Preoperative anxiety in surgical patients - experience of a single unit

Preoperative anxiety in surgical patients - experience of a single unit

Acta Anaesthesiologica Taiwanica 50 (2012) 3e6 Contents lists available at SciVerse ScienceDirect Acta Anaesthesiologica Taiwanica journal homepage:...

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Acta Anaesthesiologica Taiwanica 50 (2012) 3e6

Contents lists available at SciVerse ScienceDirect

Acta Anaesthesiologica Taiwanica journal homepage: www.e-aat.com

Original Article

Preoperative anxiety in surgical patients - experience of a single unit Anne Thushara Matthias*, Dharmanbandhu Nandadeva Samarasekera University Surgical Unit, The National Hospital of Sri Lanka, Sri Lanka

a r t i c l e i n f o

a b s t r a c t

Article history: Received 29 July 2011 Received in revised form 4 November 2011 Accepted 9 November 2011

Objectives: Preoperative anxiety has a significant effect on the outcome of anesthesia and surgery. At present, there is no published data on the preoperative anxiety levels in Sri Lankan patients. In the West, several validated questionnaires such as The Amsterdam Preoperative Anxiety and Information Scale (APAIS) and State Trait Anxiety Inventory (STAI) are used. To measure the preoperative anxiety levels in patients using APAIS and to analyze the factors affecting anxiety and the role played by the anesthetist in allaying anxiety. Methods: One hundred patients scheduled for elective surgery were prospectively studied using the APAIS. The internal consistency was checked using Cronbach’s alpha. Results: The ages varied 25 to 72 years (mean ¼ 48.7 years, SD ¼ 13.6). Reliability of the APAIS was high; Cronbach’s alpha ¼ 0.864 in the overall component and 0.84, 0.73 and 0.97 in the anxiety related to surgery, anesthesia and in the information desire components, respectively. Females were more anxious than males (p ¼ 0.02) and those who had never sustained surgery were more anxious than those who previously had surgery (p ¼ 0.05). An anesthetist’s visit and premedication reduced total anxiety scores (Z ¼ 3.07, p ¼ 0.002) and anesthesia related anxiety scores (Z ¼ 3.45, p ¼ 0.001). Conclusions: The prevalence of anxiety is high among Sri Lankan patients. Females are more anxious than males and those who have never had surgery are more anxious than those who have had surgery. The anesthetist’s visit could reduce anxiety. Sinhala version of the APAIS is highly reliable in assessing the preoperative anxiety levels. Copyright Ó 2012, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved.

Key words: anxiety; The Amsterdam Preoperative Anxiety and Information Scale; preoperative care

1. Introduction Anxiety is described as a vague, uneasy feeling, the source of which is often nonspecific and unknown to the individual1 but known to cause abnormal hemodynamics as a consequence of sympathetic, parasympathetic and endocrine stimulation. The preoperative period is well known to be anxietyeprovoking for most patients scheduled for surgery2,3 and is still a major problem, although surgical techniques have been improving and become much safer. The incidence of preoperative anxiety varies according to the setting of surgery. It is around 60%e80% in the western population.4,5 Anxiety can be measured in many ways. It can be measured directly by measuring plasma cortisol and urinary catecholamines, or indirectly by measuring BP and pulse.5,6

* Corresponding author. University Surgical Unit, The National Hospital of Sri Lanka No. 300/14, Dr C V S Corea Mawatha, Westwood Park, Hokandara Road, Thalawathugoda, Sri Lanka. E-mail address: [email protected] (A.T. Matthias).

In recent years, with more emphasis on dayecase surgery, there has not been enough time for anesthetists to conduct thorough preoperative interviews with patients. This could possibly lead to less than required information given to patients about surgery and anaesthesia. If there is a quantitative assessment tool like a questionnaire, the anesthetist can realize, in a short time, the patient’s level of anxiety and address the factors affecting it. At present, several validated questionnaires are used to measure anxiety. These include: the State Trait Anxiety Inventory (STAI), Hospital Anxiety and Depression Scale (HADS), Visual Analogue Scale (VAS), Amsterdam Preoperative Anxiety Information Scale (APAIS) and Multiple Affect Adjective Check List (MAACL). The APAIS is a widely accepted screening tool which has been translated and used in many countries including Germany,7 the Netherlands,8 Mexico,9 Thailand,10 Turkey,11 Korea12 and Japan.13 The assessment of anxiety is important, because the response to anesthesia and analgesia in anxious patients is different when compared with noneanxious patients.14 Patients with extreme preoperative anxiety, for example, tend to require larger doses of induction agents and analgesics and tend to have longer hospital stays.15,16

1875-4597/$ e see front matter Copyright Ó 2012, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved. doi:10.1016/j.aat.2012.02.004

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The objective of this study was to find the prevalence of preoperative anxiety in Sri Lankan surgical patients, the factors contributing to their anxiety and to identify the role played by the anesthetists in allaying anxiety. 2. Methods This was a prospective study. The inclusion criteria were age > 18 years, physical status of American Society of Anesthesiologists (ASA) class 1e3 and ability to read and understand Sinhala language (i.e., the official language of Sri Lanka). Patients with psychiatric illnesses, unable to answer the questionnaire, and those who did not give consent, were excluded from study. This study was approved by the Ethical Clearance Committee of the National Hospital of Sri Lanka. We used a validated questionnaire in the Sinhala language as the screening tool. All patients who consented to participate were given the questionnaire prior to the anesthetists’ visit and premedication. The questionnaire consisted of two parts. Part 1 contained demographic data. Part 2 contained the Visual Analogue Scale (VAS) and APAIS. The APAIS was used to measure anxiety while the VAS was used to identify the roles played by various factors on anxiety. The APAIS consisted of four questions concerning patients’ anxiety about anesthesia and surgery, and two questions evaluating the need for information. All questions were scored on a 1e5 Likert scale. This six-item questionnaire has been sub-grouped into three components; anesthesia-related anxiety (sum A), surgery-related anxiety (sum S) and information desire component (sum IDC). The total of sum A and sum S was defined as sum C. The APAIS was translated into the Sinhala language and translated back into English to preserve the original meaning. The VAS was used to measure anxiety and various factors affecting it. The VAS consisted of a 100 mm line, one end of which showed no anxiety and the other end of which illustrated the highest anxiety possible. The left side of this line was marked as “no anxiety” (score ¼ 0), while the extreme right was marked as "maximum anxiety” (score ¼ 100). The patients were asked to assess their own anxiety and mark it on the anxiety line. The causes for anxiety listed were: waiting for the operation, being at the mercy of medical staff, result of the operation, postoperative pain, time after waking up from operation, postoperative nausea and vomiting, not knowing what is happening, physical and mental harm after operation, not awakening after operation, awareness during anesthesia, nil by mouth, financial loss, concern about family, needle prick and needing a blood transfusion. Statistical analyses were made possible with SPSS (Version 16, Chicago, Illinois, USA). The Pearson’s correlation was used for correlating information requirement and anxiety level. The Kruskall Wallis test was used to compare anxiety scores against education level and race. The MannWhitney U test was used to determine the difference in sex, marital status, type of surgery, previous surgery and anesthesia, insurance, known person undergoing surgery, lives with family/alone contrasted with anxiety level. Significance level was set at < 0.05, unless otherwise specified. 3. Results The study comprised of a total of 100 patients; their demographic data are shown in Table 1. The age varied from 25 to 72 years (mean ¼ 48.7 years, SD ¼ 13.6). The means for total anxiety score (sum C), anesthesia-related anxiety (sum A), surgery-related anxiety (sum S) and information desire component (sum IDC) were 15.60, 4.63, 4.17 and 7.49, respectively. The mean and APAIS scores are shown in Table 2.

A.T. Matthias, D.N. Samarasekera Table 1 Demographic characteristics. Variable

No.

Sex

Male Female

36 64

Race

Muslim Sinhala Tamil

6 91 3

Marital status

Married Single

80 16

Insurance

Has Does not have

19 76

Education

No education Grade 1e5 Grade 6e10 O/Lae A/Lb Graduate

1 7 21 60 21

Income

< 50c 50e100 100e190 > 190

1 15 23 28

Lives

With family Alone

93 1

Type of surgery

Major Minor

31 66

Previous surgery

Yes No

46 54

Previous anesthesia

Yes No

46 54

a Ordinary level examination e barrier examination of the schooling system of Sri Lanka that is held at the end of grade 11(11 years of formal education). b Advanced level examination e barrier examination of the schooling system of Sri Lanka that is held at the end of grade 13 (at end of schooling). c Monthly income in US dollars.

Reliability of the APAIS was high, with Cronbach’s alpha ¼ 0.864 in the overall component, 0.84 in the anxiety related to surgery component, 0.73 in the anesthesia related anxiety component and 0.97 in the information desire component. Females were more anxious about anesthesia when compared with males (p ¼ 0.02). Those who had experienced surgery before were less anxious (p ¼ 0.05). Females who had surgery/anesthesia before were less anxious than those who had never experienced surgery/anesthesia (p ¼ 0.011 and p ¼ 0.018, respectively) as shown in Table 4. All other parameters did not show any difference in the level of anxiety or information requirement. The relationship between sex, marital status, education, occupation, type of operation and experience of previous surgery, are shown in Table 3. The Pearson correlation between information requirement and sum C was 0.791, which was significant at the 0.01 level. The Wilcoxon Signed Ranks Test showed that the anesthetist’s visit and premedication reduced total anxiety scores (Z ¼ 3.07, p ¼ 0.002) and anesthesia related anxiety scores (Z ¼ 3.45, p ¼ 0.001). However, there was no change on the information requirement (Z ¼ 1.75, p ¼ 0.07) and on surgery related anxiety (Z ¼ 1.69, p ¼ 0.09). Table 2 The scores of the APAIS. Component

Mean

SD

Anesthesia-related anxiety (sum A) Surgery-related anxiety (sum S) Information desire component (sum IDC) Total anxiety score (sum C ¼ sum A þ sum S)

4.63 4.17 7.49 15.60

2.65 2.53 3.19 7.08

Preoperative anxiety in surgical patients

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Table 3 The relationship between the scores of the APAIS with patient characteristics. Characteristic

Male/female Race Marital status Type of surgery Previous Surgery Previous anesthesia Insurance Known person who has had a bad experience with surgery/anesthesia Education Income

p sum A

sum S

sum IDC

sum C

0.02 0.24 0.23 0.47 0.05 0.13 0.28 0.26

0.80 0.09 0.36 0.40 0.87 0.55 0.41 0.96

0.63 0.53 0.95 0.76 0.03 0.49 0.12 0.20

0.95 0.22 0.34 0.91 1.0 0.96 0.56 0.77

0.33 0.79

0.86 0.18

0.72 0.70

0.79 0.48

4. Discussion Our study showed that the prevalence of anxiety in this group of Sri Lankan preoperative patients under study was 76.7% when the APAIS score was 11 or more. The cut off value of 11 produces a good predictive value and is suitable for identifying anxious patients.8 The prevalence is much higher than in studies done elsewhere, which showed values ranging from 32% in a study done on patients awaiting general surgery,8 to 50% in patients awaiting coronary artery bypass graft surgery(CABG).17 A relatively higher prevalence in our patients could be attributed to many factors. Sri Lanka is still a developing country, with a well established free health care system (health care, either curative or preventive, is provided free of charge in government hospitals and other governmental healthcare institutions). The governmental hospitals in Sri Lanka mainly provide aid for poor and lower middle class patients. Trust and respect of surgeons is built-in culture. Therefore, any doubts are usually not raised following doctors’ questions, due to the social barrier and respect for the doctors. As a result, concerns over surgery and anesthesia are concealed. In addition, there are not many forums and patientbased support groups for discussing the issues related to their anxiety. An ideal preoperative anxiety assessing tool should be short and easy to use. It should be as reliable and accurate as questionnaires designed to measure anxiety in a psychiatric setting. The estimate made by anesthetists and surgeons, without the use of a standard questionnaire, often leads to an overestimate of anxiety. Based on the results, we found that a high reliability of the Sinhala version of APAIS as the internal consistency determined by Cronbach’s alpha, was 0.864, which could be considered high as shown by many studies done previously.8 Therefore, it can be used as an effective tool to measure preoperative anxiety levels in Sri Lankan patients. The gold standard in measuring anxiety is the STAI-state. The sum C of APAIS has been found to moderately correlate with the STAI-state, as found in several studies including: Apniya et al (r ¼ 0.565, n ¼ 34),18 Nishimori et al13 (r ¼ 0.67, n ¼ 126), Moerman et al8 (r ¼ 0.74, n ¼ 200), Miller et al19 (r ¼ 0.82, n ¼ 85) and Boker et al20 (r ¼ 0.63, n ¼ 197). Since no studies have been undertaken to

correlate APAIS and STAI in Sri Lanka, this could be a good subject for future study. The factors which affected anxiety levels in patients, varied in studies done in different countries. The epidemiology of preoperative anxiety in this study showed some differences from, and some similarities to, previous studies. Recent studies have shown that there is no statistically significant relationship between APAIS anxiety scores and sex, age, type of operation and previous experience of surgery.8,13,21 Another study, by Sirinan et al,22 found that there was no association between the level of anxiety and ASA physical status, type of surgery, previous experiences in surgery and anesthesia, educational level and marital status. In this study, most factors which were tested had no statistically significant effect on anxiety. Females were more anxious about anesthesia than males, which was also consistent with many other studies.13,21,22 Those who had not had previous surgery, were more anxious than the experienced patients, as found in another study.18 This difference was seen primarily in females. Prior knowledge of factors affecting anxiety can be used to reduce anxiety. The VAS, a reliable tool for measuring anxiety,23 was used in this study to assess anxiety levels for various anxiety causing factors. The principal causes for anxiety in our study included: awareness during anesthesia, outcome of the surgery, postoperative pain, waiting for surgery and being at the mercy of medical staff. A study by Kindler et al23 showed that waiting for the operation, being at the mercy of medical staff, result of the operation and postoperative pain ranked first to fourth in order of significance for anxiety, respectively, while awareness during anesthesia ranked last. The fact that awareness during anesthesia was the number one cause for anxiety in our study patients, signifies the importance of the anesthetist’s visit; therefore, we should focus more attention on this area, and give patients more information regarding anesthesia to minimize their fear. This study found a high positive correlation between highlyinformed seekers and anxiety scores. This was also found in another study, by Janis.24 No previous studies have used APAIS to describe this association. Apniya et al speculated that there might not be a relationship between information requirement and anxiety scores in patients in developing countries. However, this study shows that even in developing countries, those with a high information requirement are more anxious. The clinical implication of this finding is that in high information seekers, more information is needed to reduce anxiety. This has also been suggested by Moerman et al. Adequate management of anxiety may result in a smoother induction and even a better outcome of surgery.25 The anesthetist’s visit prior to surgery fulfills two objectives: to provide a platform for patients to clarify their doubts about anesthesia and customization by the anesthetist of premedication, both of which help to allay anxiety. This was proven in our study, as the total anxiety scores and the anaesthesia related anxiety scores showed a statistically significant reduction after the anesthetist’s visit. This was previously proven by Egbert et al26 and Leigh et al,27 who showed that the anesthetist’s visit alone is as good as the visit plus premedication. 5. Conclusion

Table 4 Anxiety scores based on gender. Variable

Gender

p

Previous surgery e had vs. not had

Male Female

0.503 0.011

Previous anesthesia e had vs. not had

Male Female

0.450 0.018

Testing preoperative anxiety is an important step in reducing anxiety. Testing can be easily done with a questionnaire such as APAIS. Our study showed that patients with high information requirement and females are more anxious preoperatively. Also, those who have never undergone surgery are more anxious compared with their experienced counterparts. Therefore, this

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study proves that providing more information regarding surgery and anesthesia, might help in reducing the preoperative anxiety levels. The study did not compare the STAI with the APAIS. This could be the focus of a future study. Authors’ contributions All authors were involved in planning, data collection, analysis of data and writing the manuscript. All authors read and approved the final manuscript. References 1. Klopfenstein CE, Forster A, Gessel EV. Anesthetic assessment in an outpatient consultation clinic reduces preoperative anxiety. Can J Anesth 2000;47: 511e5. 2. Johnston M. Anxiety in surgical patients. Psychol Med 1980;10:145e52. 3. Domar AD, Everett LL, Keller MG. Preoperative anxiety: is it a predictable entity? Anesth Analg 1989;69:763e7. 4. Shevde K, Panagopoulos G. A survey of 800 patients knowledge, attitudes and concerns regarding anesthesia. Anesth Analg 1991;73:190e8. 5. Hicks JA, Jenkins JG. The measurement of preoperative anxiety. J R Soc Med 1988;81:517e9. 6. Wallin BG. Neutral control of human skin blood flow. J Auton Nerv Syst 1990;30:185e90. 7. Berth H, Petrowski K, Balck F. The Amsterdam Preoperative Anxiety and Information Scale (APAIS) - the first trial of a German version. Psychosoc Med 2007;4:Doc01. 8. Moerman N, van Dam FS, Muller MJ, Oosting H. The Amsterdam Preoperative Anxiety and Information Scale (APAIS). Anesth Analg 1996;82:445e51. 9. Gavito Md C, Corona MA, Villagrán M, Morales J, Téllez JE, Ortega-Soto HA. La información anestésica quirúrgica: su efecto sobre la ansiedad y el dolor de los pacientes toracotomizados. Rev Inst Nal Enf Resp Mex 2000;13:153e6. 10. Sirinan C, Rungreungvanich M, Vijitpavan A, Morkchareonpong C. Preanesthetic anxiety assessment:HADS versus APAIS. Thai J Anesth 2000;26: 155e63. 11. Garip H, Abali O, Goker K, Gokturk U, Garip Y. Anxiety and extraction of third molars in Turkish patients. Br J Oral Maxillofac Surg 2004;42:551e4.

A.T. Matthias, D.N. Samarasekera 12. Shin WJ, Kim YC, Yeom JH, Cho SY, Lee DH, Kim DW. The Validity of Amsterdam Preoperative Anxiety Information Scale in the Assessment of the Preoperative Anxiety. Compared with hospital anxiety depression scale and visual analogue scale. Korean J Anesthesiol 1999;37:179e87. 13. Nishimori M, Moerman N, Fukuhara S, van Dam FS, Muller MJ, Hanaoka K, et al. Translation and validation of the Amsterdam preoperative anxiety and information scale (APAIS) for use in Japan. Qual Life Res 2002;11:361e4. 14. Jafar MF, Khan FA. Frequency of preoperative anxiety in Pakistani surgical patients. J Pak Med Assoc 2009;59:359e63. 15. Williams JG, Jones JR. Psychophysiological responses to anesthesia and operation. JAMA 1968;203:415e7. 16. Maranets I, Kain ZN. Preoperative anxiety and intraoperative anesthetic requirements. Anesth Analg 1999;89:1346e51. 17. Koivula M, Paunonen-Ilmonen M, Tarkka MT, Tarkka M, Laippala P. Fear and anxiety in patients awaiting coronary artery bypass grafting. Heart Lung 2001;30:302e11. 18. Apinya K, Siriporn P, Puchong L. Validity and Reliability of the Amsterdam Preoperative Anxiety and Information Scale (APAIS); Thai version in adult Thai pre-operative patients. J Psychiatr Assoc Thailand 2009;54:86e9. 19. Miller KM, Wysocki T, Cassady JF, Cancel D, Izenberg N. Validation of measures of parents’ preoperative anxiety and anesthesia knowledge. Anesth Analg 1999;88:251e7. 20. Boker A, Brownell L, Donen N. The Amsterdam preoperative anxiety and information scale provides a simple and reliable measure of preoperative anxiety. Can J Anaesth 2002;49:792e8. 21. Berth H, Petrowski K, Balck F. The Amsterdam Preoperative Anxiety and Information Scale (APAIS) - the first trial of a German version. Psychosoc Med 2007;4:Doc01. 22. Sirinan C, Rungreungvanich M, Vijitpavan A, Morkchareonpong C. Preanesthetic anxiety assessment: HADS versus APAIS. Thailand J Anesth 2000;26: 155e63. 23. Kindler CH, Harms C, Amsler F, Ihde-Scholl T, Scheidegger D. The visual analog scale allows effective measurement of preoperative anxiety and detection of patients’ anesthetic concerns. Anesth Analg 2000;90:706e12. 24. Janis IL. Psychological stress: psychoanalytic and behavioral studies of surgical patients. New York: Wiley; 1958. 25. Chen CC, Lin CS, Ko YP, Hung YC, Lao HC, Hsu YW. Premedication with mirtazapine reduces preoperative anxiety and postoperative nausea and vomiting. Anesth Analg 2008;106:109e13. 26. Egbert LD, Battit GE, Turndorf H, Beecher HK. The value of the preoperative visit by an anaesthetist. J Am Med Assoc 1963;185:553e5. 27. Leigh JM, Walker J, Janaganathan P. Effect of preoperative visit on anxiety. BMJ 1977;2:987e9.