Jason Burnett

Self-Neglect Among the Elderly: A Model Based on More Than 500 Patients Seen by a Geriatric Medicine Team

OBJECTIVES We sought to identify the functional, cognitive, and social factors associated with self-neglect among the elderly to aid the development of etiologic models to guide future research. METHODS A cross-sectional chart review was conducted at Baylor College of Medicine Geriatrics Clinic in Houston, Tex. Patients were assessed using standardized comprehensive geriatric assessment tools. RESULTS Data analysis was performed using the charts of 538 patients; the average patient age was 75.6 years, and 70% were women. Further analysis in 460 persons aged 65 years and older showed that 50% had abnormal Mini Mental State Examination scores, 15% had abnormal Geriatric Depression Scale scores, 76.3% had abnormal physical performance test scores, and 95% had moderate-to-poor social support per the Duke Social Support Index. Patients had a range of illnesses; 46.4% were taking no medications. CONCLUSIONS A model of self-neglect was developed wherein executive dyscontrol leads to functional impairment in the setting of inadequate medical and social support. Future studies should aim to provide empirical evidence that validates this model as a framework for self-neglect. If validated, this model will impart a better understanding of the pathways to self-neglect and provide clinicians and public service workers with more effective prevention and intervention strategies.

The utility of the Kohlman Evaluation of Living Skills test is associated with substantiated cases of elder self-neglect.

Purpose: Self‐neglect is the most prevalent finding among cases reported to Adult Protective Services (APS) and is characterized by an inability to meet one’s own basic needs. The Kohlman evaluation of living skills (KELS) has been validated in geriatric populations to assess performance with both instrumental and basic activities of daily living and as an assessment tool for the capacity to live independently; therefore, the purpose of this analysis was to compare the scores of the KELS between substantiated cases of self‐neglect and matched community‐dwelling elders. Data sources: This is a cross‐sectional pilot study of 50 adults aged 65 years and older who were recruited from APS as documented cases of self‐neglect and 50 control participants recruited from Harris County Hospital District outpatient clinics. Control participants were matched for age, race, gender, and ZIP code. A geriatric nurse practitioner (NP)–led team administered a comprehensive geriatric assessment in homes of all study participants. The assessment included the KELS and mini‐mental state examination (MMSE) tests. Chi‐square analyses were used to determine if cases of self‐neglect were significantly more likely to fail the KELS test than matched controls. Conclusions: The analyses revealed that self‐neglectors were significantly more likely to fail the KELS than non‐self‐neglectors (50% vs. 30%, p = .025). When stratified by MMSE scores, self‐neglectors with intact cognitive function remained significantly more likely to fail the KELS compared to matched, cognitively intact controls (45% vs. 17%, p = .013). Abnormal results using an in‐home KELS test were significantly associated with substantiated cases of self‐neglect. Implications for practice: There is currently no gold‐standard measure for identifying capacity with self‐care behaviors among cases of self‐neglect. As a result, self‐neglect may remain unidentified in many clinical settings. The KELS provides clinicians with an objective measure of an individual’s capacity and performance with everyday life–supporting tasks and thus, provides information that can help NPs identify elders at risk for self‐neglect. These findings suggest that the KELS test has significant utility as part of a comprehensive geriatric assessment to aid clinicians in suspected cases of self‐neglect.

Social Networks: A Profile of the Elderly Who Self-Neglect

ABSTRACT Background. Self-neglect is an independent risk factor for early mortality in older people and has been linked to depression and the occurrence of mental and physical decline. Sound social networks have been shown to slow the process of decline in the elderly, and currently little is known about the social networks associated with elder self-neglect. The aim of this study was to explore the social networks associated with elder self-neglect compared with a matched-control group. Methods. Ninety-one Adult Protective Services-validated cases of elder self-neglect were compared on formal and informal social network factors with 91 controls matched for age, race, gender, and socio-economic status. Results. Elders in the self-neglect group were significantly less likely to (1) Live with a spouse, (2) Live with others, (3) Have weekly contact with children or siblings, (4) Visit with neighbors and friends and (5) Participate in religious activities. Conclusions. Less adequate social resources related to family, friends, and religious affiliations are significantly associated with elder self-neglect.

What is the association between self-neglect, depressive symptoms and untreated medical conditions?

ABSTRACT Objective. There have been no studies describing the occurrence of untreated medical condition(s) in elders with depression who self-neglect. This study compares the prevalence of depression as indicated by an abnormal score (≥5) on the Geriatric Depression Scale-Short Form (GDS-SF) between self-neglecters and matched non self-neglecting community-dwelling elders. It also describes the relationship between untreated medical condition(s) associated with self-neglect and abnormal scores on the GDS-SF. Methods. The two samples consisted of 50 self-neglect cases validated by Adult Protective Services and 50 matched non-self-neglecters recruited from a hospital geriatric unit. The cases and controls were matched on age, gender, ethnicity and socio-economic status when possible. All were assessed in their home. Each participant received a comprehensive geriatric assessment, which included the Geriatric Depression Scale-Short Form, the Mini-Mental State Exam, the Self-Rated Health and Mortality question, and the Physical Performance Test. A laboratory blood analysis was also conducted. Untreated medical condition(s) was determined during the assessment by a geriatric nurse practitioner. Results. There was a statistically significant difference in the distribution of abnormal GDS-SF scores between the self-neglect (n = 25, 51%) versus the control group (n = 14, 28%; χ2 = 5.49, df = 1, p = .019). Self-neglecters with scores indicative of depression were also significantly more likely (56% vs. 21%) to have untreated medical condition(s) compared to self-neglecters scoring normal on the GDS-SF (OR = 4.84,95% CI = 1.37–17.09). Conclusion. Clinicians should anticipate untreated medical condition(s) in elderly patients with depressive symptomatology who self-neglect.

Vitamin D Deficiency Associated with Self-Neglect in the Elderly

ABSTRACT Background. Vitamin D deficiency is common in elders. However, little is known about the implications of vitamin D deficiency in elder self-neglect. Specific Aims. To characterize a group of self-neglecting elders with vitamin D deficiency based on clinical, cognitive, and functional status. Participants. Forty-four self-neglecting elders referred by the Adult Protective Services. Methods. Vitamin D status of the self-neglecting elders was based upon serum levels of 25-hydroxyvitamin D (25-OHD). Demographics, cognitive, and functional characteristics of vitamin D deficient self-neglecting elders were described and compared to those without vitamin D deficiency. Results. Vitamin D deficiency (25-OHD < 25 nmol/L) was detected in 16 out of 44 self-neglecting elders (36%). Self-neglecting elders with vitamin D deficiency had lower scores in the Physical Performance Test and higher scores in the Kohlman Evaluation of Living Skills, compared with those who were not vitamin D deficient (p = 0.014 and p = 0.018 respectively). Conclusions. Vitamin D deficiency is common in elder self-neglect. Self-neglecting elders with vitamin D deficiency have impaired physical performance and inadequate living skills, which can be potentially improved by treating vitamin D deficiency.

SWiFT: a rapid triage tool for vulnerable older adults in disaster situations.

BACKGROUND : In 2005, Hurricane Katrina caused extensive damage to parts of Mississippi, Louisiana, and Alabama, causing many people, including vulnerable older adults, to evacuate to safe surroundings. Approximately 23,000 evacuees--many of them 65 years old or older, frail, and lacking family to advocate for their care--arrived at the Reliant Astrodome Complex in Houston, Texas. There was no method for assessing the immediate and long-term needs of this vulnerable population. METHODS A 13-item rapid needs assessment tool was piloted on 228 evacuees 65 years old and older by the Seniors Without Families Team (SWiFT), to test the feasibility of triaging vulnerable older adults with medical and mental health needs, financial needs, and/or social needs. RESULTS The average age of the individuals triaged was 66.1 +/- 12.72 (mean +/- standard deviation [SD]) years. Of these, 68% were triaged for medical and or mental health needs, 18% were triaged for financial assistance, and 4% were triaged for social assistance. More than half of the SWiFT-triaged older adults reported having hypertension. CONCLUSIONS The SWiFT tool is a feasible approach for triaging vulnerable older adults and provides a rapid determination of the level of need or assistance necessary for vulnerable older people during disasters. The tool was only piloted, thus further testing to determine reliability and validity is necessary. Potentially important implications for using such a tool and suggestions for preparing for and responding to disaster situations in which vulnerable older adults are involved are provided.

Severe Self-Neglect: An Epidemiological and Historical Perspective

ABSTRACT Older adults with severe self-neglect have multiple deficits in various social, functional and physical domains, and often live insqualor. These individuals often present with poor personal hygiene, domestic squalor and hoarding which results in a threat to their own health as well as personal and public safety. Severe self-neglect occurs along a continuum with older adults often having cognitive and affective disorders compared with younger individuals presenting with psychiatric illnesses. In cases of severe self-neglect with hoarding, evidence has shown this behavior occurs in diverse social strata and not among the wealthy and professionals alone as believed earlier. Due to the multiple conditions associated with severe self-neglect, this population will require an interdisciplinary, multidimensional approach to reduce morbidity and mortality rates including nursing home placement. Research on this group has been limited and is rarely described in the medical and nursing literature. Future research is needed to provide practitioners with effective screening instruments and interventions on cases of severe self-neglect.

Is pain a significant factor in elder self-neglect?

ABSTRACT Purpose. Pain is a worldwide health concern leading to cognitive impairments, depression, and decline in activities of daily living when poorly controlled. Self-neglect is also a serious public health issue being the most common allegation reported to Adult Protective Services (APS). The purpose of this analysis is to determine whether self-reported pain is associated with validated cases of self-neglect compared with matched controls. Methods. This is a cross-sectional study of 80 (APS) validated cases of self-neglect aged 65 years and older and 80 control participants recruited from a geriatric clinic at Harris County Hospital District. Control participants were matched for age, race, gender, and zip code. Both groups were administered the Wong-Baker FACES rating scale and the Mini-Mental State Examination in their homes by a geriatric nurse practitioner and a research assistant. Summary of Results. Self-reported pain was noted in 43% of the self-neglect group compared with only 28% in the control group (χ2 = 3.85, df = 1, p = .05). This difference became non-significant after stratifying for MMSE scores of 19 or greater (χ2 = 3.38, df = 1, p = .066). The self-neglecting elderly also reported significantly higher levels of pain compared with the matched controls (t = 2.5, df = 143, p = .014). This mean difference remained significant after stratifying by MMSE scores of 19 or greater (t = 2.6, df = 124, p = .009). Conclusion. The data provide preliminary support for the relationship between self-reported pain and elder self-neglect. Research is needed to determine whether pain is a causal or associated factor in self-neglect and whether therapeutic intervention can improve the syndrome of self-neglect.

Four Subtypes of Self-Neglect in Older Adults: Results of a Latent Class Analysis

To determine whether there are subtypes of elder self‐neglect (SN) with different risk factors that can be targeted using medical and social interventions.

Assessing capacity in the setting of self-neglect: development of a novel screening tool for decision-making capacity.

ABSTRACT Compared with older adults with disabilities and those who autonomously choose to live in squalor, self-neglect syndrome arises from a predicate state of vulnerability in frail older adults. This state of vulnerability is characteristically associated with a decline in decision-making capacity regarding the ability to care for and protect oneself. We developed the COMP Screen to evaluate vulnerable older adults to identify potential gaps in decision-making capacity using a screening tool. A total of 182 older adults were evaluated and consistent declines in cognitive ability and decision-making processes were present in this population. However, there were no significant differences between elders referred for self-neglect and matched older adults. These findings suggest that declines in decision-making processes are not uncommon in vulnerable older adults but traditional conceptualizations of decision-making capacity may be inadequate for differentiating the capacity for self-care and protection in elders who self-neglect.