Abstract

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 = 48.7 years, SD = 13.6). Reliability of the APAIS was high; Cronbach's alpha = 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 = 0.02) and those who had never sustained surgery were more anxious than those who previously had surgery (p = 0.05).

An anesthetist's visit and premedication reduced total anxiety scores (Z = −3.07, p = 0.002) and anesthesia related anxiety scores (Z = −3.45, p = 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.

Keywords

anxiety; The Amsterdam Preoperative Anxiety and Information Scale; preoperative care;

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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 anxiety–provoking 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%–80% 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

In recent years, with more emphasis on day–case 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 non–anxious 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

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 1–3 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 1–5 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 = 0), while the extreme right was marked as "maximum anxiety” (score = 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 Mann−Whitney 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 = 48.7 years, SD = 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.

Reliability of the APAIS was high, with Cronbach's alpha = 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 = 0.02). Those who had experienced surgery before were less anxious (p = 0.05). Females who had surgery/anesthesia before were less anxious than those who had never experienced surgery/anesthesia (p = 0.011 and p = 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 = −3.07, p = 0.002) and anesthesia related anxiety scores (Z = −3.45, p = 0.001). However, there was no change on the information requirement (Z = −1.75, p = 0.07) and on surgery related anxiety (Z = −1.69, p = 0.09).

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 patient-based 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 = 0.565, n = 34),¹⁸ Nishimori et al¹³ (r = 0.67, n = 126), Moerman et al⁸ (r = 0.74, n = 200), Miller et al¹⁹ (r = 0.82, n = 85) and Boker et al²⁰ (r = 0.63, n = 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 highly-informed 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

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 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.