This is a two-part unit on self-neglect. Part 1 examined definitions of the phenomenon, its characteristics and risk factors. This article, part 2, discusses nurses’ role in the identification and assessment of self-neglect. Due to its complex nature, a multi-agency and multidisciplinary approach is required to meet and protect the needs of vulnerable adults.
Day, M.R., Leahy-Warren, P. (2008) Self-neglect 2: nursing assessment and management. Nursing Times; 104: 25, 28-29.
Mary Rose Day, MA, BSc, RGN, RM, RPHN; Patricia Leahy-Warren, MSc, BSc, RGN, RM, RPHN, are college lecturers, both at the School of Nursing and Midwifery, University College Cork, Ireland.
- Understand the steps that are involved in the identification, assessment and management of self-neglect.
- Identify services or resources available to manage cases.
The growing older population means that self-neglect is a common problem. Evidence suggests that best practice requires early identification and a preventative approach. Most cases of self-neglect are often identified as a result of a complaint received from a variety of sources, such as healthcare professionals, GPs, neighbours and community organisations (Pickens et al, 2007).
The identification and management of cases is very difficult and complex, and requires a multi-agency and multidisciplinary approach to meet and protect self-neglecting older adults’ interests. However, nurses are the largest group of healthcare professionals and have a key role in identification and management. Nurses require information, education and knowledge about the decision-making process in managing self-neglect (Gunstone, 2003).
Identification and assessment
Nurses need to assess and establish whether a situation is one of neglect by others, self-neglect, or a combination of these (Gunstone, 2003). The multifaceted presentation of clinical signs and symptoms and the complexity of ageing make assessment crucial in evaluating what can be attributed to self-neglect versus underlying illness or disease.
Nurses need to undertake a comprehensive assessment of the individual client. Components of assessment can involve: a physical examination; observation; and self-reporting. The assessment will include the following: a detailed social and medical history; a description of the self-neglect; a historical perspective of the situation; the person’s perception of their situation; and willingness to accept support. Interviewing family members, healthcare professionals and people in the client’s social network can assist in gathering facts and in gauging a client’s decision-making capacity. Risk assessment by nurses may cover a number of areas (observation of home/client, activities of daily living, functional and cognitive abilities, nutrition, social support and environment) (Gibbons, 2006; Gunstone, 2003).
The following are domains for assessment:
- Activities of daily living;
- Instrumental activities of daily living (ability to use phone, shopping, food preparation, housekeeping, laundry, mode of transport, responsibility for own medications and ability to handle finances);
- Environmental assessment;
- Cognitive assessment.
This nurse assessment may identify the need to refer people with self-neglect for a more specialist assessment (for example physician or neurologist).
A range of measures can be used to assist nurses and multidisciplinary team members in the assessment of risk factor domains. These may include:
- Mini-mental state examination/cognitive screening;
- Geriatric depression scale;
- Wolf-Klein clock drawing test;
- Kohlman evaluation of living skills (KELS)/instrumental activities of daily living (IADL) and activities of daily living (ADL);
- Alcohol misuse assessment;
- Nutrition assessment;
- Duke social support index.
Assessment of capacity
Following assessment and identification of risk factors, nurses need to assess a person’s capacity to make and implement decisions in relation to their personal, health and safety needs. Capacity has been defined as the ability ‘to make a decision themselves or to pass that decision on to another person if impaired (decisional capacity); and the process of putting that decision into effect alone or by delegating to another person (executive capacity)’ (Naik et al, 2008).
This definition demonstrates that to make and implement decisions, people need skills to understand, appreciate, reason and process decisions in order to implement them. Capacity needs to be considered along a continuum by nurses and other staff (Marson et al, 2000).
Cases of self-neglect can pose significant ethical issues for practitioners, and it has been suggested that their judgement of it can be influenced by their own beliefs and values. The Articulate-Demonstrate Method (ADM) will support identification of clients’ capacity to maintain and implement decisions in relation to self-care and health and safety needs. The ADM gives guidance and examples of questions that nurses can use in hospital and home assessment to assist evaluation of capacity. This model was developed by Naik et al (2008) and is outlined in Fig 1 in Portfolio Pages at nursingtimes.net. Key requirements for living in the community are ensuring that personal care and health and safety needs are maintained and supported.
Once a case of self-neglect has been established, nurses can identify clinical interventions and supports required across health and social care to meet each individual client’s needs. This will be done with support from the multidisciplinary team as a team approach will aid and support decision-making in cases of self-neglect, optimising access to health and social care services and resources.
Best practice involves a person-centred approach, listening to the client’s views of their circumstances and building a therapeutic relationship (Cooney, 2005). Nurses are advocates for their clients and recognise their interests, seeking informed consent where possible before any intervention. Based on a multidisciplinary assessment of needs, a range of interventions and supports can be offered and discussed with clients and their families.
Interventions and supports
The range of interventions and supports necessary can include:
- Adult protection services;
- Geriatrician or neurologist assessment;
- Multidisciplinary team, for example occupational therapist or community welfare officer;
- Home help/social care services;
- Alcohol and/or drug misuse rehabilitation programme advocacy services;
- Environmental health officers;
- Housing services;
- Voluntary agencies, for example St Vincent de Paul Society, Age Concern, the Princess Royal Trust for Carers;
- Money advice and budgeting services.
Some older people who self-neglect have poor social support networks, poor services, may refuse help or support offered or lack the ability to come forward to obtain help.
It is recommended that any interventions need to take an empowering approach and be person-centred. Building a therapeutic relationship with clients who self-neglect is critical to the process (Lauder et al, 2005). Cases of self-neglect will need to be constantly reviewed and evaluated and nurses are vital in ensuring the safety and protection of individuals and communities. Therefore, reassessment and ongoing monitoring of clients’ circumstances is required.
Multi-agency and multidisciplinary review, goal-setting (such as putting a caregiver in place to administer medication and help with day-to-day care), and documentation of outcomes are key aspects of care. If the health and safety consequences pose risks for clients or their community, and the potential harm outweighs the threat to autonomy, then nurses and the multidisciplinary team may override the person’s wishes.
A multidisciplinary and multi-agency approach is very important in the day-to-day management of complex cases of self-neglect to support healthcare professionals, individuals and communities (Lauder et al, 2005). Protocols and guidelines to support best practice in the identification and management of cases are important and can contribute to raising awareness. Gunstone (2003) suggested that practitioners lack knowledge in relation to management of self-neglect.
Lauder et al (2005) recommended that interagency training and support should be made available.
The frailty, functional decline, cognitive impairment, or psychiatric illness associated with increasing age may increase the vulnerability of older people to self-neglect.
It is a complex multidimensional phenomenon. Nurses and primary healthcare staff are central to the identification, assessment, management and ongoing support of people who self-neglect in the community. Nurses and primary care practitioners, particularly community nurses, are vital in identifying and assessing vulnerable older people at risk. Using a person-centred approach, nurses are key in supporting individuals within a multi-agency and multidisciplinary context. Raising awareness of neglect and self-neglect, educating nurses and healthcare professionals and research-based guidelines are all fundamental to this process.
Portfolio pages online
Portfolio Pages can be filed in your professional portfolio as evidence of your learning and professional development. They contain learning activities that correspond to the learning objectives in this unit, presented in a convenient format for you to print out or work through on screen.
Cooney, C. (2005) Diogenes syndrome - a review. Irish Psychiatrist; 6: 10, 13-16.
Gunstone, S. (2003) Risk assessment and management of patients whom self-neglect: a ‘grey area’ for mental health workers. Journal of Psychiatric and Mental Health Nursing; 10: 287-296.
Lauder, W. et al (2005) A framework for good practice in interagency interventions with cases of self-neglect. Journal of Psychiatric and Mental Health Nursing; 12: 2, 192-198.
Naik, A.D. et al (2008) Assessing capacity in suspected cases of self-neglect. Geriatrics; 63: 2, 24-31.
Pickens, S. et al (2007) The utility of the Kohlman evaluation of living skills test is associated with substantiated cases of elder self-neglect. American Academy of Nurse Practitioner; 19: 137-142.
The full reference list for this unit is available in the Portfolio Pages corresponding to this unit.