Self-Neglect by Older Adults

The Purpose of This Overview Paper

The purpose of this fact sheet is twofold: to help older adults, family members, friends and formal care providers ¹ to better understand self-neglect in later life and to suggest some steps for trying to prevent it. One often finds it difficult to know when to intervene and what to do in order to be most helpful in the situation of older adults who are neglecting themselves.

An older adult's right to choose how to live is an important consideration in any self-neglect situation. A balance must be found between ensuring the safety, security and well-being of older adults while respecting their right to be as independent as possible. By learning more about what self-neglect is, why it happens, and what signs to look for, we will be better prepared to deal with self-neglect or to help, in a respectful way, when necessary.

Understanding Self-Neglect by Older Adults

Self-neglect by older adults is a serious problem. A U.S. study has indicated that nearly one half of all abuse cases and two thirds of neglect cases in later life investigated by authorities involve self-neglect. ²  In fact, self-neglect may be the most common form of neglect among older adults. This is why it is so important that their entourage and formal care providers learn more about this problem.

Self-neglect occurs when older adults, by choice or by lack of awareness, live in ways that disregard their health or safety needs, sometimes to the extent that this disregard also becomes hazardous to others.³  For example, a person may choose to have a dirty kitchen, which is not necessarily harmful to others. However, if a fire starts because of this dirty kitchen and spreads to a neighbour's apartment, this self-neglectful behaviour is clearly objectionable.

Older adults who neglect themselves are not willing or able to perform essential self-care tasks such as:

• providing food, clothing, adequate shelter
    
• obtaining adequate medical care
    
• obtaining goods and services necessary to maintain physical and mental health, well-being, personal hygiene and general safety
    
• managing financial affairs ⁴ .

Signs of Self-Neglect

There are several signs or symptoms of self-neglect that you can look for. Poor overall self-care is a major indication of self-neglect. Specific signs to look for include:

* Dehydration

* Malnutrition

* Hypothermia/hyperthermia (exceptionally low/high temperature)

* Excessive dirt or odour, hazardous, unsafe or unclean living conditions

* Inadequate or inappropriate clothing

* Absence of needed eyeglasses, hearing aids, dentures or prostheses

* Unexpected or unexplained deterioration of health

* Bedsores

* Signs of excessive drugging, refusal to take medication or other drug misuse.5

Some Characteristics of Self-Neglectful Older Adults

Older adults who neglect themselves usually have certain characteristics. Knowing about these characteristics can assist those who are trying to help. For example, older adults who neglect themselves are more likely to live alone.⁶ They are also more likely than others to suffer from mental illness or physical illnesses such as Alzheimer's disease, decreased physical abilities, and/or alcohol and drug problems.⁷ There are also some gender differences. More women than men neglect themselves, but this may be because more women than men live alone.⁸

Intervention and Prevention of Self-Neglect

There are relatively clear signs that can help in determining if older adults are neglecting themselves. However, it is less clear what steps family members, friends and formal care providers can take. It may be helpful to consider legal and other intervention strategies in self-neglect situations.

Legal Implications of Self-Neglect

Competent older adults, - able to exercise their rights - including those who live in situations of self-neglect, have the right to decide the risks to which they want to expose themselves and the right to refuse assistance and care. The Canadian Charter of Rights and Freedoms,⁹ which is applicable in some situations, grants everyone the right to life, liberty and the security of the person. Unless the individual is found to be incompetent, help can be offered, but it cannot be forced upon the person. But where the individual poses a risk to others or is violating the Criminal Code, intervention in a self-neglect situation may also be appropriate.

In Canada, there is no general test of competency.¹⁰ The definition of competency varies across legislation, institutions, agencies and provinces/territories. However, it can be generally defined as a person's ability to understand the situation he or she is in and the decisions that have to be made about that situation.¹¹ The legal determination of incompetency is a last resort since it dramatically changes the rights of an individual. For this reason, it is important that the least restrictive approaches are taken before attempting to have an older adult declared incompetent.

The main concern of family members and professionals who are trying to prevent self-neglect among older people is how to balance the independence and well-being of self-neglectful older adults. However, there is no easy answer about how to do this and each case must be treated individually. All people who are trying to help must learn to listen to, respect and counsel the older adult in an appropriate way.

The following questions come from Resource and Training Kit for Service Providers: Abuse and Neglect of Older Adults.¹²

How can the community care for an older adult without jeopardizing that individual's rights?

If an older adult chooses to be neglectful, people must respect this choice in any attempt to help.

The Canadian Charter of Rights and Freedoms may be applicable in the particular situation. Provincial/territorial laws may also recognize certain rights and specify the process that must be followed to provide care when it is believed that the older adult is at risk due to self-neglect. Because these laws are changed on a regular basis, it is important for you to be aware of and stay up-to-date on the current laws in your province or territory. Your appropriate provincial/territorial Office (addresses below) can help.

Do older adults who neglect themselves fully understand the risk to themselves and to others?

Not necessarily, but as long as older adults have sufficient information about their situation and are able to make decisions about it, without endangering others, their choices must be respected and each case must be dealt with individually.

It is important to recognize that even if an older adult's ability is declining, incompetency must not be assumed. Help may be appropriate if it is determined that a decline in ability, combined with other factors such as physical or mental health problems, may be contributing to a case of self-neglect.

However, help by family members and others must be offered voluntarily, with the consent of the older person. Choice is a right of older adults and is also essential for maintaining a sense of dignity and personal control.

Is there a real danger of intruding on the civil rights and privacy of older adults when intervening in cases of self-neglect?

Yes. Competent, self-neglectful seniors have been reported to various authorities because of outside concern regarding their medical needs, physical needs and unsafe surroundings.¹³ For this reason, older adults are especially concerned about the implications of including self-neglect as a category of mistreatment. Older adults who have not been declared incompetent have the right to make choices about lifestyle and to live at risk if there is no danger to others.

Prevention of Self-Neglect by Older Adults

Isolation and carelessness are two main causes of self-neglect among older adults. Social support by family, community and formal care providers is very important in helping seniors remain safely in the community.¹⁴ By decreasing the likelihood of isolation of older adults, these support systems may help prevent self-neglect.

Intervention in Situations of Self-Neglect by Older Adults

Intervention in potential situations of self-neglect must always recognize the rights of older people. When legal considerations have been respected, family, community and social service and health care interventions can, in many cases, help make the situation better.

Family Intervention

Family members may be the first to notice self-neglectful behaviour among older people. Because relatives usually know the history and the lifestyle of seniors in their family, they are often the best judges of whether self-neglect is a relatively new development or whether it has been a life-long habit. While there may be limits to what family members can do, or will be allowed to do, here are some possible approaches:

• Learn to recognize the signs of self-neglect
   
• Help the older adult find his/her own solution to the situation (empowerment)
   
• Keep in contact with the older person; ask if there is anything you can do Offer help and make suggestions about options to the older adult
   
• Find ways that can reduce the older person's isolation
   
• Establish a connection, if there is none, between the older adult and formal care providers.

Community Intervention

When family members need more support, or are absent from a self-neglectful older person's life, there are many ways the community can help. Friends, neighbours, and members of service clubs and religious organizations can offer support to older adults who may be neglecting themselves. These community members may be effective and more accepted by older adults who already know, trust and respect them.

Community services such as friendly visiting, regular telephone calls and volunteer driving may help reduce the isolation of the older adult. However, even if the older adult is less isolated, there may still be a certain amount of self-neglect. While reducing isolation may help in some situations, it is not a complete solution in and of itself.

The potential for self-neglect is much higher when older adults are not able to obtain services, such as transportation, medical care and adequate housing, among others.¹⁵  These services must be available and financially accessible to older adults.

Social Service and Health Care Intervention

Formal care providers can help reduce isolation through coordinated social and health care services such as transportation, meals-on-wheels and homemaking and nursing services. However, formal care providers can also experience difficulties in solving the challenge of isolation of older adults if the individual chooses to remain isolated.

Social and health care services can focus on supplying the medical, physical and environmental resources to meet the needs of older adults who are self-neglectful.¹⁶  These services must be seen as "needed" by the person; for example, meals-on-wheels may be seen as an essential need while mental health services may not. If the self-neglectful older adult admits the need for a social or health service, there is a better chance for help without compromising the person's rights. Communication between formal care providers and self-neglectful older adults is essential. It is important for formal care providers to establish rapport and trust so the help offered is appropriate for that individual.¹⁷

Conclusion

Self-neglect by older adults is a complicated situation. It affects the well-being of older adults as well as those around them. However, family members, friends, neighbours and formal care providers can offer help to self-neglectful older adults without interfering with their rights regarding independence.

Endnotes

• Formal care providers refer to professional and non-professional health care, social service and community support workers.
   
• McCuan, E.R., & Jenkins, M.B. (1992). A general framework for elder self-neglect. In E.R.McCuan & D.R. Fabian (eds.), Self-Neglecting Elders: A Clinical Dilemma. Westport, Conn.: Auborn House as cited in Byers, B. & Zeller, R.A. (1995). Social judgements of responsibility in elder self-neglect cases. The Journal of Psychology, 129(3), 331-344.
   
• Murphy, N. (1994). Resource and Training Kit for Service Providers: Abuse and Neglect of Older Adults. Ottawa: Minister of Supply and Services Canada.
   
• Longres, J.F. (1994). Self-neglect and social control: a modest test of an issue. Journal of Gerontological Social Work, 22(3/4), 3-20.
   
• Wisconsin Coalition Against Domestic Violence (WCADV) in collaboration with the Wisconsin Bureau of Aging and Long Ter Care Resources (BALTCR). (1997). Elder Abuse, Neglect and Family Violence: A Guide for Health Care Professionals; The National Centre on Elder Abuse at the American Public Human Services Association. (1998).
   
• Longres, J.F. Ibid.
   
• Longres, J.F. (1994). Self-neglect and social control: a modest test of an issue. Journal of Gerontological Social Work, 22(3/4), 3-20; Vinton, L. (1992). An exploratory study of self-neglectful elderly. Journal of Gerontological Social Work, 18(1/2), 55-67.
   
• MacMillan, D. & Shaw, P. (1966). Senile breakdown in standards of personal and environmental cleanliness. British Medical Journal, (2), 1032-37 as cited in Roberge, R.F. (1998). Le syndrome de Diogène : une entité gériatrique. Canadian Family Physician, 44, 812-817.
   
• Canada. Canadian Charter of Rights and Freedoms.
   
• Harvey, W. (1993). Ethics in the Health Care of the Elderly Person in Ethics and Aging. Ottawa: National Advisory Council on Aging, 52-69. Cited in Murphy, N. (1994). Resource and Training Kit for Service Providers: Abuse and Neglect of Older Adults. Ottawa: Minister of Supply and Services Canada.
   
• Murphy, N. (1994). Resource and Training Kit for Service Providers: Abuse and Neglect of Older Adults. Ottawa: Minister of Supply and Services Canada.
   
• Murphy, N. Ibid.
   
• Vinton, L. (1992). An exploratory study of self-neglectful elderly. Journal of Gerontological Social Work, 18(1/2), 55-67.
   
• Keigher, S.M. (1991). Informal supportive housing for elders: a key resource for preventing self-neglect. Journal of Elder Abuse & Neglect, 3(2), 41-59.
   
• McCuan, E.R. & Jenkins, M.B. (1992). A general framework for elder self-neglect. In E.R. McCuan & D.R. Fabian (eds.), Self-Neglecting Elders: A Clinical Dilemma (pp. 13- 24). Westport, Conn.: Auborn House.
   
• Longres, J.F. (1994). Ibid.
   
• Mixson, P.M. (1991). Self-neglect: a practitioner's perspective. Journal of Elder Abuse & Neglect, 3(1), 35-42.

Suggested Readings and Videos

Davis, D. & Miniette, R. (Producers). (1988). The Golden Years? [Videotape]. Seattle: KCTS Ass.

Murphy, N. (1994). Resource and training kit for service providers: Abuse and neglect of older adults. Ottawa: Minister of Supply and Services Canada.

Wisconsin Coalition Against Domestic Violence (WCADV) in collaboration with the Wisconsin Bureau of Aging and Long Term Care Resources (BALTCR). (1997). Elder abuse, neglect and family violence: A guide for health care professionals.

Wright, L (Director), Basjajian, S., & Spotton, J. (Producers). (1987). Mr. Nobody [Videotape]. Toronto: National Film Board.

Provincial Contacts

For legislation and other information, contact your provincial/territorial office:

Yukon Territory
Department of Health and Social
Services
P.O. Box 2703
Yukon Government
Whitehorse, Yukon Territory
Y1A 2C6
Telephone: (867) 667-3798
Fax: (867) 667-3096

Northwest Territories
Department of Health and Social
Services
P.O. Box 1320
Yellowknife, Northwest Territories
X1A 2L9
Telephone: (867) 873-7925
Fax: (867) 873-7706

British Columbia
Office for Seniors
Ministry of Health and Minister
Responsible for Seniors
1-2, 1515 Blanshard Street
Victoria, British Columbia
V8W 3C8
Telephone: (250) 952-1238
Fax: (250) 952-1159

Alberta
Alberta Community Development
Seniors Division
P.O. Box 3100
Edmonton, Alberta
T5J 4W3
Telephone: 1-800-642-3853
(toll-free in Alberta)
(780) 427-2705 (outside the province
and in Edmonton)
Fax: (780) 422-5954

Saskatchewan
Saskatchewan Social Services
1920 Broad Street
Regina, Saskatchewan
S4P 3V6
Telephone: (306) 787-3494
Fax: (306) 787-1032

Manitoba
Manitoba Seniors Directorate
822 - 155 Carleton Street
Winnipeg, Manitoba
R3C 3H8
Telephone: 1-800-665-6565
(toll-free in Manitoba)
(204) 945-6565 (outside the province
and in Winnipeg)
Fax: (204) 943-2314

Ontario
Seniors' Secretariat
Office of the Minister Responsible for Seniors
Mowat Block, 3rd Floor
900 Bay Street
Toronto, Ontario
M7A 1R3
Telephone: (416) 327-0510
(in Toronto)
1-888-910-1999
(toll-free in Ontario)
TTY: 1-800-387-5559
Fax: (416) 326-9338

Quebec
Ministère des Relations avec les citoyens et de l'immigration
360 McGill Street
Montreal, Quebec
H2Y 2E9
Telephone: (514) 873-4546
(in Montreal)
1-800-363-1363
(toll-free in Quebec)
or (819) 772-3232
Fax: (514) 873-7349

New Brunswick
Department of Health and Community Services
Office for Family and Prevention Services
P.O. Box 5100, 520 King Street,
4th Floor
Fredericton, New Brunswick
E3B 5G8
Telephone: (506) 453-2950
Fax: (506) 453-2082

Nova Scotia
Senior Citizens' Secretariat
4th Floor
Dennis Building
1740 Granville Street
P.O. Box 2065
Halifax, Nova Scotia
B3J 2Z1
Telephone: 1-800-670-0065
(toll-free in Nova Scotia)
(902) 424-0065
(Halifax-Dartmouth)
Fax: (902) 424-0561

Prince Edward Island
Acute, Medical and Continuing Care Division
Department of Health and Social
Services
P.O. Box 2000
Charlottetown, Prince Edward Island
C1A 7N8
Telephone: (902) 368-6132
Fax: (902) 368-6136

Newfoundland
Continuing Care Division
Department of Health
Confederation Building
West Block, P.O. Box 8700
St. John's, Newfoundland
A1B 4J6
Telephone: (709) 729-3657
Fax: (709) 729-5824

On the Internet, you can consult the Senior Policies and Programs Database (SPPD) for which seniors are the primary beneficiaries. It was developed and is maintained by federal, provincial and territorial governments.
Its Web address is: http://www.sppd.gc.ca

Bibliography

Byers, B. & Zeller, R.A. (1995). Social judgements of responsibility in elder self-neglect cases. The Journal of Psychology, 129(3), 331-344.

Davis, D. & Miniette, R. (1988). The Golden Years? [Videotape]. Seattle: KCTS Ass.

Fabian, D.R. & McCuan, E.R. (1992). Elder self-neglect: a blurred concept. In E.R. McCuan & D.R. Fabian (eds.), Self-Neglecting Elders: A Clinical Dilemma (pp. 3-12). Westport, Conn.: Auborn House.

Keigher, S.M. (1991). Informal supportive housing for elders: a key resource for preventing self-neglect. Journal of Elder Abuse & Neglect, 3(2), 41-59.

Longres, J.F. (1994). Self-neglect and social control: A modest test of an issue. Journal of Gerontological Social Work, 22(3/4), 3-20.

McCuan, E.R. & Jenkins, M.B. (1992). A general framework for elder self-neglect. In E.R. McCuan & D.R. Fabian (eds.), Self-Neglecting Elders: A Clinical Dilemma (pp. 13-24). Westport, Conn.: Auborn House.

Mixson, P.M. (1991). Self-neglect: a practitioner's perspective. Journal of Elder Abuse & Neglect, 3(1), 35-42.

Murphy, N. (1994). Resource and Training Kit for Service Providers: Abuse and Neglect of Older Adults. Ottawa: Minister of Supply and Services Canada.

Neugeboren, B. (1991). Community responsibility for the self-neglectful client. Journal of Aging & Social Policy, 3(1/2), 111-126.

Podnieks, E. (1992). National survey on abuse of the elderly in Canada. Journal of Elder Abuse & Neglect, 4(1/2), 5-58.

Roberge, R.F. (1998). Le syndrome de Diogène : une entité gériatrique. Canadian Family Physician, 44, 812-817.

The National Centre on Elder Abuse at the American Public Human Services Association. (1998). The National Elder Abuse Incidence Study: Final Report. Washington, D.C.: The U.S. Department of Health and Human Services.

Vinton, L. (1992). An exploratory study of self-neglectful elderly. Journal of Gerontological Social Work, 18 (1/2), 55-67.

Wisconsin Coalition Against Domestic Violence (WCADV) in collaboration with the Wisconsin Bureau of Aging and Long Term Care Resources (BALTCR). (1997). Elder Abuse, Neglect and Family Violence: A Guide for Health Care Professionals.

Wright, L. (Director), Basjajian, S. & Spotton, J. (Producers). (1987). Mr. Nobody [Videotape]. Toronto: National Film Board.

This document was prepared under contract by Michael J. MacLean, Director, AgeWise Inc., with the assistance of Chris Clapp and Leigh Doussett. The contribution of the following individuals is gratefully acknowledged: Dr. Jean Kozak, Director of Research, Sisters of Charity of Ottawa; Janice Ireland and Liette Lalonde, Family Violence Prevention Unit, Health Canada.

NCFV contact information