Elder Abuse Module 2 Self-Neglect

1. Elder AbuseModule 2Self-Neglect Debra Mostek, M.D. Geriatric Section OVAMC & NEBGEC 981320 UNMC Omaha NE 68198-1320 Web: geriatrics.unmc.edu December 2005

2. PROCESS A series of modules and questions Step #1: Power point module with voice overlay Step #2: Case-based question and answer Step # 3: Proceed to additional modules or take a break

3. Objectives • Define self-neglect • Describe the associated risk factors • Describe the clinician’s role in the evaluation and management of self-neglect

4. Self-Neglect • “Senile breakdown in standards” 1966 MacMillan & Shaw: • “Multifaceted behavioral entity involving inability or refusal to attend to one’s own health, hygiene, nutrition, or social needs”

5. APS definition of SN “The result of an adult’s inability due to diminished capacity to perform essential self-care tasks such as providing essential food, clothing, shelter, and medical care; obtaining goods and services necessary to maintain physical health, mental health, emotional well-being and general safety; and/or manage financial affairs.”

6. Self-Neglect • Annual incidence: 5.2 per 1000 elders • Self-neglect 50-75% of elder mistreatment • 90% of all self-neglect APS ≥ 65y/o • ♀ > ♂ • Ethnic composition • Decreased survival 40.3% died within 13 years follow-up • Self-neglect patients more likely to die in NH Lachs et al. JAMA 1998

7. Self-Neglect Associated Risk Factors • Living alone • Advanced age • Medical burden • Depressive symptoms • Cognitive impairment

8. Environmental assessment • Lack of food, stored unsafely, rotting food • Clutter • Multiple animals • Home in disrepair Dyer CB: The Medical Management of Elder Abuse: A Practical Approach. Presentation. August, 2003

9. Depression and Dementia in Elder Abuse or Neglect • 82% of total cases of abuse or neglect carried diagnosis of self-neglect • Prevalence of depression (62% vs 12%) • Prevalence of dementia (51% vs 30%) Dyer CB et al. JAGS 48:205-208, 2000

10. Risk Factors for Harm in Cognitively Impaired Seniors who Live Alone • 18 month prospective study • 139 community-dwelling subjects; ≥ 65y/o; • Dementia Rating Scale score < 131; • Living alone • Informant with weekly contact and PCP who agree to participate • Informants and PCPs contacted Q 3 months re: subjects’ use of emergency servicesTierney MC et al. JAGS 52:1435-1441, 2004

11. Risk Factors for Harm… Baseline measures: • MMSE; • Social resources (OARS); • Medical diagnoses (Charlson Co-morbidity Index); • Medication use (classified by > 3 prescribed meds) Harm outcome (must involve all 3): • (a) physical injury to self or other, property loss or damage; • (b) due to self-neglect or behaviors 2° to disorientation • (c) emergency service intervention Tierney MC et al. JAGS 52:1435-1441, 2004

12. Risk Factors for Harm… • Thirty participants (21%) had incident of harm • Most common: failure to eat and drink (9) • 73 avoided harm & remained in community • Variables with significant increased risk of harm: • COPD (HR 7.7) • Perception of fewer social resources • Poor performance on MMSE • Cerebrovascular disease (HR 3.1) Tierney MC et al. JAGS 52:1435-1441, 2004

13. Risk Factors for Harm… • OARS social resources measure potential use in primary care • Regular monitoring of high risk individuals’ intake, medical conditions, potential for infection due to poor hygiene • Limitations: these studies exclude the most vulnerable and challenging patients—those without family or close social relationships Tierney MC et al. JAGS 52:1435-1441, 2004

14. Criteria for Personal Care Competence Adapted from McKay, 1989 • Is there evidence that the person may not be adequately caring for himself or herself in terms of: fire/water hazard, nutrition, hygiene, and ADLs? • Does he/she have a realistic appreciation of his/her strengths and weaknesses with respect to providing a secure environment, food and clothing? • Continued… Hazelton LD et al. General Hospital Psychiatry 25 (2003) 130-135

15. Criteria for Personal Care Competence, Continued…Adapted from McKay, 1989 • If she/he cannot function independently in some ADL areas, are they willing to make use of available resources? • Is there evidence of impairment of judgment which resulted in accidents which endangered themselves or others? • Continued… Hazelton LD et al. General Hospital Psychiatry 25 (2003) 130-135

16. Criteria for Personal Care Competence, continued… Adapted from McKay, 1989 • Is there is a fluctuating level of competence, can the person safely care for themselves during the periods of poorest level of function? • Are there delusions or hallucinations that would impair his/her capacity to care for him/herself? Hazelton LD et al. General Hospital Psychiatry 25 (2003) 130-135

17. Risk Assessment and management of patients who self-neglect: a ‘grey area’ for mental health workers • Risk assessment: • Underclass (disadvantaged re: relationships, employment, housing) • Medical disempowerment • Threat (danger to others) • Vulnerability • Self-harm • Dependency Gunstone S. J Psych and Mental Health Nursing, 2003. 10:287-296

18. Decreasing the “grey areas” • Develop a clear philosophy of care • Assessment tools when used in conjunction with clinical assessment • Know policies, procedures, legislation • Guidance from interdisciplinary team • Balance intervention with self-harm and dangerousness Gunstone S. J Psych and Mental Health Nursing, 2003. 10:287-296

19. Sources • Dyer CB: “Neglect”. Presentation at Conference: The Medical Management of Elder Abuse: A Practical Approach. August 22, 2003 • Gunstone S. Risk assessment and management of patients whom self-neglect: a ‘grey area’ for mental health workers. Journal of Psychiatric and Mental Health Nursing. 2003;10:287-296.

20. Sources • Hazelton LD, Sterns GL, et al. Decision-making capacity and alcohol abuse: clinical and ethical considerations in personal care choices. General Hospital Psychiatry. 2003; 25:130-135. • Friedman SM, Williamson JD, et al. Increased Fall Rates in Nursing Home Residents After Relocation to a New Facility. Journal of the American Geriatrics Society. 1995; 43:1237-1242. • Lachs MS, Williams CS, et al. Adult Protective Service Use and Nursing Home Placement. The Gerontologist 2002; 42(6):734-739

21. Sources • Dyer CB, Pavlik VN et al. The High Prevalence of Depression and Dementia in Elder Abuse or Neglect. Journal of the American Geriatrics Society. 2000; 48:205-208. • Tierney MC, Charles J, et al. Risk Factors for Harm in Cognitively Impaired Seniors Who Live Alone: A Prospective Study. Journal of the American Geriatrics Society. 2004;52:1435-1441.

22. The End of Module Two on Elder AbuseModule 2 Self Neglect

23. Post-test The most common cause of elder mistreatment is: • Physical Abuse • Financial Abuse • Emotional Abuse • Self-neglect

24. Correct Answer: Self-neglect • Feedback: • Was aSelf-neglect comprises 50-75% of all elder mistreatment cases. • 90% of all self-neglect cases referred to APS are more that 65 years old. • More females than males self neglect • 40.3% of reported self neglecters died within 13 years follow-up