What is the best approach to manage anxiety in hospitalized patients, particularly older adults or those with pre-existing medical conditions, to reduce anxiety-associated mortality?

Management of Anxiety in Hospitalized Patients to Reduce Mortality

Routinely assess anxiety levels in all hospitalized patients, particularly those with acute coronary syndromes, and manage with behavioral interventions and short-term anxiolytic medications when indicated, as anxiety predicts in-hospital complications and cardiac events within the first year. 1

Evidence for Anxiety-Associated Mortality Risk

The relationship between anxiety and mortality in hospitalized patients varies significantly by clinical context:

• In acute MI patients, anxiety prevalence reaches 40% or more during hospitalization, with 15-20% reporting persistent anxiety one year post-discharge. 1 Among older coronary artery disease patients (mean age 68 years), the age-adjusted hazard ratio for anxiety was 1.97 (95% CI 1.03-3.78) for nonfatal MI or death. 1

• Critical distinction: Meta-analyses demonstrate that anxiety's association with mortality becomes nonsignificant after adjusting for clinical covariates in post-acute coronary syndrome cohorts, but remains significant in stable CAD patients. 2 This suggests anxiety screening and intervention should target the stable outpatient period rather than the acute hospitalization phase alone.

• In-hospital consequences: Anxiety predicts recurrent ischemia, arrhythmias during hospitalization, and cardiac events during the first year after MI. 1

Immediate Assessment Protocol

Screen all hospitalized patients with cardiac conditions using standardized tools to quantify anxiety severity and guide treatment intensity:

• Use the GAD-7 (Generalized Anxiety Disorder-7) for systematic assessment, which has sensitivity of 57.6-93.9% and specificity of 61-97% for anxiety disorders. 3
• Assess for comorbid depression, as depression carries stronger mortality associations (2-4 times risk of all-cause mortality) and often coexists with anxiety. 1 Older depressed post-MI patients have up to four times the risk of dying four months after discharge. 1
• Treat depression first when both conditions are present at moderate-to-severe levels, as anxiety symptoms often improve with depression treatment. 4

Treatment Algorithm for Hospitalized Patients

Acute Hospitalization Phase

For short-term anxiety management during hospitalization:

• Behavioral interventions are first-line: Implement stress reduction strategies including progressive muscle relaxation, provide informational support about the diagnosis and treatment plan, and offer referral for counseling. 1

• Anxiolytic medications are reasonable for short-term use to alleviate acute anxiety or altered behavior related to hospitalization. 1 However, avoid benzodiazepines as primary treatment in older adults due to cognitive impairment, fall risk, and lack of depression treatment. 1, 4

• For elderly hospitalized patients with agitation: Use haloperidol 0.5-1 mg orally at night and every 2 hours as needed, or lorazepam 0.25-0.5 mg orally four times daily as required, only after addressing reversible medical causes (pain, hypoxia, urinary retention, infections, dehydration). 5

Transition to Outpatient Management

Establish a structured follow-up plan before discharge to address persistent anxiety and reduce long-term mortality risk:

• Initiate SSRI pharmacotherapy (sertraline, escitalopram, or paroxetine) as first-line agents for anxiety disorders, which show small to medium effect sizes compared to placebo (SMD -0.55 to -0.67 for generalized anxiety and social anxiety disorder). 4, 3

• Refer for cognitive behavioral therapy (CBT) delivered by licensed mental health professionals using manualized protocols, which demonstrates large effect sizes for generalized anxiety disorder (Hedges g = 1.01) and small to medium effects for panic disorder (Hedges g = 0.39). 4, 3

• Provide comprehensive psychoeducation to patients and families about anxiety symptoms, treatment options, stress reduction techniques, sleep hygiene, and available supportive care services. 1, 4

Monitoring and Treatment Adjustment

Implement structured follow-up at specific intervals to prevent treatment failure:

• Week 4 assessment: Evaluate symptom relief using GAD-7 and assess medication adherence, side effects, and barriers to mental health referrals. 1, 4

• Week 8 assessment: If symptoms show little improvement despite good adherence, modify the regimen immediately by adding psychological intervention to pharmacotherapy, switching SSRI class, or transitioning from group to individual therapy. 1, 4

• Monthly reassessment until symptoms subside, as patients with anxiety pathology commonly fail to follow through on referrals due to avoidance behaviors. 1

Critical Pitfalls to Avoid

• Do not ignore comorbid depression, which has stronger mortality associations than anxiety alone and requires prioritized treatment. 1, 4

• Do not use benzodiazepines as primary long-term treatment in older adults, as they cause cognitive impairment, falls, fractures, and do not address underlying depression. 1, 4

• Do not delay treatment of anxiety in stable CAD patients, as this population shows persistent mortality associations even after covariate adjustment, unlike post-ACS patients. 2

• Do not overlook social support assessment, as emotional support is a powerful predictor of survival after MI—55% of patients without support died at 1-year follow-up compared to 27% with two or more sources of support. 1