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DIAGNOSING SELF-NEGLECT IN THE ELDERLY

How can physicians maintain respect for patient autonomy while assessing self neglect? Welcome to the Clinician's Roundtable. I am Susan Dolan, your host and with me is Dr. Lisa Gibbs, Associate Clinical Professor in the Geriatrics Program at the University of California, Irvine Medical Center in Orange, California.

SUSAN DOLAN:

Dr. Gibbs welcome to The Clinician's Roundtable.

DR. LISA GIBBS:

Thank you for having me.

SUSAN DOLAN:

How do you define self-neglect in elderly?

DR. LISA GIBBS:

Self-neglect is really the inability to care for ones own basic needs including healthcare, welfare, and safety. It is one of the most common reasons for referrals to Adult Protective Services and accounts for approximately 50% of elderly cases.

SUSAN DOLAN:

What led to your interest in this area?

DR. LISA GIBBS:

Well I think it is a fascinating area, #1 because, you know, those of us working in this field can be advocates for our older patients. We have a forensics center in Orange County, California which draws upon multiple agencies to really investigate the most difficult cases of elder abuse and we get to work with a lot of other professionals which is also sometimes unique in the field of medicine. For instance, geriatricians here at UC Irvine work with law enforcement, domestic violence experts, social workers from Adult Protective Services. We work with the district attorney and in the Witness Advocate's Office. So we have a lot of variety in our work as we you know seek to understand interesting cases and the geriatricians and psychologists often make home visits with the social workers. We often end up giving our professional opinion and expert opinion regarding medical records, diagnoses, or whether someone received proper attention and also sometimes we end up testifying in court or a district attorney's office to assist in the prosecution of these cases. In addition, you know, geriatrics is probably one of the most fascinating fields of medicine because we really feel like we treat the whole person in terms of chronic medical problems, the complexity of medical problems. We think about the interactions between multiple medications, social situations, and it is just a very fascinating field which is coming in to its own.

SUSAN DOLAN:

What factors contribute to self-neglect?

DR. LISA GIBBS:

Self-neglect is as yet somewhat poorly understood, but we know that one of the biggest risk factors is the presence of memory problems. There is often a lack of social support, a lack of a caregiver which is inherent in the definition because self-neglect is really the inability to care for ones own basic needs and it is very different from the case of neglect where a caregiver is present and the caregiver is failing to provide for ones basic needs. There is also some research that in addition to memory problems, persons who self-neglect have something called executive dysfunction or the inability to have insight in terms of their decisions and the inability and difficulty with organizing and when this occurs for instance people may have problems planning their day. They may have problems organizing their financial records for the month and being able to pay their bills on time. Lot of self-neglecting persons is unable to properly clean their homes, keep their environment safe and that includes self-hygiene. A lot of people who are self-neglecting have difficult time taking care of their self-hygiene. So risk factors include, you know, multiple medical problems, the presence of dementia, perhaps the presence of executive dysfunction and a lack of social support among other things.

SUSAN DOLAN:

Is self-neglect a geriatric syndrome?

DR. LISA GIBBS:

Some people feel that self-neglect is a geriatric syndrome. Geriatric syndromes assume that something that occurs comes from a multifactorial process. For instance a geriatric patient may have a problem with fall. In many cases, it is not one specific medical condition that causes that fall, but it may be a compilation of different etiologies such as poor vision, specifically perhaps poor night vision, and difficulty with balance and/or peripheral neuropathy where they are unable to feel where their feet are in relationship to the ground. So a syndrome is something that results from multifactorial process and so we are in some cases looking at self-neglect as a geriatric syndrome where there is not one specific condition that causes this, but it is a compilation of etiologies.

SUSAN DOLAN:

Describe the physician's role in assessing self-neglect in older patients.

DR. LISA GIBBS:

Well the physician is really in a very unique position to address self-neglect and to discover a person who may be self-neglecting. If a person chooses to come to a physician and many self-neglecting persons do. For instance in one study, many of the self-neglecting patients that came to the notice of APS had recently seen their physician, but also you may have self-neglecting persons who haven’t see a physician for months or years. So it really depends, but we do know that at least in one study a fair number of them do continue medical care. So a physician is in a very unique position and many times it is because it seems like the patient isn't really compliant in terms of the medical recommendations. For instance, I have had many patients with blood pressure problems who are prescribed blood pressure medication and you might expect after doing that and having somebody return, that their blood pressure will be better, but in a self-neglecting person, they may not have the ability to actually go and get that medication filled and take that medication on a regular basis. So instead of getting upset with somebody who doesn’t seem to be following, you know, doctor's orders, you know, we might want to look a step further and say what is the problem here, you know, where is this breaking down. Is it because there is no transportation to the pharmacy which might be something fairly easy to fix, or is it really because this person really is unable to complete the steps that it takes to get this medicine and take it and come back. So at that point, you know, one might think about whether the person really can take care of themselves or not. And that is just one example of where a physician might be. One of the first people to key in on a problem, especially if somebody doesn’t have good social support or family members that are looking after them.

SUSAN DOLAN:

If you are just joining us, you are listening to ReachMD, The Channel for Medical Professionals. I am Susan Dolan, your host, and with me is Dr. Lisa Gibbs, Associate Clinical Professor in the Geriatrics program at the University of California, Irvine Medical Center in Orange, California, discussing self-neglect in the elderly.

Dr. Gibbs what are the components of a comprehensive assessment for self-neglect?

DR. LISA GIBBS:

The components are good history, a good physical exam, and a good functional exam which is really something that we as geriatricians are very careful about obtaining and many clues to self-neglect can be noted by performing these exams. There are certain medical conditions associated with self-neglect which as I mentioned before can be dementia, depression, alcoholism, which occurs more frequently than people realize in older patients or even the presence of psychosis. So by doing these, you know, we may find a person who has a chronically open wound that really doesn’t seem to have the appropriate amount of concern for themselves. We may find that there is a lack of compliance with medical recommendations including taking medicines or the person may just seem confused and not be able to answer questions with a fair amount of detail. Certainly by having that interaction and by having the continuity of care with primary care provider is extremely important. So we get to know our patients, we may naturally discover that they are not functioning as well as they used to and then we can then search for, you know, the reason behind that.

SUSAN DOLAN:

How can physicians maintain a respect for patient's autonomy while assessing self-neglect?

DR. LISA GIBBS:

I think that one; we must realize that patients are considered to have capacity if they have the appropriate testing done to determine incapacity. So I think by treating people with the appropriate amount of respect even if they have memory problems. You know, for instance we don’t talk around them or talk to somebody else, we address our patients directly and we don’t appear as if we are just going to take over decisions for them, I think that is very important and also just to realize that they are their own person and they retain their person hood and self determination, you know, again only until or if appropriate testing is done. That shows us that they are truly incapable of taking care of themselves and for their own good, then perhaps steps have to be taken to find conservators or caregivers that can make decisions for them.

SUSAN DOLAN:

Do physicians have a responsibility to report suspected self-neglect?

DR. LISA GIBBS:

Yes, physicians are mandated reporters as well as all other healthcare providers and self-neglect is among the category of elder abuse that requires reporting to Adult Protective Services.

SUSAN DOLAN:

How does the physician make a report?

DR. LISA GIBBS:

Each of the 50 states has Adult Protective Services Agency and the numbers are readily available. It simply takes a phone call to one of those social services agency, in some cases a followup written document, but that’s all it takes, it probably takes about 5 or 10 minutes of someone's time and from that, then social services will take the responsibility of visiting the patient and investigating whether this is a situation requiring more intervention.

SUSAN DOLAN:

What resources are available for healthcare professionals to learn more?

DR. LISA GIBBS:

One may look up the web sites for social service agencies, specifically Adult Protective Services. There are national agencies including the NCEA which stands for the National Center for Elder Abuse and then centers such as our Center for Excellence on Elder Abuse which have a very strong educational mission. Those are probably the best ways to pursue investigating knowledge of elder abuse.

SUSAN DOLAN:

Dr. Gibbs what is your take home message?

DR. LISA GIBBS:

In terms of healthcare providers, I think the take home message is to be aware of our patients who perhaps live alone, who care for themselves, but seem to have some difficulty doing so and to really know that I think one of the most important things we can do is when we suspect this, is to first ensure their safety and sometimes just the decision that we need to report to APS, could be a life saving decision for these patients. Also if we have the opportunities to be working with social workers or interdisciplinary teams, sometimes we can arrange for home visit and do some more investigating. So take home message is that, you know, we really need to really keep in mind that it may a possibility for patients who appear to be struggling and you know even though our office visit maybe very short time period, making that call to APS or rallying the support of interdisciplinary team members can be a life saving move.

SUSAN DOLAN:

Dr. Gibbs thank you so much for joining us to discuss self-neglect in the elderly.

DR. LISA GIBBS:

You are welcome and thank you very much.

I am Susan Dolan; you’ve been listening to The Clinician's Roundtable on ReachMD, the Channel for Medical Professionals. Please visit our web site at www.reachmd.com which features our entire library of on-demand pod casts. Thank you for listening.