‘Acopia’ and ‘inability to cope’ remain unhelpful and pejorative labels for complexity in older adults presenting to the acute hospital

Sir, Older adults make up an increasing proportion of those attending acute hospital services and present with increased complexity and acute illness severity in comparison to their younger counterparts [1]. Frequently, ageist and pejorative terms such as ‘acopia’ and ‘inability to cope’ are unfortunately used to describe older patients who are either experiencing functional difficulties, appear to have no acute medical issue or are considered ‘inappropriate admissions’ [2]. Such patients may present with complex (and often multiple) geriatric syndromes and comorbid medical illnesses [3]. Strikingly, the only empirical study on patients labelled with ‘acopia’ published a decade ago in this journal has even demonstrated a mortality rate of 22% for the index admission [4]. Nevertheless, and despite the few papers in the literature on the use of ‘acopia’ discouraging its use [2, 3], as a diagnostic label it persists. In fact, over two-fifths of hospital doctors consider it a useful term (just under one-third consider it an acceptable diagnostic term) [5]. One of the factors that terms such as these may mask is underlying clinical complexity in older patients. We examined the patient records and clinical notes of 97 patients (57% female) labelled with ‘acopia’ (n = 40) or ‘inability to cope’ (n = 57) in their ‘reason for admission’ on routinely completed discharge summaries in a busy acute hospital. The vast-majority (87%) were aged 65 years or older (mean age = 76.8 ± 12.08). Nearly all (91%; 88/97) had another primary medical diagnosis included under their reason for admission. Three-quarters (74%; 72/97) had documented dementia/cognitive impairment and one-third (34%; 33/97) had another psychiatric diagnosis. Median score on Rockwood’s Clinical Frailty Scale (estimated from routine OT/Physiotherapy/Clinical Notes) was 6 (range: 2–9). The median Charlston Comorbidity Index was 8 (range 2–14) and the mean number of regular medications was 10.2 (standard deviation = 5.2). The majority (86%; 83/97) received social work input during their stay, with just over half discharged to long-term care (54%; 52/97) or home with an increased homecare package (17%; 16/97). Thus, nearly all older adults labelled with ‘acopia’ or ‘inability to cope’ have another primary medical diagnosis on presentation to the acute hospital in addition to high levels of dementia/cognitive impairment, frailty and polypharmacy. Increased attention to teasing out the natural complexity underlying the acute presentation and clinical history of older patients and the avoidance of all-encompassing terms such as ‘acopia’ or ‘inability to cope’ is warranted, not least to avoid therapeutic nihilism and adverse outcomes for older adults. We should take advantage of increasing knowledge of cognitive impairment/dementia, frailty and polypharmacy and avoid such terminology to avoid diagnoses being missed and overlooked. In short, our older patients deserve better than such ageist and pejorative descriptors.