Sabrina Pickens

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.

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.

Future research: A prospective longitudinal study of elder self-neglect

In almost every U.S. jurisdiction, elder self‐neglect is the most common allegation addressed by Adult Protective Service (APS) agencies. Not only is self‐neglect common, but this form of mistreatment is an independent risk factor for death. A lack of understanding of the precipitating factors and root causes and of the effect on social and medical systems persists in this field. Research in this area has been limited, because the needs of these vulnerable elderly people are complex and diverse. Moreover, these factors encompass interrelated medical, psychiatric, economic, social, and functional problems.

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.

Prescription Medication Use Among Self Neglecting Elderly

&NA; The elderly use approximately one‐third of the prescription medication in the United States, often for problems such as chronic pain, insomnia, and anxiety. This study will describe the use of prescription medication, specifically drugs of abuse such as benzodiazepines and opioid analgesics, in a sample of community dwelling elderly referred to Texas Adult Protective Services for self‐neglect. We hypothesize that self‐neglecting behavior may result in increased use of prescription drugs with known abuse potential. Self‐neglecting elders (n = 100) were matched with community controls and interviewed by geriatric nurse‐practitioners in their homes. Benzodiazepine use among self neglecting elderly was four‐fold that of matched controls, (OR = 4.2, 95% CI = 0.9–20.4), and the use of opioid analgesics slightly higher among self‐neglecting elders, (OR = 1.1, 95% CI = 0.5–2.4). Self‐neglecters were significantly less likely to be taking non‐opioid pain medications such as acetaminophen (p < .011) and gabapentin (p < .02). Self‐neglecting elders using benzodiazepines were less likely to be female (OR = .81, 95% CI, 0.2–3.6), live alone (OR = .94, 95% CI, 0.2–4.0), report pain (OR = 0.2, 95% CI, 0.1–2.0), or depression (OR = .66, 95% CI, 0.1–3.2). Those using opioid analgesics were less likely to be female, (OR = 0.6, 95% CI, 0.2–1.9), however, more likely to live alone (OR = 1.7, 95% CI, 0.6–1.9), report pain (OR = 1.5, 95% CI, 0.5–4.5), or depression (OR = 3.2, 95% CI, 1.1–4.9). Self‐neglecting elders demonstrate a unique pattern of prescription drug use. Further studies are required to determine if self‐neglecting behavior in the elderly increases the prescription of benzodiazepine and opiate drugs.

Identifying Cognitive Impairment in Hospitalized Older Adults to Prevent Readmission: Two Case Studies

ABSTRACT Objective: To describe two patient outcomes post-discharge from an acute hospital admission. Both patients underwent cognitive testing during hospitalization. Methods: A battery of cognitive tests was administered to two hospitalized older adult patients. Both patients were evaluated in their homes within 72 hours of discharge and again at 14- and 30-days by a nurse practitioner. Results: One of the patients was readmitted within 30 days of hospital discharge due to complications from an amputation. This patient did not perform well on cognitive measures which may have been related to his pain levels and/or his medication regimen. Conclusions: Not all readmissions are avoidable; however, if readmissions are related to cognitive impairment, implementing strategies tailored to this population may reduce readmission rates. Clinical Implications: Risk factors for readmission should be identified so the discharge team can develop a tailored plan of care. Including both the patient and an informal caregiver may reduce the chance of a hospital readmission in older adults with cognitive impairment regardless of the etiology.

Ethical Issues in Geriatric Research

Imagine yourself as a new research investigator conducting your first pilot study. Your ultimate goal is to develop an intervention that will alleviate detrimental health outcomes in the older adult population. In your first interaction with a potential study participant, Mrs. S., you suspect she may have dementia because she has asked the same question about the study at least five times. How should you proceed with the informed consent process? Should you enroll Mrs. S, despite your suspicion that she may not understand your study? Both new research investigators and experienced investigators will face ethical dilemmas like this one with Mrs. S. on a regular basis. Ethics is the study of conduct and character, and understanding ethics in the context of research with the geriatric population is critical in order for researchers to make the best decisions when ethical dilemmas present themselves. This chapter describes basic ethical issues in geriatric research, including ageism, informed consent concerns, challenges of under-recruitment, and information security risks that concern geriatric researchers.

Dementia and Hospital Readmission Rates: A Systematic Review

Background: Although community-dwelling persons with dementia have an increased risk of hospital readmission, no systematic review has examined the contribution of dementia to readmissions. Summary: We examined articles in English, with no restrictions on publication dates, from Medline, PubMed, PsycINFO, CINAHL, and EMBASE. Keywords used were dementia, Alzheimer disease, frontotemporal lobar degeneration, elderly, frontotemporal dementia, executive function, brain atrophy, frontal lobe atrophy, cognitive impairment, readmission, readmit, rehospitalization, patient discharge, and return visit. Of 404 abstracts identified, 77 articles were retrieved; 12 were included. Four of 5 cohort studies showed significantly increased readmission rates in patients with dementia. On average the absolute increase above the comparison groups was from 3 to 13%. Dementia was not associated with readmission in 7 included case-control studies. Key Message: Findings suggest a small increased risk of hospital readmission in individuals with dementia. More study is needed.