'Acopia' and 'social admission' are not diagnoses: why older people deserve better.

In any NHS general hospital, a quick trawl through the clinical notes of older patients would identify several with labels, such as ‘acopia’, ‘social admission’, ‘bed-blocker’ or ‘atypical presentation’. None of these are recognized diagnoses and their presence on discharge summaries would cause consternation to clinical coders. Moving from what staff write to what they sometimes casually say – sometimes even within earshot of a geriatrician or (worse) patients or visitors – we hear more value-laden terms (e.g. ‘crumble’, ‘bed-blocker’ or ‘GOMER’). One consultant colleague from another hospital recently opined to me that even internal – rather than geriatric – medicine house jobs had ‘far too much social work medicine to be of any use in training’. In another instance, a physician clinical director stated at a directorate meeting, without self-consciousness, that he was spending too much time ‘market gardening’ (i.e. caring for old patients who were ‘cabbages’). In a third, a surgeon arrived on my ward with his usual entourage, and laughingly announced (in front of our own ward team) that he ‘didn’t understand how anyone could stand to work in a ward looking after all these “crumblies”.’ In my experience and that of fellow geriatricians, such incidents are depressingly commonplace. If even senior practitioners seem to have so little interest in performing what is actually much of the job of acute medicine in the 21st century, what price adequate mentorship for their juniors? My contention is that the use of such terminology is inappropriate, unprofessional and singularly unhelpful to patient care. It would certainly not be used if the patients were children or younger adults. Similarly prejudicial remarks have long been recognized as inappropriate when applied to, for example, gender or ethnicity. Are older people the last frontier? It isn’t just about politically correct language, however. These attitudes affect diagnosis and treatment. The customary diagnostic rigour, which we have been trained to apply as standard, can be mysteriously replaced in older patients by ageist therapeutic nihilism. Education, training and received values in medicine need to change to reflect the reality of modern medical practice. The core business of hospitals in the NHS and throughout the developed world is in patients with illnesses which are long-term and common and in treatments which are low-tech and palliative or disease-modifying. Yet professional values and training still overly prioritize the acute, the rare, the high-tech and the curative. If we are providing a public service based on need, we must give adequate assessments to the patients who actually turn up in the system, rather than those whom we would find more personally engaging, or those ‘consumers’ who shout loudest.