Evidence to guide ethical decision‐making in the management of older people living in squalor: a narrative review

Abstract

Older people living in squalor present healthcare providers with a set of complex issues because squalor occurs alongside a variety of medical and psychiatric conditions, and older people living in squalor frequently decline intervention. To synthesise empirical evidence on squalor to inform ethical decision-making in the management of squalor using the bioethical framework of principlism. A systematic literature search was conducted using Medline, Embase, PsycINFO and CINAHL databases for empirical research on squalor in older people. Given the limited evidence base to date, an interpretive approach to synthesis was used. Sixty-seven articles that met the inclusion criteria were included in the review. Our synthesis of the research evidence indicates that: (i) older people living in squalor have a high prevalence of frontal executive dysfunction, medical comorbidities and premature deaths; (ii) interventions are complex and require interagency involvement, with further evaluations needed to determine the effectiveness and potential harm of interventions; and (iii) older people living in squalor utilise more medical and social resources, and may negatively impact others around them. These results suggest that autonomous decision-making capacity should be determined rather than assumed. The harm associated with squalid living for the older person, and for others around them, means a non-interventional approach is likely to contravene the principles of non-maleficence, beneficence and justice. Adequate assessment of decision-making capacity is of particular importance. To be ethical, any intervention undertaken must balance benefits, harms, resource utilisation and impact on others.

Diogenes syndrome - causes and treatment of pathological hoarding and self neglect

“…The environment makes daily functioning so difficult, that other people from the same cultural background as the patient would admit that intensive cleaning is needed [11]. Although living in squalor is not exclusive to the elderly patients, it is particularly dangerous for them because of the increasing care needs and greater susceptibility to illnesses [12].…”

“…Options for non-pharmacological interventions include cognitive-behavioral therapy, "medical case management", cognitive remediation, compassion-focused therapy, and public sector response [12]. "Medical case management" may improve quality of life, but is not sufficient to eliminate hoarding disorder [12,32]. CBT is effective in younger people with hoarding syndrome but does not work in older people [12,33].…”

“…"Medical case management" may improve quality of life, but is not sufficient to eliminate hoarding disorder [12,32]. CBT is effective in younger people with hoarding syndrome but does not work in older people [12,33].…”

“…It targets memory and executive functions. It is exposure therapy, developing coping strategies and relapse prevention [12,34]. It has very good efficacy immediately after intervention with an older person, but shows little long-term effect [12].…”

“…Compassion-focused therapy (CFT) regulates emotions through mindfulness and activation of the parasympathetic nervous system to help calm emotions during decluttering [12,35]. In small studies, the results of this therapy have been clinically significant and achieved reductions in the severity of syllogomania [12,35].…”