Preoperative Anxiety Levels in Surgical Patients: A Comparison of Three Different Scale Scores

Preoperative psychological distress is associated with mortality within 1 year of non-cardiac surgery

OBJECTIVE

To characterize the association between preoperative psychological distress and postoperative complications at 30 days and mortality at 1 year in a non-cardiac surgery sample.

METHOD

Data were taken from a subsample of the VISION cohort study (n = 997; 2011-2012). Participants were scheduled to undergo major non-cardiac surgery under general or regional anesthesia. Participants self-reported past 30-day psychological distress on the day of surgery using the Kessler-6 (K6) Scale. Complications were assessed via interviews and/or chart reviews. Multivariable logistic regressions characterized the relationship between preoperative psychological distress and postoperative complications. Models were fitted for sociodemographics, surgery type, preoperative medical morbidity, and smoking.

RESULTS

Among participants with a completed K6 (n = 938), 7.9 % experienced mortality within 1 year. After controlling for age, ethnicity, sex, surgery type, preoperative medical morbidity, and smoking, higher levels of preoperative psychological distress were associated with 30 day complications such as myocardial infarction, non-fatal cardiac arrest, leg/arm deep vein thrombosis/ pulmonary embolism, new acute renal failure, pneumonia, and congestive heart failure (AOR3 (3rd model), 1.12, [95 % CI, 1.02-1.22, p < 0.05]) and 1-year mortality (AOR3, 1.09, [95 % CI, 1.02-1.18, p < 0.05]). Sensitivity analyses demonstrate that the latter association was being driven by symptoms of depression (AOR3, 1.17 [95 % CI 1.04-1.33, p < 0.05]) but not anxiety (AOR2, 0.94 [95 % CI, 0.61-1.62, p > 0.05]).

CONCLUSION

Elevated preoperative distress increased the risk of 30-day complications and mortality at 1 year. These results underscore the need for future research to examine if supporting patients' mental health during the perioperative period can mitigate risk.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov, no. NCT00512109 (main VISION study).

Perioperative Anxiety: Current Status and Future Perspectives

Perioperative anxiety is a multifaceted phenomenon that significantly impacts patients undergoing surgical procedures. Despite advancements in surgical techniques and anesthetic management, the psychological burden associated with anesthesia and surgery remains a significant challenge for healthcare providers. Up to 30% of patients suffer from anesthesia-related preoperative anxiety, irrespective of whether the procedure is elective or emergent. Notably, anxiety can adversely affect patient outcomes, including pain management, patient safety, overall quality of care, and patient satisfaction. Addressing perioperative anxiety requires a comprehensive understanding of its causes, assessment tools, and management strategies to ensure optimal perioperative care. This review examines the historical context, incidence, causes, pathophysiology, assessment tools, and current evidence regarding management strategies for anesthesia-related anxiety, and provides an outlook on future directions for research and everyday practice.

Non-Pharmacological Interventions Before Cataract Surgery for Preoperative Anxiety: A Systematic Review and Meta-Analysis

AIM

The present study was conducted to determine the effect of non-pharmacological interventions before cataract surgery on preoperative anxiety.

DESIGN

Systematic review and meta-analysis.

METHODS

Five databases were systematically searched until 9 June, 2024. The risk of bias was evaluated using the ROBIN-I instrument for non-randomised studies and risk of bias 1 (ROB1) for RCTs. For cases with heterogeneity, random effects, rather than fixed effects, were reported, and subgroup analysis was performed based on the type of intervention. The investigation of publication bias was done in the form of a funnel plot, the Egger regression test and the Trim-and-Fill test. Meta-regression analysis was performed to examine the impact of possible confounding factors on the effect size. Sensitivity analysis evaluated the robustness of our findings by excluding quasi-experimental studies and applying the Knapp-Hartung method to assess their influence on the overall results.

RESULTS

A random-effects meta-analysis of 22 studies and 1998 participants revealed that non-pharmacological interventions (back massage, hand massage, foot massage, music, educational video, patient education, aromatherapy and relaxation techniques) significantly reduced mean preoperative anxiety compared to the control group. The subgroup analysis indicated that all interventions were effective in reducing preoperative anxiety; however, hand and foot massage did not yield significant effects. Meta-regression analysis showed a significant correlation between the percentages of women with effect size. The sensitivity analysis confirmed the robustness of non-pharmacological interventions, while the Knapp-Hartung method maintained the overall effect size but indicated wider confidence intervals. More high-quality research is needed to validate these interventions and establish clearer guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Use of virtual reality in preoperative education of cardiac surgery patients - A feasibility study

OBJECTIVE

A Virtual Patient Tour (VPT) was developed to inform cardiac surgery patients about their hospitalization from the admission to their postoperative stay on the ward. The objective of our study was to assess the feasibility and acceptability of this VPT following the framework of the Virtual Reality Clinical Outcomes Research Experts Committee.

METHODS

In this single-centre cross-sectional study, adult patients admitted to the hospital for elective cardiac surgery were included. Acceptability, usability, and tolerability were measured by the validated questionnaires Unified Theory of Acceptance and Use of Technology (acceptability), System Usability Scale (usability), and Virtual Reality Sickness Questionnaire (tolerability). Descriptive statistics were used for the analysis.

RESULTS

Twenty-eight participants used the VPT. Results showed high acceptability (mean 16.7 ± 1.5), acceptable usability (mean 86.7 ± 9.3), and high tolerability (sickness score, median 7.1 % [0-17.1 %]).

CONCLUSION

The use of the VPT is a feasible and promising technique. The next step is to optimize the content and technique of the VPT based on the suggestions of the participants.

PRACTICE IMPLICATIONS

We recommend incorporating the VPT into preoperative patient education in addition to the routine information in cardiac surgery patients.

Cross-sectional and Correlational Examination of Patients' Preoperative Anxiety, Information Need, and Health Literacy in a Presurgical Consultation

PURPOSE

This study elucidates the preoperative anxiety (PA), information need (IN), and health literacy (HL) levels of an elective preoperative sample in Switzerland and examines the possible associations between PA and the patients' characteristics. By knowing these patient dimensions, which can influence perioperative outcomes, one can tailor individualized nursing interventions to improve patients' surgical experience.

DESIGN

This was a cross-sectional and correlational study.

METHODS

The sample consisted of 88 patients who underwent a preoperative consultation at a Swiss tertiary hosptial. Patients' PA and IN were assessed using the Anxiety Preoperative and Information Scale, and their HL was measured using the Functional, Communicative, and Critical Health Literacy Scale. Data on other patient characteristics were collected from the patients, physicians, and electronic patient records. Association tests, as well as univariate regressions, were performed on PA, IN, HL, and patient characteristics.

FINDINGS

Among participants, 40.91%, 78.41%, and 59% reported having PA, IN, and low HL, respectively. Finally, PA was associated with IN, HL, solitary living, and the American Society of Anesthesiology score.

CONCLUSIONS

A high proportion of patients scheduled for presurgical consultation were found to be anxious. They presented high IN and low HL. An examination of patients' PA-associated characteristics can help improve their surgical experience. More studies should examine PA-associated characteristics.

Factors related to preoperative anxiety in older patients with sensory impairment: A cross-sectional study

AIM

To identify the factors related to preoperative anxiety in older adults with sensory impairment.

DESIGN

Descriptive quantitative research design.

METHODS

Study participants were 120 older adults admitted to a tertiary hospital in Seoul, South Korea to undergo eye or ear surgery. Data were collected from 11 February to 30 April 2023. The collected data were analysed using descriptive statistics, t-tests, ANOVA, and multiple regression analysis using SPSS 28.0. The study was reported following the STROBE checklist.

RESULTS

Preoperative anxiety differed significantly according to gender (p = .002), average monthly household income (p < .001), subjective health status (p = .003), subjective vision loss (p = .004), one-sided or both-sided eye discomfort (p = .002), use of glasses (p = .010), subjective hearing loss (p = .022) and anxiety coping mechanisms (p < .001). The results of a multiple regression analysis on the significant variables identified that gender (β = .178, p = .036) and anxiety coping mechanisms (β = .336, p < .001) had the most significant effect on preoperative anxiety, with an explanatory power of 34.5%.

CONCLUSION

The development and practical application of tailored nursing interventions catering to specific genders and anxiety coping mechanisms would contribute to reducing preoperative anxiety and providing efficient nursing care for older adults with sensory impairment.

The translation and validation of the surgical anxiety questionnaire into the modern standard Arabic language: results from classical test theory and item response theory analyses

BACKGROUND

Preoperative anxiety is commonly found in patients who are waiting for surgery and can lead to negative surgical outcomes. Understanding the sources of surgical anxiety allows healthcare providers to identify at-risk patients and implement psychosocial interventions such as counseling, relaxation techniques, and cognitive‒behavioral therapy to minimize anxiety. Few comprehensive psychiatric measures are available to assess preoperative anxiety in Arabic.

OBJECTIVE

Our study aimed to translate, adapt, and validate the Surgical Anxiety Questionnaire (SAQ) into the modern standard Arabic language, also known as Fusha al-Asr Arabic.

METHODS

To translate the questionnaire, the research team used the gold standard process of forward translation by two independent translators along with back translation evaluation by four trained medical doctors. A cross-sectional study was conducted using an online survey completed by 208 Arabic speakers (mean age 38 years, 44% women) from four countries. Psychometric analyses, which included internal consistency, test-retest reliability, convergent validity, confirmatory factor analysis, and item response analysis, were performed. Convergent validity tests were performed against the Generalized Anxiety Disorder 2-item Scale (GAD-2), Patient Health Questionnaire-4 (PHQ-2), Perceived Stress Scale 4 (PSS-4), and Arabic version of the Visual Analog Scale for anxiety (VAS-A).

RESULTS

The mean SAQ of our sample was 19.38 ± 12.63 (possible range 0-68). The Arabic SAQ translation demonstrated excellent internal consistency, with McDonald's omega and a Cronbach's alpha of approximately 0.90. The test-retest reliability was also high, with an intraclass coefficient of 0.94. The SAQ showed strong convergent validity against the GAD-2 (r = 0.94, p < 0.01). The SAQ also showed weak-moderate correlations with the PHQ-2 (r = 0.26, p < 0.01), PSS-4 (r = 43, p < 0.01), and VAS-A (r = 0.36, p < 0.01) scores. The original three-factor structure was supported by confirmatory factor analysis, confirming the original structure reported in the original English language version. The results for fitness indices showed acceptable preliminary results (CFI/TLI approximately 0.90), and deleting some items improved the model fit (CFI/TLI > 0.90, RMSEA < 0.08). We suggest retaining the original factorial solution until further validation studies can be conducted. The item response theory (IRT) results identified no items that were excessively difficult or subject to guessing. The multidimensional IRT provided evidence that the SAQ items form a multidimensional scale assessing surgical anxiety that fits the classical model reasonably well.

CONCLUSION

The SAQ has demonstrated acceptable reliability and validity; thus, it is a trustworthy and valid tool for evaluating preoperative anxiety in Arabic speakers. Future research could benefit from using the SAQ in both surgical and psychiatric research.

The Effect of Lidocaine-Prilocaine Cream Combined with or Without Remimazolam on VAS and APAIS Anxiety Score in Patient Undergoing Spinal Anesthesia

Purpose

This study aimed to investigate patients' expectative pain of spinal anesthesia puncture and anxiety pre-anesthesia, and to examine the effect of lidocaine-prilocaine cream and remimazolam prior to spinal anesthesia puncture on pain relief and anxiety release.

Methods

Patients undergoing spinal anesthesia were divided into control, lidocaine-prilocaine cream, and lidocaine-prilocaine cream with remimazolam groups. A questionnaire consisting of The Amsterdam Preoperative Anxiety and Information Scale (APAIS) and patient's concerns and Visual Analog Scale (VAS) was used to evaluate patient's anxiety and pain. The primary outcomes were differences in VAS and anxiety scores. Patient's spinal anesthesia-related concerns, advent events and hemodynamic index were also recorded.

Results

The expected spinal anesthesia puncture pain was 5.34±0.27 and anxiety scores before spinal anesthesia was 10.88 ± 0.64. A statistically significant positive correlation of 31.3% was detected between VAS and APAIS scores (r = 0.313; P=0.003). The VAS score at the time of puncture decreased by 29.7% (3.78±0.40, P=0.001) in lidocaine-prilocaine cream group and 29.2% (3.75±0.39, P=0.001) in lidocaine-prilocaine cream with remimazolam group compared with the expected VAS score. Lidocaine-prilocaine cream combined with or without remimazolam reduced the percentage of moderate pain (21.4% and 31.3% vs 50.0%, P=0.0001) and increased mild pain (60.7% vs 59.4% vs 22.7%, P=0.03). Anxiety score in lidocaine-prilocaine cream group was reduced by 2.84 (8.04±0.76 vs 10.88 ± 0.46, P=0.05) when compared with pre-anesthesia. Concerns about postoperative pain (P=0.03) and fear of the needle or intervention (P=0.000) both decreased post-anesthesia among groups.

Conclusion

Approximately half of the patients scheduled for spinal anesthesia experienced a moderate level of preoperative anxiety. The patient's pain expectation from the spinal anesthesia puncture was moderate, which was higher than the actual pain. Lidocaine-prilocaine cream with or without remimazolam sedative before spinal anesthesia puncture reduced the patient's pain and anxiety scores after surgery.

Psychometric Properties of the Turkish Version of the Surgical Anxiety Questionnaire (SAQ)

PURPOSE

This study aimed to determine the psychometric properties of the Turkish surgical anxiety questionnaire (SAQ) version.

DESIGN

This study design was methodological.

METHODS

The study was evaluated with construct validity, exploratory (EFA) and confirmatory factor analysis (CFA), and convergent and discriminant validity. For scale reliability, internal consistency, Cronbach Alpha Coefficient, Pearson Correlation Analysis, and Inter-item Correlation Analysis, test-retest, and parallel forms methods were used.

FINDINGS

The Turkish version of the surgical anxiety questionnaire consisted of a 3-factor structure, and the Cronbach's alpha value was 0.93. The CFA factor loads varied between 0.48-0.98. A positive, high correlation was found between SAQ and the Amsterdam Preoperative Anxiety and Knowledge Scale (APASIS). A positive, moderate correlation between SAQ and State-Trait Anxiety Inventory-1(STAI-1) was found.

CONCLUSION

SAQ has strong validity and reliability in the Turkish society. Nurses could use the SAQ to determine the anxiety level in surgical patients.

Psychometric evaluation of Urdu-translated Amsterdam preoperative anxiety and information scale and assessment of preoperative anxiety in adult surgical patients of Karachi, Pakistan: A cross-sectional study

Objective

The primary aim of this study was to develop an Urdu-translated version of the Amsterdam preoperative anxiety and information scale and perform a psychometric evaluation of it. A secondary aim was to estimate the prevalence of preoperative anxiety using Urdu-translated Amsterdam preoperative anxiety and information scale in patients undergoing surgery in Karachi, Pakistan, and the factors contributing to anxiety among them.

Method

This cross-sectional survey included 267 patients enrolled for elective surgery under general anesthesia from March 5 to November 20, 2022. In psychometric analysis, face validity, criterion validity, construct validity, and reliability of Urdu-translated Amsterdam preoperative anxiety and information scale were determined. Face validity was evaluated by performing blind-back translation and a pilot study. Criterion validity was evaluated by correlating the Amsterdam preoperative anxiety and information scale with the visual analog scale for anxiety. Exploratory factor analysis and Cronbach's α test were used to analyze construct validity and reliability, respectively. The associate variables were identified by performing a one-sample t-test and one-way analysis of variance on SPSS 26.

Results

Cronbach's α test is 0.85 for the Amsterdam preoperative anxiety and information scale anxiety scale and 0.70 for the need for information. 65.3% of the total variance is explained by the Urdu version of Amsterdam preoperative anxiety and information scale items in factor analysis and the intercorrelation of all items was >0.20 (mean: 0.575). Urdu-translated Amsterdam preoperative anxiety and information scale and visual analog scale for anxiety showed a good correlation (r = 0.664, p < 0.001). The overall prevalence of preoperative anxiety among patients is 52.4% suggested by the Amsterdam preoperative anxiety and information scale cutoff score of more than 11. Females, students, and patients elected for major surgery shared significantly higher anxiety levels (p < 0.05). The commonest factors contributing to anxiety are postoperative pain in 140 (52.4%) patients, fear of death in 115 (43.1%), and financial loss in 91 (34.1%).

Conclusions

The Urdu-translated Amsterdam preoperative anxiety and information scale is a reliable, valid, and acceptable screening tool for preoperative anxiety. The prevalence of preoperative anxiety was high. The preoperative anxiety level is significantly associated with gender, employment status, and type of surgery.

Prevalence and factors associated with surgery anxiety in hospitalized patients: a point-prevalence study

BACKGROUND

Preoperative anxiety is a challenging problem in the preoperative care of patients. Identifying risk factors helps nurses provide psychological support during the pre-operative visit so that stress can be reduced.

AIMS

This study aimed to determine the prevalence of surgical anxiety and related factors in hospitalized surgical patients.

METHODS

This research was designed as a point-prevalence study. The study was completed with 223 patients hospitalized in the surgical clinics of a tertiary hospital in Turkey. Surgical anxiety questionnaire (SAQ) and State-trait anxiety inventory (STAI) were used for the assessment of anxiety.

RESULTS

Preoperative anxiety prevalence was 69.5% according to the SAQ and 49.3% according to STAI. Women, participants with no primary school education, those who were unemployed and had low income, those with no previous surgery, those living in fear of surgery, the participants who underwent major surgery and general anesthesia, and those who did not have knowledge about the surgical procedure and anesthesia had higher anxiety according to the two scales. A highly significant and positive correlation was found between total STAI and total SAQ.

CONCLUSION

The importance of surgical anxiety for the health system, which affects two out of every three hospitalized patients, should not be underestimated. Therefore, national and global plans should be made to prevent and manage surgical anxiety.

Does surgery cause anxiety, stress and fear in geriatric patients?

BACKGROUND

Because of physiological changes in geriatric patients, their surgical process differs from that of young adults. In this regard, the perioperative period is an extremely risky time for geriatric patients. The present study examined preoperative fear, anxiety, and perceived stress levels as well as the factors affecting them in elderly patients prior to surgical intervention.

METHODS

This study adopted a cross-sectional descriptive design. The study sample consisted of geriatric patients (n = 407) scheduled for elective laparoscopic cholecystectomy in a research and training hospital in northeast Turkey. Data were collected by the researchers using the personal information form, Perceived Stress Scale (PSS-10), Surgical Fear Questionnaire (SFQ) and Anxiety Specific to Surgery Questionnaire (ASSQ). In the data analysis, descriptive statistics, the t-test in independent groups, one-way analysis of variance (ANOVA), correlation analysis and Bonferroni tests for post hoc analyses were used.

RESULTS

On the PSS-10, the mean score was higher for the 75-and-older age group, single patients, patients with a disease requiring medication, and those who had previously undergone surgery (P < 0.05). On the ASSQ, the mean score was lower for patients aged 65-69, university graduates, patients without children, and those without a disease requiring medication (P < 0.05). On the SFQ, the mean score was higher for the 75-and-older age group, primary school graduates, and single patients (P < 0.05).

CONCLUSION

It was determined that being single, having a chronic disability, and advancing age had an effect on the patients' surgery-specific anxiety, perceived stress, and fear of surgery. Long-standing chronic diseases can negatively affect both stress and anxiety levels of individuals.

Prevalence of preoperative anxiety among hospitalized patients in a developing country: a study of associated factors

BACKGROUND

Preoperative anxiety is a health concern among patients scheduled for surgical interventions. Little is known about the prevalence of preoperative anxiety among patients in different healthcare systems of developing countries. This study was conducted to determine the prevalence of preoperative anxiety among patients undergoing surgery in Palestine. Another objective was to identify the factors associated with preoperative anxiety.

METHODS

This study was conducted in a cross-sectional descriptive design. Patients scheduled for surgical interventions were interviewed using an interviewer-administered questionnaire. The questionnaire collected the demographic, clinical, and surgical variables of the patients. The questionnaire also contained the Amsterdam preoperative anxiety and information scale (APAIS), and a short version of the Spielberger state-trait anxiety inventory (STAIS-5/STAIT-5).

RESULT

A total of 280 patients were included. The mean APAIS total score was 13.6 ± 5.9, the mean APAIS anxiety domain score was 8.3 ± 4.3, and the mean APAIS need for information domain was 1.6 ± 0.50. Of the patients, 76 (27.1%) had high anxiety and 160 (57.1%) expressed a high need for information. The higher APAIS anxiety scores were predicted by being female, having chronic diseases, being scheduled to be operated on within 24 h, and having experienced surgical complications. The mean STAIS-5 score was 10.0 ± 4.2 and the mean STAIT-5 was 10.3 ± 3.8. Of the patients, 140 (50.0%) had high state anxiety and 56 (20.0%) had high trait anxiety. Higher STAIS-5 scores were predicted by being female, younger than 42 years, and scheduled to be operated on within 24 h. Higher STAIT-5 scores were predicted by being female. A positive correlation was identified between APAIS total, APAIS anxiety, APAIS need for information, STAIS-5, and STAIT-5 scores.

CONCLUSION

Preoperative anxiety was prevalent among patients scheduled for surgical operations in Palestinian hospitals. Anesthesiologists and other providers of perioperative care should screen preoperative patients who are female, have chronic diseases, are scheduled to be operated on within 24 h, and having had experienced surgical complications for preoperative anxiety. More studies are still needed to investigate the effects of the implemented measures on the prevalence of preoperative anxiety.

Should Preoperative Information Before Impacted Third Molar Extraction Be Visual, Verbal, or Both?

PURPOSE

Offering preoperative information is one option to help patients cope with the anxiety associated with oral and maxillofacial surgical procedures. Although this information is commonly delivered verbally, written information, audio recordings, and videos are also recommended. This study aimed to evaluate the effects of different preoperative information techniques on patients' anxiety levels before and after third molar tooth extraction.

MATERIALS AND METHODS

A single-blind randomized controlled clinical trial with parallel groups was performed. 92 patients who fulfilled the inclusion criteria were randomly assigned to one of four groups. Group 1 was provided information via a silent video with subtitles. Group 2 was informed via a video with background audio. Group 3 was provided a written information brochure. Group 4, designated as the control group, was informed verbally. The Spielberger state anxiety inventory (STAI-S), dental fear scale (DFS), modified dental anxiety scale (MDAS), and visual analog scale (VAS) were used pre- and postoperatively to evaluate the dental anxiety of patients. The primary predictor variable was the preoperative information method. The primary outcome variables were the scores of STAI-S, DFS, MDAS, and VAS. Gender was also set as a covariate variable. Data analysis was performed with the IBM SPSS Statistics 25.0 software program. Unless otherwise stated, P < .05 was considered statistically significant.

RESULTS

A total of 86 patients scheduled for impacted third molar extractions under local anesthesia were included in the study. There was no statistically significant difference among the groups in the mean age (P = .275) or distribution of gender (P = .070). Compared to preoperative values, the postoperative scores of MDAS and VAS were decreased significantly in group 1 (P = .002, P = .003, respectively) and group 3 (P = .007; P = .009, respectively). No statistically significant differences were found between the preoperative and postoperative scores of STAI-S, DFS, MDAS, and VAS in group 2 (P = .300, P = .028, P = .063, P = .038, respectively) and group 4 (P = .127, P = .587, P = .072, P = .016, respectively).

CONCLUSIONS

The findings indicate that visual or written material, without audio or oral delivery, substantially reduced the anxiety associated with oral and maxillofacial surgery. Therefore, clinicians should preferentially provide information via written methods to control patients' anxiety before impacted third molar surgery.

The Relationship Between COVID-19 Anxiety and Preoperative Anxiety during the Pandemic

PURPOSE

The aim of this study was to determine the relationship between COVID-19 anxiety levels and preoperative anxiety in patients who will undergo elective surgery during the pandemic period.

DESIGN

This study was an analytical cross-sectional study.

METHODS

The study was carried out with 228 patients between May and December 2021 in the surgical clinics of a training and research hospital. The data were collected using patient information form, Coronavirus Anxiety Scale (CAS) and Amsterdam Preoperative Anxiety and Information Scale (APAIS).

FINDINGS

The patients' APAIS total score level was 15.86 ± 6.44, and the CAS score was 6.63 ± 3.61. A positive, moderate and statistically significant relationship was found between the CAS score and the APAIS total score (r = 0.547; P = .000) and, the CAS score and anxiety due to anesthesia surgery (r = 0.545; P = .000) and information (r = 0.501; P = .000) sub-dimensions.

CONCLUSIONS

The results of this study showed that the preoperative anxiety level increased in individuals with increased coronavirus anxiety levels.