The prevalence and characteristic of patients with 'acopia'

SIR—‘Acopia’ is a pejorative term used in hospitals to describe patients who are unable to cope with activities of daily living. Although the term is not a recognised English word or disease entity, it is becoming increasingly common for older patients to be triaged as ‘acopia’ on admission to the Accident & Emergency (A&E) department. Australian studies have shown that the term is mainly used to describe either patients with no acute medical problems or who are deemed inappropriate admissions [1, 2]. Older patients identified as being ‘social admissions’ are known to have a significantly higher risk of death or increased dependence [3]. Richardson showed that the presence of a ‘social problem’ was more strongly associated with death or increased dependence than cardiac failure [1]. This study aims to assess the frequency of the usage of the term ‘acopia’ in a district general hospital in the UK and to determine the characteristics of these patients. A retrospective review of patients’ medical records was carried out at a district general hospital from January 2005 to March 2006. Patients who were triaged with ‘acopia’ as their presenting complaint on their A&E ‘front sheet’ were identified via a computer-generated search for the term. The following data were collected from patients’ case notes: age, sex, pre-admission usage of social services, length of stay, admission and discharge diagnosis, medical co-morbidities and discharge destination. Patients who presented within 2 weeks of discharge from the hospital were considered as a failed discharged. Patients who presented to the A&E department monthly for 6 consecutive months were deemed to be frequent attendees. A total of 93 patients were identified as presenting with ‘acopia’ to the A&E department during the study period. The A&E and medical records of 81 patients were retrieved for the study. Twelve patients were excluded from the study as their case notes could not be located. The total number of patients attending A&E during this period was 50,335; 13,411 (26.6%) were aged >65, and 36,924 (73.4%) aged ≤65. The median age of patients presenting with ‘acopia’ was 85 years (range 22–98), 76 patients (93.8%) were aged >65 and 5 patients (6.17%) aged <65. Older patients (>65) were more likely to be triaged as acopia than younger patients (≤65), 76 out of 13,411 (0.56%) compared to 5 out of 13,411 (0.01%), P<0.01. Fifty-six patients (69.1%) were females. Twenty patients (24.7%) were failed discharges, and seven (8.64%) were frequent attendees to the A&E department. Sixty-six patients (81.5%) had one or more co-morbid conditions such as previous stroke, chronic obstructive pulmonary disease, cardiac disease, diabetes, Parkinson's disease, dementia, depression or malignancy. Thirty-four patients (42.0%) had one co-morbid condition, 22 (27.2%) had two co-morbid conditions and 10 (12.4%) had three or more co-morbid conditions. Forty-two patients (51.9%) did not receive any social services input prior to admission. Thirteen patients (16.1%) had home help once a day, and a similar number of patients had home help twice a day. Five patients (6.17%) had home help three times a day, four patients (4.94%) four times a day and two (2.47%) received home help twice a week. Social services utilisation was unknown in two patients. Seventy-eight patients (96.3%) lived in their own home, two (2.47%) lived in a residential home and one (1.23%) resided in a nursing home. Fifty-nine patients (72.9%) were admitted to hospital with a median length of stay 10 days (range 1–139 days). Twenty-one patients (25.9%) were discharged directly from A&E. A total of 18 patients (22.2%) died. One died soon after being brought into A&E and another 17 during their admission. Thirty-eight patients (46.9%) presented with geriatric syndromes—22 (27.2%) presented with falls, 11 (13.6%) presented with immobility and 5 (6.17%) presented with confusion. Table 1 details patients discharge diagnosis. Five patients (6.17%) had no active medical problems. Discharge diagnosis Percentages do not add up to 100% as some patients had multiple discharge diagnosis. Discharge diagnosis Percentages do not add up to 100% as some patients had multiple discharge diagnosis. Patients were discharged to a variety of destinations. Some patients were referred to the intermediate care team (ICT) for further rehabilitation. Table 2 details patients’ discharge destination. Discharge destination Discharge destination The term ‘acopia’ was used more frequently for older patients. The majority of these patients had acute medical illness as well as concurrent co-morbidities. Over half of these patients had no previous input for social services. Our results suggest that a patient presenting with an inability to cope is a strong indicator for acute medical illness. Only five patients in this study had no active medical problem. The high mortality rate highlights that there is often a pathological condition that warrants urgent medical treatment in these patients. Clinicians and para-medical staff should avoid labelling older patients as social admission until a proper medical assessment is undertaken. This is consistent with results obtained by Obeid et al. who found that ‘acopia’ may cause bias in clinicians leading to important medical diagnosis being missed. Obeid also pointed out that there is a danger of reversible pathology being underdiagnosed in these patients [4]. Previous studies have similarly shown that patients labelled as ‘acopia’ frequently present with complex geriatric syndromes necessitating a specialist geriatric input [4, 5]. Our study reflects a similar result with nearly half of patients presenting with geriatric syndromes such as falls, immobility and confusion. It has been proposed that ‘acopia’ is an inappropriate, unprofessional and unhelpful term that should not be used in clinical practice [6]. However, it is difficult to eradicate any slang or colloquialism that is engrained in medical subculture. We suggest that by embracing the term ‘acopia’ and re-defining it as an all-encompassing term to describe the frail older patient with multiple medical problems culminating in an inability to function independently. Clinicians could recognise the term as a need for urgent referral to a specialist geriatrician for the multi-disciplinary input these patients require. Perhaps by removing the negative associations from the term, these patients will be provided the medical care that they deserve. ‘Acopia’ is commonly used and probably ingrained in medical subculture. It should be seen as a strong indicator for medical illness in older patients rather than a pejorative term. ‘Acopia’ is a pejorative term describing the older patient who is ‘unable to cope’. This study assessed the characteristics of patients presenting with ‘acopia’ to a district general hospital in the United Kingdom. Nearly half of ‘acopia’ patients presented with geriatric syndromes such as falls and confusion. Redefining ‘acopia’ as an all-encompassing term to describe the frail older patient with multiple medical problems may help identify patients in need of urgent specialist geriatric input. None.