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Self-neglect: a practitioner's view

Aging, Spring, 1996 by Wendy Lustbader

Older people who neglect their needs for nutrition, hygiene, financial solvency, medical care, or adequate shelter do so for reasons as varied as there are human predicaments. Some people have always neglected themselves in one or more of these areas, coming to professional attention in old age simply because they have attained the status "elderly" and now qualify for protective programs. Others took good care of themselves all their lives and now through the strains of memory loss, illness, poverty, or the deaths of loved ones are losing their ability to maintain their previous quality of life. Still others choose to live on the edge of social conventions or literally on the edge of the wilderness, with the result that they accept risks to their health and safety deemed neglectful by others.

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The key difference between services for protecting children and those for adults is that mentally competent adults who do not wish to be protected have the right to refuse all assistance. When self-neglect is severe, this right to self-determination places relatives and professionals in heartbreaking dilemmas. How strenuously should they try to persuade such a person to accept help? Should they attempt to enforce safety measures by threatening to abandon the person entirely if there is no cooperation? Should they try to compel acceptance of unwanted services by bribing the person with desired rewards or benefits?

This legal duty to respect older people's right to run their own lives may become equivalent to witnessing slow suicide, unless acceptable interventions are found. It is important to understand the dynamics of individual and family problems that lead to self-neglect in order to develop effective interventions. The following are some of the typical situations in which elderly people neglect their health and welfare and some interventions that have proven successful in those situations.

Loss of the Will To Live

Ordinarily, motivation for self-care arises from motivation for life. In some cases, self-neglect is best understood as disaffection from life, a loss of the will to live. Interventions which provide something to live for can be effective in these instances, but devising them is not easy. When older people are socially or geographically isolated, or too frail to participate in volunteer programs, meaningful activities may be in short supply. Some may have lost previously satisfying pursuits through sensory losses, such as no longer seeing well enough to paint or no longer hearing well enough to play the piano.

Depression may be at the heart of someone's self-neglect. The person's view of the world may be obscured by tunnel vision, with their depression blocking out fresh ideas for reviving their spirit for life. In these situations, the temporary use of antidepressant medication may widen their vision and help mobilize the very changes which would broaden the scope of their possibilities. For some, knowing that the medication can be stopped once this revival is achieved may make this remedy tolerable. Others may need to learn how many millions of people use these medications at some point in their lives.

Grief is another major cause of self-neglect. Some people let their lives dwindle during a bereavement and then find themselves stuck in a state of malaise long after their grief should have subsided. Caught in a self-defeating cycle, they lack the will to get out and do things and then must face the deadening sameness of a daily life without involvements. This monotony further dampens their drive to keep up with friendships and activities, leading to still less motivation to take care of themselves.

Asking the question, "What would make life worth living for you?" is often a helpful starting point. Some people respond with clear statements about wishing they could be useful or that they had a pet or a garden to look after. Their replies are full of hints for ways to re-awaken their spirit for life. Others become stymied by this question because they have lost faith in themselves, in God, or in other people. In these instances, it may be helpful to venture a few specific ideas, even if the person vehemently rejects these options as unsuitable or unrealistic.

In their very vehemence, some people reveal themselves. Listening carefully while someone bursts forth with negative feelings may yield clues. Residual shreds of enthusiasm may emerge as one option after another is rejected: "I don't want to sit all day with a bunch of old duds at day care, not doing anything, not learning anything, just existing." Doing and learning may be the key to any intervention created for people appalled by the absence of activity and novelty in their lives.

No one can presume to know what would make life worth living for someone else. Without such dialogue, relatives and professionals who still have full health and freedom can easily overlook a solution that would mean a great deal to someone living in reduced circumstances. Small changes often lead to large rewards in a life that has been devoid of provocation or stimulation. For instance, a woman who never leaves her apartment may find that having help getting down to the lobby once a week to see a bit of the world may give her something to look forward to and a reason to start taking her blood pressure medication more faithfully.

Health Care Industry

Self-neglect: a practitioner's view

Aging, Spring, 1996 by Wendy Lustbader

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