Review: diogenes syndrome

Household factors and prevalence of squalor: meta-analysis and meta-regression

BACKGROUND

Severe domestic squalor occurs when a person lives in a dwelling that is significantly unclean, disorganised and unhygienic. The limited previous research has primarily focused on the characteristics of those who live in squalor and the associated risk factors. Robust and reliable studies of squalor prevalence have not been conducted. This study sought to produce a reliable estimate of the point prevalence of squalor.

METHODS

Using data from 13-years of the English Housing Survey, N = 85,681 households were included in a prevalence meta-analysis. Squalor prevalence over time, subgroup analysis and logistic regression investigated the role played by household and community characteristics.

RESULTS

The point prevalence of squalor was estimated to be 0.85% and squalor was seen to decrease significantly over time. More significant community deprivation, a rented dwelling, lower income and high numbers of people in the home was associated with a greater risk of squalor.

CONCLUSIONS

Squalor prevalence was higher than previous estimates and supports community care services in associated service planning. The results regarding household characteristics help to inform which households and individuals may be at a higher risk of living in squalid conditions.

Evidence to guide ethical decision-making in the management of older people living in squalor: a narrative review

Older people living in squalor present healthcare providers with a set of complex issues because squalor occurs alongside a variety of medical and psychiatric conditions, and older people living in squalor frequently decline intervention. To synthesise empirical evidence on squalor to inform ethical decision‐making in the management of squalor using the bioethical framework of principlism. A systematic literature search was conducted using Medline, Embase, PsycINFO and CINAHL databases for empirical research on squalor in older people. Given the limited evidence base to date, an interpretive approach to synthesis was used. Sixty‐seven articles that met the inclusion criteria were included in the review. Our synthesis of the research evidence indicates that: (i) older people living in squalor have a high prevalence of frontal executive dysfunction, medical comorbidities and premature deaths; (ii) interventions are complex and require interagency involvement, with further evaluations needed to determine the effectiveness and potential harm of interventions; and (iii) older people living in squalor utilise more medical and social resources, and may negatively impact others around them. These results suggest that autonomous decision‐making capacity should be determined rather than assumed. The harm associated with squalid living for the older person, and for others around them, means a non‐interventional approach is likely to contravene the principles of non‐maleficence, beneficence and justice. Adequate assessment of decision‐making capacity is of particular importance. To be ethical, any intervention undertaken must balance benefits, harms, resource utilisation and impact on others.

Development of a Conceptual Framework for Severe Self-Neglect (SN) by Modifying the CREST Model for Self-Neglect

Self-neglect is an inability or refusal to meet one's own basic needs as accepted by societal norms and is the most common report received by state agencies charged with investigating abuse, neglect and exploitation of vulnerable adults. Self-neglect is often seen in addition to one or multiple conditions of frailty, mild to severe dementia, poor sleep and depression. While awareness of elder self-neglect as a public health condition and intervention has significantly risen in the past decade as evidenced by the increasing amount of literature available, research on self-neglect still lacks comprehensiveness and clarity since its inception to the medical literature in the late 1960s. With the burgeoning of the older adult population, commonness of self-neglect will most likely increase as the current incidence rate represents only the "tip of the iceberg" theory given that most cases are unreported. The COVID-19 pandemic has exacerbated the incidence of self-neglect in aged populations and the need for the use of intervention tools for aging adults and geriatric patients living alone, many of which may include in-home artificial intelligence systems. Despite this, little research has been conducted on aspects of self-neglect other than definition and identification. Substantial further study of this disorder's etiology, educating society on early detection, and conceivably preventing this syndrome altogether or at least halting progression and abating its severity is needed. The purpose of this research is to provide a definition of severe self-neglect, identify key concepts related to self-neglect, comprehensively describe this syndrome, present a conceptual framework and analyze the model for its usefulness, generalizability, parsimony, and testability.

Capacity to Choose Place of Residence: Autonomy vs Beneficence?

Health care workers often perceive a conflict between autonomy and beneficence when dealing with clients living at risk in the community. Respect for personal freedom and the desire to help and protect vulnerable People frequently appear to demand opposite interventions. The assessment of decision-making capacity is a vital part of any process that deals with these complicated situations and can resolve some of the apparent conflict. Standardized assessment tools which are flexible enough to deal with the complexities of capacity assessment are needed. Health care workers aim to maximize the safety of People incapable of making decisions while protecting the freedom and autonomy of the capable. Some limits to autonomy must be accepted, especially where others’ interests are threatened.

TD: The case of Diogenes Syndrome-deficit or denial?

Diogenes Syndrome (DS) is characterised by extreme self-neglect, domestic squalor, hoarding, social withdrawal, and lack of concern and shame for the individual's residential situation. This paper describes TD who was unable to identify emotional expressions of disgust and was borderline-impaired for facial recognition associated with perceptual difficulties. Problems interpreting expressions of disgust were interesting as TD was living in squalor, neglecting himself, and lacked concern for his circumstances. This led us to question whether the basis of his difficulties were neuropsychological or psychological in nature, which became the objective of this study, with a focus on shame and disgust. TD completed neuropsychological and psychological assessments alongside an experimental task investigating processing of disgust and his living situation. Results highlighted executive dysfunction but understanding of living with the consequences of squalor was spared as was emotion based decision-making. Assessment indicated difficulties with olfactory processing and aspects of interoceptive awareness. TD showed poor awareness of his living conditions and a lack of shame. Disgust sensitivity was unimpaired. It is unclear if TD's difficulties were caused by psychological or neuropsychological impairments, although both likely play a part. Further research is required to understand processes underpinning DS, particularly disgust and shame.

Diogenes Syndrome in Frontotemporal Dementia

Diogenes syndrome refers to the combination of extreme self-neglect and excessive collecting with clutter and squalor, which is often present in patients with dementia. Diogenes syndrome may be particularly common in behavioral variant frontotemporal dementia (bvFTD), and the investigation of these patients may help clarify the nature of this syndrome. We describe 5 patients with bvFTD who exhibited a decline in self-care accompanied by hoarding behaviors. These patients, and a review of the literature, suggest a combination of frontal lobe disturbances: loss of insight or self-awareness with a failure to clean up or discard, a general compulsive drive, and an innate impulse to take environmental items. This impulse may be part of the environmental dependency syndrome in frontal disease, with specific involvement of a right frontolimbic-striatal system. Further investigation of the similarities and mechanisms of these symptoms in bvFTD could help in understanding Diogenes syndrome and lead to potential treatment options.

Harnessing neuroplasticity in Diogenes syndrome: a proposed mechanism to explain clinical improvement

Extreme neglect of one's living space and self-care is a perplexing condition termed Diogenes syndrome, where outcomes of intervention are often poor, with high relapse and mortality rates. Relatively little has been reported regarding management approaches. We present a case of Diogenes syndrome responsive to a structured behavioral paradigm during a hospital admission and speculate on the mechanism of neuroplasticity-based behavioral treatment in facilitating clinical improvement.

Does self-neglect occur among older adults with dementia when unsupervised in assisted living? An exploratory, observational study

The phenomenon of older adults with dementia who develop behavioral expressions when they are unsupervised in assisted living residences is understudied. This qualitative study aimed to bridge this gap in the literature by focusing on 12 residents in various stages of dementia. Grounded Theory was followed to guide data collection and analysis. Data were collected in two special care units of an assisted living residence for 10 months. Participant observation was the primary data collection strategy. Semistructured interviews with staff and managers and review of clinical records augmented the observation data. While unsupervised, residents exhibited a wide spectrum of negative emotional states, behavioral expressions, functional difficulties, wayfinding difficulties, serious hygiene problems, and safety risks. More than half of the identified incidents represented self-neglectful behaviors. The study highlights the need for enhanced supervision and targeted interventions for residents with dementia who are susceptible to self-neglect.

Diogenes' syndrome: review and case history

Our objective in writing this paper was to present a case of Diogenes' syndrome and to examine the evolution of thinking about the phenomenon. To do this we looked at original case material and then carried out a literature review, the results of this showed the syndrome has been reported most often in the elderly and in higher socio-economic groups. It represents a non-specific final common pathway for many interacting variables.

In our conclusion we found that a detailed multidisciplinary assessment is indicated in all cases. Further work is required to estimate the role of personality disorder and organic frontal lobe dysfunction in the aetiology of this syndrome. A multiaxial approach to diagnosis should be employed. Intervention should be based on objective findings and risk-assessment, rather than on ideological grounds. Irish law does not allow a large variety of options to the helping professions.

Recognizing Diogenes syndrome: a case report

BACKGROUND

Diogenes syndrome is a behavioural disorder characterized by domestic squalor, extreme self-neglect, hoarding, and lack of shame regarding one's living condition. Patients may present due to a range of reasons. Recognizing these will allow for earlier management of this high-mortality condition.

CASE PRESENTATION

61-year Caucasian female known with bipolar 1 disorder presented with manic symptoms. She was very unkempt and foul smelling. After being admitted involuntarily, she requested that someone go to her home to feed her pets. Her house was filled with garbage, rotting food, and animal feces. She had no insight into any personal hygiene or public health problems.

CONCLUSIONS

Patients with Diogenes syndrome may be difficult to identify. Knowledge of the characteristics of Diogenes syndrome can aid in earlier recognition of such individuals, in order to decrease morbidity and mortality, and to improve public health.

Diogenes syndrome in patients suffering from dementia

Diogenes syndrome (DS) is a behavioral disorder of the elderly. Symptoms include living in extreme squalor, a neglected physical state, and unhygienic conditions. This is accompanied by a self-imposed isolation, the refusal of external help, and a tendency to accumulate unusual objects. To explore the phenomenon of DS in dementia we searched for the terms: “Diogenes syndrome, self-neglect, dementia. ” It has long been understood that individuals with dementia often become shut-ins, living in squalor, in the Eastern Baltimore study, dementia was present in 15% of the elderly cases with moderate and severe social breakdown syndrome; twice as many as in the general population of the same age group. Researchers have underlined the frequent presence of DS (36%) in frontotemporal dementia (FTD): different neuropsychological modifications in FTD may contribute to symptoms of DS. The initial treatment should be a behavioral program, but there is not sufficient information regarding pharmacological treatment of the syndrome.

The need to consider mood disorders, and especially chronic mania, in cases of Diogenes syndrome (squalor syndrome)

We report the case of a 69 year-old female patient who was hospitalized for Diogenes syndrome, defined by marked self-neglect, social withdrawal and excessive hoarding, leading to squalor. Somatic causes were eliminated. Her personal history showed an eight-year depressive episode followed by a 20-year hypomanic episode without remission, followed by a persistent manic episode associated with Diogenes syndrome for four years. The Diogenes syndrome was successfully treated with mood stabilizers. Mood disorders - in particular chronic mania (i.e. a manic episode lasting more than two years) - should be considered in cases of Diogenes syndrome and in current classifications.

[Severe domestic squalor]

BACKGROUND

People who live in domestic squalor and deny help may have a condition known as severe domestic squalor, previously Diogenes syndrome. The object of this article is to provide a review of incidence, possible etiology, clinical description and management of this condition.

MATERIAL AND METHODS

The article is based on literature retrieved through a non-systematic search in PubMed and the author's clinical experience.

RESULTS

Severe domestic squalor may affect people of all ages, but is particularly prevalent among the elderly. Those affected live in severe squalor with garbage, rotting food, rats and mice, urine and faeces in furniture. Some tend to hoard. The annual incidence among persons above 60 years of age, referred to a specialist, is approximately 0.5 per 1000. True community prevalence is unknown. More than 50 % of cases have a concomitant diagnosis of dementia, schizophrenia or substance dependency. An association between frontal dysfunction and severe domestic squalor is sparsely, but increasingly documented. Those affected do not express concern about their situation and are unwilling to be helped. Cases are complex and very difficult to handle for general practitioners and district nurses. Respect for autonomy and a wish to help contradict each other.

INTERPRETATION

It is very difficult to help persons who live in severe domestic squalor. The incidence in Norway is unknown and should be determined.

The mummified corpse in a domestic setting

A mummified body of an 86-year-old white man with a history of coronary atherosclerosis was found in the reception-room of his apartment located in a condominium of the city-center of Bari (Southern Italy) approximately 7 years after disappearance. Unpaid electricity bills caused the power stations to turn off electricity while unpaid condominium bills forced the manager of the condominium to open the apartment where the body was found. The corpse was well preserved through the mummification process and no external injuries were observed. Signs of a very low insect activity were also present, reasonably consistent with a rapid skin dehydration. The body was sitting on the carpet in front of an easy-chair, fully clothed by a woollen vest with dark paints and shoes. The head was lying face down on the easy-chair. The corpse was very light in weight, fixed in the sitting position by the brittle dehydrated tissues. The carpet on which the body was sitting and the covering tissue of the easy-chair on which the head was lying absorbed most of the early putrefactive fluids coming from the corpse. The internal organs were grossly identifiable but essentially unremarkable. On histologic examination most of the tissues were found to be autolyzed. Toxicology studies revealed only decompositional products. The cause of death was undetermined but presumed natural. Based on the ante-mortem data available the corpse was soon identified by dental comparison to be that one of the apartment owner missing 7 years before. The delayed recovery of elderly people who lived alone, incapacitated or unable to get help, or even of lonely deaths of nobody seems to miss are often explained by the isolation os such people even in urban areas in addition to a deficient family support, missing social and neighborly relationships, worsening of the health and financial conditions.

The Environmental Cleanliness and Clutter Scale (ECCS)

BACKGROUND

Development of a scale to rate the degree and various aspects of uncleanliness will facilitate description and research in cases of severe domestic squalor.

METHODS

Discussion with representatives of relevant agencies led to selection of various aspects of domestic uncleanliness and clutter to be assessed when describing cases of squalor. Rooms and areas with varying functions (toilet, kitchen, bedroom, etc.) were all to be rated, along with other indicators of squalor (e.g. odor, vermin). Trial use and further discussion resulted in reduction to ten items, each rated on a four-point scale, with succinct descriptions of anchor-points. Two experienced psychogeriatricians then used this new Environmental Cleanliness and Clutter Scale (ECCS) to rate independently 55 dwellings which had been reported by Aged Care staff as cluttered or unclean, and also rated overall degree of squalor. Reliability and indications of validity were analyzed.

RESULTS

The inter-rater reliability for the ten items was considered satisfactory (kappa 0.48, varying from 0.31 to 0.58). Cronbach's alpha for the new scale was 0.94, demonstrating high internal consistency. Each author's ratings of degree of squalor (none to severe) matched well with the other's ratings on the scale; a score of >12 usually indicated moderate or severe squalor.

CONCLUSION

The ECCS proved reliable and useful in rating cases where elderly people were living in severe domestic squalor.

How and when to intervene in cases of severe domestic squalor

BACKGROUND

Little has been published concerning how best to intervene in cases of severe domestic squalor.

METHODS

Background literature and reports on how best to intervene in cases of severe domestic squalor were reviewed.

RESULTS

Reports by groups in London (Ontario), and Sydney (Australia) have provided recommendations for development of coordinated services to intervene in cases of squalor. Guidelines have been issued. Treatments for compulsive hoarding may contribute to improvement in cases where squalor is attributable to restricted access due to clutter.

CONCLUSIONS

Effective interventions in cases of severe domestic squalor are commonly expensive and require good inter-agency collaboration. Budgetary support must be available to enable appropriate services to take on cases and provide case management.

Developing self-neglect theory: analysis of related and atypical cases of people identified as self-neglecting

Self-neglect is a complex, relatively common and as yet not fully understood phenomenon. People who self-neglect often do not undertake those activities which are judged necessary to maintain a socially accepted standard of personal and household hygiene or to maintain their health status. This may be explained by a variety of factors of which psychopathology, culture, social class and poverty all play a role in the construction of this phenomenon. The self-neglect literature overwhelmingly presents professional views and focuses on the most severe cases. This paper explores some core issues in relation to self-neglect theory through in-depth interviews with atypical (related) cases. These cases allow the boundaries of what is and is not self-neglect to be tested. Analysis of these cases suggests that self-neglect remains a useful concept but contains a far wide range of presentations than previously reported.

Forensic Issues in Cases of Diogenes Syndrome

Diogenes syndrome is a syndrome described in the clinical literature in elderly individuals characterized by social isolation and extreme squalor. A number of typical features are found in the forensic evaluation of these deaths as the cases usually initiate medicolegal investigations due to the circumstances and the lack of recorded medical histories. Examinations of the death scenes are often difficult as victim's houses are in a state of disrepair, with filth and clutter, and pet dogs may resent the intrusion of strangers. Bodies are often filthy, with parasitic infestations, and are often putrefied due to the social isolation of the deceased and the delay in the finding of the corpse. Bodies may be traumatized from postmortem animal depredation by rodents or pets (eg, cats, dogs), and injuries such as bruises and lacerations may be present from falls associated with terminal illnesses or alcoholism. Blood or putrefactive fluids may be spread throughout the house by pets. Treatable medical conditions are often present in advanced stages, and features of hypothermia may be found. Attending police may suspect robbery due to disarray of the house and homicide due to apparent "bleeding" around the body from purging of putrefactive fluids, injuries from falls, or postmortem animal activity and "blood stains" throughout the house from antemortem injuries and/or fluid spread by animals. Finally, the identification of the deceased may be compromised by decay and/or postmortem animal activity. Thus, in addition to having typical clinical manifestations, such individuals appear to form a distinct subset of forensic cases having characteristic death scene and autopsy features and presenting particular difficulties in postmortem evaluations.

Severe domestic squalor: a review

BACKGROUND

Referrals to clinical services of people living in severe domestic squalor are not uncommon. It is timely to review literature concerning and discussing such cases.

METHOD

Using Medline, Psychinfo, Embase, CINAHL and reference lists from relevant publications, literature referring to over 1100 cases was identified and then reviewed.

RESULTS

Half of those described as living in severe squalor are elderly. Outcomes of intervention are often poor. People living in severe squalor are most commonly diagnosed as having dementia, alcoholism or schizophrenia, though personality problems are evident in a high proportion. There is evidence to suggest that neglect of hygiene and of attention to cleanliness of accommodation may be largely attributable to frontal lobe changes. The review also revealed a second body of literature, not often cited in papers focussed on unclean living conditions and published in psychiatric or medical journals, that concludes that hoarding is most commonly due to obsessive-compulsive disorder (OCD). Accumulation of rubbish is described in over half of the case reports on severe domestic squalor, but it is suggested that this should only be called hoarding if it results from purposeful collection of items. Lack of impulse control may contribute to collecting behavior, resulting in reduction in living space if there is also a failure to discard.

CONCLUSIONS

There is a need for further studies, using standardized ratings of living conditions, investigating and trying to understand the complex interplay of triggers and vulnerabilities, exploring how best to intervene and examining outcomes of interventions.

Is collectionism a diagnostic clue for Diogenes syndrome?

BACKGROUND

Diogenes syndrome (DS) is characterized by extreme self-neglect, domestic squalor, and social withdrawal. Despite having been described decades ago, it is still difficult to persue a correct diagnosis in primary care clinics.

METHODS

This paper reports a case of an elderly man with extreme self neglect and an abnormal collecting pattern whose condition remained undetected for many years. His collectionism was manifested with a tendency to store items in an organized manner but without a clear purpose.

CONCLUSION

The authors suggest that the presence of collectionism could be a helpful clue towards diagnosis of DS in similar cases.

Elder Abuse and Neglect in Long-Term Care

Patient and caregiver education and other interventions targeted toward risk factors or types of abuse or neglect play an invaluable role in preventing elder abuse and mistreatment.

A framework for good practice in interagency interventions with cases of self-neglect

Self-neglect is probably more common than has generally been thought and gives rise to a number of difficult conceptual, identification and intervention problems for health and social care workers. These patient management issues are compounded by the lack of any evidence-base for practice which nurses can draw on when faced with managing people who self-neglect. Nurses working with self-neglecters operate in an interdisciplinary context which includes professional groups, such as environmental health officers, who do not normally figure within health and social care teams. In the absence of such an evidence-base, a pragmatic solution in the form of a framework for interagency practice has been proposed. The background underpinning this framework, including a research study of housing in self-neglect and interagency responses, is briefly outlined in this paper.

On phenomenology and classification of hoarding: a review

OBJECTIVE

Hoarding is a behavioural abnormity characterized by the excessive collection of poorly usable objects. It is described mainly in association with obsessive-compulsive disorders (OCDs) and in geriatric populations. Yet the literature on the phenomenon is heterogeneous and the notion obviously lacks a consistent definition. This review attempts to describe the psychopathological and clinical spectrum of hoarding and may contribute to clarify its classification.

METHOD

Systematic review and discussion of the literature on hoarding.

RESULTS

Hoarding is a complex behavioural phenomenon associated with different mental disorders. The psychopathological structure is variously composed of elements of OCDs, impulse-control disorders, and ritualistic behaviour. Severe self-neglect is a possible consequence of hoarding.

CONCLUSION

Without further specifications the term hoarding is of limited heuristic value and cannot guide therapeutic interventions satisfactorily. The condition needs to be evaluated carefully in every particular case in relation to the aforementioned psychopathological concepts.

Sociological and psychological theories of self-neglect

BACKGROUND

Self-neglect can be defined as the failure to engage in those self-care actions necessary to maintain a socially acceptable standard of personal and household hygiene and/or a failure to adequately care for one's own health. It is generally acknowledged that research and practice in the area of self-neglect has been hampered by a lack of theoretical development. Socio-psychological theories, such as 'social constructivism' and 'negotiated interactionism' can contribute to a deeper understanding of the phenomenon and to the further development of self-neglect theory.

AIMS

This paper seeks to apply social and psychological theories to understanding self-neglect. Self-neglect is an underconceptualized phenomenon, which requires to be studied within a broader theoretical context than is at present the case.

IMPLICATIONS

Sociological and psychological theories offer radically different ways of looking at self-neglect, as opposed to the medical model, as they seek to explain and understand, rather than simply classify it as a medical disorder caused by some form of underlying psychopathology. These theories emphasize the dynamic and interpretative nature of self-neglect and illustrate the arbitrary way in which this label is applied.

Diogenes syndrome: the self-neglect elderly

Diogenes syndrome (DS) is characterized by severe self-neglect, domestic squalor, social withdrawal, syllogomania, and refusal of help that may be precipitated by stressful events. Secondary DS is related to mental disorders. Its management includes day care center and community care.

Constructions of self-neglect: a multiple case study design

Patients who neglect personal hygiene, household cleanliness and their own health are familiar to most nurses. Despite this familiarity, self-neglect is a poorly conceptualized and little researched phenomenon. This multiple case study design uncovers the perceptions of self-neglect held by professionals, patients and relatives. The assumptions which underpin Orem's Theory of Self-Care and the medical model construction of self-neglect are explored and it will be suggested that there are limitations in understanding self-neglect using these theoretical frameworks.

A survey of self-neglect in patients living in the community

Self-neglect is a familiar concept to all community nurses. Nevertheless there have been few empirical studies undertaken in this area over the last 30 years. The study of self-neglect has been hampered by inadequate conceptualization and a lack of theoretical frameworks. This article reports a study of patients who did and did not self-neglect, drawn from district nursing caseloads. Patients with self-neglect had lower levels of operable self-care agency than patients in a comparison group. Only self-neglecting patients had the nursing diagnoses 'ineffective management of therapy' and 'non-compliance'.