REVIEW ARTICLE

Year : 2016 | Volume : 17 | Issue : 2 | Page : 37--42

Preoperative anxiety-an important but neglected issue: A narrative review

Teena Bansal, Akanksha Joon
Department of Anaesthesiology and Critical Care, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India

Correspondence Address:
Dr. Teena Bansal
2/8 FM, Medical Campus, PGIMS, Rohtak - 124 001, Haryana
India

Abstract
Anxiety is an emotional state characterized by apprehension and fear resulting from the anticipation of a threatening event.
The incidence of preoperative anxiety ranges from 11% to 80% in adult patients and also varies among different surgical
groups. Preoperative anxiety may lead to various problems and a wide range of physiological and psychological responses.
A variety of objective and subjective methods are available for measuring preoperative anxiety. Every patient scheduled for
surgery should be assessed for the presence of anxiety in their routine preoperative anesthesia assessment, and counseling
should be done by anesthesiologist in patients with a high level of anxiety. Surgery information reduces anxiety in the
preoperative period.

How to cite this article:

Bansal T, Joon A. Preoperative anxiety-an important but neglected issue: A narrative review.Indian Anaesth Forum
2016;17:37-42

How to cite this URL:

Bansal T, Joon A. Preoperative anxiety-an important but neglected issue: A narrative review. Indian Anaesth Forum [serial
online] 2016 [cited 2019 Jun 1 ];17:37-42
Available from: http://www.theiaforum.org/text.asp?2016/17/2/37/195955

Full Text

INTRODUCTION

Anxiety is an emotional state characterized by apprehension and fear resulting from the anticipation of a threatening event.
The incidence of preoperative anxiety ranges from 11% to 80% in adult patients and also varies among different surgical
groups.[1]

Preoperative anxiety may lead to various problems such as difficult venous access due to peripheral vasoconstriction,
autonomic fluctuations, delayed jaw relaxation and coughing during induction of anesthesia, and increased anesthetic
requirement. In addition, it also has been correlated with increased pain, nausea, and vomiting in the postoperative period;
prolonged recovery; and increased the risk of infection.[2],[3],[4] High preoperative anxiety levels are related to an altered
neuroendocrine response which might be deleterious in the postoperative period.[5],[6]

A wide range of responses may be caused by anxiety. Physiological responses include tachycardia; hypertension; elevated
temperature; sweating; nausea; and a heightened sense of touch, smell, or hearing.[7] Psychological responses include
changes in behavior such as increased tension, apprehension, nervousness, and aggression.[8]

Anxiety is a subjective emotion. Various factors influencing anxiety in a patient planned for surgery include age, gender, the
extent and type of surgery, previous hospital experiences, susceptibility to and ability to cope with stressful experiences, and
preoperative information.[9]

We searched PubMed and Scopus databases with preoperative anxiety, prevention, and management as keywords for
literature search.

Measurement of Preoperative Anxiety

Objective methodsSubjective methods.

The measurement of preoperative anxiety in modern elective surgery is becoming very difficult, mainly due to the imposed
time restrictions. A variety of objective and subjective methods are available for measuring preoperative anxiety. Objective
methods include indirect measurement of sympatheticoadrenal activity using heart rate and blood pressure or skin
conductance.[10],[11] Plasma cortisol, urinary catecholamine excretion, and plasma catecholamines have been used as
more direct measures of sympatheticoadrenal activity.[12],[13],[14]

Nisbet et al. measured and displayed changes in electrical skin potential and suggested that these changes provide a
continuous record of one sign known to vary with anxiety and sedation.[11] In a study by Martinez et al., in thirty patients
scheduled for elective surgery emotional responses before anesthesia and surgery and the sedative effect of drugs used for
preoperative medications were estimated by the measurement of urine catecholamines. Values of 20 ng/min of adrenaline in
the urine were considered indicative of significant emotional tension.[13] Fell et al. assessed the value of measurement of
plasma catecholamine concentration as an objective index of anxiety. A study was performed on 48 surgical patients who
were asked to rate their perceived anxiety on the linear analog scale immediately before premedication and immediately
before induction of anesthesia. There were no significant changes in perceived anxiety or plasma noradrenaline
concentration following premedication. However, compared with values before premedication, there was a mean percentage
increase in plasma adrenaline concentration of 40% before induction of anesthesia. The authors suggested that the
measurement of plasma catecholamine concentration may be a useful method for the objective assessment of anxiety in the
period before the operation and for assessing the efficacy of different preoperative medications.[14]

Subjective methods include hospital anxiety and depression (HAD), state-trait anxiety inventory (STAI), visual analog scale
for anxiety (VAS-A), the Amsterdam preoperative anxiety and information scale (APAIS), multiple affect adjective check list
(MAACL), and linear analog anxiety scale (LAAS).[15],[16],[17],[18],[19]

Hospital Anxiety and Depression Scale

[Table 1]{Table 1}

HAD was originally developed by Zigmond and Snaith and is commonly used by clinicians to determine the levels of anxiety
and depression that a patient is experiencing.[15] It is a fourteen item scale. Seven of the items relate to anxiety and seven
relate to depression. This is a useful tool for the detection of anxiety and depression in people with physical health problems.

The items of questionnaire that relate to anxiety are as follows:

I feel tense or wound upI get a sort of frightened feeling as if something bad is about to happenWorrying thoughts go through
my mindI can sit at ease and feel relaxedI get a sort of frightened feeling like butterflies in the stomachI feel restless and
have to be on the moveI get a sudden feeling of panic.

The items of questionnaire that relate to depression are as follows:

I still enjoy the things I used to enjoyI can laugh and see the funny side of thingsI feel cheerfulI feel as if I am slowed downI
have lost interest in my appearanceI look forward with enjoyment to thingsI can enjoy a good book or radio or TV program.

Each item on the questionnaire is scored from 0 to 3 with three indicating higher symptom frequencies. Score for each
subscale (anxiety and depression) can range from 0 to 21 [Table 1]:

However, the limitation of this scale is that it measures the psychological stress expressed as anxiety by the patients during
the week before surgery.

State-Trait Anxiety Inventory

[Table 2] and [Table 3]{Table 2}{Table 3}

STAI is suitable for individuals who are 15-year-old and older [Table 2] and [Table 3]. The STAI Form Y is the definitive
instrument for measuring anxiety in adults. It clearly differentiates between the temporary condition of "state anxiety" and the
more general and long-standing quality of "trait anxiety." The inventory's simplicity makes it ideal for evaluating individuals
with lower educational backgrounds. Adapted in more than forty languages, the STAI is the leading measure of personal
anxiety globally. The STAI has forty questions with a range of four possible responses to each. The state anxiety scale (STAI
Form Y-1) consists of twenty statements that evaluate how the respondent feels "right now" at this moment. The trait anxiety
scale (STAI Form Y-2) consists of twenty statements that evaluate how the respondent feels "generally." In responding to the
S-anxiety scale, the patients choose the number that best describes the intensity of their feelings: (1) not at all, (2)
somewhat, (3) moderately, and (4) very much so. In responding to the T-anxiety scale, patients rate the frequency of their
feelings on the following four-point scale: (1) almost never, (2) sometimes, (3) often, and (4) almost always.

Each STAI item is given a weighted score of 1-4. A rating of four indicates the presence of high levels of anxiety for the ten S-
anxiety items (#3, 4, 6, 7, 9, 12, 13, 14, 17, and 18) and eleven T-anxiety items (#22, 24, 25, 28, 29, 31, 32, 35, 37, 38, and
40). A high rating indicates the absence of anxiety for the remaining ten S-anxiety items and nine T-anxiety items. The
scoring weights for the anxiety present items are the same as the chosen numbers on the test form. The scoring weights for
the anxiety-absent items are reversed. Scores for both the S-Anxiety and the T-anxiety scales can vary from a minimum of
twenty to a maximum of eighty. The sum of the scores on all items constitutes the individual's score.[16]

Visual Analog Scale-A

VAS-A is a useful and easily applicable method for evaluation of preoperative anxiety and allows detection of high anxiety
levels in various surgical groups. The VAS comprises a 100 mm line, at the left hand of which is a statement indicating zero
anxiety ("not anxiety at all") and at the right hand the statement "most anxious I can imagine." Patients are asked to mark the
line to indicate the degree of their anxiety.[1 7 ]

Amsterdam Preoperative Anxiety and Information Scale

[Table 4]{Table 4}

Moerman et al. developed the APAIS, which is a six-item questionnaire. The aim of this questionnaire was two-fold: To
identify those patients who are anxious and to identify the level of information required by each individual.[18]

The APAIS is a simple tool designed to be used in the clinical area. Each question has a five-point Likert scale ranging from
1 (not at all) to 5 (extremely) [Table 4]. Scoring is straightforward, and patients mark their feelings with regard to each
question. The tool allows the health-care professional to identify what the patient is feeling at that time.

The scores from questions 1, 2, 4, and 5 are added together to show the patient's level of anxiety, while the scores for
questions 3 and 6 are added together to identify the patient's need for information. A patient with a score of 11 or more on the
anxiety scale experiences anxiety. On the information scale, patients scoring 2-4 are classified as having little or no
information requirements, patients scoring 5-7 are classified as having an average information requirement and the patients
scoring 8-10 are considered as having high information requirements. Patients with a score of 5 or above should be given
information on the topics about which they wish to be informed and in accordance with their score. A score below 5 should be
a signal to provide the patient with no more information than is legally required. The main limitation of this scale is that the
tools do not distinguish well between fear of anesthesia and fear of surgery.
 Multiple Affect Adjective Check List
[Table 5]{Table 5}

The sign in parentheses indicates either an "anxiety present" (+) or "anxiety absent" (-) adjective. Patients are asked to tick
all those words which describe their feeling at the moment. One mark is scored for each of 11 "anxiety present" adjectives
selected and also for each of 10 "anxiety absent" adjectives not selected. The possible range of scores is therefore 0-21, with
higher scores indicating greater levels of anxiety [Table 5].

Linear Analog Anxiety Scale

Patients are asked to indicate on a 100 mm horizontal scale, between the limits "calm" and "terrified," how tense they feel at
that moment.

The objective methods are considered to be reasonably good indicators of preoperative anxiety though they may be
fallacious in patients suffering from systemic diseases such as hypertension, cardiac rhythm disturbances, or some
endocrine disorders. Moreover, they require monitoring team and financial expenditure. Subjective method is a sensitive and
accurate method of measurement of anxiety, but observer bias is inevitable in such a method of assessment.

Studies on Preoperative Anxiety

Various studies have been done to measure the preoperative anxiety using different scales. Millar et al. compared the three
measurements of anxiety to determine their equivalence in assessing anxiety before surgery. Forty-four patients awaiting
breast cancer surgery completed the state scale of the STAI, the HAD scale, and a 100 mm VAS. The authors concluded that
the scales were equivalent in their assessment of anxiety before surgery, but the reference to normative data was important
in establishing such equivalence and in determining the patient's state.[17]

Hicks et al. assessed preoperative anxiety using HAD scale, MAACL, and LAAS in 100 consecutive day care patients
undergoing the termination of pregnancy. The HAD scale was readily accepted and easily understood by the patients. There
was a high degree of correlation between the HAD scale and both the MAACL (correlation coefficient 0.74) and LAAS
(correlation coefficient 0.67). There was only a moderate degree of correlation between the HAD scale and the anesthetist's
assessment of anxiety (correlation coefficient 0.46) and concluded that HAD scale is a useful method of subjective
measurement of preoperative anxiety.[19]

Facco et al. validated VAS-A in preanesthetic evaluation.[20] Kindler et al. studied anxiety in 734 patients by means of VAS
and the State Anxiety Score of the Spielberger STAI. The mean STAI anxiety score was 39 ± 1 (n = 486) and the mean VAS
for fear of anesthesia was 29 ± 1 (n = 539). Patients feared surgery significantly more than anesthesia (P < 0.001). The VAS
measuring fear of anesthesia correlated well with the STAI score (r = 0.55, P < 0.01). Young patients, female patients, and
patients with no previous anesthetic experience or a previous negative anesthetic experience had higher anxiety scores.
Patients worried most about the waiting period preceding surgery and were least concerned about possible awareness
intraoperatively.[21]

Hernandez-Palazon et al. carried out a prospective longitudinal study on 300 cardiac surgery patients. The patients were
assessed regarding their preoperative anxiety level using VAS-A, APAIS, and a set of specific anxiety-related questions.
Ninety-four percent of the patients presented preoperative anxiety with 37% developing high anxiety (VAS-A ≥7). The
preoperative length of stay >2 days was the only significant risk factor for preoperative anxiety. A positive correlation was
found between anxiety level (APAISa ) and requirement of knowledge (APAISk ). APAISa and APAISk scores were greater
for surgery than for anesthesia. In addition, the results showed that the most common anxieties resulted from the operation,
waiting for surgery, not knowing what is happening, postoperative pain, awareness during anesthesia, and not awakening
from anesthesia.[22]

Maheshwari et al. evaluated preoperative anxiety in patients selecting either general or regional anesthesia for elective
cesarean section. The overall rate of anxiety was observed in 72.7% (112/154) patients. The rate of anxiety was significantly
high in patients of general anesthesia group as compared to regional anesthesia group (97.2% [69/7] vs. 51.8% [43/83]; P <
0.01). A statistically significant association with preoperative anxiety (VAS ≥50) was observed with factors such as age <25
years, working women, nulliparous and primiparous, no previous anesthesia experience, having previous anesthesia
experience under general anesthesia, and those having their source of information from nonanesthetists. The authors
concluded that anxiety was one of the reasons for refusing regional anesthesia and suggested that every patient coming for
the elective cesarean section should be assessed for the presence of anxiety in their routine preoperative anesthesia
assessment. This measure may help to reduce the anxiety and assist in making a rational decision regarding their choice of
anesthesia technique.[23]

Prevention and Treatment of Preoperative Anxiety

Patients preparing to undergo surgery should not suffer needless anxiety. Various steps have been taken to reduce
preoperative anxiety like the use of premedicant drugs, preoperative visit by anesthetist, counseling, and videos. Sedative
premedication is routinely administered to reduce preoperative anxiety. However, sedatives have their own side effects which
can be minimized by the use of nonpharmacological interventions.

Information about surgery reduces anxiety in the preoperative period.[24],[25] Preanesthetic consultation clinic could be the
right place to transmit the necessary information and clarify the patients' enquiries. A study conducted by Stephen et al.
demonstrated that consultation at the preanesthetic checkup clinic has a statistically significant positive effect on alleviating
patients' anxiety.[26] Preoperative visit by the anesthetist also plays a major role to relieve anxiety.[27]

Jlala et al. have reported the beneficial outcomes after presenting a video containing information concerning anesthesia to
patients before their surgery.[28] Synder-Ramos et al. compared three methods of conducting the preanesthetic visit. The
patients were randomized to a routine preanesthetic interview, a brochure plus an interview, or a self-made documentary
video plus an interview. These authors suggested that the use of a documentary video to supplement a patient interview
during the preanesthetic visit may be a more effective technique than a brochure or a personal interview alone for conveying
information to patients undergoing surgery.[29]

A systematic review was conducted to investigate the effectiveness of various preoperative educational interventions in
reducing preoperative anxiety. Twelve randomized trials involving a total of 1752 participants were included in the review.
Four studies used audiovisual, two trials used visual, two trials used multimedia supported education, one trial used a
website, two trials involved verbal education delivered by a psychologist or a nurse facilitator couplets with leaflets, and one
trial used information leaflets only. Eight trials demonstrated that preoperative education intervention reduced preoperative
anxiety significantly.[30] Acupressure has also been found to be effective in decreasing preoperative anxiety.[31]

Every patient requiring surgery should be assessed for the presence of anxiety in their routine preoperative anesthesia
assessment and the patient found to have a high level of anxiety should be scheduled for an additional counseling session
from the anesthetist.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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