Is collectionism a diagnostic clue for Diogenes syndrome?

Development of a Conceptual Framework for Severe Self-Neglect (SN) by Modifying the CREST Model for Self-Neglect

Self-neglect is an inability or refusal to meet one's own basic needs as accepted by societal norms and is the most common report received by state agencies charged with investigating abuse, neglect and exploitation of vulnerable adults. Self-neglect is often seen in addition to one or multiple conditions of frailty, mild to severe dementia, poor sleep and depression. While awareness of elder self-neglect as a public health condition and intervention has significantly risen in the past decade as evidenced by the increasing amount of literature available, research on self-neglect still lacks comprehensiveness and clarity since its inception to the medical literature in the late 1960s. With the burgeoning of the older adult population, commonness of self-neglect will most likely increase as the current incidence rate represents only the "tip of the iceberg" theory given that most cases are unreported. The COVID-19 pandemic has exacerbated the incidence of self-neglect in aged populations and the need for the use of intervention tools for aging adults and geriatric patients living alone, many of which may include in-home artificial intelligence systems. Despite this, little research has been conducted on aspects of self-neglect other than definition and identification. Substantial further study of this disorder's etiology, educating society on early detection, and conceivably preventing this syndrome altogether or at least halting progression and abating its severity is needed. The purpose of this research is to provide a definition of severe self-neglect, identify key concepts related to self-neglect, comprehensively describe this syndrome, present a conceptual framework and analyze the model for its usefulness, generalizability, parsimony, and testability.

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.

Diogenes syndrome or isolated syllogomania? Four heterogeneous clinical cases

Diogenes syndrome (DS) is an acquired behavioural disturbance more often affecting elderly patients, but possible in all ages. It is characterised by social withdrawal, extreme self and house neglect, tendency to hoard any kind of objects/rubbish (syllogomania), and rejection against external help for lack of concern about one's condition. It is considered infrequent, but with quite high mortality. DS might be divided into several forms including Active (the patient gathers objects outside and accumulates them inside his house), Passive (patient invaded by his own rubbish), "à deux" (DS sharing between two people), and "under-threshold" (DS "blocked" by precocious intervention). Four cases are here presented. In case 1 (passive DS) alcoholism and cognitive impairment could be trigger factors for DS, predisposed by a "personality alteration". In case 2 (active, "à trois") superimposed psychosis could be the trigger, borderline intelligence being the predisposing factor. In case 3 (active), fronto-parietal internal hyperostosis might support an organic aetiology. Finally, case 4 was an example of isolated syllogomania in patient with evolving Alzheimer's dementia. Despite being heterogeneous, our casuistry suggest that DS can develop in both sexes, is prevalent in geriatric age and often associated with cognitive impairment/psychiatric disturbances, which are not specific, nor sufficient to justify DS. Isolated syllogomania only shares the characteristic hoarding with DS; although cognitive impairment might be present, the other DS typical aspects (social isolation, help refusal, characterial aspects, personal hygiene neglect) are absent.

Psychiatry disorders and dengue: is there a relationship?

OBJECTIVE

The aim of this study was to examine the relationship of compulsive hoarding with dengue.

METHOD

Fifty two adults notified by health vigilance authorities because of inappropriate trash accumulation in vacant lots in Goiânia, Central Brazil, completed a questionnaire regarding the presence and severity of hoarding behavior (Hoarding Rating Scale-Interview HRS-I). Five dimensions of hoarding are evaluated with this instrument: difficulty using spaces due to clutter, difficulty discarding possessions, excessive acquisition of objects, emotional distress and functional impairment due to hoarding behaviors.

RESULTS

The sample was primarily male, with an average age of 49 years. Eighty six percent of the sample scored 14 or greater on the HRS-I, indicating pathological hoarding. The medias of the five HRS-I domains were high, indicating severeness of all dimentions of pathological hoarding.

CONCLUSION

These results highlight the relationship between psychiatric disorder and actions upon environmental conditions that favors dengue, as well as its associated public health burden.

Legal implications regarding self-neglecting community-dwelling adults: a practical approach for the community nurse in Ireland

This paper explores the current literature related to legal issues encountered by the public health nurse in Ireland in visiting clients exhibiting self-neglecting behavior. Nurses working in community settings where home visiting of clients is required will at some point encounter situations of client self-neglect. Possession of a clear legal framework for the local area that addresses both the nurse's professional responsibility and the client's rights is needed. Because a high incidence of depression and dementia seen in self-neglecting adults has prompted calls for wider screening of the agreeable client, an understanding of the definition of competence and capacity in the national legal system for that client becomes critical. In Ireland, as in many other countries, refusal of care or screening is the right of any competent adult. However, issues of mandatory reporting, confidentiality, and trespass may differ from other areas. Nursing care delivered at the community level to a client exhibiting self-neglecting behavior involves a delicate balance of trust and support. Through this overview of the legal implications for self-neglecting clients in Ireland, nurses have the opportunity to begin an exploration of similarities and differences in approach on a global level.

Age at onset and clinical features of late life compulsive hoarding

OBJECTIVES

Compulsive hoarding is a debilitating, chronic disorder, yet we know little about its onset, clinical features, or course throughout the life span. Hoarding symptoms often come to clinical attention when patients are in late life, and case reports of elderly hoarders abound. Yet no prior study has examined whether elderly compulsive hoarders have early or late onset of hoarding symptoms, whether their hoarding symptoms are idiopathic or secondary to other conditions, or whether their symptoms are similar to compulsive hoarding symptoms seen in younger and middle-aged populations. The objectives of this study were to determine the onset and illustrate the course and clinical features of late life compulsive hoarding, including psychiatric and medical comorbidities.

METHODS

Participants were 18 older adults (> or =60) with clinically significant compulsive hoarding. They were assessed using structured interviews, including the Mini International Neuropsychiatric Interview (MINI), Structured Clinical Interview for DSM-IV (SCID I), Yale-Brown Obsessive Compulsive Scale (YBOCS), and UCLA Hoarding Severity Scale (UHSS). Self-report Measures Included the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), Sheehan Disability Scale (SDS), and Savings Inventory-Revised (SI-R). Psychosocial and medical histories were also obtained. To determine age at onset, participants were asked to rate their hoarding symptoms and describe major life events that occurred during each decade of their lives.

RESULTS

Results show that (1) onset of compulsive hoarding symptoms was initially reported as being in mid-life but actually found to be in childhood or adolescence. No subjects reported late onset compulsive hoarding. (2) Compulsive hoarding severity increased with each decade of life. (3) Comorbid mood and anxiety disorders were common, but only 16% of patients met criteria for OCD if hoarding symptoms were not counted toward the diagnosis. (4) The vast majority of patients had never received treatment for hoarding. (5) Older adults with compulsive hoarding were usually socially impaired and living alone.

CONCLUSIONS

Compulsive hoarding is a progressive and chronic condition that begins early in life. Left untreated, its severity increases with age. Compulsive hoarding should be considered a distinct clinical syndrome, separate from OCD. Unfortunately, compulsive hoarding is largely unrecognized and untreated in older adults.

Developing self-neglect theory: analysis of related and atypical cases of people identified as self-neglecting

Self-neglect is a complex, relatively common and as yet not fully understood phenomenon. People who self-neglect often do not undertake those activities which are judged necessary to maintain a socially accepted standard of personal and household hygiene or to maintain their health status. This may be explained by a variety of factors of which psychopathology, culture, social class and poverty all play a role in the construction of this phenomenon. The self-neglect literature overwhelmingly presents professional views and focuses on the most severe cases. This paper explores some core issues in relation to self-neglect theory through in-depth interviews with atypical (related) cases. These cases allow the boundaries of what is and is not self-neglect to be tested. Analysis of these cases suggests that self-neglect remains a useful concept but contains a far wide range of presentations than previously reported.

Diogenes syndrome in a patient with obsessive-compulsive disorder without hoarding

Diogenes syndrome (DS) is characterized by self-neglect, classically portrayed by a filthy personal appearance, dirty home, and hoarding of rubbish. We report a patient with DS who presented obsessive-compulsive disorder and Tourette syndrome in the absence of hoarding. We suggest that hoarding may be a symptom of the conditions that are frequently comorbid with DS, but is not one of its fundamental features.

Forensic Issues in Cases of Diogenes Syndrome

Diogenes syndrome is a syndrome described in the clinical literature in elderly individuals characterized by social isolation and extreme squalor. A number of typical features are found in the forensic evaluation of these deaths as the cases usually initiate medicolegal investigations due to the circumstances and the lack of recorded medical histories. Examinations of the death scenes are often difficult as victim's houses are in a state of disrepair, with filth and clutter, and pet dogs may resent the intrusion of strangers. Bodies are often filthy, with parasitic infestations, and are often putrefied due to the social isolation of the deceased and the delay in the finding of the corpse. Bodies may be traumatized from postmortem animal depredation by rodents or pets (eg, cats, dogs), and injuries such as bruises and lacerations may be present from falls associated with terminal illnesses or alcoholism. Blood or putrefactive fluids may be spread throughout the house by pets. Treatable medical conditions are often present in advanced stages, and features of hypothermia may be found. Attending police may suspect robbery due to disarray of the house and homicide due to apparent "bleeding" around the body from purging of putrefactive fluids, injuries from falls, or postmortem animal activity and "blood stains" throughout the house from antemortem injuries and/or fluid spread by animals. Finally, the identification of the deceased may be compromised by decay and/or postmortem animal activity. Thus, in addition to having typical clinical manifestations, such individuals appear to form a distinct subset of forensic cases having characteristic death scene and autopsy features and presenting particular difficulties in postmortem evaluations.

Personality change in old age

PURPOSE OF REVIEW

The present short review summarizes some of the most important personality changes in older adults.

RECENT FINDINGS

Personality changes in old age are usually minimal. Cluster B personality disorders appear to become less prevalent. Significant changes in personality are typically associated with frontotemporal lobar degeneration (e.g., slowly progressive sociopathy), Alzheimer's disease, mild cognitive impairment due to incipient dementia or underlying medical illness.

SUMMARY

Therefore, we suggest that a significant change in personality in old age always warrants careful neuropsychiatric examination.