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

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.

Analysis of patients referred for aged care assessment with concerns related to hoarding or squalor.

Patients referred with concerns related to hoarding and squalor frequently pose significant management challenges. We conducted a retrospective analysis of 120 patients referred to an Aged Care Assessment Service. The hoarding only group comprised 27%, squalor only 15% and hoarding and squalor 53%. Mild cognitive impairment was the most common cognitive diagnosis, no cognitive diagnosis was made in 25% and the usual diagnostic process could not be followed in 13%. This analysis provides relevant Australian specific data to assist with planning service delivery for a group of patients with complex management issues.

Interpreter-mediated Cognitive Assessments: Who Wins and Who Loses?

OBJECTIVES: The number of people with dementia from culturally and linguistically diverse (CALD) backgrounds is increasing dramatically in Australia. Accurate cognitive assessments of people from CALD backgrounds can be achieved with the use of skilled interpreters. This study aimed to explore the experience of interpreter-mediated assessments from the perspectives of clinicians, interpreters and carers. METHODS: Consultations with interpreters, clinicians and carers were conducted through individual interviews and focus groups. The consultations explored participants' experiences of interpreter-mediated assessments, including perception of the interpreting process, roles of interpreters, and challenges associated with interpreter-mediated assessments. RESULTS: Four themes emerged across groups: (1) the importance of having professional interpreters, (2) different perceptions of the roles of interpreters, (3) clinicians' feelings of having less control over assessments, and (4) particular challenges associated with cognitive assessments. CONCLUSIONS: Finding from this study highlight the important role that interpreters play in cognitive assessments with immigrants. However, there appears to be different perceptions of the role between clinicians and interpreters. When these different understandings are not resolved, they will lead to tension between clinicians and interpreters. These findings highlight the importance of relational aspects in interpreter-mediated assessment and suggest that the negotiation of the relationships between clinicians and interpreters is an important factor that determines the effectiveness and accuracy of these assessments. CLINICAL IMPLICATIONS: This study highlights the need for clinicians and interpreters education of roles of all parties in interpreter-mediated cognitive assessment. Areas to be covered in education could include: common misunderstandings of interpreters roles, and practice tips on how to improve communications in assessments, such as briefing before and after the assessment. Such education will enable more accurate assessment and less stress for patients and their families.

A comparison of the neuropsychological profiles of people living in squalor without hoarding to those living in squalor associated with hoarding.

OBJECTIVE: Squalor affects 1 in 1000 older people and is regarded as a secondary condition to other primary disorders such as dementia, intellectual impairment and alcohol abuse. Squalor frequently is associated with hoarding behaviour. We compared the neuropsychological profile of people living in squalor associated with hoarding to those presenting with squalor only. METHODS: This study is a retrospective case series of hospital inpatient and community healthcare services of 69 people living in squalor (49 from aged care, 16 from aged psychiatry, 3 from acute medical and 1 from a memory clinic). Forty per cent had co-morbid hoarding behaviours. The main outcomes were neuropsychologists' opinions of domain-specific cognitive impairment. RESULTS: The squalor-hoarding group (M age 75.8, SD = 6.9,) was significantly older (p < 0.05) than the squalor-only group (M age 69.9 years, SD = 13.1), significantly more likely to have vascular or Alzheimer's type neurodegeneration (p < 0.05) and significantly less likely to have alcohol-related impairment (p < 0.05). Chi-square analyses revealed significantly greater rates of impairment for the squalor-only group (p < 0.05) in visuospatial reasoning, abstraction, planning, organisation, problem solving and mental flexibility, compared with the squalor-hoarding group. Logistic regression analysis indicated that impaired mental flexibility was a significant predictor and strongly indicated squalor only (odds ratio = 0.07; 95% confidence interval: 0.01-0.82). CONCLUSIONS: Preliminary evidence suggests that squalor associated with hoarding may have distinct neuropsychological features compared against squalor only. Future work should be conducted using a larger sample and a common neuropsychological battery to better understand the deficits associated with hoarding-related squalor. Copyright © 2016 John Wiley & Sons, Ltd.

A preliminary investigation of domestic squalor in people with a history of alcohol misuse: neuropsychological profile and hoarding behavior - an opportunistic observational study.

BACKGROUND: Domestic squalor has been associated with alcohol misuse but little work has explored this. Executive dysfunction is commonly observed in squalor and is also associated with alcohol misuse. Hoarding can accompany squalor, but it is unclear whether hoarding is also linked with alcohol misuse. This study compared neuropsychology and hoarding status of individuals living in squalor with and without a history of alcohol misuse. METHODS: A subgroup analysis was conducted on a series of 69 neuropsychological reports of people living in squalor. Data on cognitive profiles, basic demographics, alcohol use, and hoarding were extracted and analyzed. RESULTS: Alcohol misuse was reported in 25 of the 69 participants (36%). Alcohol misusers were significantly younger (mean age 66.2 years, SD = 10.7) than non-misusers (mean age 75.6 years, SD = 10.3) (p < 0.00) and significantly more likely to be male (p = 0.01). No significant differences between the two subgroups were found for estimated premorbid intellectual functioning, Mini Mental State Examination (MMSE) scores, or individual neuropsychological domains. Alcohol misusers were more likely to be living in squalor without hoarding than squalor with hoarding (p = 0.01). CONCLUSIONS: Alcohol misusers living in squalor were less likely to hoard than non-misusers. This finding suggests that alcohol misuse may be a risk factor for squalor via failure to maintain one's environment rather than through intentional accumulation of objects. The similar cognitive profile among those with and without a history of alcohol misuse could represent a common pattern of executive dysfunction that predisposes individuals to squalor regardless of underlying alcohol misuse diagnosis.

Neuropsychological characteristics of people living in squalor.

BACKGROUND: Squalor is an epiphenomenon associated with a range of medical and psychiatric conditions. People living in squalor are not well described in the literature, and prior work has indicated that up to 50% do not have a psychiatric diagnosis. Squalor appears to be linked with neuropsychological deficits suggestive of the presence of impaired executive function. We present a case series of people living in squalor that examines their neuropsychological assessment and diagnosis. METHODS: Clinicians from local health networks were invited to submit neuropsychological reports of patients living in squalor. These selected reports were screened to ensure the presence of squalor and a comprehensive examination of a set of core neuropsychological domains. Assessments were included if basic attention, visuospatial reasoning, information processing speed, memory function, and executive function were assessed. RESULTS: Sixty-nine neuropsychological reports were included. Sixty-eight per cent of the group underwent neuropsychological assessments during an inpatient admission. For participants where it was available (52/69), the mean Mini-Mental State Examination score was 25.29 (SD = 3.96). Neuropsychological assessment showed a range of cognitive impairment with nearly all the participants (92.75%) found to have frontal executive dysfunction. One person had an unimpaired neuropsychological assessment. Results indicated that dorsolateral prefrontal rather than orbitofrontal functions were more likely to be impaired. Vascular etiology was the most common cause implicated by neuropsychologists. CONCLUSIONS: Frontal executive dysfunction was a prominent finding in the neuropsychological profiles of our sample of squalor patients, regardless of their underlying medical or psychiatric diagnoses. Our study highlights the importance of considering executive dysfunction when assessing patients who live in squalor.

Help seeking in older Asian people with dementia in Melbourne: using the Cultural Exchange Model to explore barriers and enablers.

The prevalence of dementia is increasing in Australia. Limited research is available on access to Cognitive Dementia and Memory Services (CDAMS) for people with dementia from Culturally and Linguistically Diverse (CALD) communities. This study aimed to determine the barriers and enablers to accessing CDAMS for people with dementia and their families of Chinese and Vietnamese backgrounds. Consultations with community members, community workers and health professionals were conducted using the "Cultural Exchange Model" framework. For carers, barriers to accessing services included the complexity of the health system, lack of time, travel required to get to services, language barriers, interpreters and lack of knowledge of services. Similarly, community workers and health professionals identified language, interpreters, and community perceptions as key barriers to service access. Strategies to increase knowledge included providing information via radio, printed material and education in community group settings. The "Cultural Exchange Model" enabled engagement with and modification of the approaches to meet the needs of the targeted CALD communities.