Acopia! The fastest way to get a Care of the Eldery Consultant fuming is to use the term "acopia" when presenting a patient in the "post-take" ward round.
Dr Nick is all for the use of the term acopia! My arguments for acopia being a proper medical term are as follows:
1. Acopia is a proper illness. According to the WHO's definition, health encompasses physical, mental & social well-being. In acopia, the main reason for admission is a lack of function & social support at home. By definition, that is an ilness!
2. Acopia sumarises everything in just 3 syllables! No long latin words required. Terms like "off-legs" & "failed OT assesment" are lengthier & don't roll off the tongue as easily!
3. Acopia is a very common illness in the elderly population & accounts for a very large proportion of hospital admissions as any hospital doctor is aware. Acopia is also a relative contraindication to many procedures like major surgery, ITU admission or even resuscitation attempts.
4. The argument against acopia is that it "hides" the reason for their loss of function. Geriatricians argue that it takes a "hit" like a urine infection or a stroke to bring a patient down & we'll be missing such problems if the term acopia is used.
Dr Nick complelety agrees that its essential to search for such contributing factors. That doesn't mean acopia can't be used. For example, the term "exacerbation of COPD" is used, and of course there mey be contributing factors like poor compliance, smoking, infection. Neverthless, "exacerbation of COPD" is generally considered a valid term.
5. Last but not least, acopia can be the only problem. There! I've said it! Now every Geriatrician in the NHS will be trying to get me "struck off" the GMC register! As we age, its accepted that most of our capabilities deteriorate inluding lung function, cognitive abilities, muscle mass, renal function etc. Its therefore completely conceivable that acopia is simply the end-result of getting old.
Agree or disagree? Feel free to comment
NB. Dr Nick is not using Acopia in a derogatory context!
15 comments:
Ah, the joys of trying to code geriatric patients.
Acopia - we can code acopia which is due to the patient not being able to cope (Z73.9), or acopia due to the care-givers (if extant) not being able to cope (Z74.-, last digit being dependant upon the details given in the notes).
Off legs - we could code this to debility / tiredness (R53), or to old age (R54), or to unsteadiness on feet (R26.8), or, if stated as geriatric falls, back to R54 again.
We can code signs, we can code symptoms, if no diagnosis has been possible. We make valiant efforts to make our codes reflect what's been written.
But my all-time favourite primary diagnosis, which came up on a regular basis as the primary diagnosis on the discharge summary for quite a while in our hospital, was 'non-specifically unwell'.
You know what the doctor means, but it's a bugger to get a decent code for it. I think we were stuck with R53 again, which includes 'general physical deterioration' - didn't really have the right feel to it, but if we code 'undiagnosed disease, not specified as to the site or system involved' (R69), we don't get any money for the patient and are told that it's poorly coded. :-(
We DO try.
Anonymous said: "Acopia - we can code acopia which is due to the patient not being able to cope (Z73.9), or acopia due to the care-givers (if extant) not being able to cope (Z74.-, last digit being dependant upon the details given in the notes)."
Oh dear, oh dear! Coding these "acopic" patients doesn't sound half as complicated as treating them!
Of course coding patients isn't as complicated as treating them :-) but, with respect, it IS more complicated than any doctor I've ever encountered believes!
Our biggest trouble with acopia as a primary diagnosis is in a situation such as you set out in example 5 in your original post - where we'd want to code 'old age' as the primary diagnosis, followed by 'acopia', but couldn't unless you'd said so in black/blue/green and white. We aren't allowed to use our iniative, of course - which is only right, including those of us with first class biomedical science degrees (or phamacology degrees).
I know this all seems like 'how many angels can fit onto the head of a pin', but if you classify anything, you come across demarcation problems, don't you?
By the way, the advice on Acopia coding was courtesy of the old NHSIA.
Dr Nick, thank you for your wee article on acopia. Believe it or not, I would like to quote you in my essay and was wondering if you would be willing to divulge your surname for my reference list. I understand if the answer is no... Thanks. Suzy, student nurse.
(Alternatively, any details of articles on acopia that I could refernce, although the point i am making is that there is little official literature on the subject)
Hey, Dr. Nick,
I just happened across your blog. I'm looking for an intelligent one to read, and yours sounded so.
There is a new report called Aging and Toxic Response released by the U.S Environmental Protection Agency. If you are interested, it's a PDF at the bottom of this page: http://cfpub.epa.gov/ncea/cfm/recordisplay.cfm?deid=156648.
I look forward to reading future entries.
I am a trainee in Geriatric Medicine in Australia, here is an abstract from a paper I wrote, in summary I think "acopia" is a great example of medical slang and is more or less equivalent to saying the patient is sick and needs to be admitted, too imprecise to convey any sensible meaning.
A preliminary study to characterise the usage of the term “acopia” at a tertiary teaching hospital
Introduction: Previous attempts to clarify the use of the term “acopia” have suggested it is applied in a wide range of diverse clinical scenarios ranging from purely social admissions to patients presenting with complex medical problems. Geriatricians generally consider this term ageist, derogatory and not diagnostic. The fact it suggests that a patients problems are social rather than medical may discourage adequate assessment, particularly of “geriatric syndromes”. Our concern was that use of the term “acopia” was both prevalent and being used in inappropriate circumstances in a tertiary hospital. We undertook a preliminary study to investigate the use of this term and to whom it was being applied.
Methods: A retrospective medical record audit was conducted of patients with “acopia” entered as free text in Reason for Admission and appropriate data was collected.
Results: 51 patients admitted with a diagnosis of “acopia” were identified. The mean age of the cases was 81±10 years. The majority of patients with “acopia” were living in their own homes and the majority of these were living at home alone. Most were independent in activities of daily living (ADLs) prior to admission, continent and independently mobile. Assessment of cognition was not recorded in 23% of cases and when dementia was recorded as a comorbidity it was seldom further characterized by severity or subtype. Formal assessment tools of cognition were underutilized. The major presenting symptoms could be broadly classified as mobility/falls, confusion, behavioral/psychiatric and cardiorespiratory problems. Mean length of stay was 17.3±16.7 days (range 1-78). Only 49% of patients were discharged to their previous accommodation. Of patients who presented with “acopia” 36% had either presented to or been discharged from the hospital in the preceding 30 days, and 30% represented to the hospital in the 30 days following discharge.
Discussion: Our study confirmed that “acopia” is a term used as an admission diagnosis within our institution. Only a minority of cases could be considered “social admissions”. Our findings support the view that it is in fact acute illness that is the reason for the patient’s or carer’s apparent inability to cope, and therefore the need for hospital admission. The term “acopia” inaccurately implies that no active acute problems are present and does not recognize the presence of geriatric syndromes. High readmission rates, low utilization of geriatricians and allied health staff, inadequate assessment of cognition, long length of stay and low numbers of recorded comorbidities suggest use of the term “acopia” may lead to inadequate assessment and possibly harm. Even where there is a significant social element to an elderly patient’s presentation, it trivializes the significance of this, which is recognized as having poor outcome in terms of loss of independence and mortality. Methods of incorporating key descriptors such as function and cognition into routine clinical practice should be actively pursued, along with avoidance of ill-defined terms such as “acopia” in assessing patients.
1. Gonski P. Acopia – a new DRG? MJA 1997; 167:421-42
2. Obeid J and Ogle S. Acopia: a useful Term or Not? Australasian Journal on Ageing 2000; 19(4):195-198
Whoa! John, thank you for that very detailed & ummm... lengthy contribution. I think the point your paper was trying to make was that the term "acopia" is imprecise & often has an organic cause i.e. UTI, pneumonia.
I still defend the use of the term "acopia" not as a diagnosis, but as a presenting complaint. I agree completely with you, from previous experience the majority of "acopics" have an underlying medical problem. It would be very shoddy Medicine to suggest that Acopia would be appropriate as a diagnosis. However, its a word which rolls off the tongue easily and can be used as a presenting complaint as opposed to "the neighbours were concerned the patient was not managing at home.
In case anyone is interested - the Read code (5 byte) GPs might use is 13Hf. (Unable to cope)- easy!
Acopia ahouldn't be used as admitting diagnosis. With my experience as a nurse in the NHS, most of the time, these patients admitted with so called ACOPIA is discharged and sent back to their homes without any diagnosis. There are lots of people out there who are unable to cope at home.If acopia is a reason for admission, then we need to build another 100,000 new Super Hospitals to admit these people who can't cope witht their medical and social problems.
I would like to say as a student social worker and currently on placement within a care managment team in a hospital, that who are you to define that someone has the inability to cope? Why have you got a right to make that decision on somebodys life, that could be the way the patient knows and likes to live, they could be eccentric. Do you not look further to WHY they maybe having problems, support networks and so on. This does not mean they are unable to cope, i feel it is a lazy term for medical professionals to diagnose due to not having any other diagnosis. This is the problem i feel personally with the medical and social profession, that we tend to come to a standstill on agreements to what the best care for patients are.
Dont you find that you are oppressing 'older people' by giving them the label 'acopia'
I think that using the term acopia is wrong, in the same way that saying an acute medical patient is 'unwell'. If they cannot cope at home - why not. If they have reduced mobility, why not say so, even if there is currently no diagnosis. If they cannot cook - why not say reduced domestic funtion or reduced dexterity or a more specific reason for why they are struggling? I think even for a presenting complaint this is just way too vague, it could mean anything.
In reply to gary, thats where an Occupational therpay assesment comes in rather handy, as it will exactly deine where the coping, functioning has been lost and in what way. Im proud to be a student OT and to have found I could reply with confidence!
Well........as a carer for my 91 year old mother [who lives with me].....I take a pretty dim view of the term ACOPIA.
This was given as the reason for my mother's re-admission to hospital four weeks ago. She had previously been in hospital for five weeks before re-admission and was home for just eight days before being re-admitted.
My arguement is that her medication was changed during her first hospital stay [for UTI and lung infection]. She became very muddled and confused and this stayed with her for the duration of her time in hospital.....When she was discharged I thought that things would improve....but they didn't she slept all the time...didn't know if it was day or night....had frequent "accidents" and didn't seem to know where she was...and at the end of the week she was taken ill again and the doctor was called out to see her...He agreed that she needed to go back into hospital...she had a temperature and he felt that there was an infection somewhere but he wasn't sure where and he thought that she had had a mini stroke. She was re-admitted and they said that she was suffering from dehydration...which could cause symptoms similar to UTI or such like. She was later transferred back to our local elderly care unit where it was remarked to me that she hadn't "lasted long" at home before being re-admitted! I was quite upset by this and said that in fact she wasn't well for the whole week that she had been at home...to which they replied "she was perfectly well when discharged"! Well she wasn't but I wasn't blaming them, I said that I thought the problem was that her medication had changed and that was causing unwanted and unhelpful side-effects. My mothers GP changed the doseage and the side effects have [confusion/muddled] dramatically eased. At the care planning meeting I said that I thought that they were pointing the finger of blame in my direction..but I was assured that that wasn't the case. Then yesterday when mum was discharged I saw that the reason for her admission was written down as -ACOPIA due to too small care package- I feel very let down by this....I think that my mother is very well looked after and that everything was done to help her regain her strength after such a long hospital stay. Since coming home yesterday she has been so much better than before, she's regained her appitite and is awake and taking notice of what's going on around her.......Long may it continue.
Although Acopia maybe be a shorter word for you to write/say perhaps you should reconsider your opinion taking into consideration the effect it has on the people you are labeling and their family and friends.
Perhaps "acopia" reflects your lack of interest in the psychological and social needs of your patients? If problems are identified e.g. recurrent falls or reduced mobility, clear documentation would be essential for other members of the team caring for a person.
Acopia doesn't really reflect individualised person-centred care does it?
Acopia is simply a descriptive term & not meant to derogratory. Physicians must look high & low for the cause of any deterioration in patients.
The use of "acopia" may not be liked by many, so its politely rephrased as "off-legs" or "not managing at home". But that's such a mouthful.
Acopia exists. Deal with it!
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