Professional Documents
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The Amsterdam
Scale (APAIS)
Nelly Moerman,
Hans Oosting,
MD*,
Preoperative
Anxiety
and Information
J. Muller,
MA&
and
PhDt
* Department
of Anesthesiology
and t Department
of Clinical Epidemiology
and Biostatistics, Academic Medical
University of Amsterdam;
$ Department
of Clinical Psychology, Faculty of Psychology, University of Amsterdam;
+j Netherlands
Cancer Institute, Amsterdam,
The Netherlands
nxious patients respond differently than nonanxious patients to anesthesia. The insertion of
an intravenous catheter in the preoperative
phase can be a difficult task as a result of anxietyrelated vasoconstriction (1,2). In anxious patients,
larger doses of anesthetics are required to induce anesthesia (3,4) and the anesthesia itself may be associated with autonomic fluctuations (5,6). Although the
exact percentage of patients who are anxious preoperatively is not known, the literature suggests an incidence between 60% and 80% (7-10). Although a sedative drug is often given as premeditation to relieve
fear and anxiety, anxious patients might also benefit
from more attention and information from the anesthesiologist. In clinical practice, however, the anesthesiologist has very little time for preoperative consultation to identify the patients who are anxious and
may benefit from extra attention.
There are many instruments for measuring the patients level of preoperative anxiety (11,12). The instrument most commonly used is Spielbergers State-Trait
Anesthesia
Research
Centre,
and
Anxiety Inventory (STAI) (13), which has been translated into Dutch and validated by van der Ploeg et al.
(14). He also obtained norms for the Dutch population.
The questionnaire consists of two separate, 20-item,
self-report rating scales for measuring trait and state
anxiety. The trait anxiety is a relatively stable personality disposition, while state anxiety is the situationrelated anxiety and this may differ depending on the
stress of the particular moment. The state scale is
recommended for measuring patient anxiety in the
preoperative phase (15) and has been used in several
anesthesiologic studies (16-19). Although this questionnaire is fairly short, it is still too long for use in
busy outpatient clinics. Moreover, the questions are
not related to the specific situation with which the
patient is confronted.
A second aspect of preoperative care is the patients
need for information. Several studies (20-22) have
shown that information given to patients before surgery may facilitate recovery. However, some patients
like to shut themselves off from information, whereas
others want to be informed as fully as possible (23).
These different coping styles are almost never honored, as it is practically impossible for the anesthesiologist to discriminate between patients who would
like to be informed as fully as possible from those who
want to know as little as possible. It would be greatly
Society
Anesth
Analg
1996;82:445-51
445
446
MOERMAN
ET AL.
THE AMSTERDAM
PREOPERATIVE
ANXIETY
AND
INFORMATION
Methods
A six-item questionnaire, the Amsterdam Preoperative Anxiety and Information Scale (APAIS) (Table 1)
was developed in a previous studyi, covering both the
monitor and blunting aspects. Four items represented fear of anesthesia and fear of the surgical procedure (Cronbachs cx0.86). Two items represented the
need for information (Cronbachs (Y0.72). The internal
consistencies of both scales were sufficient for group
comparison.
During a period of 3 mo, 320 consecutive patients
visiting the anesthesiology outpatient department (patients who could not speak Dutch were excluded)
were asked by the nursing staff to fill out this questionnaire (Table 1). We noted the age and sex of the
patients and whether they had had surgery previously. To ascertain that our instrument really measured anxiety, the last 200 patients were also asked to
fill out the State version of Spielbergers STAI. This
questionnaire consists of a 20-item self-report rating
scale for measuring state anxiety. In the latter group
we also examined the kind of procedure involved and
the duration of the operation. We classified the operations as minor, intermediate, or major. Minor was
defined as less invasive surgery of limited duration
(minor orthopedic surgery, diagnostic procedures, arthroscopies, laparoscopies, inguinal hernia). Operations classified as intermediate had more impact for
the patient (cholecystectomy, hysterectomy), and major were extensive operations with a high impact
1 Moerman N, Dam van F, Boulogne-Abraham
T, Hooff van M.
The patients need for information in the preoperative period. Proceedings of the 9th European Congress of Anaesthesiology. Jerusalem, Israel, 1994:257.
SCALE
ANESTH
ANALG
1996;82:445-51
(APAIS)
Anxiety
about
about
of agreement
with these statements
should
scale from 1 = not at all to 5 = extremely.
(laryngectomy,
surgery).
and
reconstructive
be graded
on a
and transplantation
Statistical Analysis
Validity. To evaluate the validity of the APAIS (Table 11, we performed several analyses. Attention was
devoted to some aspects of construct (content) validity
and criterion validity, too.
Construct validity was evaluated by factor analysis.
Factor analysis is a statistical approach to reduce data
by determining the relationships among variables and
to determine the underlying structure which is formed
by latent variables known as factors. The relation between variables and a certain factor is given by the
so-called factor loadings, which indicate how much
weight is assigned to each factor. Variables with high
loadings for a factor are closely related to that particular factor. Rotation is the procedure used to make the
factor solution more interpretable (26). The results of
the factor analysis should reflect the concepts we put
into our scales and should thus concur with the results
of our previous study, i.e., two factors should emerge:
anxiety and a need for information.
As a measure of concurrent validity we determined
the correlation of the APAIS with the STAI. We hypothesized that the State version of the STAI should
correlate highly (>0.60) with the anxiety scale of the
APAIS and should have a low correlation (<0.30) with
the need-for-information scale.
For clinical use it is important to be able to identify
those patients who can be considered as anxiety cases. For this purpose we used Spielbergers STAI as
the gold standard. Auerbach (27) divided a group of
surgical patients on the basis of their preoperative
score on Spielbergers trait anxiety scale into a hightrait-anxiety group and a low-trait-anxiety
group. The
mean state anxiety score of the high-trait-anxiety
group was 46. We used this score on the state scale as
a reference point and considered patients with a score
~46 on the STAI-State as anxiety cases. Furthermore,
this point concurs 2 the 9th decile of a Dutch male
reference group and 2 the 8th decile of a Dutch female
reference group (14). We determined for different cutoff points on the APAIS anxiety scale the sensitivity
ANESTH
ANALG
1996;82:445-51
THE AMSTERDAM
(proportion
of correctly identified cases), the specificity (proportion
of correctly identified noncases), and
the positive predictive
value (probability
of a high
scale score being a case) in relation to the STAI.
The validity was further evaluated by known-group
comparison
in three different ways. 1) We hypothesized that women should have a higher score than
men on the APAIS anxiety scale. This hypothesis
was
based on data from the literature, where women are
usually regarded as being more anxious than men
(7,10,14,19,28). 2) From the work of Miller and Mangan (24,25) it is known,
that high monitors
are also
anxious people. In other words, in a threatening situation monitoring is mostly associated with higher anxiety and arousal than blunting (29). We therefore hypothesized
that, in our instrument,
patients with a
high information
requirement
should have a higher
score on the anxiety scale than patients with a low
information
requirement. 3) The effect of preanesthetic
information
is less valuable for patients who have
previous anesthetic experience than for those who do
not (30). We therefore hypothesized
that patients with
previous experience of anesthesia and surgery should
have a lower information
requirement than those who
had never had surgery. No specific hypothesis
was
formulated regarding the difference between men and
women with respect to their information
requirement.
Data were analyzed using the SPSS version 4.0. An
analysis of variance (ANOVA)
was used for group
comparison.
Students t-tests were used to compare
the mean scale scores for the subgroups
at baseline.
Statistical significance was considered at P < 0.05.
Cronbachs os were calculated as a measReliability.
ure for internal consistency
of the scales. Reliability
was considered acceptable when Cronbachs
(YS were
270
(26).
Results
Of the 322 patients who were asked to participate, 2
patients refused. Patient characteristics are presented
in Table 2. Patients had no problem completing the
APAIS and usually did so in less than 2 min. As was
predicted, we found in a factor analysis with oblique
rotation (see Table 3) two factors, which explained
72% of the variance: anxiety (questions 1, 2, 4, and 5,
Table 1) and the need for information (questions 3 and
6, Table 1). The correlation between both factors was
0.31. The following step was to convert the two factors
to scales and calculate Cronbachs (Yfor the two scales
separately. Cronbachs (Y for the four anxiety items
(questions 1, 2, 4, 5) was 0.86. Cronbachs cx for the
need-for-information
items (questions 3 and 6) was
somewhat lower (0.68), as was to be expected with a
scale consisting of only two items, but still sufficient
for group comparisons.
PREOPERATIVE
ANXIETY
AND
INFORMATION
MOERMAN
SCALE
ET AL.
(APAIS)
447
Sex
Male
Female
Mean k SD a e
(yr) (range
$
Previous
surgery
Yes
No
Kind of
operation
Minor
Intermediate
Major
APAIS
APAIS + STAI
(n = 320)
(n = 200)
121 (37.8%)
199 (62.2%)
38.3 IL 13.6 (18-87)
85 (42.5%)
115 (57.5%)
38.8 2 13.9 (18-87)
242 (75.6%)
78 (24.4%)
156 (78%)
44 (22%)
145 (72.5%)
42 (21.0%)
7 (3.5%)
AIAIS
= Amsterdam
Preoperative
Anxiety
and Information
Scale;
= Spielbergers
State-Trait
Anxiety
Inventory.
a Operations
were classified
for the last 200 patients
only; 6 patients
not operated
on.
STAI
were
Factor
1
Anesthesia
1. Worried about
2. Thinks about it continually
3. Wishes to know as much as
possible
Surgery
4. Worried about
5. Thinks about it continually
6. Wishes to know as much as
possible
Eigenvalue
Percent of variance
0.83
0.03
0.86
-0.04
0.87
0.01
0.81
0.85
-0.01
3.07
51.1
0.03
-0.02
0.87
1.25
20.8
Concurrent validity was determined by the correlation with the STAI. The correlation between the anxiety items of the APAIS and the STAI-State was high
(0.74) and the correlation between the information
items and the STAI-State was low (0.16).
Anxiety Scale
The anxiety scale consists of four items (questions 1,2,
4, 5), each of which could be scored from 1 to 5. The
score of the anxiety scale is the sum of these four
questions, with a scoring range from 4 to 20. There
was a highly significant difference (P = <O.OOl) between men and women. The mean score of men was
7.5 (SD 3.5) and the mean score of women was 9.9
(SD 4.5). But an ANOVA
indicated an interaction effect
between previous experience of surgery and gender
(P = 0.02); t-test for differences between means
showed that men who had been operated on before
448
MOERMAN
ET AL.
THE AMSTERDAM
PREOPERATIVE
ANESTH
ANXIETY
AND
INFORMATION
Scale (Questions
SCALE
surgery
Mean
SD
II
6.8
10.4
2.9
4.5
98
23
Yes
No
a t-test
for differences
*I' 5 0.001; tP
between
to Experience
of Previous
Femalet
Male*
Previous
ANALG
1996;82:445-51
(AIAIS)
Meana
9.7
10.6
SD
4.4
4.5
144
55
<O.OOl
0.91
means.
= 0.23.
Need-for-Information
Scale
scale
n Mean
24, no/little
information
requirement
5-7, average information
requirement
8-10, high information
requirement
Significant
difference
with
both
other
groups
SD
54 7.1 3.6
127 8.4 3.5
139 10.3 4.8
(Tukey
HSD
procedure
[P < 0.051).
Discussion
The purpose of the study was to develop a screening
instrument for use in the preoperative period. For this
ANESTH
ANALG
1996;82:445-51
THE AMSTERDAM
PREOPERATIVE
ANXIETY
AND
INFORMATION
MOERMAN
SCALE
ET AL.
(APAIS)
449
6. Characteristicsof the Anxiety Scale(APAIS) at Different Cutoff Points with a Score of 46 on the STAI-State as a
ReferencePoint (n = 200)
Table
Sensitivity
Specificity
Positive predictive value
Patients, n (o/o)
a. True-positive
b. False-positive
c. False-negative
d. True-negative
APAIS
= Amsterdam
Preoperative
10
11
12
13
75.0%
78.7%
62.3%
70.3%
86.8%
71.4%
59.4%
90.4%
74.5%
53.1%
97.1%
89.5%
48 (24)
45 (22.5)
18 (9)
38 (19)
13 (6.5)
26 (13)
29 (14.5)
16 (8)
107(53.5)
Anxiety
and
Information
Scale;
19 (9.5)
118(59)
STAI
= Spielbergers
State-Trait
123(61.5)
Anxiety
34
4
30
132
(17)
(2)
(15)
(66)
Inventory.
be answered. Because the APAIS is specifically attuned to the preoperative situation, patients can complete it without further explanation.
The APAIS can be used for clinical practice and for
research purposes. The scores on the anxiety scale of
the APAIS range from 4 (not anxious) to 20 (highly
anxious). The cutoff points chosen depend on the purpose for which the scale is to be used, i.e., clinical use
or research purpose. Based on a comparison with the
STAI as a gold standard, it is clear from the results that
for clinical practice the cutoff score of 11 produces a
good predictive value with an acceptable balance between false-positive and false-negative patients. So
far, the score of 11 seems a useful and efficient score
for identifying anxious patients in clinical practice. A
score of 10 would result in a lower predictive value
and a higher number of false-positive patients (anxious on the APAIS but not on the STAI) than the score
of 11 (14.5% vs 9%). Whether the anesthesiologist will
accept a score of 10 as an indication for anxiety cases
and accept a relatively high number of false-positive
patients, or prefers a score of 11 with a relatively low
number of false-positive patients depends on the
amount of time the anesthesiologist wants to devote to
a patients preoperative stress and anxiety. With
scores higher than 11 the predictive value increases
but because of the higher percentage of specificity the
number of false-negative patients (not anxious on the
APAIS, but anxious on the STAI) also increases. For
the purposes of clinical practice, it is important to
identify the patients who are anxious, and a high
number of false-negative patients is not acceptable. On
the basis of these results, we recommend for the purposes of clinical practice that patients with a score of
211 on the anxiety scale should be considered as
anxiety cases.Future research should be conducted to
clarify whether it is useful to distinguish between
anxiety casesand nonanxiety cases.
When the list is used for research purposes, the
number of false-positive patients is more important.
The score of 11 produces 9% false-positives, that is to
450
MOERMAN
ET AL.
THE AMSTERDAM
PREOPERATIVE
ANXIETY
AND
INFORMATION
SCALE
Academic
Medical
Centre for their assistance,
research
nurse, for collecting
the data about
Marion
Alhadeff
for her expertise
and support
ANESTH
ANALG
1996;82:445-51
Marjolein
Porsius,
the operations,
and
as a translator.
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ANXIETY
AND
INFORMATION
MOERMAN
SCALE
ET AL.
(APAW
451
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