Last week’s column introduced the concept of self-neglect (https://keystoneelderlaw.com/self-neglect-elder-abuse-or-individual-choice/). Over the past several years in Pennsylvania, this type of elder abuse has required involvement by Adult Protective Services (https://www.aging.pa.gov/organization/advocacy-and-protection/Pages/Protective-Services.aspx) more often than any other type of elder abuse.
What characteristics or circumstances may lead a person to neglect their own health and safety? Research is limited due to the difficulty of studying this population and the complexity of self-neglecting behaviors. A history of one or more previous traumatic experiences has been identified as one risk factor. These experiences may include having been a victim of abuse or a violent crime; the tragic loss of, separation from, or abandonment by a close family member or friend; exposure to war or political violence; or extended grief following a loss. Additional risk factors may include chronic disease or disability, dementia, social isolation, financial insecurity, distrust of medical care, substance abuse and a history of mental illness.
Some people may intentionally choose to self-neglect. They demonstrate the capacity to make their own decisions, even though their choices do not reflect societal norms. These individuals are likely to refuse offers of assistance due to their personality type, a preference for their personal lifestyle, and/or a desire for control.
Other individuals may not always recognize that self-neglect is occurring, especially when cognitive changes are present. A physical illness or disability, financial difficulties, or a significant life event (such as the loss of a spouse) may create circumstances under which the ability or desire to maintain self-care is altered.
These individuals may perceive themselves as “doing the best that they can.” They may believe that life naturally becomes more difficult as one ages and therefore lower their expectations for the appearance of their person or environment. . A lack insight into the severity of the situation or of available resources may also exist. Fear of losing independence or being forced to move from their home may prevent an older adult from seeking assistance when the tasks of daily life become more challenging. Ironically, the assistance that is feared often improves the opportunity for an individual to remain safely at home.
Red flags for self-neglect may vary. Weight gain or loss may be a sign of altered eating patterns or poor food choices. Changes in grooming habits often occur such as uncombed hair, wearing wrinkled or stained clothing, and reduced frequency of bathing. Perhaps the main room of one’s home will appear relatively neat from the doorway, but the individual may hesitate to allow anyone into the home because the remainder of the dwelling is extremely unkempt and unclean. Previously preferred hobbies and activities may be pushed aside leading the individual to gradually become more isolated.
A number of warning signs may be evident in the kitchen of a person at risk for self-neglect. The presence or absence of food and whether it is fresh or spoiled are indications of how an individual is functioning. Are there signs of a recent meal? If burnt pans or potholders are present (or pans are missing because they were thrown out), the risk of a fire may be a concern. An excessive stockpile of a certain food or household item may be a sign of memory impairment.
Piles of unopened mail, the presence of overdue notices for bills, and finding regular items in unusual places should raise concern about an individual’s functioning. They may not present an immediate threat to health and safety, but left unaddressed could develop into a more serious situation.
Whether or not unintentional neglectful choices are temporary or likely to become a long-term pattern will influence the need for and type of response. Consideration of circumstances and general functioning will help guide investigation into potential root causes of the behavior.
Has the individual or a caregiving family member experienced a recent illness or fall? Are changes in mobility evident, such as difficulty arising from a chair or holding onto walls and furniture when walking? Does the individual’s conversation reveal clues of possible changes in problem-solving, memory, and/or judgment? Is grief from the loss of a loved one or lifestyle changes impacting daily routines?
Convincing an individual who is at risk or is experiencing self-neglect of the benefits of assistance may be challenging. A careful choice of timing, words, and body language during conversations will reduce the likelihood of the individual feeling defensive and becoming uncooperative. Beginning with small adjustments to areas which are the least threatening for the individual can help boost acceptance. Enlisting the aid of someone who is a trusted friend or authority figure (such as an attorney) may help reduce some of the friction when the individual is reluctant to accept help or “advice” from a family member.
The staff of Keystone Elder Law P.C. write this column because we believe in the value of education for families. When families need to determine a course of action, an appropriate understanding of the potential dangers of certain decisions or of indecision, and the options which may be available to address an older adult’s needs, is essential.
Families often express concern that they could be held personally responsible when a loved one demonstrates self-neglect and refuses assistance. Sometimes, an individual’s choice to self-neglect must be respected. It may be heart-wrenching to watch, but this situation does not constitute negligence on the part of those persons who are aware of the circumstances and have offered help.
Karen Kaslow, RN, BSN