The Geriatrics “Profanisaurus.” Words and phrases we should ban?

David Oliver is a Consultant Geriatrician in Berkshire and a visiting Professor in Medicine of Older People at City University, London. He is President Elect of the British Geriatrics Society. ProfantaClaus

During the BGS Spring Meeting in Belfast, Prof Des O’Neill – probably the most cultured and literate geriatrician in our midst, asked many delegates, notebook in hand,  for tips on enlightening books to further his thirst for broad knowledge. Earnest as ever, I suggested George Haidt’s “The Righteous Mind” and Ha-Joon Chang’s “23 Things They Don’t Tell You about Capitalism!”. Our then Hon. Sec., the redoubtable Dr Zoe Wyrko, mischievously and persistently tried to persuade Desmond that the book he really needed was “Roger Melly’s Profanisaurus” from Newcastle’s Booker-winning publishing house, Viz magazine. I did have a wry smile at the idea of the Amazon package being eagerly opened in Dublin the following week –contents taking pride of place in vertiginous O’Neill bookshelves. I also got to thinking, “sod Roger” – what about “Dave’s Profanisaurus of Geriatric Medicine?”.  Though I don’t believe in censorship, we could list some terms that might result in an on the spot fine, a penance of extra fire safety training or a morning spent being the 15th member of the entourage following General Surgeons, P-Diddy style, round the wards.

I want to encourage my fellow BGS-ers to join in the fun and add their own “unutterables” but here is my start.

“Acopia”/”Acopic”. [sic] Whenever I see this term in patients’ notes I take the doctor aside for some gentle “re-education”. The thing I am proudest of writing is my 2008 essay in the JRSM Acopia and Social admission are not diagnoses.  As Bytheway and Johnson stated, “ageism can range from well-meaning patronage to unambiguous vilification”. Giving some colleagues the benefit of the doubt, at best the “A” word means, “I have no training in dealing with frailty and no understanding that functional impairment usually comes with treatable diagnoses”, at worst, “older people are a just a bit crumbly, its their age, what did you expect?” or,“I can’t be bothered to try making a diagnosis”.

“Off legs ? Cause” comes under this broad umbrella.  After my essay, two enterprising registrars, Drs Kee and Rippingale published an analysis in Age and Ageing of a series of cases of “acopia” – turns out it’s a dangerous diagnosis, encompassing for instance, cancer, severe sepsis, stroke &  acute kidney injury. I still have medical colleagues saying to my geriatrician-face “I have an old boy for you, he is a bit acopic”.  They do so, clearly unaware of the physical danger they have put themselves in.

“Social Admission” [See “Acopia” – above]. This is sometimes a variant on the theme. Readers, I kid you not, I have seen patients with two broken arms, one wrist fracture, spinal cord compression, sepsis and subdural labelled as “social admission” – not to mention those with severe dementia syndrome. In the case of the patients with fractures, I have been known to say, “so why didn’t you send them to the social worker instead of the fracture clinic then?”. An admission could only count as “social” in someone with no acute illness or injury, no recent change in function or cognition, whose carers have withdrawn and called 999, or perhaps someone with Dementia found wandering in the supermarket. And such people should, of course, not be admitted from the front door of the hospital as we can add no value to their care.

“Bed Blocker”.  A couple of years back, when I was still the National Clinical Director for older people, I did 12 radio interviews back-to-back for the minister discussing the rise in “bed blockers”. I pointed out on every breakfast show that these were people, as entitled to care as any other citizen and that if they weren’t in hospital they would still be requiring publicly-funded care. Such terminology is depersonalising and adds to the narrative of older people being a threat to our services and a drain on resources – which is, of course, not true.

 “The stroke in D4”. Ladies and gentlemen, this is a person….and someone’s mother, father or spouse. Someone with likes and dislikes, needs and wants, a life-history and deserving of respect as an individual. Reducing them to a number is profoundly disrespectful – think “prisoner 62”. And before you pull the data protection and confidentiality card, a BMJ survey of patients and public showed them to be intensely relaxed about their name being on display above the bed. Most patients expect professionals to share information about them with one another and we don’t conduct our board rounds using megaphones. Try stopping staff and saying “what’s that patient’s name?” and see if they always know.

“Mechanical Fall”. As all well-trained geriatricians know a fall in an older person generally results from a combination of activity, intrinsic risk factors such as gait, balance or eyesight, and external environmental ones. To be truly “mechanical” we need a fit person with no intrinsic factors slipping on the ice or a banana skin. Its just nonsense – stop it! And again, think about trying to make a diagnosis rather than “presenting complaint – fall; diagnosis – fall”. As Roger Melly would say “B****cks!”

“Failed OT assessment” and “Failed Discharge” One does not “fail” an OT assessment. The OT describes your ability to complete activities of daily living, contextualises this by describing premorbid abilities and then considers the support/equipment/rehab required to bridge the gap. I wish people would stop saying this. And as for “emergency readmissions” – they frequently occur in people for whom discharge was very carefully planned and supported.  Guess what? Conditions relapse. People get new illnesses. People can panic. We need to accept some risk in helping older people return home.

Well, that’s my Mancunian ha’porth of profanities. Who else wants to join in the fun?

35 thoughts on “The Geriatrics “Profanisaurus.” Words and phrases we should ban?

  1. Fantastic list, David, to which must be added my own personal anti-favourite: “Poor historian”. As Prof Bernard Isaacs pointed out in his classic text “The challenge of Geriatric Medicine” the historian is the person taking the history. “Poor historian” is shorthand for I couldn’t be bothered to find out anything about this delirious patient. Despite intensive training some doctors still struggle with using these new fangled telephonic devices in order to speak to someone who can provide more information.

  2. Let’s put some flashing lights on the post… “Geriatrics” is not late onset Paediatrics and is still viewed by many as something distinctly unseemly or confused – all things to everything to nothing for nobody. This is a debate that hasn’t been aired for at least 10 minutes. So whilst picking over the bones of the Turkey think about a bit of rebranding to Geratology the specialty geared to promote the best quality of life in older people with long-term conditions, multiple morbidity and disability.
    Taxi……..

    Seasonal best wishes

  3. Thank you David,

    Always your blogs lift my spirits that there is some sensible talk around!
    Can you add “the Elderly” to the profanisaurus.
    It is a word that has been mentioned several times and in research way back in 1994 as abhorrent to people who are older and the other side of 60.
    I am 65, just retired from employment at the Open University (so I know Bill Bytheway and Julia Johnson well) and just starting out as a new independent consultant on ageing as my new career move. I have also just been appointed as a visiting professor of gerontology nursing – and am really excited at what I contribute to developing curriculums in Europe.
    However, if I am ill enough to go to A&E and have to stay in hospital for a time then I may have to go in the “Care of the Elderly Unit” in Aneurin Health Board. I have challenged this name (also the concept, but then for the intransigent minds of certain areas of the NHS this is just a step too far!!!!) at the highest level but they don’t seem to understand and this is in a nation which has a Strategy for Older People, a Commissioner and policy which states what older people need to be described as – based on consultations with the different generations of older people around Wales.
    I think that use of language develops attitudes and also the other way around. If we really believe in respect for all generations of older people we will describe individuals in the way they prefer and choose, not stereotype or indeed discriminate, as the minute one is pigeon holed or labelled the opportunity to discriminate and deny rights begins.

    In Wales the only group of nurses working with older people has developed recently out of the Welsh Nursing Academy’s unique work on a Position Statement on Nursing Practice and The Older Person in Wales. It is found here as the WNA has now merged into an international nursing organisation http://upsilonxi.nursingsociety.org/new-item/new-item2.
    Here we promote relationship centred care for all older people requiring nursing practice as the evidence based approach of choice and incorporated within the Senses Framework (Nolan et al 2006). This model is evidence based, already adopted for My Home Life (www.agecymru.org.uk/mhlc , and has been piloted and evaluated in acute hospital environments as well as care homes.

    If you want to know more about the All Wales Group please contact me at Lorraine Morgan – lmorganinwales@gmail.com
    Twitter: @welshnursing
    LinkedIn: Lorraine Morgan

  4. Thanks David, the problem with so many of these phrases is that they represent shorthand for “I am not prepared to think any further/deeper about this patient.”

    In this context, a bugbear of mine is “no rehabilitation potential”. Doubtlessly there is a stage in rehabilitation when, in the face of continued multidisciplinary input, patients show no further improvement in objective markers. This is not, however, how this is used in the many parts of the modern NHS. Rather “no rehabilitation potential” usually means “therapist says no..!” – an assertion which is allowed to stand without consideration of reversible medical diagnoses which, if treated, might reveal the rehab potential.

    We need to understand that rehabilitation decisions in older people with frailty should be multidisciplinary and stop using “no rehab potential” as shorthand for, “can’t be bothered.”

  5. Thanks David and all of you for some great words.
    I see that there is significant evidence of me turning into a grumpy old woman – as I realise I agree with almost all of these(sorry Clive I still like Geriatric medicine)- As a fellow graduate of the Bernard Isaacs school of Geriatric medicine, I have lost count of the number of times I have said ‘the historian is the person who recorded the history’ to some hapless junior(and sometimes not so junior!). I hate research projects and/ or surveys which simply look at ‘the elderly’ as an homogenous biomass which suddenly emerges at age 75.
    I would also like to make a stand for ‘quality of life’ as a profanity. Many decisions about treatment in hospital are made based on the patient’s ‘quality of life’- given that those making the decision have generally never seen the patient/person outside of a dehumanising hospital setting – how on earth do they know what the quality of their life is like?
    But I guess my most pressing profanity nowadays(as a community geriatrician) is Urinary Tract Infection(or yew-tee-aye as it so frequently rolls off the tongue of colleagues junior and senior) as if that can explain why a chap with backache and fluctuating fever is intermittently confused(he actually had osteomyelitis of the spine) or why an old lady with frailty suddenly can’t walk(she had had a stroke ). The problem is that people seem to know that geriatricians like me won’t put up with ‘Gone off Legs’ or ‘acopia’- so they invoke the completely irrelevant urinalysis without thinking further. Sadly given the frequency of Urinary Tract Infection appearing on the national HES data, I may be a little isolated in my profound hatred of that diagnosis.

    • Wholeheartedly agree with all of the above and in particular I also despise the lazy use of “UTI” as the cause of all ills. My most regular rant is about patients labelled with “recurrent UTIs” who really turn out to have undiagnosed dementia which would be uncovered if anybody bothered to take a proper history and oddly enough does not respond to repeated courses of trimethoprim!

    • Thanks to all the respondents. By the way, i hear that Zoe is now officially being followed on twitter by @vizprofanisaurus – way to go! I couldnt agree more about “the elderly” – lumping all people from 65 to 100 in one category and characterising them as vulnerable and passive. “Older people” is value neutral and in line with what people would prefer to be called. “UTI” aka “acute trimethoprim deficiency” does indeed account for around 9% of all adult admissions when in reality it is a synonym for frailty. “poor historian” – absolutely right. Would we call a paediatric patient a “poor historian”? “No rehab potential” (or another bete noire) “poor motivation” are vastly over-used often by folk who havent stopped to think whether the “poor motivation” is in fact due to pain, anxiety, depression, fear of falling, postural dizziness etc. And “no rehab potential” is often used by staff in intermediate care who havent ever seen the patient, to refuse them. What we call the speciality? It is as Clive suggests a perennial and circular debate. Having started the discussion by writing a blog about use and misuse of language, paradoxically i find myself fairly relaxed on that topic – it is what we do for people that counts more than nuanced differences in nomenclature. Medicine for older people, geriatrics, clinical gerontology, geratology (though i do find the latter something of an affectation) all fine by me in terms of us describing who we are and what we do. I am not sure the general public like the G word at all though – or even the concept of the speciality and if we were re-branding that would be the driving force.

      David.

      • Thank you and i agree that all the above should be banned phrases but could we refer to the people we care for and actually re-introduce some phrases now considered old fashioned? A patient of mine told me of her ‘galloping’ TB yesterday and i for for one plan to use it often; not sure how often as work in falls and galloping often not an option
        I have started developing a wellness indicator with ‘Bright as a button’ at the top with ‘a bit peaky to be honest nurse’ (makes me worry that one) towards the bottom. I think it would completely throw our non elderly medicine colleagues which can only be a good thing

      • Love “Matron brooke’s” introduction of galloping TB, let’s add “fell at the first fence” for a failed discharge, “The Trots” needs no elaboration and dressage could be applied to the machinations and deliberations over funding for long term care…………………….profanosoriously yours harnessed, tethered etc etc

  6. This is great. Thank you Dr Oliver. Good to see ‘acopia’ right up there at the top, though all are suitably frustrating and often lazy diagnoses.

    To follow on, my least favourite label is often a common diagnosis on a nurses handover or surgical ward round. ‘Pleasantly confused’ is frequently used to describe the patient with fluctuant or moderate delirium. Whilst it is a shocking and a wholly inappropriate assessment, it serves to highlight that many of our front line staff outside the field of older patient care still have little regard for the implications of delirium or how to effectively manage it.

    With time and resources tight, I find the nurses handover an ideal opportunity to discuss many issues, including delirium. It’s quick, you have a captive audience, and can influence the whole nursing team from nursing assistants to senior ward management.

    Thanks again. Have a great Christmas and new year.

  7. Yes please add poor historian! Was going to suggest this. Suggests more about the person doing the assessment that the patient!

  8. May I add that we are having success in getting rid of the word ‘futility’. It appeared on some Treatment escalation plans (previous aka DNA CPR forms) as a reason not to attempt aggressive treatments. However, many of us have objected as the word has negative connotations and seems to judge quality of life. The thinking was, of course, that it was not humane or reasonable to attempt a treatment that has a tiny chance of success or would leave the recipient irreparably damaged. Fine, good idea, but let’s call it something other than ‘futile’ – I urge you to do so….

  9. Now……Matron Brooke…..I was wondering whether you might be having subversive fun under a Hattie Jacques style alias, but I reckon you are the real McCoy. “Galloping TB” indeed! Most Dickensian. But maybe next time I will blog on amusing phrases or malapropisms patients have used with me. “How are you today sir?” I asked once in London “a bit tower doc” “oh yes?…” “tower bridge ap n dahn!”. Another “I used one of ’em TNT tablets under my tongue when I got my angina” and another “I went to casualty and saw one of those triad nurses”. Also a secretary who put in a letter I had dictated that the patient was on “fireside diuretics”

    Dr Sloper

    • Please add the use of the words “We” and ” they ” when referring to older people. It is patronising, dehumanising and demoralising, suggesting that we Oldies are not included in the concept of normal human life.
      I am an 81 year old blogging about the Ageist Trap and the stereotyping of elderly people which prejudges their interests and abilities. http://grandmawilliams.wordpress.com/

      Maybe you should also ban the use of “Retired” as an occupational description. It is not! Ask what we are doing now! Far more relevant and may be surprising.

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  14. I would venture to add anyone ever in hospital or on a paramedic sheet saying/writing “strong smell of urine” or “smells of a UTI”. My rage is likely to triple if this is directed towards a person who has been on the floor all night.

    Oh oh and also “don’t worry dear, just go in the bed and we’ll clean the sheets. It doesn’t matter”.

    It always matters

  15. The term ‘mechanical fall’ should also be band along side all the other made up inaccurate terminology that does nothing more than serve to label older people and dehumanise them.

  16. Acopia is a place with a very small population in the province of Cusco, Peru which is located in the continent/region of South America
    I like putting a picture of it up when playing – ‘guess the diagnosis’. Silly but fun

  17. ‘MFFD’ (medically fit for discharge)
    In other words ‘I’ve treated her for UTI [see above!] by starting a course of antibiotics, now get her off my ward’.
    – said of 88yr old woman with ‘DM2, IHD, COPD, CKD’ who also happened to have early (undiagnosed) dementia, recent bereavement, peripheral neuropathy, & constipation, too…

  18. This particular post is not regarding people being referred to disrespectfully according to their age,yet I feel it’s relevant. When I was a practising midwife the term for first time pregnant ladies over 28 Years old was ‘elderly prim’ (primigravida) I refused to write it in their notes. As I approach middle age I never want to be defined by my age when it comes to treatment in hospitals. My aunt was asked if she wanted to put herself through breast cancer treatment given her age. She was 70 years old and running marathons the previous year and probably far fitter than the person half her age who posed the question. Needless to say she went ahead with treatment and lived fruitfully for another nine years. We need to stop generalising about patients where age is concerned. We are all individuals.

    • The reason that so many of these phrases anger geriatricians so much is that they do precisely that. They imply that there is a cohort of patients who, by virtue of implicit criteria which usually comprise a mixture of chronological age and frailty, deserve less thorough attention.

      If one adopts a truly needs-based model (as opposed to making assumptions on the basis of age or frailty) then the converse is, in fact, true. The more conditions a patient has, the more complex each of these conditions is, the more medications they are taking, the greater the number of domains of assessment in which they demonstrate problems, then the greater the attention to detail, concentration and time that is required to meet their clinical need.

      So Jane, you’re right, chronological age is a distraction. But one which doctors who apply the terms from the Profanisaurus are frequently beguiled by. When they start using terminology which is more detailed and precise, it will show that they are starting to grapple with the true complexity of the situation.

  19. Re: words and phrases I would like to see banned, please oh please stop calling the transfer of patients from hospital to their home or other place for continued care as ‘ discharge! When I was a nurse, discharge was something nasty, probably infected, that seeped out of a wound! The use of the word ‘discharge’ now is used wrongly ,in my book as it implies an end of an episode of care needing no follow up at all and very few transfers out of hospital come into that category. So please can we call it what it should be…transfer of care, (TOC) be it to whichever service is needed to continue recuperation or care. Such a term might even change how the spectrum of care is perceived by everyone from bed managers to the media!
    Vivienne Williams.

  20. Great stuff. I recall a number of times after my fathers stroke when he was an inpatient and then sent home to be ‘reabled’ when he was described as ‘non compliant’. He was nothing of the sort – he had just had his brain scrambled and needed abit of time for things to calm down. People need to walk in the shoes of those who are frail before using such stupid language.

  21. Reblogged this on and commented:
    Please add the use of the words “We” and “they ” when referring to older people! It is patronising, dehumanising, demoralising and sees normal human life as excluding us Oldies. See my blog on the Ageist Trap.

  22. Completely agree with everything & just when you think you’ve seen it all another classic line rises it’s ugly head. I have also sadly witnessed someone with spinal cord compression labelled as off legs ? cause & of course they were “medically fit for discharge” with no diagnosis at this stage. The latest nonsense terms I have encountered are “failed behaviour chart”, “failed bed rails assessment” & the ultimate “failed 4 call simulation”. All terms drive me mad because they mean nothing!!!

  23. Please ban the term ‘Difficult patient’ which is a description covering a range of ‘sins’ such as ringing the bell more than once, asking for a drink outside of tea rounds, wanting to have a bath etc. It was applied to my Mum in a side ward and when her repeated calls on the bell were not answered she banged on the wall with her walking stick. Those who know me will no doubt be smiling at the thought that I will probably be labelled difficult if this label still in use!

  24. David – where do you stand on the use of the word “Sufferer”? To me, as a GP it is fairly common practice to hear patients refer to themselves as suffering with heart failure, cancer etc but since writing my http://www.mumhasdementia blog it is clear that many people with dementia deeply resent the word – wishing instead to be referred to as people living with dementia. I can fully appreciate the sentiments behind this – the word ‘suffering’ implies that it is not possible to live well with a condition and it is perhaps demoralising to use it but I also feel that there are times when ‘suffering’ IS an appropriate term, particularly in the context of dementia, and to avoid suggesting that someone might be struggling with their diagnosis is to ignore the elephant in the room.

    By the way – Excellent to see Viz-related literature on the recommended reading list. A colleague of mine was very keen to introduce a ‘Literature in Medicine’ component to the undergraduate course. I suspect this is what he had in mind.

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  26. Great blog, can I add the term Geriatrician and Geriatric to the list! I would hate to be called a Geriatic, wouldn’t you? From a social worker.

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