The cornerstone of proper evaluation of the older self-neglector is multidisciplinary geriatric assessment, wherein medical, cognitive, psychosocial, functional and environmental factors are evaluated in a comprehensive team approach mostly to create a safety net around the individual while addressing remediable problems. The irony is that most self-neglectors would not submit to such an exhaustive evaluation voluntarily. Thus, while physicians may occasionally see such patients in ambulatory practice, they are far more likely to be encountered in situations where serious medical or social sequelae of self-neglecting behaviors have made contact with the health care system unavoidable. Examples include non-elective hospitalization (such as a hip fracture), as a medical consultant during involuntary psychiatric hospitalization, as a physician-expert in the setting of guardianship proceedings, or in the course of making a home visit at the request of family, a state agency, or local social service program.
Physicians who encounter these individuals in ambulatory practice are likely to be overwhelmed by the multiple medical and social problems they harbor. The task is made additionally daunting because no team is typically available to assist in such outpatient settings. Thus, the presentation of the self-neglecting patient to the hospital provides a rare but crucial opportunity to make a relatively expeditious assessment with the help of other professionals.
Irrespective of setting, we offer here several tools to assist the general practitioner in recognizing, evaluating, and treating self-neglect. In addition to the typical history and physical exam, we urge primary care providers to pay particular attention to the following areas: 1) medical history, 2) cognitive assessment, 3) basic and instrumental ADLs, 4) extent of social networks, 5) depression screening and other psychiatric history, 6) environment. Table outlines several red flags that may suggest probable self-neglect. The medical history should look at the “trajectory” of these behaviors using as many sources as possible, and a non-judgmental approach. If self-neglecting behaviors are of acute onset then the probability of an underlying medical problem as culprit (e.g., stroke, delirium, medications) becomes much higher. Any and all sources of information should be used in garnering history about the patient; interviews with family, neighbors, and the person’s ad hoc social network (e.g., local merchants, landlord) often provide a fascinating history into the “life-course” of the person.
Clinician’s Guide to Red Flags of Possible Self-Neglect
The complete medical and psychiatric history may need to be obtained piecemeal over time. Similarly information about any impairment in basic and instrumental ADLs should be corroborated, as self-neglectors typically hide, underestimate, or deny their limitations. A home visit, if allowed by the patient, is crucial in revealing safety and health hazards that may otherwise go unnoticed. At every stage of the patient’s assessment it is important for the clinician to ask about reasons behind particular behaviors. Religious or cultural beliefs may influence behaviors. Alternatively behaviors may indicate a lack of capacity and serve as the basis for interventions.