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Correspondence: Address correspondence to Aanand D. Naik, MD, Michael E. DeBakey VA Medical Center (152), 2002 Holcombe Boulevard, Houston, TX 77030.
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Key Words: Elder mistreatment • Functional assessment • Geriatric self-neglect • Geriatric syndrome
Given the increased prevalence of self-neglect in later life and the adverse health consequences associated with it, self-neglect has been characterized as a potential geriatric syndrome (Dyer & Goins, 2000; Pavlou & Lachs, 2006; Pickens, Naik & Dyer, 2006). Geriatric syndromes (e.g., delirium, urinary incontinence, and falls) are characterized by multiple predisposing factors, presentation with other geriatric syndromes, associations with functional impairment and medical or psychiatric morbidities, and an independent risk factor for mortality (Tinetti, Inouye, & Gill, 1995; Tinetti & Fried, 2004). Recent studies have reported clear evidence linking self-neglect with many of the criteria, just described, for a geriatric syndrome (Dyer, Goodwin, Pickens-Pace, Burnett, & Kelly, 2007; Dyer, Pavlik, Murphy, & Hyman, 2000; Lachs, Williams, O'Brien, Pillemer, & Charlson, 1998; Pavlou & Lachs). However, evidence supporting an association between self-neglect and functional impairment or subsequent functional decline has been equivocal and limited as a result of confounding factors (Pavlou & Lachs).
To characterize self-neglect definitively as a geriatric syndrome, evidence is needed for an independent association with functional impairment, defined as a decline in the ability to perform one or more of the basic or instrumental activities of daily living. Our aim in the current study was to identify an independent association between self-neglect and functional impairment by using standardized measures of functional status in a community-living population of older adults.
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48.002(a)(4), which stipulates a "failure to provide for one's self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide the goods or services." After APS staff received authorization from their clients for the release of their names for study purposes, research personnel contacted potential participants for the self-neglect referral group (SN group) to set up a home visit in order to obtain consent. In addition, researchers recruited 100 community-living adults from the Geriatrics Clinic of the Harris County Hospital District and matched them for age, race, gender, and zip code with members of the SN group; these adults had no prior referral for or history suggestive of self-neglect. These participants constituted the community-living control group (CC group).
Measures
Two research team members conducted a comprehensive geriatric assessment in the homes of each of the 200 study participants. Included in the comprehensive evaluation were demographic variables, a full history and physical examination, pill count of all medications, and measures of social supports. In addition to the functional status measures described in the following paragraphs, the assessments included a validated Health Status self-report (Idler & Angel, 1990), Mini-Mental State Examination (MMSE), and the 15-item Geriatric Depression Scale (GDS).
Manual Muscle Testing by Use of a Handheld Dynamometer
We had a test administrator use a manual muscle-testing dynamometer (Lafayette Manual Muscle Test System Model 01163, Lafayette Instrument Company, Lafayette, IN) to objectively measure muscle strength for shoulder abduction and knee extension (Chandler, Duncan, Kochersberger & Studenski, 1998; Wang, Olson, & Protas, 2002). We did not have these tests performed if the participant had surgery in the previous 3 months or was experiencing significant pain. For measuring knee extension strength, the test administrator stabilized the lower extremity by placing her hand on the back of the leg to support the knee and then instructed the participant to fully extend and hold the leg while pressing down on the dynamometer. For measuring shoulder abduction strength, the administrator had the participant place his or her arm in a neutral position at the side with the elbow flexed at 90° and the palm facing the body. The test administrator placed the dynamometer on the outside of the upper arm just above the elbow. The research team obtained three measurements for each of the muscle groups tested.
Eight-Foot Walk Test
Timed walk tests are measures of lower extremity function (Chandler et al., 1998; Wang, Olson, & Protas, 2005). Participants walked at a pace they normally would walk in a grocery store. A measuring tape marked a clear 8-ft (2.4-m) pathway on the floor, and the test administrator instructed the participant to start walking a couple of steps before the beginning of the tape measure. The administrator recorded the faster of two trials, in seconds. The administrator also noted any assistive devices used such as a cane or walker.
Modified Physical Performance Test
The Physical Performance Test (PPT) objectively assesses functional capabilities in the following domains of physical function: write a sentence, simulate eating, lift a book onto a shelf, pick up a penny from the floor, turn 360°, and take a timed 50-ft ( 15.2-m) walk (Reuben & Siu, 1990). The PPT is highly correlated with established measures of activity of daily living (ADL) performance and the Tinetti gait score and has demonstrated high interrater reliability and internal consistency (Reuben & Siu). For the current study, we eliminated the 50-ft walk item (in lieu of the 8-ft walk test) and we modified the PPT scale, with scores ranging from 0 to 24. The research team timed and scored each of the tasks by using validated criteria.
Kohlman Evaluation of Living Skills
The Kohlman Evaluation of Living Skills (KELS) assesses ADLs in the following five areas: self-care, safety and health, money management, transportation and telephone, and work and leisure. The KELS is a tool that is commonly used by occupational therapists in clinical settings (Kohlman-Thomson, 1992). In addition, previous studies have established the convergent validity of the KELS with established ADL measures and the sensitivity of the KELS to identify older adults who are not capable of living safely and independently in the community (Zimnavoda, Weinblatt, & Katz, 2002). The scoring system ranges from 0 to 16, with a score 
6 suggesting that the person cannot live independently without assistance. The research coordinator was trained by an experienced occupational therapist to use the KELS in community-based settings for the current study (Pickens et al., 2007).
Statistical Analysis
We designed our analyses to test the hypothesis that group membership (SN group vs CC group) was significantly associated with declines in one or more measures of functional status. We calculated frequencies, proportions, and distributions for all baseline characteristics of the study population. We assessed distributional differences for ordinal and dichotomous variables by using Pearson chi-square analyses. We conducted independent-samples t tests to determine the mean differences between continuous variables as well as the bivariate relationship between group membership and the five functional status measures: shoulder abduction, knee extension, 8-ft walk, modified PPT (mPPT), and the KELS. We chose functional status measures with a probability value of p 
.10 as the dependent variables for analysis in distinct analysis of covariance (ANCOVA) models.
To better understand potential modifiers of the relationship between self-neglect and functional status, we tested a series of five ANCOVA models. Model 1 (sociodemographic) consisted of five covariates: age, race, gender, monthly income, and education attainment. The covariates for Model 2 (social support) were living alone, marital status, and routine religious participation. Model 3 (health status) tested the effects of the covariates of self-rated health, number of chronic conditions, number of medications, MMSE score, and GDS score. Models 4 (for mPPT) and 5 (for the KELS) combined all the significant covariates from Models 1 through 3 for each of the dependent variables. Adjusted R-square values provide a quantitative estimate of the variance contributed by the independent variable after all covariates are factored. We chose two-tailed tests of significance with an alpha level of p <.05 for these analyses.
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Discussion |
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Despite the significant clinical and public health consequences resulting from self-neglect in older adults, few studies have quantitatively evaluated the causes, diagnosis, or treatments of this condition in comparison to other older adults. To further our understanding of this condition, recent studies have attempted to characterize self-neglect as a geriatric syndrome building on the evidence of a multifactor etiology as well as associations with other geriatric syndromes, comorbidities, and increased mortality (Dyer & Goins, 2000; Pavlou & Lachs, 2006; Pickens et al., 2006). The findings of the current study address an important remaining criterion for defining a geriatric syndrome for which definitive data were lacking. Functional impairment is fundamental to the assessment of the geriatric patient and is characteristically described as a decline in the ability to perform one or more of the basic or instrumental ADLs. By this definition, the mPPT and KELS tests may be better assessments of basic and instrumental ADLs than are timed-gait or muscle performance tests. The KELS has particular strengths for evaluating impairment in the context of geriatric self-neglect because it assesses physical, cognitive, and executive functioning across five domains of independent living (Kohlman-Thomson, 1992). Furthermore, unlike many functional status tests that rely on self-report, the KELS also includes observation- and performance-based measurements. These findings suggest that safe and independent living in the community may be based on the adequacy of executive function for the performance of instrumental ADLs.
There are several limitations to the study results. The ideal relationship between a geriatric syndrome and functional decline should be independent and causal. The current study did find an independent association, but our study design cannot distinguish whether self-neglect is the cause or effect of functional impairment. Future longitudinal studies of older adults with self-neglect are needed. Second, participation in the SN group was based on referral to and evaluation by APS, which does introduce some detection bias for functional impairment. Nevertheless, the baseline characteristics and performance on functional tests of the CC group describe a comparison cohort that is both frail and at risk for functional decline as based on established prognostic data (Covinsky, Hilton, Lindquist, & Dudley, 2006; Gill, Richardson, & Tinetti, 1995). Furthermore, our case definition of self-neglect was based on APS verification using criteria derived from Texas State statutes, which may limit the external validity of our results. In addition, over 20 participants in each group did not complete each of muscle or timed-gait tests. However, these missing data were evenly distributed between the two study groups and results from the KELS were missing for fewer than 10 participants overall.
Practice Implications
Self-neglect has often been regarded as a personal preference or behavioral idiosyncrasy that becomes more apparent in older age. The findings of the current study, building on other recent evidence (Dyer et al., 2000; Lachs et al., 1998; Smith et al., 2006), suggest that self-neglect is epidemiologically a geriatric syndrome and should be regarded as a clinical red flag. When evaluating and diagnosing vulnerable older adults, clinicians and social services professionals must be aware of the limitations of functional assessment tools. Assessments that rely exclusively on muscle or performance testing may be inadequate. The KELS is an especially useful assessment tool because it identifies specific functional impairments that constitute the patient's overall vulnerability and provides insights regarding the patient's ability to implement potential interventions. Intervention strategies can then be tailored to functional and ADL impairments as well as the remediation of coincident morbidities and geriatric syndromes. Without a validated assessment method using multimodal techniques, judgments regarding one's ability to live safely and independently in the community are circumspect.
These findings raise questions about the assessment methods used in many legal jurisdictions to define self-neglect and the criteria for guardianship. Given the public health significance of this condition, future research must focus on standardizing the clinical diagnostic criteria and the definitions used by community and governmental organizations such as APS. Strategies to ameliorate self-neglect and other forms of elder mistreatment will require comprehensive approaches involving clinical and social services as well as governmental organizations. The findings of this study provide further evidence for the epidemiological and public health consequences of self-neglect in vulnerable older adults, and they offer support for future collaborations between clinical researchers and public health advocates.
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We thank Becky Novelli, OTR, for her assistance in the training of the research team and Sharon L. Olson, PT, PhD, for her assistance with the interpretation of measurements from the manual muscle tests.
1 Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, TX.
2 Consortium for Research in Elder Self-Neglect of Texas (CREST), Houston.
3 Department of Internal Medicine, University of Texas Health Science Center at Houston.
William J. McAuley, PhD, Decision
Received for publication May 11, 2007. Accepted for publication July 31, 2007.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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| All GSA journals | Journals of Gerontology Series A: Biological Sciences and Medical Sciences | Journals of Gerontology Series B: Psychological Sciences and Social Sciences |
