ABSTRACT
In the current list of acceptable causes of death in the medical certificate of cause of death, some causes are either linked to old age or could be used for all people over the age of 80 years. Notable ones include ‘frailty of old age’, ‘debility of old age’ and ‘senility’. It is best to avoid these terms as they provide an erroneous impression that these conditions occurred because a person was old; we recommend that the list of acceptable causes of death is revised by engaging all stakeholders.
Introduction
It is crucial to give an accurate cause death as far as possible in the medical certificate of cause of death (MCCD). The list of acceptable causes of death was updated last year by the Royal College of Pathologists.1 Even though ‘old age’ has been as an acceptable cause of death for a long time, the list also has other causes linked to the term ‘old age’ that includes ‘frailty of old age’ and ‘debility of old age’. Also, terms like ‘advancing years’, ‘senility’, ‘senile dementia’ and ‘old age’ could be used if a person is above the age of 80 years. However, these terms are not used in clinical practice and there has been some criticism recently regarding the use of ‘frailty of old age’ in the MCCD, especially when the family thought the person wasn't frail.2 Hence, to gather the views of geriatricians, we undertook an online survey regarding the appropriateness of use of some of these causes of death in the MCCD.
Methods
We devised an online questionnaire comprising nine questions and one free-text box. The questionnaire was sent to the Sarcopenia and Frailty Research Special Interest Group (SIG) of the British Geriatrics Society and to a list of consultant geriatricians via the authors' personal contacts.
Results
There were 69 respondents to the survey, of which, eight were from the SIG (Table 1). The majority (73.9%) of the respondents felt that ‘frailty of old age’ should not be used as a cause of death and that this should be referred to as just ‘frailty’. Seventy per cent felt that ‘frailty of old age’ is ageist terminology and 90% disagreed that this term could be applied to all persons above the age of 80 years. Almost all disagreed that ‘debility of old age’ and ‘senility’ should be acceptable as causes of death in the MCCD. There was no difference in opinion between the SIG members and other geriatricians. Selected comments from the free-text box expressing different views are given in Box 1.
Online questionnaire, n=69
Selected free-text comments from the questionnaire
Discussion
The results from our survey demonstrate that causes of death should not be linked to old age. This is probably because it implies that these conditions occur only in people above the age of 80 years and people develop these conditions simply because they are old.
Even though few other conditions (including senile dementia and old age) were listed as causes that could be used if a person was above the age of 80 years, we wanted to explore certain causes that are specifically linked to the term ‘old age’ that erroneously give an impression that they only occur because a person is aged above 80 years.
One-tenth of those surveyed had faced some concerns relating to ‘frailty of old age’ documented in the MCCD from families of the deceased. Frailty is a state of impaired resolution to homoeostasis following a stressor event and is not exclusively associated with old age.3 Even though it is common when people get older, not every person who is older than 80 years becomes frail, and frequently we encounter people younger than 80 years who are frail. Even though the majority of people who become frail have associated multimorbidities, some develop frailty in the absence of any life-threatening illnesses.3,4 However, the true incidence of frailty purely linked to old age is unclear.
Ninety per cent disagreed that ‘debility of old age’ should be an acceptable cause and 99% disagreed that ‘senility’ should be on the list of acceptable causes of death for the MCCD. Since sarcopenia is often linked with frailty, about half felt that this could be used as a cause of death in the MCCD.
The recent guidance from the Office for National Statistics (ONS) discourages using ‘old age’ or ‘frailty of old age’ as the sole cause of death, unless only in very limited circumstances.5 If these are used as causes contributing to death, there should be adequate information in the MCCD to justify this. Many trusts and health boards in the UK now have the medical examiner service to scrutinise all deaths, and it would be prudent for them to question the validity and accuracy of some of these diagnoses if a practitioner chooses to include them in the MCCD.
We contacted the ONS to find out the frequency of use of the term ‘frailty of old age’, but we were informed that there isn't a specific code for ‘frailty’ or ‘old age’ in the globally used diagnostic tool (the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10)), so this could not be easily explored from their database (personal communication).6 Instead, terms such as ‘old age’ and ‘frailty’ are either coded as R54 (a code for ‘age-related physical debility’ or ‘senility’) and R68.8 (a code for ‘other specified general symptoms and signs’) in ICD-10.
For the years 2017, 2018 and 2019, there were 7,661, 8,038 and 7,414 deaths coded under R54, respectively, and 3,310, 4,441 and 4,781 under R68.8 for England and Wales, respectively (personal communication).7 The increase in the number of death codes as R68.8 might reflect increase in use of terms such as frailty or old age.
Hawley's paper looking at the usage of ‘old age’ as a cause of death on 4,300 cremation papers revealed that 300 (7%) deaths were stated to be associated with old age and 98 were attributed to old age alone.8 Hawley's further enquiries revealed between one and six comorbid conditions in at least two-thirds of those certified as dying solely from ‘old age’ and only 8% had no underlying medical conditions.
A limitation of our study is the small number of respondents, and one respondent mentioned that the way the questions were phrased might have influenced the answers. Our low response rate is, however, in keeping with the evidence that responses to web-based surveys are decreasing continuously.9
Conclusion
We realise the importance of recognising frailty as a syndrome in appropriate patients. However, if this is deemed as a cause of death then it should be documented in the MCCD as ‘frailty syndrome’ rather than ‘frailty of old age’, and the conditions leading to frailty should be clearly stated. Failure to adequately record important comorbid conditions would not only affect the statistics of the occurrence of these medical conditions but would also affect health policies and investment on managing these conditions.
Other terms like ‘debility of old age’ and ‘senility’ should be removed from the list of acceptable causes of death in the MCCD. Moreover, debility and senility are not clinically used terms and they are arcane, emotive and may also be offensive to the bereaved. The current list of acceptable causes of death needs a thorough review not only because of some of these terms are linked to old age, but also as there are many other diagnoses and conditions in that list that require clarification too. However, this revision needs to be undertaken through a constructive mechanism by engaging all the stakeholders, namely the Royal College of Pathologists, patient representatives, clinicians, registrars, medical examiners and coroners.
Conflicts of interest
Dr Vedamurthy Adhiyaman also has a role as a medical examiner.
- © Royal College of Physicians 2021. All rights reserved.
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