Self-neglect in the elderly: knowing when and how to intervene

Aging, Spring, 1996 by Eloise Rathbone-McCuan

This article is based on the book, Self-Neglecting Elders: A Clinical Dilemma (see box on page 46), which was edited by uuEloise Rathbone-McCuan and Dorothy Fabian, a Gerontological Consultant with the Hip Fracture Program at the Orthopedic Institute of the Hospital for Joint Diseases in New York City.

Self-neglect in the elderly accounts for the majority of cases reported to adult protective services, but frequently the problems involved are too extensive, and the issues too questionable from a legal standpoint, for agencies to feel comfortable about intervening.

Self-neglect is a blanket term used to describe situations in which older people, in the judgment of others, are thought to be neglecting their needs and putting themselves at high risk of additional and serious deterioration. Sometimes the consequences are permanent and, at other times, can be reversed if the circumstances, attitudes, and behaviors contributing to the lack of self-care are changed and improved.

What often shocks caregivers, volunteers and service providers is that shame does not always accompany blatant and dramatic conditions in which self-neglect is apparent. Sometimes it is hard for us to comprehend that the conditions which we consider to place the older person at risk are, for them, "life as usual." These elders maintain elements of personal dignity, a fierce insistence on their independence, and do not necessarily welcome outside intervention. When assistance is mandated (if the person is a danger to themselves or others) or volunteered, some elders may try to escape from those offering help, directly refuse the assistance, or sabotage efforts to improve their conditions.

The older person who is the focus of concern may be weighed down by physical, emotional, and economic stresses, any or all of which, in varying degrees and combinations, can produce self-neglect. However, even after these stresses have been acknowledged, there may not be agreement among practitioners or between them and the client on the appropriate steps to be taken to reduce risks. Reasons for disagreement usually involve value differences, such as what is an acceptable and safe standard of living, what degree of autonomy should the person be allowed regarding personal choice and behaviors, and what makes for adequate living conditions in old age. The elderly often place a high priority on their independence and consider this the major factor determining the quality of their lives in old age. Practitioners, on the other hand, may advocate introduction of supportive services that erode autonomy.

For example, a social worker may believe that it would be best for a client who is in very poor physical and mental health and lives in a rundown apartment in a dangerous neighborhood to move to a board and care home, which may be a more restrictive environment, but one that will offer safety and supportive services. The client, on the other hand, may see nothing unmanageable about the status quo and want to remain in his or her apartment, even though it needs many repairs and is located in an unsafe neighborhood.

Limited Research on the Problem

The very limited research on self-neglect published in the past few decades (no large-scale national studies have been done) mainly describes one group of elderly who fall in the self-neglect category - people who resist help and are often troublesome in the community. The literature notes that these self-neglecting elders are often confronted by police, arrive at hospital emergency rooms, and get reported repeatedly to social welfare agencies. According to the researchers, frequent efforts to offer assistance to these older people often conclude in a failure to make lasting improvements in their lives. Researchers further note that cost-driven agencies may document the direct and indirect resource expenditures that are required during each case intervention, and conclude that efforts to improve the conditions of self-neglecting elders are too costly. But community agencies and the public, the researchers point out, may also too readily accept the possibility that the lives of these difficult or resistant older people will end in tragedy.

The literature also notes that physicians have learned from repeated contact with different categories of older people who are not taking care of themselves that they will slowly progress into more serious stages of self-neglect. Doctors have found that when physical and or mental capacities are reduced, periods of not meeting basic daily hygiene and nutritional requirements or maintaining a safe living environment become much more frequent and problems more pervasive.

A Broader View: Aging and Social Breakdown

While early explanations by researchers of self-neglect in the elderly often placed the problem in the context of psychiatric problems, Kuyper and Bengtson (1973) considered the causal factors more broadly and suggested that a social breakdown syndrome might better describe what went on in many cases. They stressed that the losses that accompany aging - children moving away and deaths of spouses and friends, unclear ideas about what to expect as people age, disappearance of a reference group, and a dramatic drop in public status - all provide strong negative reinforcement to feelings of uselessness and obsolescence in old age. They argued that for some people, aging can assume a pathological flavor because changes in the social environment cause individuals to doubt their social competence, which turn leads to low self-assessment and a continuing reduction of previously employed coping skills.