What approaches can be incorporated successfully into an efficient surveillance colonoscopy program to minimise anxiety and pain fall out?

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While the literature on colonoscopy is very extensive, only a very small percentage addresses the association with anxiety.[1] Clearly, patients in the categories addressed in the recommendations will be drawn from all aspects of society.

Low socioeconomic status (SES) is colloquially believed to be associated with discomfort in relation to medical investigations. One study identified sigmoidoscopy screening for colorectal cancer as a potential stressor. The UK Flexible Sigmoidoscopy (FS) Trial was regarded as an appropriate vehicle to test this view. A subgroup of patients (n=3535) from the trial was assessed regarding psychosocial wellbeing by pre- and post-screening questionnaires. All participants in this trial (n=29804) were sent a questionnaire three months after FS that included measures of distress, anxiety and a single item questionnaire of bowel cancer worry. SES status was coded from the Townsend Index.[2] Worry about bowel cancer and anxiety were higher before screening in low SES patients. After screening, there were reductions in the factors studied but no differences due to SES were involved in the change. Lower SES patients did not show greater adverse reactivity to FS examination than higher SES participants. A key factor observed is that those with reduced education and economic resources are not necessarily more adversely affected by moderately stressful experiences.[2]

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Anxiety level before and during colonoscopy

A cross-sectional study[3] was performed to examine a possible relationship between state anxiety and trait anxiety in endoscopy in an outpatient setting. (Definitions: “Trait Anxiety” indicates the tendency to experience anxiety; it is considered to be a characteristic of personality that endures over time. “State Anxiety” is a temporary uncomfortable experience that occurs when a person feels threatened by a situation.) In effect, trait anxiety is the potential, or tendency to experience state anxiety.[4] These forms of anxiety can be measured by Charles Speilberger’s State-Trait Inventory for Adults. “The use of this inventory clearly differentiates between the temporary condition of “state anxiety” and more general long-standing “trait anxiety”.[5] Patient response was rated at initial consultation and immediately prior to endoscopy, using the Speilberger State-Trait Anxiety Inventory.[4][5][6] A distinct increase in state anxiety was observed before endoscopy (upper gastrointestinal and colonoscopy) but no change was observed in trait anxiety. Females had higher anxiety levels. Overall, anxiety levels were not related to type of endoscopic procedure.

An Australian study[1], which recognised anxiety as being common in patients undergoing invasive medical procedures, assessed the relationship between coping style of patients, pre-colonoscopy information, anxiety and pain associated with colonoscopy. Coping style was established and patients codified as either information-seekers or information-avoiders. Provision of congruent information in line with coping style was observed to reduce anxiety and ameliorate the patient’s experience of the procedure. There was, however, no effect on dose of sedation or perception of pain.

A questionnaire-based study reviewed the procedural experience of patients undergoing endoscopy.[7] Fifty five (55) consecutive patients undergoing colonoscopy had a three point evaluation of the procedural experience. One week prior to the investigation, they were assessed as to their understanding and their concerns regarding colonoscopy were recorded and rated. The second assessment occurred while awaiting commencement of the procedure and assessed preparation and fasting. The third and final questionnaire was completed 24 to 72 hours after the procedure and after recovery from sedation; it repeated the pre-procedural questionnaire and addressed comfort and social disruption due to the colonoscopy. It was observed that concerns specific to colonoscopy, including anticipation of pain, had impact on acceptance of colonoscopy. This was not improved by experience of the investigation, even if procedural anxiety and pain were reduced. The patient’s pre-procedural views of the investigation should be actively addressed to improve participation in colonoscopy.

While colonoscopy is most frequently performed on adults, it may be used in the diagnostic evaluation of children with colonic disease. Teenagers with inflammatory bowel disease (IBD) will usually require colonoscopy from time to time.

A study designed to compare children aged 10-18 years with either IBD or functional gastrointestinal disease (FGID) undergoing their first colonoscopy recorded the levels of pain or anxiety that they experienced. These levels were assessed by means of a questionnaire recorded immediately before the procedure and through a second questionnaire 48 hours later. While no differences in anxiety were reported, it was noted that higher levels of anxiety accompanied by higher pain scores were experienced by children with IBD at the time of colonoscopy. Children with FGID observe common pain symptoms during colonoscopy and may describe more post-conoscopic pain than those with IBD. It was concluded that anxiety is associated with severity of pain after colonoscopy in children with IBD, while not observed to be a factor in children with FGID.[8]

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Amelioration of anxiety in relation to colonoscopy

State anxiety is moderately increased in patients undergoing outpatient diagnostic endoscopy.[9] This increase is not significantly influenced by age, sex, type of procedure or source of referral. The ability of the endoscopist to estimate patient anxiety is generally poor. It is suggested that this is because the increase in state anxiety is usually at a mild level. An RCT[10] explored the view that information provided before interventional clinical procedures should improve knowledge of the procedure and reduce anxiety related to it. The study involved approaching patients a week before colonoscopy, providing an information leaflet on the subject and having them complete a Speilberger State Anxiety Inventory (STAI).[6] Patients were randomly assigned to view or not view an information video before colonoscopy, while all patients completed a second STAI and knowledge test. The study involved 150 patients; 72 video-watchers and 78 non-video-watchers. The groups were generally similar in relation to age, sex, socioeconomic status and initial anxiety score, although female patients had higher baseline STAI scores than those with previous experience. Patients who watched the video were less anxious and achieved a higher score on the knowledge questionnaire than those who did not. Understanding the purpose, procedural details and potential complications of colonoscopy better prepared patients for the procedure. This study is supported in a commentary[11] advocating an information video as a better way to convey information about colonoscopy. It is suggested that the technique may be cost-effective in reducing cost of sedation and post-operative recovery time.

A study of 201 patients undergoing colonoscopy randomised patients into three groups,[12] those provided with pre-procedure information by video plus discussion, video alone or discussion only. All patients answered a thirteen item test of knowledge and all underwent State-Trait Anxiety Inventory.[6] Those patients who were exposed to the video had statistically significant better scores (p<.001) than patients involved only with discussion, but no difference was observed between the video groups. It was concluded that understanding of colonoscopy and its risks and benefits did not increase anxiety. It was considered that the overall approach may save time for the clinician and provide opportunity for more personalised discussion and reassurance of the patient.

Another randomised study[13] included an information video in the pre-procedural activity. Control patients did not view the video. Situational anxiety was measured using the State-Trait Anxiety Inventory (STAI) questionnaire.[6] Patient satisfaction was rated, as was their experience with pain. The colonoscopist and endoscopy nurse were blinded as to which stream a patient had entered and completed a questionnaire as to medication employed, outcome of procedure, its level of tolerance and level of pain experienced. It was reported that midazolam dosage was the same in all patients, but that those who viewed the video used higher doses of fentanyl (p <0.2). Women found the experience to be more painful (p=0.001) and expressed less satisfaction with the procedure. It was observed that there was no impact on tolerability or anxiety among video-observers, but it was suggested that gender differences warranted adjustment of information and medication associated with the procedure.

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Evidence summary and recommendations

Evidence summary Level References
Colonoscopy is generally accepted as a useful and non-threatening procedure. It is still, however, regarded with some suspicion and promotes anxiety in a body of people undergoing the procedure. II, III-3 [2], [14], [3], [1]
Patients with reduced educational and economic resources are not more adversely affected than those with greater resources by moderately stressful experiences. III-3 [2]
Patients’ pre-procedural view of colonoscopy needs to be actively addressed to improve participation in colonoscopy. III-3 [15], [14]
Previous colonoscopy reduces patient anxiety when the procedure is to be repeated and increases rate of compliance. II, III-3 [15], [16], [17]
Provision of congruent information in line with coping style has been observed to ameliorate patient’s experience of the procedure. II [1]
Patients provided with a pre-operative video on colonoscopy were less anxious than those not shown a video. II [10], [12], [13]
Understanding the purpose, procedural details and potential complications of colonoscopy can better prepare patients for the procedure. II [10]
Evidence-based recommendationQuestion mark transparent.png Grade
Pre-colonoscopic advice to patients by means of educational material, video and clinical explanation can assist in improving patient experience with the procedure and in reducing anxiety.
C


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References

  1. 1.0 1.1 1.2 1.3 J Morgan, L Roufeil, S Kaushik, M Bassett. Influence of coping style and precolonoscopy information on pain and anxiety of colonoscopy. Gastrointest.Endosc 1998 Aug;48(2):119-127.
  2. 2.0 2.1 2.2 2.3 AE Simon, A Streptoe, J Wardle. Socioeconomic status differences in coping with a stressful medical procedure. Psychosom.Med. 2005 Mar;67(2):270-276.
  3. 3.0 3.1 F Ersoz, AB Toros, G Aydogan, H Bektas, O Ozcan, S Arikan. Assessment of anxiety levels in patients during elective upper gastrointestinal endoscopy and colonoscopy. Turk.J Gastroenterol. 2010 Mar;21(1):29-33.
  4. 4.0 4.1 www.ehow.com.facts/5674194definitiontraitanxietyhtml. Definitions Trait and State Anxiety. 2011 Feb 8.
  5. 5.0 5.1 C Speilberger. State-Trait Inventory. www.mindgarden.com/products/stais.htm 2011 Feb 2.
  6. 6.0 6.1 6.2 6.3 C Linden. State-Trait Anxiety. http://www.thelindenmethod.co.uk/articles/state-trait-anxiety/ 2010 Dec 20.
  7. Condon A, Graff L, Elliot L, Ilnyckyj A. Acceptance of colonoscopy requires more than test tolerance. Can J Gastroenterol. 2008 Jan 1;22(1):41-47.
  8. WV Crandall, TE Halterman, LM Mackner. Anxiety and pain symptoms in children with inflammatory bowel disease and functional gastrointestinal disorders undergoing colonoscopy. J Pediatr.Gastroenterol.Nutr. 2007 Jan;44(1):63-67.
  9. MP Jones, CC Ebert, T Sloan, J Spanier, A Bansal, CW Howden et al. Patient anxiety and elective gastrointestinal endoscopy. J Clin.Gastroenterol. 2004 Jan;38(1):35-40.
  10. 10.0 10.1 10.2 A Luck, S Pearson, G Maddern, P Hewett. Effects of video information on precolonoscopy anxiety and knowledge: a randomised trial. Lancet. 1999 Dec;354(9195):2032-2035.
  11. A Jabber, R Wright. Effects of video information on pre-colonoscopy anxiety and knowledge: a randomized trial. Gastrointest.Endosc. 2001;53(1):140-142.
  12. 12.0 12.1 P Agre, RC Kurtz, BJ Krauss. A randomized trial using videotape to present consent information for colonoscopy. Gastrointest.Endosc. 1994;40(3):271-276.
  13. 13.0 13.1 P Bytzer, B Lindenberg. Impact of an information video before colonoscopy on patient satisfaction and anxiety - a randomized trial. Endoscopy. 2007;39(8):710-714.
  14. 14.0 14.1 Condon A, Graff L, Elliot L, Ilnyckyj A. Acceptance of colonoscopy requires more than test tolerance. Can J Gastroenterol. 2008 Jan 1;22(1):41-47.
  15. 15.0 15.1 P Colquhoun, HC Chen, JI Kim, J Efron, EG Weiss, JJ Nogueras et al. High compliance rates observed for follow up colonoscopy post polypectomy are achievable outside of clinical trials: efficacy of polypectomy is not reduced by low compliance for follow up. Colorectal Dis. 2004 May;6(3):158-161.
  16. HH Ko, H Zhang, JJ Telford, R Enns. Factors influencing patient satisfaction when undergoing endoscopic procedures. Gastrointest.Endosc. 2009;69(4):883-891.
  17. L Chartier, E Arthurs, MJ Sewitch. Patient satisfaction with colonoscopy: a literature review and pilot study. Can J Gastroenterol. 2009;23(3):203-209.

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Appendices

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