Anaesthesiology Intensive Therapy

2019, vol. 51, no 1, 64–69

ISSN 1642–5758
10.5603/AIT.a2019.0013
REVIEWS www.ait.viamedica.pl

Measures of preoperative anxiety

Adam Zemła1, Katarzyna Nowicka-Sauer1, 2, Krzysztof Jarmoszewicz1, Kamil Wera3,
Sebastian Batkiewicz1, Małgorzata Pietrzykowska2

1Department of Cardiac Surgery, Ceynowa Specialist Hospital in Wejherowo, Poland

2Department of Family Medicine, Medical University of Gdansk, Poland
3Department of Cardiology and Cardiac Intensive Care, Specialist Municipal Hospital in Torun, Poland

Abstract
The evaluation of treatment from the patient’s perspective (Patient Reported Outcomes, PROs) currently remains one
of the most vibrant and dynamically developing fields of research. Among PROs, patient self-assessment of various
symptoms, including one’s psychological state, is of great importance.
Anxiety is one of the most frequently observed psychological reactions among patients awaiting various surger-
ies, and may occur even in up to 80% of patients scheduled for high-risk surgical procedures. An increased level of
preoperative anxiety has been proved to be related to negative consequences, both psychological and somatic, and
affecting, in consequence, anaesthesia, postoperative care and treatment, along with the rehabilitation process. It is
also considered as a risk factor for mortality in patients after surgeries.
Planning of necessary educational, pharmacological and psychological interventions should be preceded by the
evaluation of anxiety level which should be considered a routine element of preoperative care. The assessment of
anxiety intensity may be performed using psychometric scales. Various factors should be taken into consideration
while choosing the scale, including its reliability and accuracy, the aim of the assessment, the patient’s age and
clinical state, as well as the type of surgery being planned. In the current article, we present standardised and reli-
able methods which may be used in the evaluation of preoperative anxiety among patients scheduled for surgery,
namely: the State-Trait Anxiety Inventory (STAI); the Hospital Anxiety and Depression Scale (HADS); the Amsterdam
Preoperative Anxiety and Information Scale (APAIS); and the Visual Analogue Scale (VAS). A detailed description of
the scales, including their main advantages and limitations, as well as their usefulness in both clinical evaluation of
various patients’ groups and scientific research are presented.

Anaesthesiology Intensive Therapy 2019, vol. 51, no 1, 64–69

Key words: preoperative anxiety, assessment methods

The issues concerning the incidence of preoperative Anxiety is inextricably associated with stress and acti-
anxiety, its predictors, and short- and long-term conse- vates the neuroendocrine hypothalamic-pituitary-adrenal
quences, as well as attempts to find effective therapeutic axis and the autonomic system. In response to endocrine
interventions are of interest of many researchers, not only regulatory mechanisms and excitation/stimulation of the
psychologists but also anaesthesiologists [1–4]. Anxiety is adrenergic system, concentrations of „stress hormones”,
one of the most common psychological reactions among such as adrenaline, vasopressin, cortisol or prolactin, in-
patients awaiting surgery. Study findings have demonstrat- crease. The activity of the above-mentioned substances
ed that severe preoperative anxiety can affect up to 80% of causes a number of reactions, including acceleration of the
those awaiting surgeries [1]. In addition to the significant heart rate, an increase in arterial pressure, the respiration
discomfort experienced by patients, increased levels of anxi- rate and muscle tone, as well as dilation of the pupils, or
ety are often associated with adverse clinical sequels. hyperglycaemia [5–7]. Excessive excitation of the physiologi-

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cal systems related to anxiety results in numerous adverse suggested that in case of assessing anxiety in pre-surgery
changes that are likely to unfavourably affect not only the patients a score of 44/45 should be interpreted as a clinical-
anaesthesia itself or the early postoperative period but also re- ly significant, while in general population a score of 39/40 is
mote behavioural and physiological adverse effects [5, 6, 8, 9]. considered cut-off for alleviated anxiety level [21–24]. The
A postoperative period preceded by increased anxi- above scale is considered to be the gold standard among
ety is often associated with a higher level of experienced the instruments assessing the level of anxiety [23], not only
pain and, in consequence, higher demands for analgesics. in clinical psychology and psychiatry but also in medicine.
Increased intensity of postoperative anxiety also leads to Moreover, the STAI is one of those most frequently used
diminished susceptibility to anaesthetic drugs, prolonged for assessing anxiety level, including preoperative anxiety
wound healing, occurrence of chronic postoperative pain, [4, 7, 10, 16, 22, 25–30].
and the reduced efficacy of postoperative rehabilitation and The state anxiety subscale allows one to follow the
recovery [6, 7, 10–13]. Moreover, the symptoms of anxiety changes in anxiety symptoms, even in short intervals;
and depression present before surgery are predictors of hence its high usefulness for prospective studies as well as
worse satisfaction and patients’ subjective assessment of monitoring the patient mental status. In everyday clinical
treatment efficacy, including long-term assessment [14, 15]. practice, the limitations of STAI include difficulty related to
Of note is the fact that intensified preoperative anxiety is its duration, the number of statements included, as well
also a risk factor of death after surgical procedures [16–18]. as difficulties in filling in the questionnaire faced by the
An early and suitably planned preoperative interven- elderly. The authors’ experience shows that mistakes occur
tion (educational, pharmacological, psychotherapeutic) can consisting of the automatic marking of extreme answers,
bring clear benefits in terms of the patient`s subjective which prevents reliable assessment of results. In such cases,
status, improvement of care, but also objective clinical in- it is recommended to verify the answers with the patient.
dicators, thus preventing long-term side effects of anxiety. The Polish version of STAI can be purchased from the
Many researchers have stressed the importance of routine Psychological Test Laboratory of the Polish Psychological
assessment of preoperative anxiety [1, 4, 16], which should Association (www.practest.com.pl). A Master of Arts (MA)
precede planning of therapeutic interventions, including degree in psychology is required. Both the paper and elec-
decisions concerning the assistance of psychologist. The in- tronic versions are available.
tensity of anxiety symptoms can be assessed during clinical
interview, as well as through using psychometric methods. Hospital Anxiety and Depression Scale
The aim of the present study is to present in detail the The HADS consists of 14 items divided into two sub-
scales assessing preoperative anxiety, their limitations and scales assessed separately, namely: 7 statements related
benefits in the context of their usefulness in everyday clinical to anxiety – HADS-Anxiety (HADS-A) and another 7 state-
practice and research. Detailed descriptions of the individual ments related to depression — HADS-Depression (HADS-D).
scales are presented in Table 1. The presentation of such Preoperative anxiety is assessed with the HADS-Anxiety
tools seems to be part of the dynamic development of subtest. Respondents address each of the symptoms by
studies regarding the Patient Reported Outcomes (PROs) choosing one of four available answers best describing
recently observed in the medical literature, among which their emotions. The answers are assessed according to
patient mental status is essential [19, 20]. the 4 point Likert scale (score 0–3). The range of scores is
0–21; a higher score denotes a higher intensity of anxiety
State-Trait Anxiety Inventory symptoms. A score of 0–7 is considered normal, 8–10 bor-
The STAI contains two independent subscales consisting derline and 11 or more as pathological, clinically relevant
of 40 items. Twenty of these assess state anxiety (STAI-X1), anxiety [24, 31]. The major advantage of this scale is its
i.e. situational anxiety experienced during the examination reliability, ease of use, short time to complete and the
(„How are you feeling now”); another 20 items measure possible immediate interpretation of results by a clinician.
trait anxiety (STAI-X2), understood as a relatively constant Since 1983, the scale has been widely used among patients
trait („How do you usually feel”). The subscales are assessed with somatic diseases and, consistent with its name and
separately; preoperative anxiety is assessed using the state purpose, among hospitalised patients. Moreover, the scale
anxiety subscale. Patients address each statement by choos- has been frequently used in surgery and anaesthesiology
ing one of four options. The 4-point Likert scale is applied for [11, 18, 29, 32–36], which confirms its clinical usefulness for
assessment (score 1–4). The minimum score is 20 while the assessing preoperative anxiety. The HADS test is available
maximum is 80. A higher score indicates higher anxiety. It is at www.gl-assessment.co.uk.

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Table 1. Characteristics of scales assessing anxiety

STAI HADS APAIS VAS
Time to complete State-anxiety subscale: Anxiety subscale: about 3 About 2 min. 1–3 min.
about 10 min. min.
Full scale: 15– 20 min. Full scale: about 5–10 min.
Characteristics 40 items, including 20 for 14 items, including 7 for 6 statements, including 4 Visual scale — a 100-mm line
state-anxiety assessment assessing anxiety and 7 for anxiety assessment and
and 20 for trait-anxiety assessing depression 2 for need-for-information
assessment assessment
Range of scores 20–80 0–21 Anxiety subscale: 4–20. 0–10
Separate scores for state and Separate scores for each Need-for-information
trait anxiety subscales subscale subscale: 2–10.
In all scales higher score represents higher level of anxiety
Cut-off points 44–45 8 10–11 for anxiety-related Population-dependent
for clinically items
significant anxiety
Major adventage „Gold standard” for anxiety Short time of completion; Dedicated for preoperative The shortest time of
assessment — measures also enables one to assess anxiety assessment; completion, easy to
state and trait anxiety. symptoms of depression. Additionally, assesses need- complete for elderly and
for-information; patients in poor clinical state.
Free of charge with authors` Widely available.
consent.
Major limitations Number of items; Possible errors during None None
Time to complete; completion
Difficult for the elderly —
those with poor clinical state;
cognitive impairment;
Application ++ +++ +++ +++
in research in
anaesthesiology
and surgery
Main applications Clinical psychology and Patients with somatic Surgery; The widest use, hospital
psychiatry; patients with diseases; Anaesthesiology wards, including intensive
somatic diseases. hospitalised patients; care units, anaesthesiology
clinical psychology and surgery departments
Prospective +++ Only state-anxiety scale +++ +++ At various stages of the +++
assessment, preoperative period
monitoring the
level of anxiety
STAI: State Trait Anxiety Inventory; HADS: Hospital Anxiety and Depression Scale; APAIS: Amsterdam Preoperative Anxiety and Information Scale; VAS: Visual Analogue
Scale; +++ Extremely useful; ++ Moderately useful

Amsterdam Preoperative Anxiety The APAIS is available free of charge. The reliability and
and Information Scale internal consistency of its Polish version presented in Table
The APAIS test was developed specifically to assess 2 was confirmed using the HADS and Visual Analogue Scale
preoperative anxiety. It comprises six items, four of which in a group of cardiac surgery patients. The cut-off point in
relate to the general measurement of preoperative anxiety the Polish version of APAIS was set at 10 [38]. The reliability
(two concern anaesthesia-related anxiety while the other of APAIS has also been confirmed in many other studies
two concern surgery-related anxiety). The remaining two among patients awaiting various types of surgeries, both
items assess the patient’s need for anaesthesia-related under local and general anaesthesia [2, 27, 30, 37–40]. Due
and surgery-related information. Patients address each to possible differences in the internal consistency of APAIS
of the items by choosing one of the available answers in different groups of patients (high/low risk procedures,
rated from 1 — „not at all” to 5 — „extremely”. The maxi- general or local anaesthesia) and the fact that the cut-off
mum score on the anxiety subscale is 20, and 10 on the values of clinically relevant anxiety may differ for women
need-for-information subscale [37]. The higher the scores, and men [27, 41], it is recommended to assess the psy-
the more intense the preoperative anxiety and need for chometric properties of APAIS for particular populations
information are. of patients.

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Table 2. Amsterdam Preoperative Anxiety and Information Scale (APAIS)*

Please tick the answer which best matches your opinion (APAIS)
I am worried about anaesthesia Not at all Slightly Moderately Very Extremely
I am constantly thinking about anaesthesia Not at all Slightly Moderately Very Extremely
I would like to know as much as possible about anaesthesia Not a all Slightly Moderately Very Extremely
I am worried about surgery Not at all Slightly Moderately Very Extremely
I am constantly thinking about surgery Not at all Slightly Moderately Very Extremely
I would like to know as much as possible about surgery Not at all Slightly Moderately Very Extremely

An important advantage of APAIS worth-stressing, one STAI and HADS tests among surgical and intensive care
distinguishing it from the remaining scales, is the fact that unit patients [2, 23, 38, 44].
it assesses not only the level of anxiety but also the need
for information concerning anaesthesia and surgery. For Summary and practical comments
health professionals dealing with surgical patients, this kind The literature review presented above demonstrates
of information is extremely important. The study findings that there are several methods available to evaluate the
have demonstrated that higher levels of anxiety are accom- intensity of preoperative anxiety and preliminary diagnosis
panied by higher needs for information [2, 23, 38]; moreover, of clinically significant anxiety. The aim of the review was
education and information provided to patients awaiting to discuss the selected scales to facilitate the choice of the
surgery favours a reduction in the level of anxiety [2, 3, 42]. method most appropriately corresponding to the study
Nevertheless, it should be remembered that the provision aim or to the clinical situation. The essential criterion of
of too many pieces of information, when burdened with the choice is the type of clinical situation (the type and extent
emotional component, can lead to the increase of anxiety of surgery; its mode, namely, emergent/elective), patient’s
level. Therefore, the kind of information health professionals age and clinical state (including e.g. severity of pain, dysp-
provide and the way they provide it, rather than the amount noea, cognitive impairment, consciousness disorders). The
of information, are crucial [43]. somatic condition of a patient is likely to cause difficulties
in completing the questionnaire, to increase tension and
Visual Analogue Scale anxiety being experienced, and to reduce the reliability
The VAS comprises a 100-mm line with the ends de- of assessment.
noting 0 and 10. The scale is both simple and the most As for research and decision-making regarding further
commonly used method for studies in psychology, medi- therapeutic management based on the assessment of anxi-
cine and interdisciplinary research. The VAS test is most ety with the VAS and APAIS, it is recommended to adjust
frequently applied to assess pain but is also a recognised the cut-off values to the population tested. The studies
method for assessment of other somatic and psychologi- evaluating the psychometric properties of these scales have
cal symptoms, as well as one’s general health condition shown that the scores indicating the pathological level of
and quality of life. The most frequently used form of VAS- anxiety may differ according to population and gender. This
anxiety is the line where 0 indicates „no anxiety” while can be associated with a tendency to mask the symptoms
10 represents „highest anxiety that can be imagined” or of anxiety among men and higher anxiety level observed
„most intensive anxiety”. The major advantage of this among women [26, 30, 38, 44] as well as some other factors.
scale is that it is both easy and patient-friendly; addition- Therefore, in these two methods, the determination of cut-
ally, its shortness and short time needed for interpretation off points using the receiver operating characteristic (ROC)
are beneficial. Thanks to the above features, the scale can curve and evaluation of specificity and sensitivity seem fully
be successfully used to assess and monitor the intensity justifiable. Furthermore, the acceptance of cut-off points
of fear/anxiety in elderly and severely ill patients. In the with a higher coefficient of false positive results (lower
latter situations the usefulness of extended question- specificity and higher sensitivity) appears to be more ben-
naires is limited due to their difficulty for patients and eficial from the point of view of clinical care. In such cases,
the higher probability of mistakes associated with dif- the likelihood of abandonment of interventions in patients
ficulties in focusing attention or e.g. concomitant severe requiring deeper psychological evaluation or therapeutic
pain. Moreover, another unquestionable advantage of interventions is lower, even though the odds to undertake
the VAS test is its reliability for assessing the level of actions in patients not requiring such assessments and in-
preoperative anxiety confirmed in the studies using the terventions are higher.

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