Several studies have shown that the term FTT is often applied to older adults in the acute medical setting with the implication that there is a social, rather than medical, reason for presentation to hospital [12, 13]. However, no study to date has studied the effect of this label on delivery of care. Our study suggests that many older adults with an admission diagnosis of FTT are in fact medically acute, and that there may be an association between this label and delays in care.
The medical acuity of this cohort of older adults is evidenced by two main findings. Firstly, of those admitted with FTT, 88% had acute medical diagnoses at time of discharge. Interestingly, this observation has been noted in an older study that found the related term “acopia” was recorded as a discharge diagnosis in only 12% of their cohort of 109 patients admitted with that label [14]. Another study identified that the most common diagnoses were malignancies and their associated sequelae, infections, and dehydration [3].
A second factor that points to medical acuity is that this cohort received a number of investigations and interventions in the ED including blood work, imaging and intravenous antibiotics. There was also no statistical difference between the frequency and timing of investigations and use of IV antibiotics between the FTT group and the controls (Table 4). That observation had also been previously reported, where 35% of patients admitted with FTT received IV antibiotics and 56% received CT scans (25 and 57% respectively in our cohort) [12]. Interestingly, double the number of non-FTT patients in our study received antibiotics and blood cultures compared to the FTT group while in the ED. This may suggest that patients labeled with an acute medical diagnosis at time of admission were more likely to be perceived as medically acute by ED staff, in contrast to patients labeled as FTT. Unfortunately, the scope of our data collection did not document whether patients in the FTT group went on to receive antibiotics and blood cultures later in their admission.
Our cohort of patients labeled FTT is medically acute, yet they experienced delays throughout their trajectory in the ED. Previous studies have shown that older adults with similar labels are medically active, yet these studies did not include objective measurements of delays in care, such as length of time to physician assessment, admission, and length of stay in the ED. [3, 12, 14]
Previous studies have identified several factors that may pose challenges in the management of older adults in the ED. These include the presence of atypical presentations, polypharmacy, multimorbidity, and barriers in communication stemming from sensory impairment, baseline cognitive impairment, and/or superimposed, evolving delirium [9, 15]. The shortage of resources and the emphasis on efficiency of patient flow through the ED further compounds these challenges. While assigning a label of FTT may be considered as a way to increase efficiency, our study shows that the use of this term on admission is associated with more prolonged trajectories through the ED and longer overall lengths of stay in hospital. In turn, this increases the risk of functional decline during and following hospitalization, with resulting loss of independence, higher risk of readmission, and increased mortality [3, 16]. Notably, Geriatrics involvement did not prolong lengths of stay in hospital in either group, which was included in our study to determine if subspecialty involvement could have contributed to the difference. Previous studies have shown that subspecialty involvement did prolong lengths of stay for older adults, but this was confounded by features that necessitated subspecialty care, like increased morbidity, cognitive impairment, and functional dependence [17].
With awareness of these factors unique to older adults, Acute Care of the Elderly units have become more abundant, yet few models exist to address the need for similar care models in the ED. One conceptual model proposed includes a frailty assessment at time of presentation, assignment of case managers to frail older adults, and creation of an intermediate care area to transition those patients out of the ED. [18] While such models have yet to be tested, logistical reworking and resource redistribution is only part of the solution, as the use of FTT and associated terms is also grounded in negative perceptions of older adults among practicing physicians and trainees [19,20,21].
The term FTT suggests an inherent “failure” on the part of the patient and is unfortunately often perceived as a part of normal aging. The term perpetuates the stereotype of older adults as “demented and decrepit”, and being more prone to “aches and pains”, “mental slowness” and “worrying more” [13, 19]. As a result, complaints like pain, fatigue, depression, and worsening cognition could be wrongfully attributed to a patient’s age, missing critical clinical cues for an underlying, undiagnosed condition [19]. Systematic reviews and qualitative studies found that medical students preferred younger patients with acute diseases that can be “cured”, as opposed to older adults who required more “care”, as they tended to have a number of medical problems and atypical disease presentations that required more time to elucidate [20, 21].
Older adults labeled as FTT are medically acute and therefore require urgent care. Our study suggests that there may be an association between this term and delays in care, which supports conclusions from previous studies that the use of the label may “hinder the urgent search for treatable, reversible causes of deterioration” [13]. Therefore, the use of the label FTT is problematic and potentially harmful to older adults presenting to acute care. We suggest instead using the symptoms described by the patient as a working admission diagnosis, such as “weakness” or “dyspnea” for which there is a differential diagnosis. Other alternatives in the absence of medical descriptors could be considered, such as “decline in function”, “cognitive decline”, or even “frailty”. Importantly, those terms also have ICD codes and are therefore accepted diagnoses on medical documentation.
Study limitations
While this study captured a relatively sizeable cohort of FTT patients compared to other studies on this topic, it was performed at a single, urban academic institution, which may limit generalizability. We also acknowledge that our findings may only pertain to medicine patients, as no surgical patients were included in our study population. Due to the case-control design of our study, we also recognize that our results represent an association between FTT and delays in care and not causation.
We were not able to determine which health care practitioners initially assigned this label, due in part to lack of written communication between emergency room physicians and admitting services. Even with documentation, there was a noted lack of explanation as to why this term was used. As such, the timing of when this diagnosis was applied is uncertain, and qualitative studies are underway to better ascertain when and where the term first originates. We have also used the Charlson Comorbidity Index as a way of accounting for differences in medical complexity between the control and FTT cohorts but would have preferred to calculate frailty scores should that information have been available to us on the electronic medical record. Valuable information such as functional, nutritional, and cognitive status, medications, or comprehensive geriatric assessments were not reliably available in all patient charts, so these components were not included in the study. Subsequent follow-up after discharge from hospital, such as re-admission or mortality, were unfortunately not included in the study due to the limitations of a chart review design.
Future directions
This study has formed the basis for a qualitative study in which health care practitioners will be interviewed to explore why the term FTT is used in our health care system. It is anticipated that the information obtained during this qualitative study will inform education and interventions to reduce the use of this label for older adults presenting to acute care.