a mutual understanding. If appropriate, encourage patient participation in his or her care. One Lorazepam (Ativan) 0.25–5 mg TID helpful intervention for pediatric patients is bibliotherapy, Temazepam (Restoril) 15–30 mg at bedtime which is the use of literature and storytelling to allow children to tell their version of the situation. By using a Antipsychotics/Neuroleptics book to stimulate thought or create a unique story, the Haloperidol (Haldol) 0.5–2 mg q2–12 hr child has assistance to review the situation, foster emo- tional responsiveness, discuss psychological reactions, Olanzapine (Zyprexa, 5–15 mg daily and consider coping strategies (Pao & Wiener, 2011). Zydis) Animal therapy is also quite effective in relieving stress Risperidone 1–3 mg daily as the animal reduces the threatening feelings by offer- ing a social connection and unconditional love (Pao & Quetiapine 25–200 mg daily Wiener, 2011). Azapirones Dietary modifications, stress management, and psycho- therapy are examples of nonpharmacological treatment Buspirone (BuSpar) 5–20 mg TID that can benefit anxiety. Nutritional assessment includes Children evaluating the diet for caffeine and alcohol (Blatt, 2012). Benzodiazepines Sometimes, simply decreasing the daily intake of caf- feine (present in all forms of tea, coffee, and chocolate) Lorazepam (Ativan) Younger children: 0.025–0.05 mg/kg is helpful, although in many cases, caffeine needs to be every 4–6 hr eliminated. If this is the case, weaning off caffeine in a Adolescents above 12 years: planned process helps to avoid common withdrawal 1–2 mg every 8 hr symptoms of headache, nausea, and general malaise. In Clonazepam Younger children: 0.01–0.03 mg/kg addition, a review of over-the-counter medications for (Klonipin) every 24 hr coughs and colds should include eliminating ephedrine. Adolescents above 12 years: High alcohol intake is common in anxious patients, 0.5–1.5 mg every 24 hr and it may worsen anxiety because it affects sleep and Diazepam (Valium) Younger children: 0.08–0.12 mg/kg cognition. Alcohol is commonly consumed as beer, wine, every 8–12 hr or hard liquors, but is also present in cough medicines Adolescents above 12 years: 5 mg and mouthwashes. Reduction or elimination of alcohol every 8 hr intake entirely may be helpful in the management of TID, three times a day. anxiety. Finally, nicotine may contribute to anxiety, and patients may require smoking cessation programs and/ Sources: Adapted from Blatt, L. (2012). Psychosocial issues. In C. ­Dahlin & M. Lynch (Eds.), Core curriculum for the advanced prac- or smoking substitutes, such as nicotine patches and tice hospice and palliative registered nurse (2nd ed., pp. 187–224). gums, to successfully quit smoking. Pittsburgh, PA: Hospice and Palliative Nurses Association; Mullaney, Stress management can include exercise programs, E. (2011). Symptom management in pediatric palliative care. In G. breathing exercises, relaxation techniques, massage, Santucci (Ed.), HPNA core curriculum for the pediatric hospice and pal- liative nurse (pp. 67–106). Pittsburgh, PA: Hospice and Palliative Nurses touch, distraction, music therapy, and visualization. ­Association; Pao, M., & Wiener, E. (2011). Psychological symptoms. In Guided imagery and hypnosis may offer the patient J. Wolfe, P. Hinds, & B. Sourkes (Eds.), Interdisciplinary pediatric pallia- more control in everyday life and in stressful situa- tive care (pp. 229–238). Philadelphia, PA: Elsevier Saunders; Pasacreta, tions (Plaskota et al., 2012). Some hospitals, healthcare J. V., Minarik, P. A., Nield-Anderson, L., & Paice, J. A. (2015). Anxiety and depression. In B. Ferrell & N. Coyle (Eds.), Oxford textbook of palliative systems, and insurance plans offer exercise programs nursing (4th ed., pp. 366–385). New York, NY: Oxford University Press. or gym reimbursement. Many Young Women’s Chris- tian Associations/Young Men’s Christian Associations (YWCA/YMCAs) offer gentle exercise programs or values, preferences, and beliefs in the form of advance special programs directed at keeping people of various care planning may be helpful to patients and families to ages healthy, and provide discounts or subsidies for promote proactive planning and provide patients some patients who need financial assistance. Shopping malls control in their care. Additionally, interventions such as may offer patients the ­opportunity to walk in a safe, cognitive behavioral therapy, relaxation training, and weather-friendly environment often at off-hours to allow supportive counseling may be helpful (Traeger et al., patients to avoid crowds. For patients in assisted living Matzo_27129_PTR_22_545-580_05-24-18.indd 551 5/24/18 7:38 PM  552 IV. PHYSICAL HEALTH: SYMPTOM MANAGEMENT or skilled nursing facilities, physical therapists (PTs) can reduce stress and normalize their illness. Of particular often help promote gentle exercise. importance is attendance at school and related activities Massage therapy can be an effective method to help since these activities play a major role in the context patients relax. Of course, the patient must be assessed of their daily routine and social networks (Mullaney, regarding his or her comfort with physical touch and 2011). Parents may need to participate with the child any conditions or injuries that would preclude massage. so they may experience anxiety reduction together. This Some older adults may not have experience with formal is important if the child appears to be reactive to the massage and may be uncomfortable with such intimate parent’s or guardian’s anxiety. touch. Often patients may receive modified massages from healthcare personnel in various settings, such as Dependent, Independent, and outpatient oncology settings, hospitals, skilled facilities, Collaborative Interventions or day care centers. Distraction can be used to manage anxiety, and it Treatment of anxiety for a patient with a life-threatening may occur in many forms including watching television; illness requires a collaborative approach by an interpro- listening to the radio; reading digital devices, books, fessional team. The nurse has a role in assuring team and newspapers; participating in arts and crafts; and communication within the plan of care. Specifically, the performing hobbies. It is important to assess how the team needs to review the patient history and medications patient spends his or her time and what activities are and then determine symptom management together. distracting and helpful for him or her. Music therapy has Since treatment usually requires psychological support been shown to be effective in anxiety, as it can reduce and medication management, clear delineation of roles pain, promote physical comfort, and induce relaxation should be clarified for the patient and his or her family. (Meghani, Tracy, Hadidi, & Lindquist, 2017). This provides consistent direction and support to the Evaluating a patient’s environment may be very patient and family without provoking further anxiety. A important, as patients may worry about aspects of physician or an advanced practice registered nurse can their living situation, particularly navigating stairs and diagnose and treat anxiety, as well as provide medica- bathroom areas. PTs and occupational therapists (OTs) tions and psychological support. A social worker can be can assist with home-safety evaluations, and social quite effective in assessing the living conditions and the workers can assist with issues of personal safety. In the family dynamics that affect anxiety, as well as offering case of older adults, social workers evaluate situations both counseling and stress management techniques. An of potential abuse and neglect, transportation, or lack OT or PT can assess in-home safety and teach the family of access to good nutrition. Too often, the patient loses safe transfers to promote mastery in the delivery of care control over his or her life as the disease, treatments, in the home. A pharmacist can examine a medication or side ­effects interrupt daily routines. Facilitating the regimen for polypharmacy. A common observation for patients’ control in the details and planning their day nurses working with patients is that the anxiety can be decreases anxiety. This includes their self-care, meals, easily absorbed. Therefore, anxious patients and families healthcare appointments, and other activities that can can make the nurse feel anxious or frustrated. Therefore, help them feel less anxious. the nurse needs time and distance to dispense or relieve Psychotherapy may include counseling, spiritual care, himself or herself of the anxiety of the patient and family. and cognitive behavioral therapy. Counseling generally includes exploration of specific fears and conversations about those fears. Spiritual care interventions focus on Family Concerns and Considerations existential fears around death and dying by offering supportive exploration and guidance (Borneman, 2012). Education for the family and caregiver is important as Cognitive behavioral therapy focuses on restructuring this information may promote early recognition of symp- the issues using various techniques over a discrete ­period toms and can help the patient utilize both medications of time. and complementary strategies to manage anxiety. The For children, stress and anxiety management may patient and family should also understand that in some be developed into more structured programs. Children cases, long-term use of medication to treat anxiety may may need specially trained pediatric practitioners to be necessary. These medications may cause some or all assist with these areas. Anxiety can be managed with of the following side effects to greater or lesser degrees: a variety of therapies including expressive therapy (art, daytime somnolence, confusion, unsteady stance or gait, music, and journaling), touch therapy, and talk therapy paradoxical effects, memory disturbance, depression, (Mullaney, 2011). Art and music therapy may promote a withdrawal, abuse, dependence, and respiratory prob- release in anxiety from tactile and intellectual stimulation. lems. Safety may be an issue, and prior to starting any Other therapeutic activities include sports, music, or, for medications, the prevention or management of potential younger children, play therapy activities with child life medication side effects should be discussed. The patient specialists. Adherence to routines and schedules helps and family may need to discuss the risk–benefit ratio of Matzo_27129_PTR_22_545-580_05-24-18.indd 552 5/24/18 7:38 PM  22. Anxiety, Depression, and Delirium 553 interventions, particularly if medication side effects are to be normal coping mechanisms in the process of debilitating and worse than the anxiety itself. ­accepting a terminal illness (Block, 2000; Breitbart & Medication information is imperative, as prescription Dickerman, 2017), so the treatment of depression medications as well as over-the-counter medications can was not prioritized. The thought was that treatment cause anxiety, particularly in older populations. A careful would interfere with the natural dying process and the review of each medication, its intent, and its dosage can emotional work of dying. It is now understood that help decrease confusion and improve compliance. A medica- not treating depression can interfere with a patient’s tion box prefilled by family or healthcare personnel with ability to bring closure to his or her end-of-life issues medication in the correct time slots can be tremendously and concerns. helpful in ensuring correct medication dosage and timing. Depression can be challenging to identify in patients In addition, a patient or family member can keep a diary with comorbid conditions, including cardiovascular dis- of medications, dosages, and time of administration. In ease, neurological conditions, autoimmune diseases, and creating medication schedules it is best to work around endocrine disorders (Pasacreta et al., 2015). Specifically previous rituals such as mealtime and other activities of in cancer, depressive symptoms can mimic symptoms daily living, with particular attention paid to sleep sched- caused by the immunological, chemotherapeutic, and ules. Stress management techniques that can be utilized radiotherapeutic treatments; loss of appetite from che- by both the patient and the family should be offered. For motherapy; fatigue induced by the metabolic changes older adults, these interventions may include promoting in cancer; and lack of sleep from compliance with control over their environment (e.g., simple planning of continuous pain- and symptom-medication regimens daily activities, toileting, mealtimes, and visiting times). (Breitbart & Dickerman, 2017). All patients and family members can benefit from a Depression in children may be complex to assess periodic review of anxiety-related symptoms and their and manage due to the potential challenges associated management and prevention. Dealing with persistent with their developmental stages (APA, 2013). Moreover, anxiety can be difficult, so it is important to encourage children may exhibit more irritability and withdrawal time for ventilation of feelings and concerns regarding due to the consequences of the illness. Their depression the illness experience. Education is particularly important may stem from the social issues related to being ill, such in terms of how to diffuse anxiety and suggestions for as being different from their friends and losing connec- helpful behaviors or strategies that patients and family tion with their communities within and around school. members can follow to de-escalate stress. Depression may result from changes in the routines of Care should be taken to simplify the day by not over- school and afterschool activities. Treating depression in booking activities for the seriously ill patient. In addition, children is further complicated as they may understand the nurse can provide information to prepare the patient their illness through their continued repeated interactions for any treatment, change in plans, or visitation by other within a healthcare system, rather than understanding medical personnel; this can greatly help decrease anxiety the illness itself (Pao & Wiener, 2011). They may also because the patient will know what to expect and can pick up on behaviors and attitudes from their parents, control the schedule. Concurrently, an appropriate sleep so it is important to assess the family system (Pao & rest schedule should be planned to reduce anxiety and stress Wiener, 2011). While there have been no specific stud- secondary to fatigue and exhaustion. All persons involved ies conducted on depression in dying children, a recent with the anxious patient need to show patience, speak study showed that children with acute lymphoblastic calmly, and provide any direct care as gently as possible. leukemia have a higher-than-expected risk for anxi- This is particularly true when the patient has hearing or ety and depression at 1 month post diagnosis and the vision deficits or cognitive impairments. In settings outside risk of depression persists up to 1 year post diagnosis the hospital, education regarding medications can allay (Myers et al., 2014). anxiety and fears, particularly in the home or assisted Depression in the older adult may be masked by the living facility. With a careful review, patients may under- normal aging processes that include age-related changes stand the appropriate use of each medication. In addition, in energy, sleep–wake cycles, diminishing appetite, and realistic schedules can be created to apply when there is the ability to continue previous pursuits (Derby, 2012; no 24-hour nursing support for medication regimens that Pasacreta et al., 2015). Specific to the older patient, the include steroids or diuretics and antianxiety medications. diagnosis of depression may be difficult secondary to the misperception that older adults experience depres- sion as a normal part of the aging process. Many older DEPRESSION adults do not perceive they are depressed; they may be of a generation in which psychological problems were When dealing with a serious illness, it is common not discussed or admitted. for patients to experience psychological distress in Further complicating the diagnosis and treatment of response to their serious or life-threatening diagnosis. depression in seriously ill adult and pediatric patients For many years, grief and depression were considered is inadequate healthcare provider knowledge regarding Matzo_27129_PTR_22_545-580_05-24-18.indd 553 5/24/18 7:38 PM  554 IV. PHYSICAL HEALTH: SYMPTOM MANAGEMENT the treatment of depression (Breitbart & Dickerman, illness (APA, 2013). Depressive disorder is related to the 2017). A thorough assessment requires sufficient time circumstances of the direct pathophysiological consequences to assess and interview a patient more extensively than of a medical condition and is not explained by a mental a cursory initial evaluation or a comparatively brief disorder, and it affects the social interaction of the patient follow-up visit. Effective treatment and management (APA, 2013). For patients with chronic, progressive, or require a time commitment that involves working on serious life-threatening illnesses or injuries in the context psychological issues, prescribing psychotropic agents, of life changes and adaptations resulting from these condi- and monitoring the potential side effects of such agents. tions that alter quality of life, disease and the associated Under the time constraints common in healthcare, the treatment and side effects alone may result in many of necessary time to perform a complete assessment may the criteria listed in this depression profile (APA, 2013). feel overwhelming to the novice clinician. Ageist attitudes on the part of the prescribing clinician can also affect the Incidence treatment for older and younger patients. Clinicians can struggle to understand the complex interrelatedness of a Depression is common in patients with cancer, with an serious illness and the related physical and psychosocial estimate that 10% to 25% of patients are affected at aspects. Some clinicians express feelings of hopelessness any given time. Depression may increase with disease around the treatment of life-limiting illness and feel progression and in certain types of cancer, including that depression cannot be well treated (Block, 2000). pancreatic, lung, and head and neck cancers; it is also Furthermore, healthcare professionals, including nurses, seen in human immunodeficiency virus and acquired may believe that by asking about depression, they add to immunodeficiency disease syndrome (HIV/AIDS) and the patient’s psychological distress. Clinicians may feel coronary artery disease (CAD; Breitbart & Dickerman, unprepared and overwhelmed by the responsibility of 2017; Chovan, 2016). Depression is a major health caring for patients with life-threatening illnesses, which problem and the most common psychiatric disorder is why it is important to involve the resources of the secondary to the events that occur later in life, but it interdisciplinary team. Finally, it is worth noting that may be overlooked and/or mistaken for dementia in for some patients with serious and life-limiting illness, older populations. Most studies on depression look at total alleviation of their depression may not be possible. prevalence rather than incidence. The incidence of depression in children is less Definition ­understood because of the absence of large generalized studies to evaluate depressive symptoms in children. Depression is a mood disorder with both psychologi- Moreover, children have unique ways of coping that cal and somatic symptoms that alter mood, affect, and are age ­dependent. More often than not, disruptions personality (APA, 2013). It is a compilation of signs and in routines, relationships, physical condition, and, for symptoms that are not considered to be a normal reac- teenagers, loss of independence can be risk factors for tion to daily life occurrences. According to the DSM-5, depression, along with the adult reports of low self-esteem, depression is defined as a loss of interest or pleasure in guilt, hopelessness, and suicidal ideation (Kersun & nearly all activities (anhedonia) for 2 weeks or longer Shemesh, 2007; Pao & Wiener, 2011). without improvement. In addition, four or more symptoms are present from the following list: changes in appetite; sleep, weight, or psychomotor activity; decreased energy; Etiology feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions; or recurrent thoughts The etiology of depression is multifactorial and falls of death, suicidal ideation, or attempts at such (APA, into the following overlapping four categories: physical, 2013). If sufficient criteria are not met for the diagnosis psychological, social, and biological (see Table 22.6). of major depression, patients can be classified as having It is postulated that depression may be caused by de- situational depression, or “adjustment disorder” with ficiencies in serotonin, norepinephrine, and prolactin, depressive features, which may or may not improve as as well as abnormal cortisol and dopamine levels. the patient adapts to the reality of the illness (Breitbart ­Additionally, there may be factors secondary to certain & Dickerman, 2017). Depression can be persistent and medical conditions that are associated with depression last indefinitely if left untreated. Symptoms of chronic (see Table 22.7). Physical factors encompass medical depression can include inconsistent memory or com- conditions, specific diseases, medication effects, and plaints of memory loss, increased speech latency, and sensory deprivation from loss of vision or hearing. an irritable affect (Chovan, 2016). Medications that may cause side effects that mimic Like anxiety, the most recent DSM-5 recognizes an depressive symptoms include chemotherapeutic agents, aspect of depression named Depressive Disorder Due to opioids, and glucocorticoids (Marks & Heinrich, 2013). Another Medical Condition, which relates to the patient Psychological issues that may precipitate depression with a chronic, progressive, or serious life-threatening cover a wide spectrum, including unresolved conflicts, Matzo_27129_PTR_22_545-580_05-24-18.indd 554 5/24/18 7:38 PM  22. Anxiety, Depression, and Delirium 555 TABLE 22.6 Etiology of Depression for Adults and TABLE 22.7 Medical Conditions Associated With Children Depression Category Examples Category Examples Physical Medical conditions including cardiac Endocrine Hypothyroidism, hyperparathyroidism, disease, cerebrovascular disease, disorders diabetes, Cushing’s syndrome, Addison’s autoimmune disease, and endocrine, syndrome liver, and renal failure; specific disease relationships; medication effects; symptom Cardiovascular Congestive heart failure, myocardial related, such as pain or sleep disturbances; conditions infarction, cardiac arrhythmias, stroke treatment effects, such as radiation Neurological Cerebral vascular accident, anoxia, sensory deprivation conditions Huntington’s disease, Alzheimer’s Psychological Memory loss, unresolved conflict, loss of disease, dementia, multiple sclerosis, independence, change in living situation, post-concussion syndrome, myasthenia financial consequences from illness, poor gravis, narcolepsy, subarachnoid coping and substance abuse hemorrhage, Parkinson’s disease Social Changes in body image, loss of Immune and HIV/AIDS, rheumatoid arthritis, independence, loss of family and friends, rheumatological polyarthritis nodosa, lupus loss of community such as school-related disorders activities, isolation, loss of employment, Cancer Pancreatic, brain, lung, hematologic, previous conflicted relationships head and neck, CNS Biological Family history, previous episodes of Other Chronic pain syndrome, alcoholism, depression, neurotransmission deficiencies anemia (serotonin, norepinephrine, dopamine, cortisol, prolactin), central nervous effects CNS, central nervous system. of cytokine Sources: Adapted from Breitbart, W., & Dickerman, A. L. (2017, May 10). Assessment and management of depression in ­palliative Source: Adapted from Pasacreta, J. V., Minarik, P. A., Nield-­ care. In D. M. F. Savarese & D. Solomon (Eds.), UpToDate. ­Retrieved Anderson, L., & Paice, J. A. (2015). Anxiety and depression. In from https://www.uptodate.com/contents/assessment-and B. Ferrell & N. Coyle (Eds.), Oxford textbook of palliative nursing -management-of-depression-in-­palliative-care; Chovan, J. (2016). (4th ed., pp. 366–385). New York, NY: Oxford University Press. Depression and suicide. In C. ­Dahlin, P. Coyne, & B. Ferrell (Eds.), Advanced practice palliative nursing (pp. 321–330). New York, NY: ­Oxford University Press; Pasacreta, J. V., Minarik, P. A., memory loss, loss of independence, change in living Nield-­Anderson, L., & Paice, J. A. (2015). Anxiety and depression.In B. ­Ferrell & N. Coyle (Eds.), Oxford textbook of palliative nursing situations, and possible financial consequences incurred (4th ed., pp. 366–385). New York, NY: Oxford University Press. from a life-limiting illness (Pasacreta et al., 2015). When a person has a serious illness, the loss of his or her social network may cause depression. Patients may not have disease or condition and treatment-related changes in the ­energy to participate in hobbies or activities or may their physical appearance (Mullaney, 2011). want to be private about visible aspects of their condi- tion. ­Biological factors of depression include f­amily Cardinal Signs of Depression history of depression or other mental illness, prior epi- sodes of depression, neurotransmission deficiencies, and Depression may affect all aspects of a patient’s life. This ­central nervous effects of cytokines. Family history may is because depression may play a role in other conditions, ­increase the risk of depression by a factor of 1.5 to 3, such as pain, confusion, agitation, anxiety, or irritabil- and 50% of people with depression have recurrence. ity. As previously stated, contrary to public knowledge, Other mental disorders may accompany depression, ­depression is not a normal part of aging. However, as part including ­somatoform disorders (Blatt, 2012). of aging, the older adult may develop physical symptoms For children and adolescents with serious illness, that mimic depression rather than changes in emotional the loss of independence and the loss of school and affect (Derby, 2012). For that reason alone, it is suggested related community can be difficult (Mullaney, 2011). that the clinician assess cognitive mood symptoms rather Young children may experience loss of teachers, friends, than neurovegetative symptoms (Breitbart & Dickerson, sports, afterschool activities, and other social interac- 2017). Patients may present with a dysphoric mood or tions. Coping with the debilitating physical aspects of lack of pleasure. Other signs include poor permanal having a life-limiting illness may also cause depression, hygiene and grooming; slow thought processes and including pain and exhaustion. Other triggers include speech; sadness, tearfulness, hopelessness, helplessness, loss of routines and, more importantly, changes in body worthlessness, and social withdrawal; changes in sleep image. Older children may be embarrassed about the patterns and appetite; fatigue; behavioral slowing; and Matzo_27129_PTR_22_545-580_05-24-18.indd 555 5/24/18 7:38 PM  556 IV. PHYSICAL HEALTH: SYMPTOM MANAGEMENT complaints of diminished ability to think (Pasacreta assessment. Lack of a previous suicide attempt may et al., 2015). not be significant in assessing suicidal risk because the Signs of depression in children manifest as somatic majority of older patients who commit suicide have no complaints, periods of anger, and other behaviors as prior suicidal behaviors. Many older people who com- well as sadness or melancholy. For teenagers and young mit suicide have been found to have the most treatable adults, depression may be manifested by low self-esteem, types of depression if they had received appropriate guilt, and hopelessness. Patients of all ages may express interventions (U.S. Preventive Services Task Force, 2016). recurrent thoughts of worthlessness, excessive or inap- The risk for suicide in the general population includes propriate guilt, and a sense of being a burden (Derby, prior psychiatric diagnosis, including previous depression, 2012; Pao & Wiener, 2011). family history of suicide, poor social support with isola- Patients with dementia manifest depression differently tion, delirium, fatigue, advanced illness with disfiguring from the person whose cognitive function is intact. More disease or surgery, substance or alcohol abuse, poorly peripheral symptoms may have been seen in older adults controlled pain, increasing age, and lack of control with with altered cognition such as loss of interest and engage- hopelessness (Braun et al., 2010). Because there are no ment with activities, isolation and social withdrawal, specific pediatric and teen suicide assessments, they should agitation, repetitive vocalization, apathy, insomnia, food be screened as adults (Pao & Wiener, 2011). Assessment refusal, and/or resisting care (Pattanayak & Sagar, 2011). and evaluation of the following areas is essential for Depression in this population may lead to increased determining suicide potential: strong character; fear of dependence on activities of daily living and decreased dependence on and/or being a burden on others; refusal ability to engage in meaningful activities. of assistance; fear of financial issues related to treatment; Most patients with a life-threatening illness fulfill unrelieved severe pain; poor functional status; and previ- several of the criteria for depression under DSM-5 (APA, ous psychiatric distress. Other factors include retirement, 2013). The challenge lies in differentiating depression recent change in housing, changes in health, history of from grief (Block, 2000; Chovan, 2016). Grief is the poor interpersonal relationships, and a terminal diagnosis. normal response to a loss, injury, insult, illness depriva- For teenagers, the loss of social relationships with the tion, or disenfranchisement that is usually proportionate school community, such as loss of relationships due to to the disruption caused by the loss (Jacobsen, Zhang, healthcare treatments, as well as an inability to attend Block, Maciejewski, & Prigerson, 2010). To differenti- school, activities, or sports, are of particular significance. ate between grief and depression in the patient with a When suicidal ideation is detected, it can be an emo- serious illness, the clinician must perform a thorough tional time for the clinician. In a nonjudgmental manner, interview that examines how the patient has coped with the clinician must evaluate for the severity of the suicidal past crises to assess resiliency. Evaluation of the somatic ideation (Box 22.1). This includes a review of the pres- distress the patient is experiencing includes hopelessness ence of suicidal thoughts, any details of a suicide plan, or helplessness, whether he or she has retained a capac- the seriousness of the intent, the patient’s social supports, ity for joy and whether he or she looks to the future. and the degree of the patient’s impulsivity (APA, 2016). If the patient can still experience joy, if he or she can In addition, the clinician should assess the his- look forward to the future, and if the symptoms come tory, determine the degree of intent, and evaluate the in wavelike fashion, the patient is likely experiencing ­existence and quality of internal and external controls. grief rather than depression (Block, 2000). This may include a safety assessment of the home to check for firearms, weapons, and alcohol along with Severe Depression and Suicide the presence of multiple medications. If possible, the clinician should initiate a safety plan with family and Depression in its most severe form puts a person at a friends. This usually consists of a safety contract with risk for suicide. The rate of suicide increases with age, the patient and ensuring the patient is not left alone. Of with suicide being the third leading cause of death for utmost importance is consultation with mental health or older adults. One out of five suicides involves a person of 65 years or older. Recent studies have found that hav- ing five or more health systems affected by disease was a predictor of suicide (Almedia et al., 2016). Suicidal Box 22.1 behavior in the older adult differs from that of a younger Suicidal Ideation Questions person in that the elder person is less likely to express suicidal ideation and more likely to utilize lethal meth- Would you prefer that death would come sooner rather than later? ods. In children and teenagers, depression may be subtle Have you thought that it would be a relief to die sooner? and may include passive thoughts such as being tired Have you thought about ending your life or killing yourself? of fighting or feeling like it would be okay not to wake Have you thought about what method you would use? up from sleep (Pao & Wiener, 2011). Suicidal ­ideation (Blatt, 2012) is a psychiatric emergency and warrants immediate Matzo_27129_PTR_22_545-580_05-24-18.indd 556 5/24/18 7:38 PM  22. Anxiety, Depression, and Delirium 557 psychiatric providers for assistance and an evaluation vitamin deficiencies; liver function tests (LFTs) to rule plan (Chovan, 2016). out liver failure; renal function tests to rule out renal failure; a urinalysis to rule out infections; and an ECG Assessment to rule out cardiac issues (see Table 22.9). Physical assessment includes a general examination Assessment of depression includes both cognitive and of the following areas: cardiopulmonary, gastrointesti- physical assessments. It is imperative that the palliative nal, genitourinary, and neurological. If pain develops, care clinician normalize depression by first performing a radiological and gastrointestinal studies are indicated to depression screen and evaluating risk factors, which include rule out fractures, ulcers, and neoplasms. Complaints many of the aspects of disease progression. In particular, of chest pain should be evaluated with an electrocar- this includes past history of psychiatric disorders and sub- diogram. Noninvasive cardiovascular studies can rule stance abuse. The clinician should monitor for changes in out myocardial infarctions, congestive heart failure, and life circumstances, function, medications, and comorbid arrhythmias. Shortness of breath justifies chest films, conditions. Cultural assessment should be incorporated pulmonary function test, pulse oximetry, and blood gases since there are racial, religious, and ethnic variances in the to rule out COPD, lung neoplasms, and other pulmo- expression of depression. Education includes normalization nary conditions. Moderate-to-severe constipation can that depression often occurs in serious illness but can be be evaluated with an occult blood test. Barium enema well managed. Psychosocial assessment includes assessment of various domains of life (see Table 22.8). A thorough physical assessment of the patient TABLE 22.9 Types of Conditions and Treatment includes laboratory testing to rule out other conditions, of Related Depression if appropriate. Prior to proceeding, it is important to consider whether the collection of blood tests presents Condition Class of Medications an undue burden on the patient and there are plans to Cardiovascular SSRIs: Sertraline, Paroxetine, Fluoxetine, treat whatever deficiencies are found. Laboratory studies disease Fluvoxamine, Citalopram may include serum electrolytes to rule out dehydration; Dopamine reuptake agents: Bupropion circulating blood count and hematocrit to rule out anemia; thyroid profile to rule out hypothyroidism; a SNRIs: Venlafaxine venereal disease research laboratory (VDRL) screen to 5 HT antagonists: Trazodone rule out an STD; vitamin B12/folate levels to rule out Gastrointestinal Tricyclics: Nortriptyline, Desipramine disease Dopamine reuptake agents: Bupropion TABLE 22.8 Depression Assessment Areas 5 HT antagonists: Trazodone Areas of Psychosocial Assessment for the Patient Renal disease Tricyclics: Nortripyline, Desipramine Ability to engage Boredom vs. inability to be active in life SSRIs: Sertraline, Paroxetine, Fluoxetine, Fluvoxamine, Citalopram