Modern Approaches to Self-Neglect
H Smyth, S Kennelly, D O’Neill
Department of Age Related Health Care, Tallaght University Hospital, Dublin.
One of the highlights of the Hugh Lane Gallery in Dublin is the studio of Francis Bacon, an extraordinary example of clutter and disarray. It serves, however, as an eloquent example of how neglect and clutter can co-exist with substantial artistic integrity and output, and remind us of the challenge of contextualizing the condition of senile squalor in later life. The artistic metaphor is useful, in that also allows a window on squalor across the lifespan: Tracy Emin’s celebrated work, My Bed, revealed intimate details about her life during a period of mental illness which allows consideration of whether self-neglect is associated with mental illness or may be a life-long trait. Public attention has been aroused to this aspect through a documentary series, Britain’s Biggest Hoarders.
This increasing prominence in the public domain on self-neglect reflects the challenges of assessment and management of hoarding and concerns over self-neglect in clinical practice. Surveys have been carried out amongst medical professionals including old-age psychiatrists and GPs who frequently encounter cases of extreme self-neglect. Amongst old-age psychiatrists, the most common characteristics of self-neglect were loss of self-care and poor hygiene with dementia, lifelong personality disorder and alcoholism being the top three contributing conditions1. Over three-quarters of psychiatrists found self-neglect more frustrating to deal with compared to other clinical issues. Amongst GPs, the most common forms of elder abuse encountered were psychological and self-neglect2. These cases highlight the complexity of self-neglect and the interplay of physical, mental, social, personal and environmental factors. It is an increasingly common problem and a public health issue affecting millions of older people. A study found a prevalence of self-neglect close to 30% in a community-dwelling population3.
But where do self-neglect, hoarding and elder abuse lie together and are they a related phenomenon? By definition, self-neglect is “an inability (intentional or non-intentional) to maintain a socially and culturally accepted standard of self-care, with the potential for serious consequences to the health and wellbeing of the self-neglecters and perhaps even to their community”. Elder abuse was defined as “a single repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person” (WHO). Elder abuse affects about 5% of older people4.
In 2002 in Ireland, the Working Group on Elder Abuse released a report Protecting our Future to help build a framework and create a context in which older people and people involved in cases of Elder Abuse could disclose their concerns and receive an appropriate response5. In this report, self-neglect was separated from the official definition of elder abuse. In 2014, the HSE established a national policy on safe-guarding which included self-neglect6. This was on the basis that the assessment and management strategies were similar to those in elder abuse in terms of balancing the right to individuality with duty of care, as well as the concern to ensure that the self-neglect did not arise in part from inappropriate or inadequate care, one of the manifestations of elder abuse.
Given the parallels between the sophisticated approach required to assess and support people with either elder abuse or self-neglect, it is worth considering what options may improve capacity to manage these conditions in the Irish health services. Irish GPs considered that increasing the availability of home care nurses with increased awareness and an education programme would have the potential to result in a more protective model for older people in Ireland2. Management of patients with self-neglect should include a combination of detection, comprehensive assessments for health, welfare and safety with a MDT approach. This has been facilitated in our institution, and potentially nation-wide, with the development of an older persons Integrated Care Team (ICT).
In a joint project between the local HSE Community Healthcare Organization (CHO 7) and Tallaght University Hospital, the older persons ICT was rolled out in January 2017 to “join up” primary and secondary care for older people with complex conditions. It is the first implementation of what is planned to be a national service offering an integrated model of care for older people. The ICT is directed towards cases with complex needs and/or frequent hospital and community service usage. The team consists of two clinical case managers who are senior public health nurses, a consultant geriatrician and registrar, physiotherapist, occupational therapist, medical social worker and clerical support. The objectives of the services are to:
1. Identify needs and deliver timely, efficient care while coordinating service access across both acute hospitals and community services.
2. Anticipate potential crisis situations and support planning.
3. Minimise avoidable acute hospital admissions.
4. Facilitate appropriate timely discharge from the hospital.
5. Prevent premature Long Term Care (LTC) placement.
6. Work with the community to fast track access to LTC if required7.
The objectives are achieved through a Comprehensive Geriatric Assessment and each case is discussed at a weekly multidisciplinary meeting. All patients are initially assessed at home by the case manager with involvement then of the appropriate therapy teams. If needed, the patient is offered an appointment in a rapid access review clinic or domiciliary home visits are made with the geriatrician. Care planning meetings are held as required. Interventions include provision of home care packages, referrals to day hospitals or centres and when necessary liaising with psychiatry of old age and palliative care in the community, as well as to the evolving system of local Safeguarding and Protection Teams.
Some examples of interventions in our cases of self-neglect included employing Tús workers to assist with a traffic light sticker system clearing system, providing gas safety locks and peg memory boards, referrals to Age Action Care & Repair for tradesmen and day centres. The expansion of Integrated Care Teams will provide an important support for the assessment and management of the expected increase in number of self-neglect cases. Meeting the challenge of knowing when to intervene and balancing autonomy and vulnerability present in most cases will be best addressed through the interdisciplinary gerontological knowledge and skills of such interdisciplinary initiatives.
Dr Hannah Smyth, Department of Age Related Health Care, AMNCH Tallaght Hospital, Dublin
1. O’Brien J, Cooney C, Bartley M, O’Neill D. Self-neglect: A survey of old age psychiatrists in Ireland. International Psychogeriatrics. 2013b Epub July 5, 2013.
2. James G. O’Brien, Ailis Ni Riain, Claire Collins, V. Long & Desmond O’Neill. Elder Abuse and Neglect: A Survey of Irish General Practitioners. Journal of Elder Abuse & Neglect Vol. 26, Iss. 3,2014. http://dx.doi.org/10.1080/08946566.2013.827955
3. Dong X, Simon MA, Mosqueda L, Evans DA. The prevalence of elder self-neglect in a community-dwelling population: hoarding, hygiene, and environmental hazards. J Aging Health. 2012 Apr;24(3):507-24. doi: 10.1177/0898264311425597. Epub 2011 Dec 20
4. C. Naughton, J. Drennan, M.P. Treacy, A. Lafferty, I. Lyons, A. Phelan, S. Quin, A. O’Loughlin, L. Delaney. The National Study of Elder Abuse and Neglect, The National Centre for the Protection of Older People.
5. Protecting Our Future, Report of the Working Group on Elder abuse, September 2012
6. Safeguarding Vulnerable Persons At Risk of Abuse. National Policy & Procedures. Incorporating Services for Elder Abuse and for Persons with a Disability. HSE, December 2014
7. Integrated Care Programme for Older Persons, Update from Pioneer Sites June 2017. National Clinical & Integrated Care Programmes, HSE.