Introduction: Older patients with agoraphobia and other anxiety disorders are at increased risk for delay in medical care. We present a long-term care resident who had documented conservative goals of care who developed back pain. She was subsequently evaluated in the emergency department and found to have nephrolithiasis. Upon further discussion, the patient shared that that goal was due to a fear of leaving the facility, not a desire for palliative care.
Case Description : A 72-year-old female who was residing in long-term care was evaluated for acute on chronic back pain. Medical history was significant for Parkinson disease, severe depression, and chronic pain syndrome. Prior discussions with skilled nursing facility providers included documentation regarding a desire to avoid transfer to the emergency department or hospitalization. She was evaluated for back pain and, through shared decision-making discussion, was transferred to the emergency department for further assessment. Evaluation in the emergency department demonstrated nephrolithiasis. Upon further discussion with the patient, she shared that her primary reason for not wanting to go to the hospital was not due to conservative goals of care but rather a fear of leaving the facility. A ureteral stent was placed, and she was dismissed back to her long-term care facility.
Discussion: Phobias, including agoraphobia, are common in older adults. The prevalence of agoraphobia in older adults has varied widely between 1 and 10%. It is likely underrecognized in older patients due to misattribution of difficulty with leaving the home due to poor health. Late-onset agoraphobia is more often associated with severe depression and anxiety symptoms and less with concomitant panic disorder than in younger persons. Unrecognized agoraphobia has a significant impact on functionality and quality of life, including an increased risk for suicidality. This case emphasizes the importance of mental health assessment as a core component of shared decision making, including advanced care planning.
