REDUCING ANXIETY BEFORE SURGERY MAY 2002


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REDUCING ANXIETY BEFORE SURGERY

  • Getting ready for surgery

  • Information and interventions to help people cope can relieve anxiety before surgery

  • Relaxation techniques (including music) may help some people cope better with anxiety, but more research is needed

  • Anti-anxiety drugs (pre-medication) can help before surgery, but might not be offered to people having day surgery

  • Story, play and other ways that might help children (and their parents) cope with surgery

  • Sources and other information

    Getting ready for surgery

  • Anxiety and surgery

  • Decision making around surgery


    Anxiety and surgery

    When people face a very stressful situation, it can lead to anxiety or fear 1. Feeling anxious is a normal human feeling, but it can be accompanied by unwanted and distressing physical symptoms 1, such as palpitations (racing, pounding or irregular heartbeat), 'butterflies' or other stomach or gut responses, shortness of breath, nausea and difficulty falling asleep or staying asleep 2. These symptoms are not signs of serious physical problems, but the feelings themselves can add to anxiety.

    Anxiety is, naturally, very common around surgery, especially for a very serious condition and/or when a child is involved. The health problem itself that leads to surgery is often a cause of anxiety already. Added to that, being in hospital can cause anxiety, and people often have fears about surgery, needles or other painful procedures, being alone in hospital, anaesthesia and/or the operation's outcomes. People can also be afraid of the unknown, and of being embarrassed or being out of control. Being very anxious before surgery does not necessarily mean the person will have worse outcomes, or find it harder to recover from the operation 3. Being very anxious, though, can make it difficult for some people to understand or remember things they are told (which around surgery, will include information that may be vital to their recovery). This might be particularly true as people get older.

    People use a variety of different ways of responding to stress and anxiety in their lives, and these may be useful in facing surgery. For example, some people exercise or use relaxation techniques (such as deep breathing). Some try to remove or relieve anxiety by thinking or talking about the feelings or issues involved. Others use distraction techniques such as reading or listening to music to keep their minds off the problem. The anxiety some people feel, especially during the previous night and immediate hours before an operation, is quite severe, and they may need extra help to cope.

    There are three basic approaches towards reducing anxiety around surgery, both among the people having surgery and their friends and families:

  • Doing as much as possible to reduce the cause of fear (for example by providing information to lessen fear of the unknown, or to develop a plan ensuring the person gets adequate pain relief)
  • Minimise the distressing situations the person (or their family) has to cope with (for example, having a sedative before before procedures that might be upsetting, shortening the time people have to wait to get into hospital, minimising the wait in hospital before their operation or avoiding postponements of the operation)
  • Relieve the anxiety, or improve people's ability to manage it

    This Hot Topic looks at a variety of things people can do to cope themselves or to help someone they are supporting who is having surgery. It also describes some common strategies which may be available for them in hospital. These options include:

  • Information and coping strategies
  • Relaxation techniques, including music
  • Anti-anxiety drugs and other medications
  • Techniques specifically designed to help children cope

    People may need to consider a variety of issues around decision making, including whether the surgery is indeed necessary. Those issues are covered briefly in this Hot Topic.

    This Hot Topic on reducing anxiety before surgery is part of a series of Hot Topics about surgery. The first of these Hot Topics is already available. "Getting Ready for Surgery" looks at the impact of smoking, depositing blood ahead of surgery for one's own use, medicines and recreational drugs, routine pre-operative tests and planning for after-care. Other Hot Topics will be prepared in future on other aspects of health and medical preparation for surgery (such as fasting), anaesthesia and pain relief.

    There are several procedures that some hospitals will use to try to reduce people's anxiety, and help the patient and their family and friends cope with the process. For example, they may offer tours of the relevant parts of the hospital, or have special introductory programs. This might be offered, in particular, for children and parents.

    There may be a difference in the amount of anxiety involved, depending also on when during the day a person's operation is scheduled. It may be that being early on the operating list in the day reduces anxiety 4. This may be an important option for people who are particularly anxious and could become more and more upset during the day while they wait for surgery.

    The hospital may also be able to provide support for family and friends who may be anxious while someone (especially a child 4) is in the operating theatre. For example, they might be able to make sure that, if at all possible, a nurse or someone else talks to them about how the operation is going. They may make sure that people who will have to wait a long time know about facilities available to them (such as where to get food and drink, where to wait comfortably or where they can go for privacy if they become distressed). Although there are several ways to try to reduce anxiety for family and friends, we could identify no evidence from reviews on which methods might help. All the research in this Hot Topic relates to the patients themselves.

    There is also too little research about the specific needs of older people having surgery, especially for people with cognitive (thinking and memory) problems. Being out of their familiar environment may be enormously stressful, challenging and disorienting, requiring special care and support.

    The hospital should be able to help the patient prepare for what to expect while he or she is 'in recovery' (the time immediately after the surgery), and what will happen next 2. Family and friends may cope better if they know in advance the condition that person is likely to be in when they see her or him after the operation, know when they might get to talk to the surgeon, and who might be able to help care for their relative. If the hospital cannot provide someone to be at the patient's bedside while they are in hospital, it may be possible for a family member (particularly a parent or spouse) to stay with the person (especially when the patient is a child). Hospital policies around the world differ greatly on these matters, though.

    The hospital may have a variety of different support people who can help. Some will have counsellors, social workers, clergy (such as hospital chaplains, rabbis, sisters or nuns), Aboriginal liaison officers (or other cultural liaison personnel), patient advocates or psychologists. Any of these support people may be able to help patients and their families or friends get the most out of the institution's processes and facilities, or help them cope.


    Decision making around surgery

    Surgery is now so common that as many as one in 10 or 20 people in some countries have surgery in any one year 5. Surgery will often be vital to save a person's life or improve their wellbeing. However, not all surgery may be so worthwhile.

    The first question for many people in reducing the risks of surgery is to be sure that the surgery itself is really necessary.

    A government agency in the United States recommends consumers get a second medical opinion before having surgery, and has also produced a list of 12 questions they say consumers should ask before having surgery (with explanations of why these questions are important) 6. The list is available in English and Spanish. The National Safety and Quality Council in Australia has adapted information from this US agency, adding other tips for consumers to avoid harm from health care (see page 28 of that report).

    The value and usefulness of strategies such as these (using lists of questions and getting second opinions) and other decision-making and support strategies also need to be assessed scientifically. As reviews in these areas become available, we will produce Hot Topics on them. A Cochrane review is available on 'decision aids' (special tools to help a person make a decision on whether or not to have surgery or a screening test), but decision aids are not yet widely available.

    People can have many different decision-making options to consider before surgery, although there are not yet enough reviews in this area to help with these. These options include:

  • Negotiated care plans (discussing with care providers what a person's preferred options in certain situations would be)
  • Having notes about medical, personal or cultural issues put on their hospital records
  • Making decisions about privacy in relation to their family and friends (how much the person wants others to know about what is happening to them)
  • Living wills and advance directives (documents to record a person's wishes in case of certain events)
  • Medical guardians or enduring power of attorney (having someone formally designated to make decisions on a person's behalf when they cannot do so)

    Hospitals and clinics may also have information for patients and families about policies and facilities they have to try to help people through the experience of surgery. If the hospital or clinic has not provided practical information about policies and facilities (including facilities available to people who are waiting while someone is having surgery), then it might be worth asking. Being prepared to deal with practical issues (such as where to park a car) can help make the experience of hospitalisation easier, especially when the hospital (and the city or suburb in which it is located) is unfamiliar.


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    Information and interventions to help people cope can relieve anxiety before surgery

    While unquestionably some information may make some people more anxious, research has shown that in general, people having surgery do not get as much information as they would like 7. People may want a variety of types of information: information about procedures; what they might see and feel; and advice on how to cope 8. People may need to make various decisions and need information to help them choose between their options.

    A Cochrane review is underway on the effects of pre-operative information for people having hip or knee replacement surgery 9. There is no Cochrane review on pre-operative information generally. However, we have found six other reviews of a similar type that address information provision 8 10 11 12 13 14. The most recent was published in 2000 14.

    All but one of the reviews concluded that pre-operative information is generally beneficial. It reduces anxiety, pain and length of time in hospital, and improves people's satisfaction with their experiences 8 14. A review which looked at purely information interventions, that is, excluding any which involved educational or psycho-therapeutic interventions (but only looking at studies in English), found that there was not enough evidence to show that the interventions were effective (and not enough evidence to show whether they cause anxiety or other harm either).

    There are now around 200 trials of pre-operative information for various situations. Some of these studies (and the reviews) combine ordinary information-giving or education interventions, with behaviour change interventions (such as pamphlets which include statements aiming to help relieve anxiety, rather than simply to provide information). These behaviour change interventions (also called cognitive interventions 15) aim to affect how people think, such as using distraction, focusing attention away from the surgery and positive thinking. It can also involve imaging (imagining positive experiences), effective communication strategies, role plays and combinations of these kinds of techniques.

    Interventions sometimes include an audio or video tape which a person can use on their own, or an instructional pamphlet, or there might be one-to-one or group instruction. An example of one of these interventions is a coping pamphlet addressing general worries by providing positive statements for people to repeat to themselves such as "Many thousands of people have general anaesthesia each year, they do well and so will I" 14. Unfortunately, all but one of the reviews do not clearly differentiate between information provision and these other kinds of interventions where the information is designed to achieve a certain effect, other than increasing knowledge. It is all generally included in the term 'information'.

    Despite all these trials and the several reviews, there are many problems with the existing research, and many important questions remain unanswered 16. For example, while reviewers have concluded that there is enough evidence to show the value of at least some kinds of pamphlets, there is not yet enough evidence on the use of videos or computer-assisted instruction 14. There are also major areas of health care, such as heart disease and cancer, for which sufficient evidence does not yet exist to enable conclusions to be drawn 8.

    There is also too little information on the needs of older people. There are many things to learn and remember when having surgery, and to ensure best possible recovery. The same techniques that work for younger people may not be as useful for older people.

    Many different approaches to pre-operative education have been used, including 14:

  • Group lectures (either a single lecture or a series)
  • One-to-one, individual teaching
  • Printed information in pamphlets, booklets or books
  • Learning packages
  • Audio-visual presentations
  • Combinations of some or all of these

    Some information pamphlets that were given to people before admission to hospital have been shown to improve their knowledge, and to increase the likelihood that they will follow recommendations on, for example, exercising after the operation 14. One review suggests that information and educational interventions are more effective when they are given before admission to hospital, rather than after the surgery 14. Although there are still many unanswered questions about the effect of information on people's anxiety, none of the reviews raised concerns that the information itself actually increased people's anxiety. However, even if pamphlets, for example, can be valuable for some people, other people will not read them 17. Other strategies might be needed to both provide information and reduce anxiety.

    As well as formal attempts to provide information, people having surgery may be exposed to many other pieces of information, or comments, which may make them anxious. Sometimes, when people are preparing for surgery, others tell them their surgery 'war stories', or talk about things that might go wrong, and this can cause anxiety. Contradictory and confusing information from different health care practitioners might also cause anxiety. It may be worthwhile, when people have heard something that scares them, to speak with a health care practitioner, to be sure that the information causing concern is accurate.


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    Relaxation techniques (including music) may help some people cope better with anxiety, but more research is needed

  • Aromatherapy and herbal remedies (covered in the next section )
  • Massage and reflexology (a particular type of foot massage)
  • Humour
  • Guided relaxation
  • Music

    There is some evidence from a review that massage may relieve anxiety in people in hospital or other health care institutions 19. However, we could find no strong evidence about massage which looked specifically at people getting ready for surgery. A review of massage in hospitals and institutions showed that massage used to be a routine part of afternoon or evening nursing care for all hospital patients, in many hospitals. It seems to have gone out of general use since the 1970s 19. The opinion of the people who did this review is that the practice should be re-introduced.

    There is also a small amount of evidence from a review to show that reflexology (a particular type of foot massage) may help relieve anxiety 20. There are no reviews that look at humour as an intervention for the relief of pre-operative anxiety, but there has been at least one trial which showed no benefit from listening to a funny tape while waiting for day surgery 21.

    We did not identify any review of hypnosis to reduce anxiety before surgery, although there is at least one trial (which showed some benefit) 22. Without a proper search for all such trials, and a review of them, it is not possible to come to any conclusions about whether hypnosis is likely to help.

    We did not identify any reviews of research into specific relaxation techniques for people having surgery. There have been some individual pieces of research, though, on some techniques, for example, tapes of guided imagery to prepare for surgery. Guided imagery involves a person, either in person or on tape, leading the patient through an imaginary series of events about the operation they will have. This positive scenario is designed to increase their confidence and replace fearful imaginings.

    In one trial, people having bowel surgery listened to guided imagery tapes in the three days before their surgery as well as during anaesthesia, through the surgery and afterwards 23. This lowered their anxiety considerably, as well as their need for pain medication. A review is needed to be sure whether this might work for others. In contrast, another type of intervention (a tape with positive suggestions) did not work in at least one trial 24.

    Teaching relaxation techniques is usually only offered once a person is already in hospital. Yet, it may be that the most anxious day for many people is the day before they go into hospital 18. People having day surgery may be even more anxious than others, possibly because of not having enough time to settle into the hospital environment 18. They may also miss out on some of the information and pre-surgery visits that an inpatient in the hospital would get 18.

    There are also guided progressive relaxation tapes, which teach people how to relax. These are audio-tapes which take the listener through the steps of muscle relaxation, deep breathing and/or meditation. In discussing why day surgery patients benefited in their trial of a guided relaxation tape, the researchers suggested that the effect of distraction itself may be valuable 18. In other words, lying in a hospital bed waiting, perhaps with nothing to think about apart from the surgery ahead, creates anxiety. However, it needs to be an effective distraction. In that trial, the people who listened to the relaxation tape enjoyed it. They were compared with another group of people whose attention was distracted by being read to: all of whom said it was a boring story and was not worth listening to.

    There is no strong evidence to show that any particular type of relaxation method or tape is likely to be beneficial. There are many tapes on the market, and several websites sell tapes that have been made especially for people having surgery.

    People have tried music, either for the whole room or ward, or by using a 'walkman' personal audio-tape player) to relieve anxiety in the following ways:

  • Each day leading up to the surgery (as well as afterwards) 25
  • For children before surgery 26 27
  • The night before surgery 28
  • In the operating room's holding area 29 30
  • During the administration of anaesthetic 31 or during painful or distressing procedures (not part of this Hot Topic)
  • While having surgery awake (with epidural or spinal anaesthesia which only puts the lower half of the body under anaesthesia) 32 33 34
  • While under general anaesthetic 35 36

    There are also several trials of music used after surgery, but these are not discussed here (anxiety after surgery is not the subject of this Hot Topic).

    Theories about the possible effects of music are that music itself (or some particular types of music) might be calming and relaxing, or that some music may have pleasant connotations (meanings or memories) for people. However, it has also been suggested that some music or songs could promote tension rather than relaxation, and that familiar music may sometimes have unhappy connotations 37. Other researchers have concluded that it does not matter whether the music is chosen by the person having the surgery (and so is a personal favourite), or if it is chosen by someone else 38.

    It has been suggested that music has a beneficial effect simply because it blocks out the sounds of the hospital or operating room 39. It might also help by helping people sleep better 35, or distracting them from their anxious thoughts 18.

    Trials in which people having surgery listen to music have generally showed some reduction in anxiety, as well as other effects (such as less tiredness and need for painkillers). However, not all trials show a benefit 40. We could not find any reviews that assess thoroughly the effects of music for people having surgery.

    Some people promote particular types of music (such as mood music, 'calming' music, music with no lyrics, classical music or music played by a harp or sitar). However, in the absence of a review, there is no strong evidence to show that any particular music should be avoided or chosen.


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    Anti-anxiety drugs (pre-medication) can help before surgery, but might not be offered to people having day surgery

  • Anxiolytics (anti-anxiety) medication (commonly called tranquilisers or sedatives), often referred to as pre-medication
  • Drugs to help people get to sleep (especially the night before the operation)
  • Aromatherapy or herbal preparations (such as kava, St John's wort, valerian or Bach flower 'Rescue remedy')
  • Recreational drugs (such as alcohol)

    When people are admitted to hospital the night before the operation, it is common for them to be offered a drug to help them sleep, or a tranquiliser of some sort if they are anxious. The most common of these anxiolytic (anti-anxiety) drugs is benzodiazepine. Pre-medication with one of these drugs before being prepared for anaesthesia is common, as a distressed person may have greater needs for anaesthesia and the process may be more difficult as a result 18.

    However, when people are having day surgery (coming in for the surgery and returning home the same day), it is common not to offer any anxiety-reducing pre-medication. Cochrane reviewers have suggested this practice developed for two reasons. Firstly, day surgery used to be only for very minor procedures, and it was assumed people would not be anxious about these. However, day surgery has become more common for a wider variety of procedures, and more people having day surgery would like medical help for anxiety 41. The second reason people having day surgery are often not offered medication for anxiety is a fear that it may make them too sleepy to return home straight after the operation.

    The Cochrane reviewers concluded that more research is needed to determine the best option for adults having day surgery. There is currently no Cochrane review specifically addressing children's needs. However, while more research is needed, existing evidence shows that some forms of pre-medication for anxiety do not necessarily delay people's recovery from surgery. Pre-medication for anxiety can be given one or two hours before surgery, or at the time anaesthetic is started. The Cochrane reviewers suggested that some forms of medication (such as midazolam and diazepam in 15mg doses) might interfere with people's quick recovery, and that a particular group of anti-anxiety drugs (the beta-adrenoceptor blockers) may be preferable.

    While these forms of anti-anxiety medication may not interfere with people's recovery, other forms of medication might cause problems. Smoking to relieve stress before an operation, for example, increases the chances of complications from surgery (see the Hot Topic on Getting Ready for Surgery). The effects of alcohol may also cause problems. Some herbal medicines, including St John's Wort, kava and valerian, might prolong the impact of anaesthetic and slow down a person's recovery 42 43. Kava, which is a common ingredient in herbal mixtures to aid sleep and/or reduce anxiety, has been withdrawn from sale in Germany and Switzerland because of concerns about its safety 44. Regulatory authorities in the US are also considering the safety of kava generally 44. This is because of concerns that kava sometimes has toxic effects on the liver.

    Dependence on drugs may also have an effect on pain relief needs. Health care practitioners who are familiar with the recreational or addictive drugs (including alcohol) their patients are using can better provide care around surgery.

    Aromatherapy aims to produce a soothing effect, usually by burning essential oils to release their scent into the air. It is a possible alternative to conventional pre-medication and should be studied 45. There has been a review of the effects of aromatherapy (alone or with massage) 46. Although there were problems with the quality of the research that was reviewed, the reviewers concluded that people find aromatherapy to be pleasant for people and that it can reduce anxiety slightly in the short term. (Geranium oil was the scent used in the trial anxiety, although it was not specifically for anxiety about surgery.)

    There is a Bach flower remedy (a very diluted herbal substance in a small amount of brandy) called 'Rescue remedy'. It is intended for adults and children to relieve intense anxiety or fear. We could find no review of rescue remedy for surgery or any other purpose. Two trials of rescue remedy in students facing examinations found that both the remedy and a placebo it was compared with had a small effect, but the rescue remedy was no better 47 48. However, a thorough search for all trials and a review is needed to come to any reliable conclusions about rescue remedy.

    From the Cochrane review:
    AF Smith, AJ Pittaway. Premedication for anxiety in adult day surgery


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    Story, play and other ways that might help children (and their parents) cope with surgery

    In many countries, hospitals have adapted in recent years to make surgery as free of trauma and pain as possible for children, and their parents. Surgery will often be done on a same day basis, with the parents staying with their child until she or he is under the anaesthetic, and being at their side when they wake. When children have to stay in hospital overnight, at least one parent will often be allowed or encouraged to sleep over with them. However, this is not the case everywhere. Even having a parent with a child during premedication and induction of anaesthesia (starting the anaesthetic) which can be very distressing for children particularly, is routine in some places, but not others 49. Keeping a parent (or someone else familiar to the child) with the child for as long as possible is a major part of reducing children's anxiety when they are in hospital 49.

    The range of interventions covered in this Hot Topic may all be options for children as well as adults. There is not as much evidence, however, about the effects of these interventions for children as there is for adults. We could find no reviews that specifically address children's experiences while facing surgery, or the best ways to help children cope. There have been trials of music alone and dimming lights and playing music while inducing anaesthesia for children 26 27 , and teaching coping and relaxation skills to parent and child pairs 50. The people in those trials were helped by the techniques, but a review is needed to draw reliable conclusions about these strategies.

    There are also several anxiety-reduction strategies that have been developed especially for children, usually centring on story-telling, play, art or puppets. Story-telling, story books and puppet shows are particularly used to help prepare children for the experiences they will have, and to help them understand medical procedures and equipment. Trials have been done on play therapy (for children aged three or four years 51, and for children from five to 11 52) and using puppets for hospitalised children 53. Interventions such as these are very popular, but we could find no review to show how well these work.

    Hospitals may also have special story books that can be borrowed to help prepare a child for an operation. Some children's hospitals have special art programs and entertainment programs, including special TV and radio channels for children in hospital (see for example The Children's Hospital at Westmead below). Some stories (including ones based on puppet preparations) are available on websites of children's hospitals. People could contact their local or regional children hospitals for ideas and resources, including hints for parents and children. Some children and teenagers are now developing websites of their own, sharing experiences and resources around being in hospital and having surgery.

    Note to readers: If you have examples of websites you have found helpful, please tell us about them by posting a message on the comments section.

    Some examples of what is available from hospitals and similar agencies on the Internet can be found at:

    Information for parents

    The Children's Hospital Westmead, Australia (in the parents' section, "Your child in hospital")

    The Women's and Children's Hospital, Australia ("If your child is having surgery")

    Canadian Child Care Federation (When a child is hospitalized")

    The Credit Valley Hospital, Canada ("Just for Parents: Some Tips")

    The Hospital for Sick Children, Canada ("Getting ready for an operation")

    Information for children

    The Women's and Children's Hospital, Australia

    ("Check it Out")

    Online stories for children about tonsillectomy, Canada

    The Credit Valley Hospital, Canada ("What Happens at the Hospital")

    Children's Mercy Hospital, USA ("Mercy Bear's Big Adventures")

    Children's Hospital of Buffalo, USA ("Kids Department")


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    Sources and other information

  • Authorship and disclaimer

  • Cochrane reviews used in this Hot Topic

  • References external to Cochrane Consumer website:


    Authorship and disclaimer

    This Hot Topic was last amended on 30 May 2002.

    This Hot Topic was written and produced by Hilda Bastian, with the assistance of Sabrina Gupta, for the Cochrane Collaboration Consumer Network (Inc). This Hot Topic was sponsored by Medibank Private Ltd. Copyright: Cochrane Collaboration Consumer Network (Inc).

    Thanks to the Cochrane review group on Anaesthesia, who prepared the Cochrane review used in this Hot Topic, and to the Cochrane Field on Older People who also helped ensure that the experiences and needs of older people were reflected in this Hot Topic.

    Thanks to the people who generously reviewed and improved the draft of this Hot Topic: Mike Clarke, Kathel Dunn, Sally Green, Rosanne Leipzig, Steve McDonald, Philippa Middleton, Maryann Napoli, David Potter, Elizabeth Royle, Silvana Simi, Andrew Smith, Vasily Vlassov, Janet Wale, Penny Waterson and Amy Zelmer.

    Disclaimer: The information is for general use, and is not intended to substitute for professional advice. The information comes from Cochrane Collaboration reviews of evidence and other sources as outlined below. The opinions are those of the author, and are not necessarily shared by the Cochrane Collaboration, the Consumer Network or Medibank Private Limited.

    The Cochrane Collaboration is a charity, registered in the United Kingdom. The Consumer Network is a non-profit association, registered in South Australia.


    Cochrane reviews used in this Hot Topic

    Cochrane reviews are scientifically rigorous summaries and analyses of the results of clinical trials of health care interventions, published on The Cochrane Library. The content of each Cochrane review has been assessed by people who have considered carefully the relevant research in the area under review. Scientists, doctors and other health care practitioners, and consumers have been involved in the preparation and assessment of the quality of Cochrane reviews. Scientific summaries (abstracts) and consumer summaries where available are published on the Cochrane Collaboration Consumer Network's website at:

    http://www.cochraneconsumer.com/

    Cochrane review used in this Hot Topic

    From the Cochrane review:
    AF Smith, AJ Pittaway. Premedication for anxiety in adult day surgery


    References external to Cochrane Consumer website:

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