Neglect and Self-Neglect

Neglect is the failure of caregivers to fulfill their responsibilities to provide needed care.

"Active" neglect refers to behavior that is willful - that is, the caregiver intentionally withholds care or necessities. The neglect may be motivated by financial gain (e.g. the caregiver stands to inherit) or reflect interpersonal conflicts

"Passive" neglect refers to situations in which the caregiver is unable to fulfill his or her care giving responsibilities as a result of illness, disability, stress, ignorance, lack of maturity,

or lack of resources

Self neglect refers to situations in which there is no perpetrator and neglect is the result of the older person refusing care.

Who are the perpetrators?

• Perpetrators may be paid attendants, family members, employees of long term care facilities, or others

• Caregivers who lack adequate skills, training, time, or energy

• Caregivers who are mentally ill, or who have alcohol, substance abuse or other mental health problems

• In self-neglect cases, there are no perpetrators

Who is at risk?

• Persons with physical or mental disabilities who depend on others for care

• Persons with high care needs. The literature on care giving suggests that certain conditions are particularly stressful to caregivers. These include fluctuations in the older person's need for care, disturbed sleep, incontinence, and lack of support from other family members.

• Self-neglect is often associated with mental health problems, including substance abuse, dementia, and depression.

What are the indicators?

Indicators are signs or clues that neglect has occurred. Indicators of neglect include the condition of the older person's home (environmental indicators), physical signs of poor care, and behavioral characteristics of the caregiver and/or older person. Some of the indicators listed below may not signal neglect but rather reflect lifestyle choices, lack of resources, or mental health problems, etc. One should look for patterns or clusters of indicators that suggest a problem.

Signs of neglect observed in the home

• Absence of necessities including food, water, heat

• Inadequate living environment evidenced by lack of utilities, sufficient space, and ventilation

• Animal or insect infestations

• Signs of medication mismanagement, including empty or unmarked bottles or outdated prescriptions

• Housing is unsafe as a result of disrepair, faulty wiring, inadequate sanitation, substandard cleanliness, or architectural barriers

Physical indicators

• Poor personal hygiene including soiled clothing, dirty nails and skin, matted or lice infested hair, odors, and the presence of feces or urine

• Unclothed, or improperly clothed for weather

• Decubiti (bedsores)

• Skin rashes

• Dehydration, evidenced by low urinary output, dry fragile skin, dry sore mouth, apathy, lack of energy, and mental confusion

• Untreated medical or mental conditions including infections, soiled bandages, and unattended fractures

• Absence of needed dentures, eyeglasses, hearing aids, walkers, wheelchairs, braces, or commodes

• Exacerbation of chronic diseases despite a care plan

• Worsening dementia

Behavioral indicators

Observed in the caregiver/abuser

• Expresses anger, frustration, or exhaustion

• Isolates the elder from the outside world, friends, or relatives

• Obviously lacks care giving skills

• Is unreasonably critical and/or dissatisfied with social and health care providers and changes providers frequently

• Refuses to apply for economic aid or services for the elder and resists outside help

Observed in the victim

• Exhibits emotional distress such as crying, depression, or despair

• Has nightmares or difficulty sleeping

• Has had a sudden loss of appetite that is unrelated to a medical condition

• Is confused and disoriented (this may be the result of malnutrition)

• Is emotionally numb, withdrawn, or detached

• Exhibits regressive behavior

• Exhibits self-destructive behavior

• Exhibits fear toward the caregiver

• Expresses unrealistic expectations about their care (e.g. claiming that their care is adequate when it is not or insisting that the situation will improve)

How can I learn more?

• Volume 11, Number 2 (1999) of the Journal of Elder Abuse & Neglect is devoted to the issue of self-neglect. For more information about JEAN, and a listing of articles in the issue, click here.

• Duke, J. (1991). A national study of self-neglecting adult protective services clients.Richmond, VA: Virginia Department of Social Services.

• Fulmer, T. & Paveza, G. Neglect in the elderly patient. (1998). Nursing Clinics of North America. 33(3), 457-467.

• Rathborn-McCuan, E., & Fabian, D.R. (Eds.). (1992). Self-neglecting elders: A clinical dilemma. Westport, CT: Auburn House

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