July 2025: Self-Neglect in Older People — Clinical, Social & Ethical Challenges
The issue
Self-neglect is the most common reason for maltreatment of the elderly.
What do I need to know?
Among older Americans suffering from maltreatment, many are often both the victim and the perpetrator. They are victims of self-neglect, where missed medications and unpaid bills can result in hospitalizations and evictions.
Doctors are expected to recognize signs of self-neglect and intervene, but calling Adult Protective Services (APS) is seen as an extreme measure that destroys trust. Balancing patient safety with adult autonomy and dignity is difficult, especially in cases of mild cognitive decline. Most doctors simply do not have the training to make a formal competency determination.
In a recent NEJM Perspective, two researchers have proposed a clear set of guidelines to help doctors know what sort of intervention is appropriate:
Potential risk of self-neglect
No immediate safety risk.
Recommended Actions:
Monitor carefully.
Discuss risk with the patient and family.
Imminent risk of self-neglect
Patient behavior poses a substantial safety risk.
Recommended Actions
Assess cognitive function.
Discuss risk with the patient and family.
Consider a formal competency assessment.
Report case to APS if there is a high likelihood of harm.
Confirmed self-neglect
The patient has experienced harm linked to lack of self-care.
Recommended Actions
Assess cognitive function.
Consider a formal competency assessment.
Report case to APS.
Discuss APS report with the patient and family.
What can I do?
As a caregiver, it is crucial to let the patient’s doctor know what is going on. Even if it seems small, tell the doctor about changes in behavior, especially when the patient refuses help. Ask whether self-neglect is potential, imminent, or confirmed.
Understand that even when APS intervenes, the patient could still live at home. Intervention could involve gradually increasing levels of home care, installing safety equipment and arranging medication-management protocols, meal-service delivery, and regular wellness checks.
More than 20% of older adults in the United States have mild cognitive impairment, and another 10% have dementia. Do not wait until your loved one has experienced harm before considering intervention. Talk to the physician.
