GENERAL ARTICLES

The Amsterdam Preoperative Anxiety and Information

Scale (APAIS)
Nelly Moerman, MD*, Frits S. A. M. van Dam, rhq§, Martin J. Muller, MA& and
Hans Oosting, PhDt
* Department of Anesthesiology and t Department of Clinical Epidemiology and Biostatistics, Academic Medical Centre,
University of Amsterdam; $ Department of Clinical Psychology, Faculty of Psychology, University of Amsterdam; and
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+j Netherlands Cancer Institute, Amsterdam, The Netherlands

The purpose of the present study was to assess patients’ emerged that 32% of the patients could be considered as
anxiety level and information requirement in the pre- “anxiety cases” and over 80% of patients have a positive
operative phase. During routine preoperative screen- attitude toward receiving information. Moreover, the re-
ing, 320 patients were asked to assess their anxiety and sults demonstrated that 1) women were more anxious
information requirement on a six-item questionnaire, than men; 2) patients with a high information requirement
the Amsterdam Preoperative Anxiety and Information also had a high level of anxiety; 3) patients who had never
Scale (APAIS). Two hundred patients also completed undergone an operation had a higher information re-
Spielberger’s State-Trait Anxiety Inventory (STAI- quirement than those who had. The APAIS can provide
State). Patients were able to complete the questionnaire anesthesiologists with a valid, reliable, and easily applica-
in less than 2 min. On factor analysis, two factors emerged ble instrument for assessing the level of patients’ preoper-
clearly: anxiety and the need for information. The anxiety ative anxiety and their need for information.
scale correlated highly (0.74) with the STAIState. It (Anesth Analg 1996;82:445-51)

A
nxious patients respond differently than non-
anxious patients to anesthesia. The insertion of
an intravenous catheter in the preoperative
phase can be a difficult task as a result of anxiety-
related vasoconstriction (1,2). In anxious patients,
larger doses of anesthetics are required to induce an-
esthesia (3,4) and the anesthesia itself may be associ-
ated with autonomic fluctuations (5,6). Although the
exact percentage of patients who are anxious preop-
eratively is not known, the literature suggests an inci-
dence between 60% and 80% (7-10). Although a sed-
ative drug is often given as premeditation to relieve
fear and anxiety, anxious patients might also benefit
from more attention and information from the anes-
thesiologist. In clinical practice, however, the anesthe-
siologist has very little time for preoperative consul-
tation to identify the patients who are anxious and
may benefit from extra attention.
There are many instruments for measuring the pa-
tient’s level of preoperative anxiety (11,12). The instru-
ment most commonly used is Spielberger’s State-Trait
Accepted for publication September 15, 1995.
Address correspondence to Nelly Moerman, MD, Department of
Anesthesiology, Academic Medical Centre, University of Amster-
dam, PO Box 22700,llOO DE Amsterdam, The Netherlands.
Anxiety Inventory (STAI) (13), which has been trans-
lated 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 person-
ality disposition, while state anxiety is the situation-
related 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 ques-
tionnaire 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 patient’s
need for information. Several studies (20-22) have
shown that information given to patients before sur-
gery 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 hon-
ored, as it is practically impossible for the anesthesi-
ologist 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

01996 by the International Anesthesia Research Society

0003-2999/96/$5.00 Anesth Analg 1996;82:445-51 445
446 MOERMAN ET AL.
THE AMSTERDAM PREOPERATIVE ANXIETY AND
beneficial to clinical practice if anesthesiologists knew
whether they were dealing with a patient who wanted
more than basic information which is routinely given,
or a patient who would rather not be given any extra
information.
As we could not find a clinically applicable instru-
ment in the literature which fulfilled all our require-
ments, i.e., short, specifically attuned to the preoper-
ative situation, and easy to interpret, we decided to
develop a new instrument. Our point of reference was
the work of Miller and Mangan (24,25), who studied
the way patients cope with the stress of a threatening
situation. They differentiated between “monitors” and
“blunters,” defining monitors as people who want to
know as much as possible and search actively for
information and blunters as those who have no need
for information and even try to avoid it. This instru-
ment should make it possible to distinguish anxious
from nonanxious patients and patients who want in-
formation from those who do not.
Methods
A six-item questionnaire, the Amsterdam Preopera-
tive Anxiety and Information Scale (APAIS) (Table 1)
was developed in a previous studyi, covering both the
“monitor” and “blunting” aspects. Four items repre-
sented fear of anesthesia and fear of the surgical pro-
cedure (Cronbach’s cx0.86). Two items represented the
need for information (Cronbach’s (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 (pa-
tients who could not speak Dutch were excluded)
were asked by the nursing staff to fill out this ques-
tionnaire (Table 1). We noted the age and sex of the
patients and whether they had had surgery previ-
ously. To ascertain that our instrument really meas-
ured anxiety, the last 200 patients were also asked to
fill out the State version of Spielberger’s 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 oper-
ations as minor, intermediate, or major. “Minor” was
defined as less invasive surgery of limited duration
(minor orthopedic surgery, diagnostic procedures, ar-
throscopies, laparoscopies, inguinal hernia). Opera-
tions classified as “intermediate” had more impact for
the patient (cholecystectomy, hysterectomy), and “ma-
jor” were extensive operations with a high impact
1 Moerman N, Dam van F, Boulogne-Abraham T, Hooff van M.
The patient’s need for information in the preoperative period. Pro-
ceedings of the 9th European Congress of Anaesthesiology. Jerusa-
lem, Israel, 1994:257.
ANESTH ANALG
INFORMATION SCALE (APAIS) 1996;82:445-51
Table 1. The Amsterdam Preoperative Anxiety and
Information Scale (APAIS)
1. I am worried about the anesthetic.
2. The anesthetic is on my mind continually.
3. I would like to know as much as possible about
the anesthetic.
4. I am worried about the procedure.
5. The procedure is on my mind continually.
6. I would like to know as much as possible about
the procedure.
The measure of agreement with these statements should be graded on a
five-point Likert scale from 1 = not at all to 5 = extremely.
(laryngectomy, reconstructive and transplantation
surgery).
Statistical Analysis
Validity. To evaluate the validity of the APAIS (Ta-
ble 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 be-
tween 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 partic-
ular 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 hy-
pothesized 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 cas-
es.” For this purpose we used Spielberger’s STAI as
the “gold standard.” Auerbach (27) divided a group of
surgical patients on the basis of their preoperative
score on Spielberger’s trait anxiety scale into a high-
trait-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 cut-
off points on the APAIS anxiety scale the sensitivity
ANESTH ANALG MOERMAN ET AL. 447
1996;82:445-51 THE AMSTERDAM PREOPERATIVE ANXIETY AND INFORMATION SCALE (APAIS)

(proportion of correctly identified cases), the specific- Table 2. Patient Characteristicsby Whole Group and
ity (proportion of correctly identified noncases), and Subgroup
the positive predictive value (probability of a high APAIS APAIS + STAI
scale score being a case) in relation to the STAI. (n = 320) (n = 200)
The validity was further evaluated by known-group Sex
comparison in three different ways. 1) We hypothe- Male 121 (37.8%) 85 (42.5%)
sized that women should have a higher score than Female 199 (62.2%) 115 (57.5%)
men on the APAIS anxiety scale. This hypothesis was Mean k SD a e 38.3 IL 13.6 (18-87) 38.8 2 13.9 (18-87)
(yr) (range $
based on data from the literature, where women are
Previous surgery
usually regarded as being more anxious than men Yes 242 (75.6%) 156 (78%)
(7,10,14,19,28). 2) From the work of Miller and Man- No 78 (24.4%) 44 (22%)
gan (24,25) it is known, that high monitors are also Kind of
operation”
anxious people. In other words, in a threatening situ-
Minor 145 (72.5%)
ation monitoring is mostly associated with higher anx- Intermediate 42 (21.0%)
iety and arousal than blunting (29). We therefore hy- Major 7 (3.5%)
pothesized that, in our instrument, patients with a AI’AIS = Amsterdam Preoperative Anxiety and Information Scale; STAI
high information requirement should have a higher = Spielberger’s State-Trait Anxiety Inventory.
score on the anxiety scale than patients with a low a Operations were classified for the last 200 patients only; 6 patients were
not operated on.
information requirement. 3) The effect of preanesthetic
information is less valuable for patients who have
previous anesthetic experience than for those who do Table 3. Factor Loadings in a Two-Factor Solution (After
not (30). We therefore hypothesized that patients with Oblique Rotation)
previous experience of anesthesia and surgery should Factor
have a lower information requirement than those who
1 2
had never had surgery. No specific hypothesis was
formulated regarding the difference between men and Anesthesia
women with respect to their information requirement. 1. Worried about 0.83 0.03
Data were analyzed using the SPSS version 4.0. An 2. Thinks about it continually 0.86 -0.04
analysis of variance (ANOVA) was used for group 3. Wishes to know as much as 0.01 0.87
possible
comparison. Student’s t-tests were used to compare Surgery
the mean scale scores for the subgroups at baseline. 4. Worried about 0.81 0.03
Statistical significance was considered at P < 0.05. 5. Thinks about it continually 0.85 -0.02
Reliability. Cronbach’s os were calculated as a meas- 6. Wishes to know as much as -0.01 0.87
ure for internal consistency of the scales. Reliability possible
was considered acceptable when Cronbach’s (YS were Eigenvalue 3.07 1.25
Percent of variance 51.1 20.8
270 (26).

Results Concurrent validity was determined by the correla-

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 Cronbach’s (Yfor the two scales
separately. Cronbach’s (Y for the four anxiety items
(questions 1, 2, 4, 5) was 0.86. Cronbach’s 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.
tion with the STAI. The correlation between the anxi-
ety 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) be-
tween 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. ANESTH ANALG
THE AMSTERDAM PREOPERATIVE ANXIETY AND INFORMATION SCALE (AI’AIS) 1996;82:445-51

Table 4. The Scores on the Anxiety Scale (Questions 1, 2, 4, 5) for Male and Female Related to Experience of Previous
Surgery (n = 320)
Male* Femalet
Previous surgery Mean” SD II Meana SD n P
Yes 6.8 2.9 98 9.7 4.4 144 <O.OOl
No 10.4 4.5 23 10.6 4.5 55 0.91
a t-test for differences between means.
*I' 5 0.001; tP = 0.23.

had a lower score on the anxiety scale than those Table 5. The Relationship Between the Score on the
without previous experience of surgery. In women Information Scale (Questions 3 and 6) and the Score on
there was no such difference between those who had the Anxiety Scale (Questions 1, 2, 4, 5) (n = 320)
previous experience of surgery and those who had not Score,
(Table 4). anxiety scale
There were no statistically significant relationships
between age, type of operation, and the scores on the Score, information scale n Mean SD

anxiety scale. As the number of patients who under- 24, no/little information requirement 54 7.1 3.6
went major surgery was low, the results regarding the 5-7, average information requirement 127 8.4 3.5
type of operation has to be interpreted with caution. 8-10, high information requirement 139 10.3” 4.8
“Significant difference with both other groups (Tukey HSD procedure
Need-for-Information Scale [P < 0.051).

The need-for-information scale consists of two items

(questions 3 and 6), each of which could be scored
from 1 to 5. The sum of the need-for-information scale
is the sum of these two questions, with a scoring range
from 2 to 10. ANOVA indicated no interaction effect
between type of operation and gender; only a statisti-
cally significant main effect for previous experience of
surgery existed (P = 0.002). Patients with previous
experience had a lower score (mean 6.6, SD 2.3) on the
information scale, than those who had not been oper-
ated on before (mean 7.5, SD 2.2). There were no sta-
tistically significant relationships between age, type of
operation, and the scores on the information scale.
In order to investigate whether there was a relation-
ship between the patient’s need for information and
the level of anxiety, we divided patients according to
their score on the information scale into three groups.
Patients with a score of 2-4 on the information scale
can be classified as having no or little information
requirement and can be considered as blunters. Pa-
tients with a score of 5-7 can be classified as having an
average information requirement, and those with a
score of 8-10 as having a high information require-
ment. The latter can therefore be considered “moni-
tors.” Using this three-group classification for the in-
formation scale, it turned out that in the population of
320 patients the percentages of patients with low, me-
dium, and high information requirements were 16.9%,
39.7%, and 43.4%, respectively. After correction for sex
and experience with previous operations, patients
with a high information requirement turned out to be
the ones who were most anxious (Table 5).
We also investigated whether we could use the APAIS
for detecting “anxiety cases.” We wanted to know at
what score on the APAIS anxiety scale patients could be
considered anxious and would therefore benefit from
more attention. As mentioned in Methods, we used the
STAI-State as a “gold standard” and chose the score of 46
as a reference point. Using this reference point, the sen-
sitivity, specificity, and the predictive value were calcu-
lated at different cutoff points on the anxiety scale
(APAIS). Table 6 shows that the cutoff point of 11 leads
to a good balance. Sensitivity and specificity are good
and the predictive value is 71%. At the score of 11, 37
patients are misclassified (18 false-positives and 19 false-
negatives). This means that 9% (n = 18) of the patients
are anxious on the anxiety scale (APAIS) but not on the
STAI-State, and 9.5% (n = 19) are not anxious on the
APAIS although they are on the STAI-State. At the cutoff
score of 10 sensitivity increasesbut, becauseof the lower
specificity, the predictive value is lower, resulting in a
higher number of false-positive patients (anxious on the
APAIS but not on the STAI) than at the score of 11. At the
scores> 11 sensitivity decreasesand specificity increases.
The cutoff scores11-13 produce approximately the same
amount of misclassified patients (false-positives and
false-negatives together), varying from 34 to 39. How-
ever, an increasing predictive value reduces the number
of false-positive patients.
Using the score of 46 on the STAI-State as a refer-
ence point, the prevalence of anxiety cases in the pop-
ulation (n = 200) was 32%.
Discussion
The purpose of the study was to develop a screening
instrument for use in the preoperative period. For this
ANESTH ANALG MOERMAN ET AL. 449
1996;82:445-51 THE AMSTERDAM PREOPERATIVE ANXIETY AND INFORMATION SCALE (APAIS)

Table 6. Characteristicsof the Anxiety Scale(APAIS) at Different Cutoff Points with a Score of 46 on the STAI-State as a
ReferencePoint (n = 200)
Cutoff scoreon the anxiety scale
10 11 12 13
Sensitivity 75.0% 70.3% 59.4% 53.1%
Specificity 78.7% 86.8% 90.4% 97.1%
Positive predictive value 62.3% 71.4% 74.5% 89.5%
Patients, n (o/o)
a. True-positive 48 (24) 45 (22.5) 38 (19) 34 (17)
b. False-positive 29 (14.5) 18 (9) 13 (6.5) 4 (2)
c. False-negative 16 (8) 19 (9.5) 26 (13) 30 (15)
d. True-negative 107(53.5) 118(59) 123(61.5) 132 (66)
APAIS = Amsterdam Preoperative Anxiety and Information Scale; STAI = Spielberger’s State-Trait Anxiety Inventory.

reason, a six-item questionnaire was developed: the
Amsterdam Preoperative Anxiety and Information
Scale (APAIS). The APAIS was easily and very quickly
completed by patients. Two clear factors emerged:
anxiety and information requirements. The anxiety
scale correlated highly with the standard question-
naire for measuring anxiety: Spielberger’s STAI-State
(0.74). Both the anxiety and the need-for-information
scale showed good psychometric properties and were
feasible in clinical practice. According to the literature
we found that 1) women have a higher score on the
anxiety items than men, and 2) there is a positive
relationship between anxiety and information require-
ment. Patients with a greater need for information
were patients with a higher anxiety level than those
with a low information demand. 3) Patients without
previous experience of surgery had a higher informa-
tion requirement than those who had been operated
on before.
As already mentioned, there was a difference in
anxiety levels between men and women. Women
scored higher on the anxiety scale than men. It was,
however, striking that men who had not been oper-
ated on before were just as anxious as women. How-
ever, men who had undergone previous surgery
scored lower on the anxiety scale than men who had
not. In other words men who have been operated on
before cope differently with their fear of anesthesia
and surgery than women. This finding warrants fur-
ther research.
In contrast to our expectations, it emerged that the
questionnaire did not distinguish well between fear of
anesthesia and fear related to surgery, which means
that feelings of anxiety in the preoperative period are
diffuse and are not really focused on either surgery or
anesthesia. In this respect, the STAI-State should be a
good method for measuring preoperative anxiety, as
noted by Spielberger et al. (15). A great advantage of
our questionnaire, however, is that it is much shorter.
The anxiety scale of the APAIS consists of only four
questions, while in the STAI-State 20 questions must
be answered. Because the APAIS is specifically at-
tuned to the preoperative situation, patients can com-
plete 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 pur-
pose 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 be-
tween 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 (anx-
ious 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 patient’s 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 pur-
poses 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. ANESTH ANALG
THE AMSTERDAM PREOPERATIVE ANXIETY AND INFORMATION SCALE (APAIS) 1996;82:445-51

say, 18 patients have a high score on the APAIS, but Academic Medical Centre for their assistance, Marjolein Porsius,
not on the STAI. With a score of 13 the number of research nurse, for collecting the data about the operations, and
Marion Alhadeff for her expertise and support as a translator.
false-positives decreases to 4. If the list is used for
research purposes, where anxiety reduction is an im-
portant outcome criterion, we recommend a score of
13. At the score of 13 there are hardly any false-
positives (2%) and thus the database is less polluted. References
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