‘Self-Neglect in Older Adults A Global, Evidence-Based Resource for Nurses and Other Health Care Providers’ is the first global, evidence-based resource that targets self-neglect and important evidence-based interventions. Global leaders from the US, England, Ireland, Israel, Australia and Canada have contributed chapters. These include respected researchers, practitioners, and academics from multiple health and social care disciplines along with health and social care services who have played a critical role in advancing research, public awareness, and policy on self-neglect. The textbook is edited by Dr. Mary Rose Day, Professor Geraldine McCarthy, and Professor Joyce J. Fitzpatrick and published by Springer, New York.
Dr. Mary Rose Day, originally from Clonakilty, serves as committee member of the All Ireland Gerontolgical Society and is a member of the Institute of Community Health Nursing (ICHN) and SIA Society of Nursing and Midwifery. She is reviewer for All Ireland Gerontolgical Nurses Journal, Archives of Psychiatric Nursing and Journal of Ageing and Social Policy
As populations age in Ireland and the number of people living alone with dementia increase, Dr. Mary Rose Day says that more and more people will be seen to present with self-neglect.
Self-neglect is an important public health issue with many serious adverse outcomes that includes poor health, significantly higher mortality and nursing home placement. A behavioral condition, it may be described as a person’s unwillingness or inability to provide the goods or services necessary to care for his or her own physical and mental health.
Recent national data on safeguarding concerns from the Health Service Executive (2016), categorised 582 cases as extreme self-neglect, and represent seven per cent of the overall cases. Most of the self-neglect cases related to people in the over 65 age category and three per cent were aged 18-64 years.
The most common characteristics of self-neglect include inattention to personal hygiene or cleanliness in one’s environment, a refusal of crucial services and support, and endangerment attributed to personal behaviors. A typical picture of people who severely self-neglect is one of very poor personal hygiene, malnourishment, living conditions of extreme squalor, vermin infested, with no running water or electricity, and presence of a number of pets. Community members often label such individuals as ‘victims’, or ‘reclusive’, and many live alone and often refuse services. All of us can at different times self-neglect by failing to attend to dental care, postponing seeing the doctor or exceeding speed limits, but we would not be considered as self-neglecting, as we have not exceeded a certain threshold. How threshold is defined and by whom can raise further questions.
The underlying problems of older adults displaying the symptoms of self-neglect can be conceptualised as physical, psychological and environmental issues. Risk factors can include dementia, depression, anxiety, alcohol/substance, abuse, dependency, decline in physical function, poor coping, reduced social networks, bereavement, age, living alone, poor economic circumstances, hoarding (compulsive and animal), environmental neglect, and polypharmacy. A small proportion of people who self-neglect may hoard animals or neglect to care for their pets.
Self-neglect is difficult to detect and estimates may present only the tip of the ‘iceberg’, as many cases go unreported or are unknown to services until they are chronic or life threatening. Limited public awareness, exclusion of continuum of self-neglect and high thresholds may contribute to underreporting of cases (Day et al., 2017). Current policy ‘Safeguarding Vulnerable Persons at Risk of Abuse National Policies and Procedures (Health Service Executive, 2014) is under review and includes exceptional cases of self-neglect. Some advocate for a wider policy approach to include each stage of self-neglect severity. Self-neglect can present unique challenges for family members, health and social care professionals and communities. It is more common among older adults, and identifying self-neglect at early stage is very important.
Capacity is a central factor in both understanding what is happening and intervening in situations of self-neglect. A key component of assessment by health and social care professionals is the individual’s decision making capacity and their ability to understand the consequences of their actions. It is important to elicit whether or not the person has the capacity to understand the health and safety risks for person, visitors, family, community and animals.
Given the complexity of self-neglect, a comprehensive interdisciplinary team approach is very important. The team can include: primary care teams, safeguarding teams, general practitioner, public health nurses, mental health nurses, social workers, geriatrician, counsellor, environmental health officer, public health officers, Gardaí, housing, community agencies etc.
A holistic assessment of self-neglecting person’s needs that captures physical, psycho-social and environmental issues and home assessment of health and safety risks is a first step. A person-centred approach, seeks to know and understanding the person’s life story, listens to their perspectives of current circumstance, and ascertains whether the person has the necessary social resources. Efforts need to be focused on building and maintaining a supportive relationships with the individual, setting short and long term goals, small steps over time through which services can be negotiated. Involving the person in decisions and positive risk taking may take several visits.
Each self-neglecting case is unique, there is rarely a single solution and a multidisciplinary team approach and ongoing evaluation and re-assessment are very important. The harmful effects of self-neglect can give rise to significant ethical, personal, and professional challenges. Tensions can arise in respecting autonomy and self-determination of the individual, and perceived duty to preserve and protect health and wellbeing, safety and dignity. The endangerment and risks posed to individual, family, community and animals, will affect responses and interventions. Usually, if individuals have the capacity to make decisions for themselves, they are free to make ‘poor’ choices so long as those choices do not place others or self at risk of serious harm. Negotiated person-centered interventions based on consensus and persuasion rather than an approach which imposes changes tend to have better outcomes. All interventions need an interagency team approach guided by the legislative and policy context.
Self-neglect presents many challenges for health and social care professionals, families, community members, agencies and service. Largely hidden behind closed doors, an event such as a fall, can bring self-neglect to the attention of others.