Graeme Halliday

Severe domestic squalor: a review.

BACKGROUND Referrals to clinical services of people living in severe domestic squalor are not uncommon. It is timely to review literature concerning and discussing such cases. METHOD Using Medline, Psychinfo, Embase, CINAHL and reference lists from relevant publications, literature referring to over 1100 cases was identified and then reviewed. RESULTS Half of those described as living in severe squalor are elderly. Outcomes of intervention are often poor. People living in severe squalor are most commonly diagnosed as having dementia, alcoholism or schizophrenia, though personality problems are evident in a high proportion. There is evidence to suggest that neglect of hygiene and of attention to cleanliness of accommodation may be largely attributable to frontal lobe changes. The review also revealed a second body of literature, not often cited in papers focussed on unclean living conditions and published in psychiatric or medical journals, that concludes that hoarding is most commonly due to obsessive-compulsive disorder (OCD). Accumulation of rubbish is described in over half of the case reports on severe domestic squalor, but it is suggested that this should only be called hoarding if it results from purposeful collection of items. Lack of impulse control may contribute to collecting behavior, resulting in reduction in living space if there is also a failure to discard. CONCLUSIONS There is a need for further studies, using standardized ratings of living conditions, investigating and trying to understand the complex interplay of triggers and vulnerabilities, exploring how best to intervene and examining outcomes of interventions.

The Environmental Cleanliness and Clutter Scale (ECCS).

BACKGROUND Development of a scale to rate the degree and various aspects of uncleanliness will facilitate description and research in cases of severe domestic squalor. METHODS Discussion with representatives of relevant agencies led to selection of various aspects of domestic uncleanliness and clutter to be assessed when describing cases of squalor. Rooms and areas with varying functions (toilet, kitchen, bedroom, etc.) were all to be rated, along with other indicators of squalor (e.g. odor, vermin). Trial use and further discussion resulted in reduction to ten items, each rated on a four-point scale, with succinct descriptions of anchor-points. Two experienced psychogeriatricians then used this new Environmental Cleanliness and Clutter Scale (ECCS) to rate independently 55 dwellings which had been reported by Aged Care staff as cluttered or unclean, and also rated overall degree of squalor. Reliability and indications of validity were analyzed. RESULTS The inter-rater reliability for the ten items was considered satisfactory (kappa 0.48, varying from 0.31 to 0.58). Cronbachs alpha for the new scale was 0.94, demonstrating high internal consistency. Each authors ratings of degree of squalor (none to severe) matched well with the others ratings on the scale; a score of >12 usually indicated moderate or severe squalor. CONCLUSION The ECCS proved reliable and useful in rating cases where elderly people were living in severe domestic squalor.

How and when to intervene in cases of severe domestic squalor

BACKGROUND Little has been published concerning how best to intervene in cases of severe domestic squalor. METHODS Background literature and reports on how best to intervene in cases of severe domestic squalor were reviewed. RESULTS Reports by groups in London (Ontario), and Sydney (Australia) have provided recommendations for development of coordinated services to intervene in cases of squalor. Guidelines have been issued. Treatments for compulsive hoarding may contribute to improvement in cases where squalor is attributable to restricted access due to clutter. CONCLUSIONS Effective interventions in cases of severe domestic squalor are commonly expensive and require good inter-agency collaboration. Budgetary support must be available to enable appropriate services to take on cases and provide case management.

A study of the use of clozapine in old age psychiatry.

The aim of this study was to review the use of clozapine in a Sydney area old age psychiatry service. Data were extracted from case files of all people who were treated in a health areas old age psychiatry units with clozapine during a 15-year period. Additional details were obtained from clinicians who provided ongoing care after discharge from the hospital. Note was made of psychiatric diagnoses, length of time taking clozapine, dosage, side effects and outcome. Sixteen patients aged over 65 years commenced or continued taking clozapine while inpatients of the service. Of the 13 patients who had a history of schizophrenia or schizoaffective disorder, four patients (all female) developed neutropenia and therefore clozapine was stopped. In one case, neutropenia was first diagnosed 6 years after commencing the medication. Two women died; the nine other women, and one of the deceased, stopped taking clozapine, usually because of side effects. The mean daily dose at cessation was 236 mg. All five men were still taking clozapine (mean 260 mg daily) when followed at a mean age of 72 years, having taken it for an average of 10 years. This case review adds to evidence of the risk of neutropenia when older people are prescribed clozapine.

Antipsychotic use in the elderly: what doctors say they do, and what they do.

Objective:  To review psychiatrists’ attitudes and actual practice on the use of typical and atypical antipsychotics in the elderly.