Managing anxiety and associated disorders in the last weeks of life

For the management of anxiety presenting as agitation in the last days of life, see Agitation and restlessness in the last days of life.

The aim of anxiety management in the last weeks of life is to reduce anxiety to a level that the patient finds tolerable—follow the principles of managing anxiety and associated disorders in palliative care. For some patients, the goal is to be able to participate in usual activities and interactions with others. For other patients, comfort is the main priority.

If pharmacological therapy is indicated for anxiety in the last weeks of life (eg if psychosocial interventions cannot be used or symptoms are severe), options include a benzodiazepine, an antidepressant or a combination. If an antidepressant is used, a benzodiazepine may also be needed because response to an antidepressant is not apparent for at least 1 to 2 weeks, although some symptom relief may be experienced earlier. Delay in effect should not deter antidepressant use when indicated.

Benzodiazepines are generally well-tolerated in the last weeks of life. Choice of benzodiazepine depends on the route of administration, speed of onset and duration of action required. Also consider patient age, frailty, prior use and drug interactions.

For management of severe anxiety causing acute agitation, see Acute agitation in palliative care.

If a benzodiazepine is indicated for acute anxiety in the last weeks of life, use:

1clonazepam 0.2 to 0.5 mg orally or sublingually¹, as a single dose. If required, repeat once after 2 hours clonazepam

1diazepam 2 to 5 mg orally, as a single dose. If required, repeat once after 2 hours diazepam

1lorazepam 0.5 to 1 mg orally, as a single dose. If required, repeat once after 2 hours² lorazepam

1oxazepam 7.5 to 15 mg orally, as a single dose. If required, repeat once after 2 hours. oxazepam

If intermittent dosing is insufficient to manage acute anxiety in the last weeks of life, consider regular therapy at the lowest effective dose. Consider:

1clonazepam 0.2 to 0.5 mg orally or sublingually¹, once or twice daily clonazepam

1diazepam 2 to 5 mg orally, once or twice daily diazepam

1lorazepam 0.5 to 1 mg orally, once or twice daily² lorazepam

1oxazepam 7.5 to 15 mg orally, 3 or 4 times daily. oxazepam

Regularly review response to treatment and monitor for adverse effects (eg impaired cognition and alertness) and adjust therapy as required.

Patients who have been taking long-term regular benzodiazepine therapy are likely to have developed tolerance and may not respond to the doses recommended above but can also be at risk of toxicity with higher doses—seek specialist advice.

Antidepressants are an alternative to benzodiazepines to manage anxiety; see Generalised anxiety disorder for information on antidepressants and dose regimens. The Psychotropic guidelines describe some factors that influence the choice of antidepressant. Additional considerations in patients with palliative care needs include the patient’s:

ability to swallow or absorb drugs (an antidepressant in a formulation such as a wafer or suspension may be preferred—see Routes of drug administration in palliative care)
other symptoms requiring management—a specific antidepressant may manage other symptoms (eg neuropathic pain, anorexia, weight loss, cachexia, some types of itch).

For comprehensive management of anxiety associated with breathlessness, see Breathlessness in palliative care.

¹ Two to five drops of clonazepam 2.5 mg/mL oral liquid is equivalent to clonazepam 0.2 to 0.5 mg. Do not count drops directly into the mouth; count drops into a spoon first.Return

² Lorazepam tablets can be administered sublingually but are less bioavailable than when administered orally.Return