Barriers to Treatment

There are many barriers to treating self-neglect. Some barriers are related to autonomy; you cannot force a competent individual to follow medical recommendations. In other cases, mental and physical conditions outside of the patients’ control prevents successful treatment. The range of treatment barriers is illustrated in Figure 1.

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Figure 1: Barriers to Treating Self-Neglect

Individual Refuses APS Investigation

How APS and health care providers treat self-neglect often depends on whether the person is competent (see Competency). If the individual is believed to have the capacity to understand their situation and make appropriate decisions, APS would not be allowed to enter a house without being invited. An investigation can be stalled by the individual refusing to cooperate.

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Family involvement becomes even more important if the loved one is incompetent

Informed Refusal

When an individual is competent, his or her wishes must be respected (Smith, Lo, & Aronson, 2013). In other words, an individual of sound mind may and can refuse help. For example, a competent individual can refuse home health care, even though they would truly benefit from this service (Smith et al., 2013). Forcing care on a competent individual “for their own good” violates his or her dignity and autonomy (Naik, Lai, Kunik, & Dyer, 2008).

For competent individuals, health care providers may focus on solutions that maximize benefits. It would be unwise to try to  convince a competent individual with multiple needs to agree on every demand. Instead, APS and health care workers may persuade the individual with self-neglect to accept the most important treatments. The goal is to keep the individual living in their own home safely and to convince the individual to accept the necessary services that will achieve this goal (Naik et al., 2008). Home visitation by the health care provider or other professionals may be arranged after a trusting relationship is established. Plans for worse-case scenarios should be discussed with those involved (Smith et al., 2013).

If the person refuses to follow or seek medical treatment for serious illness (see The Case of Mary Northern) the first step is to find out why the individual is ignoring medical treatment. There may be a reasonable explanation. However, if this represents care refusal, complete treatment may need to be given up in exchange for safety.

Did You Know!
91% of individuals with self-neglect have seen their primary care provider within 3 months of an APS investigation

Non-Compliance

Individuals with self-neglect usually do not take their medications as prescribed (89%) (Social Care Institute for Excellence, 2015). This may be due to forgetfulness, refusal to believe that there is a problem, lack of trust, or cultural beliefs (Pavlou & Lachs, 2006). Health care providers may need to persuade patients to take the most important medications. Pill boxes may help for those with memory loss. Regular follow-up visits with the health care provider is encouraged (Pavlou & Lachs, 2006). Surprisingly however, 91% of individuals with self-neglect have seen their primary care provider within 3 months of an APS investigation (Burnett et al., 2007). Thus, presumably self-neglect is difficult to detect in the office setting of the primary care provider.

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A health care provider is trying to determine if the this person is incapacitated

Incapacitated

When an individual is incapacitated (or not having the capacity), it means that they are no longer able to perform certain tasks. Sometimes, this means that they are not able to make informed medical decisions. When this happens, usually a trusted family member will take on that responsibility.

Sometimes a person with mild dementia is still able to make decisions but is unable to fully take care of themselves (Sally, n.d.). In critical situations, a judge must decide competency (see Guardianship below). Health care providers are usually required by law to notify APS in situations where incompetency is suspected (Physician Case Studies, 2011).

Adult Protective Services is knowledgeable about issues of self-neglect. They can help the person, the family, and health care providers on how to proceed. However, APS does not have the right to enter a home to make an assessment without being invited (Smith et al., 2013). In other words, health care providers and APS cannot force an individual to undergo assessment or treatment. Professionals may only enter a house uninvited when there is a life-threatening situation or public health threat (Texas Department of Family and Protective Services, 2013).

Guardianship

When an individual is not competent (or is incompetent), a court can force the person to change their behavior (Smith et al., 2013). For example, an incompetent individual can be required to have life-saving surgery. The Case of Mary Northern was the first time this happened in the United States.

A health care provider should not allow an individual that is suspected to incompetent to make life-threatening decisions. If a judge finds the person incompetent, deciding how to treat the person may become easier because treatment will be based only on what is best for the individual and not their preferences (Smith et al., 2013).

References

Burnett, J., Regev, T., Pickens, S., Prati, L. L., Aung, K., Moore, J., & Dyer, C. B. (2007). Social networks: A profile of the elderly who self-neglect. Journal of Elder Abuse & Neglect18(4), 35-49.

Naik, A. D., Lai, J. M., Kunik, M. E., & Dyer, C. B. (2008). Assessing capacity in suspected cases of self-neglect. Geriatrics, 63(2), 24-31.

Pavlou, M. P., & Lachs, M. S. (2006). Could self‐neglect in older adults be a geriatric syndrome?. Journal of the American Geriatrics Society54(5), 831-842.

Physician Case Studies. (2011, October 1). Self-neglect as a form of elder abuse [Blog post]. Retrieved from https://primeinc.org/casestudies/physician/study/919/Self-Neglect as a Form of Elder Abuse

Sally, H. (n.d.). Self-neglect workshop. Retrieved on December 4, 2016 from  https://www.kent.gov.uk/data/assets/pdf_file/0018/20619/Self-neglect-workshop-presentation-part-1.pdf

Smith, A. K., Lo, B., & Aronson, L. (2013). Elder Self-Neglect—How Can a Physician Help?. New England Journal of Medicine, 369(26), 2476-2479.

Social Care Institute for Excellence. (2015, May). At a glance 60: Preventing loneliness and social isolation among older people. Retrieved January 9, 2017 from http://www.scie.org.uk/publications/ataglance/ataglance60.asp

Texas Department of Family and Protective Services. (2013, February). Denial or revocation of permission to enter. Retrieved from  https://www.dfps.state.tx.us/handbooks/APS/Files/APS_pg_2340.asp 


Last updated: February 25, 2017 at 19:50 pm by
I. M. Abumaria, AGPCNP-BC
Version 1.00