Diogenes syndrome in patients suffering from dementia

A neglected geriatric syndrome: assessment of self-neglect in the shadow of COVID-19

BACKGROUND

We aimed to screen self-neglect in older adults before and after the COVID-19 pandemic, to evaluate the effect of the pandemic on self-neglect, and to evaluate the relationship between self-neglect and geriatric syndromes in this study.

METHODS

Older adults ≥65 years old and without dementia who applied to a single-centre geriatric outpatient clinic between December 2023 and May 2024 were included in the study. We performed self-neglect screening for the pre- and post-pandemic era with the Istanbul Medical School Elder Self-Neglect questionnaire. Additionally, comprehensive geriatric assessment data and quality of life data with the Euro-Quality of Life 5D-3L scales were evaluated.

RESULTS

A total of 104 patients, with a mean age of 76.8 ± 5.9 years and 70% female, were included in the study. Self-neglect was detected in 19 patients (18.3%) at the post-pandemic period. The older adults with self-neglect were more frail, more dependent, more depressed, had higher risk of sarcopenia, also had more common polypharmacy and urinary incontinence (all P < 0.05). Also, quality of life was found to be more impaired in the self-neglect group (P < 0.001). In multivariate Cox regression analysis, being dependent and having a high risk of sarcopenia were associated with self-neglect in the post-COVID-19 period (odds ratio (OR): 0.15; CI: 0.03-0.83; P = 0.030 and OR: 1.45; CI: 1.01-2.09; P = 0.048, respectively.).

CONCLUSION

Self-neglect in older adults is an important part of comprehensive geriatric assessment and should be screened with validated methods. As it is significantly related with other geriatric syndromes, it suggests that interventions in geriatric syndromes may prevent self-neglect.

Conquering the 'Collected Treasures' of Older Adults With Dementia: A Qualitative Study on Caregiver Strategies and Challenges

AIM

To explore hoarding scenarios in older adults with dementia, document management strategies and assess caregiver challenges in these scenarios.

DESIGN

This study employed interpretative phenomenological analysis to guide data collection and analysis.

METHODS

Purposive sampling recruited 20 caregivers of older adults with dementia from long-term care facilities and community elderly centres in Taiwan. Semi-structured interviews, lasting for about 1 h, were conducted with caregivers of older adults with dementia. The study's quality was assessed using five techniques: peer debriefing, member checking, inter-coder agreement, audit trail, and thick description.

RESULTS

Key themes included hoarding scenarios, checkpoints of pre-decluttering, attitudes towards hoarding, language used for communication, management approaches for decluttering and caregivers' challenges. Caregivers highlighted the importance of assessing the emotions, cognitive function and backgrounds of older adults with dementia before decluttering for effective management. The onion skin peeling method for gradual decluttering was recommended. Success was more likely when caregivers maintained a positive attitude and adapted communication to the speech patterns of older adults with dementia. Challenges arose from ineffective communication, extreme resistance to decluttering and the need to work in highly unpleasant environments.

CONCLUSION

Caregivers face a range of complex challenges when managing hoarding behaviours in older adults with dementia. Pre-decluttering assessments, a positive caregiving attitude, effective communication and stepwise decluttering strategies can enhance the care experience and support caregivers and individuals with hoarding tendencies.

IMPACT

Managing hoarding behaviours in older adults with dementia requires comprehensive cognitive and emotional assessments, collaborative decluttering and tailored communication. The CALM guideline from this study provides an evidence-based framework for advanced nursing practice in this area. Through interdisciplinary leadership, refining guideline use and developing training programmes, nurses can standardise and enhance care quality, fostering adaptive, supportive environments for individuals with dementia and hoarding behaviours.

PATIENT OR PUBLIC CONTRIBUTION

Not applicable.

Hoarding Disorder and Diogenes Syndrome: Two Case Reports and a Narrative Review

Hoarding disorder (HD) and Diogenes syndrome (DS) are challenging and multifaceted conditions that significantly impact patients and society. These disorders are characterized by excessive hoarding behaviors, often accompanied by multiple physical and mental comorbidities, diminished quality of life, and substantial public health challenges. Through the presentation of two case reports and a narrative review, this article revisits HD and DS, highlighting the need for clinical awareness, targeted management strategies, and further research in this field. The first case report describes a 35-year-old woman with early-onset HD and comorbid obsessive-compulsive disorder, while the second details a 78-year-old woman with DS related to vascular dementia. These cases underscore the necessity of timely diagnosis, multidisciplinary interventions, and comprehensive management to prevent deterioration, address physical health issues, improve hygiene and home safety, and mitigate harm to both patients and the community. Advanced treatments such as transcranial magnetic stimulation and electroconvulsive therapy may also play a role in managing these complex conditions. The development of practical guidelines is essential for the effective assessment and care of patients with such multidimensional needs. Moreover, there is a critical need for well-designed randomized controlled trials to evaluate and compare pharmacological and non-pharmacological treatment approaches.

Hoarding behaviour: special features and complications in real-world clinical practice

OBJECTIVE

Hoarding behaviour is a common but poorly characterised problem in real-world clinical practice. Although hoarding behaviour is the key component of Hoarding Disorder (HD), there are people who exhibit hoarding behaviour but do not suffer from HD. The aim of the present study was to characterise a clinical sample of patients with clinically relevant hoarding behaviour and evaluate the differential characteristics between patients with and without HD.

METHODS

This study included patients who received treatment at the home visitation program in Barcelona (Spain) from January 2013 through December 2020, and scored ≥ 4 on the Clutter Image Rating scale. Sociodemographic, DSM-5 diagnosis, clinical data and differences between patients with and without an HD diagnosis were assessed.

RESULTS

A total of 243 subjects were included. Hoarding behaviour had been unnoticed in its early stages and the median length in the sample was 10 years (IQR 15). 100% of the cases had hoarding-related complications. HD was the most common diagnosis in 117 patients (48.1%).

CONCLUSIONS

The study found several differential characteristics between patients with and without HD diagnosis. Alcohol use disorder could play an important role among those without HD diagnosis. Home visitation programs could improve earlier detection, preventing hoarding-related complications.

Noah Syndrome: A Review Regarding Animal Hoarding with Squalor

The main objective of this preliminary review was to identify studies that investigated extreme forms of animal hoarding in an effort to define the concept of Noah syndrome, recently proposed as the animal variant of Diogenes syndrome. From the 52 scientific articles identified in our search, we included and analyzed 23 manuscripts. The main findings show that persons hoarding animals in squalor tend to be of advanced age and socially isolated, lacking perception of the consequences of their behavior on themselves, their families, and their animals. Neurological and psychiatric conditions, such as dementia, obsessive compulsive disorder (OCD), psychoses, and drug addiction were some of the most common underlying causes. We discuss psychopathological mechanisms, such as ageism and attachment disorders. Due to the limited number of manuscripts on this topic, more research is needed to develop effective intervention strategies, which should include not only psychiatric and neurologic care, but also veterinary care and familiarity with public health policies.

Diogenes syndrome in a 10-year retrospective observational study: An elderly case series in Tokyo

OBJECTIVES

Supporting people suffering from Diogenes Syndrome (DS) is a challenge for geriatric psychiatry. However, there is a lack of knowledge about DS in Japan. Therefore, a systematic longitudinal study to clarify the factors associated with DS and its prognosis was conducted.

METHODS/DESIGN

A retrospective study using data from case records of a municipal psychogeriatric service was conducted. The study population was socially isolated older adults with complex mental health and social care needs who had been referred to the service over 10 years. The participants were stratified into DS and non-DS groups, multivariate analysis was performed to identify factors associated with DS, and survival analysis was performed.

RESULTS

Of the 270 participants, 61 with Environmental Cleanliness and Clutter Scale (ECCS) scores >12 were assigned to the DS group, and 209 with ECCS scores ≤12 were assigned to the non-DS group. On multiple logistic regression analysis, significantly more people in the DS group were living alone, had advanced dementia, and had reduced basic activities of daily living (BADL) compared to the non-DS group. Furthermore, survival analysis showed that the DS group had a higher risk of early death than the non-DS group.

CONCLUSIONS

In the present study, social isolation, living alone, advanced dementia, and reduced BADL were found to be associated with DS. In addition, DS had a high risk of early death. Support for DS must take into account not only mental and social health, but also physical health from an early stage.

Diogenes Syndrome: Identification and Distinction from Hoarding Disorder

"Severe domestic squalor" or Diogenes syndrome is characterised by extreme self-neglect of environment, health, and hygiene, excessive hoarding, squalor, social withdrawal, and a distinct lack of concern or shame regarding one's living condition. This report presents a case of a 51-year-old male admitted to the hospital psychiatric ward following the police removing him from his home. Police officers attended the man's home following the alarm being raised by his stepfather that he had not been seen or heard from in 3 weeks. His home was covered in several feet of rubbish, rotting food, and debris and smelled intensely of rotting mould, urine, and faeces. He was found lying nude on top of garbage with a rug over him. Diogenes syndrome is highly comorbid with psychiatric and somatic disorders, including depression, obsessive-compulsive disorder, personality disorder, and stress. This case report provides a rare opportunity to better understand the distinction of Diogenes syndrome from the closely related condition hoarding disorder. Furthermore, creating an agreed-upon constellation of symptoms representative of Diogenes is essential to creating a formal Diagnostic and Statistical Manual of Mental Disorders (DSM) entry, which would facilitate the much-needed development of assessment measures to enable accurate diagnosis and treatment.

Diogenes syndrome in dementia: a case report

BACKGROUND

Diogenes syndrome is a neurobehavioural syndrome characterised by domestic squalor, hoarding and lack of insight. It is an uncommon but high-mortality condition, often associated with dementia.

AIMS

To describe the clinical features and treatment of Diogenes syndrome secondary to behavioural variant frontotemporal dementia (bvFTD).

METHOD

We describe a case of bvFTD in a 77-year-old man presenting with Diogenes syndrome.

RESULTS

The patient's medical and psychiatric histories were unremarkable, but in recent years he had begun packing his flat with 'art pieces'. Mental state examination revealed confabulation and more structured delusions. Neuropsychological evaluation outlined an impairment in selective attention and letter verbal fluency, but no semantic impairment, in the context of an overall preserved mental functioning. Brain magnetic resonance imaging and positron emission tomography (PET) with fluorodeoxyglucose showed mild bilateral temporo-insular atrophy and hypometabolism in the left-superior temporal gyrus respectively. An amyloid PET scan and genetic analysis covering the dementia spectrum were normal. A diagnosis of bvFTD was made.

CONCLUSIONS

The clinical framing of behavioural symptoms of dementia such as hoarding poses a diagnostic challenge. This case illustrates the importance of a deeper understanding of Diogenes syndrome, leading to timelier diagnosis and effective therapeutic strategies.

Uncommon and/or bizarre features of dementia: part IV

It is well established that the clinical picture of dementias is not clinically homogeneous. For example, non-amnestic presentations of Alzheimer's disease have been referred to as a typical variant. Careful examination of clinical characteristics contributes to understanding the neurobiology of Alzheimer's disease and other dementias and may in turn enhance knowledge of the potential risk factors involved. This study aimed at describing uncommon or bizarre symptoms/syndromes observed in patients suffering from dementia. Medline and Google scholar searches were conducted for relevant articles, chapters, and books published before 2019. Search terms used included dementia, déjà vu, zoophilia, pathological lying, and somatic symptom disorder. Publications found through this indexed search were reviewed for further relevant references. Uncommon/bizarre features of dementia were described as case reports and there were no systematic investigations.

Self-Neglect in Older Populations: A Description and Analysis of Current Approaches

Self-neglect in old age has severe effects on a person's health and quality of life and poses diverse challenges for primary caregivers and the community. The authors provide a narrative overview of the literature on self-neglect and summarize what is known to date about the main approaches for describing self-neglect, the factors that contribute to self-neglect, and the interventions that have been attempted. We found that answering the question about what factors led people into a state of self-neglect was extremely complex since many studies described a variety of interlinked factors, some of which are sociocultural and others medical. Our analysis suggested a need for a consolidated approach that focuses instead on the vulnerabilities affecting an older person and the factors that can improve resilience to adversity. Tackling vulnerability and resilience may hold the keys to successful multidisciplinary and person-centered management of self-neglect in older age.

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.

Old and dangerous: Prison and dementia

Older prisoners are the fastest growing group of prisoners in many countries. The purpose of this study is to explore the phenomenon of detention of persons suffering from dementia. Medline searches were conducted for relevant articles, chapters and books published until August 2016. Search terms included dementia, elderly, prison and criminal. Publications found through this indexed search were reviewed for further relevant references. As results, there is a lack of data about elderly with dementia in prisons. Given the rise in the average age, it is reasonable to hypothesize that the number of older prisoners is growing. Moreover, some elderly are imprisoned with a concomitant cognitive impairment or psychiatric disorder while others will develop such diseases once incarcerated. At the present time, legal and social systems seem unprepared to handle the phenomenon of dementia in prison. As proposal, health assessments for older first time offenders should become a practice inside the correctional facilities and include an evaluation for specific health issues, such as psychiatric comorbidity and cognitive impairment.

Hoarding in the elderly: a critical review of the recent literature

BACKGROUND

Hoarding is now a stand-alone diagnosis in DSM-5. The objective of this review is to critically evaluate the most recent literature on hoarding disorder (HD) in ageing patients.

METHODS

A literature search was conducted using PubMed and PsychINFO to identify papers from 2000 to 2015 that examined HD and hoarding symptoms in late-life participants.

RESULTS

Thirteen studies met inclusion criteria. Selected studies had significant methodological limitations with regard to participant sampling, diagnostic criteria, and methods for identifying co-morbid conditions. Hoarding in the elderly generally had onset before age 40 years, increased in severity after middle age, and was linked with social isolation. Depression was associated with hoarding in 14-54% of geriatric cases. Co-morbid anxiety and PTSD were also found. A variety of medical conditions were more common in seniors with hoarding including arthritis and sleep apnea. Late-life hoarding was associated with deficits in memory, attention, and executive function.

CONCLUSIONS

HD in the elderly has distinct features. A combination of self-neglect, psychiatric and medical co-morbidities, and executive dysfunction may contribute to the progression of hoarding symptoms in the elderly.

[Neglected, lonely and sick - the social breakdown : A special patient group in the emergency department]

BACKGROUND

The emergency department (ED) is increasingly becoming the primary care unit of patients who are no longer able to meet the necessary minimum requirements for a healthy life. In the emergency medical care of these patients, fixation errors and stereotyped thinking can distract from serious illnesses, which can be tended by emergency medicine. This group of patients, with their multifactorial problems, represents a special challenge for the staff of the ED. The aim of this study is to improve the quality of the care for a special patient group.

MATERIALS AND METHODS

A monocentric retrospective observation study was conducted at the University Hospital Bonn (UKB). On the basis of case studies, the emergency medical care of this special patient group was examined in the ED.

RESULTS

Over the period of 7 years (2009 to 2016), 17 patients in a state of total neglect could be examined. The endpoints identified, during the emergency care, are the therapy of life-threatening diseases, laboratory pathologies, introduction of infectious protective measures, initiation of diagnostic measures, measures to be initiated within different departments (operating room, intensive care unit) and outcome.

CONCLUSION

Patients in a state of total neglect require interdisciplinary primary care at a hospital with extended care structures. The apparent primary impression of these patients must not lead to a fixation error. Due to the often not obtainable history of the patient's and the complex appearance of these patients, the evaluation should be carried out according to a defined algorithm in the emergency room.

Eating Behaviors and Dietary Changes in Patients With Dementia

BACKGROUND

Eating problems and dietary changes have been reported in patients with dementia.

OBJECTIVES

The aim of this article is to explore the generalized problems with nutrition, diet, feeding, and eating reported among patients with dementia.

METHODS

Medline and Google Scholar searches were conducted for relevant articles, chapters, and books published before 2016. Search terms used included behavioral and psychological symptoms of dementia, dementia, dietary changes, eating behavior. Publications found through this indexed search were reviewed for further relevant references.

RESULTS

Abnormal eating behaviors, eating problems, and dietary changes are present in most people with dementia, especially in the later stages of the condition.

CONCLUSION

Individuals with dementia frequently develop serious feeding difficulties and changes in eating and dietary habits. The changes may be secondary to cognitive impairment or apraxia, or the result of insufficient caregiving, or the consequence of metabolic or neurochemical abnormalities occurring as part of the dementing process.

Delusion of pregnancy: an unusual symptom in the context of dementia

BACKGROUND

Delusions can complicate practically all brain disorders. They may be dramatic and bizarre. An example is the so-called delusion of pregnancy.

OBJECTIVE

To identify the characteristic of a psychotic symptom, the phenomenon of delusion of pregnancy, in the context of dementia.

METHOD

MEDLINE and Google Scholar searches were conducted for relevant articles, chapters, and books published before 2014. Search terms used included delusion of pregnancy, uncommon presentation, behavioral and psychological symptoms, dementia, Alzheimer's disease, and frontotemporal dementia (FTD). Publications found through this indexed search were reviewed for further relevant references. We included case reports that highlight the relationship and overlap between dementia presenting as schizophrenia-like psychosis and schizophrenia.

RESULTS

Literature on delusion of pregnancy in the course of dementia consists mostly of case reports and small samples of patients.

CONCLUSION

Psychotic phenomena such as delusion of pregnancy may be a feature in some cases of dementia. If this bizarre features of dementia appears as early presentation of FTD whose usual onset is in the presenium, it may be mistaken for schizophrenia.

Uncommon and/or bizarre features of dementia

This study aimed at describing uncommon or bizarre symptoms observed in patients suffering from dementia. Medline and Google scholar searches were conducted for relevant articles, chapters, and books published since 1967. Search terms used included uncommon presentation, behavioural and psychological symptoms, dementia, Alzheimer's disease, and fronto-temporal dementia. Publications found through this indexed search were reviewed for further relevant references. The uncommon symptoms are described as case-reports and there are no systematic investigations. Bizarre behaviours arising late in life should be thoroughly investigated as symptoms of dementia.

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.

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.