The National Center for Health Statistics predicts that the older adult population will account for 20.3% of the United States population by the year 2050, which is an increase of 8% from the 2000 census (“Federal Interagency”, 2004
). Due to this rapidly growing population and fears of increasing incidence of elder mistreatment, in 1992 Congress mandated that the National Center on Elder Abuse conduct a study to determine the incidence of abuse, neglect and exploitation in the elderly population. This study collected data through a nationally representative sample of 20 counties in 15 states among non-institutionalized elderly. According to this study, there were approximately 139,000 (25%) cases of reported self-neglect in persons 60 years of age and older compared to approximately 551,000 (75%) of other types of cases reported to APS. As in other geriatric disorders, such as depression, these numbers may reflect only the “tip of the iceberg” as only a small percentage of the total number of self-neglectors are likely to present to clinicians for care. In fact, only 1.4% of substantiated self-neglectors actually self-report, therefore, it is critical to develop and utilize a method to identify elder self-neglect in the home setting (National Center on Elder Abuse, 1998
Self-neglect syndrome is often characterized by an inability to perform or obtain assistance with Instrumental and Basic Activities of Daily Living (IADL/ADLs). Basic activities of daily living (ADLs) are self-care activities that include eating, bathing, dressing and toileting. Failure to perform these tasks predict a need for caregiver support and subsequent morbidity and mortality (Naik, Concato and Gill, 2004
). Instrumental activities of daily living (IADLs) include more complex levels of functioning such as preparing meals, performing housework, managing finances and using the telephone. Poor performance on these tasks indicate that an individual may not be able to live independently and correlates strongly with placement in long-term care (The Merck Manual of Geriatrics, 2003). In the clinic or emergency department setting, it is often difficult to detect self-neglect since suspected individuals are either too impaired to provide adequate history or decline to provide the facts of their living situation out of shame or resistance to intervention (Harrell, Toronjo, McLaughlin, Pavlik, Hyman and Dyer, 2002
). Physical examination may not reveal self-neglect as patients are examined away from their home settings and some bathe and change their clothes only when they see their clinician. Diagnostic tests that rely on self-report measures may be inadequate because cognitive or affective impairment are often associated with self-neglect (Dyer, Pavlik, Murphy and Hyman, 2000
; Guralnik, Simonsick, Ferrucci, Glynn, Berkman, Blazer et al., 1994
The standard measures of Instrumental and Basic ADLs rely on self-report or proxy report and may be inappropriate for assessing self-neglect. The Kohlman Evaluation of Living Skills (KELS) is a tool originally designed for occupational therapists to assess a client’s ability to perform basic living skills. It assesses both Instrumental (IADLs) and Basic ADLs (Kohlman-Thomson, 1992
). Unlike other measures of ADLs where assessments are either through self or proxy report, the KELS has 3 components of assessment including self-report, observation and performance. A study conducted by Zimnavoda, Weinblatt and Katz (2002)
tested the validity of the KELS as a measure of safe and independent living in the community. This study of an elderly population in Israel included those living in the community, residing in assisted living, and community-dwelling but requiring day care services. Using an in-home assessment, the authors found that the KELS test had greater prognostic validity than individual measures of cognitive, ADL and IADL functions as a measure of safe and independent living in the community. Based on this prior research, we hypothesized that the KELS test could be a useful component for an in-home assessment of suspected cases of self-neglect. The purpose of the current study is to determine if abnormal scores on the KELS is associated with substantiated cases of self-neglect compared to matched controls of community-dwelling elders.
As part of a National Institutes of Health grant funded under the Roadmap Initiative, a cross-sectional pilot study was conducted between March 2005 and October 2005. Prior to enrollment, Institutional Review Board approval was obtained from Baylor College of Medicine and Harris County Hospital District in Houston, Texas.
The KELS was part of a multidimensional battery performed on 50 substantiated cases of elder self-neglect and 50 matched, community-dwelling elders aged 65 years and older. The KELS assesses ADL and IADLs in five areas including self-care, safety & health, money management, transportation & telephone and work & leisure. Scoring is from 0–16 with higher scores indicating a need for assistance to live in a community setting. The scoring system was originally designed to place clients into three categories for the purpose of discharge planning to the home environment: (1) independent with a score of 5 or less (2) borderline skills with a score between 5-5 ½ and (3) needs assistance with a score greater than 6 (Kohlman-Thomson, 1992
). For the current study, a failed KELS test is defined as a score equal to or greater than 6.