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8/8/2019 Diogenes Lancet 1975
19. Estrada-Parra, S., Olguin-Palacios, E. in Nucleic Acids in Immuno-
logy (edited by O. J. Plescia and W. Braun); p. 96, New York,1968.
20. Schur, P. H., Monroe, M. Proc. natn. Acad. Sci. U.S.A. 1969, 63,1108.
21. Talal, N., Steinberg, A. D., Daley, G. G. J. clin. Invest. 1971, 50,1248.
22. Epstein, W. V., Tan, M., Easterbrook, M. New Engl. J. Med.1971, 285, 1502.
23. Koffler, D., Carr, R., Agnello, V., Thoburn, R., Kunkel, H. G.
J. exp. Med. 1971, 134, 294.24. Stollar, D., Levine, L. Archs Biochem. Biophys. 1963, 101, 417.25. Stollar, D., Levine, L., Lehrer, H. I., Van Vunakis, H. Proc. natn.
Acad. Sci. U.S.A. 1962, 48, 874.26. Arana, R., Seligmann, M. J. clin. Invest. 1967, 46, 1867.27. Erickson, E., Braun, W., Plescia, O. J., Kwiatokowski, Z. in Nucleic
Acids in Immunology (edited by O. J. Plescia and W. Braun);p. 201. New York, 1968.
28. Tanenbaum, S. W., Karol, M. H. ibid. p. 222.29. Leroy, E. C. J. clin. Invest. 1974, 54, 880.
A CLINICAL STUDY OF GROSS NEGLECT
IN OLD AGE
A. N. G. CLARK G. D. MANKIKAR
Department of Geriatric Medicine, Brighton General
Hospital, Brighton BN2 3EW
A study of elderly patients (fourteenSummary
men, sixteen women) who were ad-mitted to hospital with acute illness and extreme self-
neglect revealed common features which might becalled Diogenes syndrome. All had dirty, untidyhomes and a filthy personal appearance about which
they showed no shame. Hoarding of rubbish (syllo-gomania) was sometimes seen. All except two lived
alone, but poverty and poor housing standards werenot a serious problem. All were known to the social-services departments and a third had persistentlyrefused offers of help. An acute presentation withfalls or collapse was common, and several physicaldiagnoses could be made. Multiple deficiency stateswere foundincluding iron, folate, vitamin B12, vita-min C, calcium and vitamin D, serum proteins and
albumin, water, and potassium. The mortality,especially for women, was high (46%); most of thesurvivors responded well and were discharged. Halfshowed no evidence of psychiatric disorder and
possessed higher than average intelligence. Manyhad led successful professional and business lives,with good family backgrounds and upbringing. Per-
sonality characteristics showed them to tend to be
aloof, suspicious, emotionally labile, aggressive,group-dependent, and reality-distorting individuals.It is suggested that this syndrome may be a reactionlate in life to stress in a certain type of personality.
THE acutely ill old person with a dirty and neg-lected appearance, in a setting of gross domestic dis-
* DIOGENES (4th century B.C.). Greek philosopher, the first ofthe cynics. Supplied his needs in food and clothing, whichhe kept to the minimum, by begging.... His ideals were" life according to nature ",
self-sufficiency "," freedom
from emotion ", " lack of shame ","
outspokenness ", and
" contempt for social organisation ".1
order and squalor, is not uncommon, yet has attractedlittle study.2,3 Such people pose serious problems interms of community care and sometimes need urgenthospital admission. We describe here the back-
ground, presentation, psychiatric factors, and out-come in thirty such cases and investigate the sugges-tionthat this social and clinical picture might repre-sent a syndrome.
Patients and Methods
Thirty patients (foutteen male, sixteen female) aged66-92 (average 79) were seen. All lived in a desperatestate of domestic disorder, squalor, and self-neglect, and
they were referred for urgent admission to the geriatricunit between October, 1972, and July, 1973. The socialand environmental background was examined in everycase, together with conventional medical examination and
investigations on admission. Comprehensive intelligenceand psychometric testing were assessed by the intellectual
rating scale (I.R.S.), intelligence quotient by Wechsleradult intelligence scale,4 and by Cattells methodforpersonality.
Social and Environmental Factors
All patients lived in a state of domestic squalor, dis-
order, and extreme self-neglect. Their homes were
filthy on the outside-peeling paintwork and dirty,often broken, windows with dingy net curtains serv-
ing as external markers to conditions within. Inside
there was a characteristic strong, stale, and slightlysuffocating smell. The patients were usually dressed
inlayers of dirty clothing sometimes covered by anold raincoat or overcoat, and, when confined to bed,
they lay beneath a pile of ragged blankets, clothing,or newspapers. They never appeared to undress orwash, the hair being long and unkempt, with exposedsurfaces of skin deeply engrained with dirt. Onlytwo patients apologised about their personal or domes-tic state. Several hoarded useless rubbish (syllogo-mania)-newspapers, tins, bottles, and rags, often inbundles and stacks-and in six instances the size of
the collection seriously reduced living space.
Family and Home Support
Twenty-eight lived alone-one man lived with ason and grandson, and one lived with his unmarried
daughter; seventeen had relatives (eight in the Brigh-
ton area) while thirteen had none. Every patient hadbeen known to the community authorities for severalweeks to years, and the domestic predicament waswell recognised. Twelve had home services (homehelp, nursing, and meals) while ten repeatedly de-clined offers of help, sometimes refusing to open thedoor to callers.
Little food was to be found in the house, and olddishes and mouldy scraps were often seen. Tea,bread, biscuits, cakes, and tinned food seemed to bethe staple diet.
FinanceAll the patients received the old-age pension and
six had supplementary pension; two had savings ofE2600 and E5000, and seven owned their homes. No-one complained of shortage of money, and poverty
8/8/2019 Diogenes Lancet 1975
did not seem to be a feature. Food and clothing weresometimes accepted from sympathetic neighbours.
ProfessionsThree men had held Service commissions; two had
been journalists; one had been a dentist, and one a
professional violinist. Three women had been school-
teachers, one a West-End fashion designer, one amusic teacher, one an opera singer (Covent Garden),and one a teacher of needlework. Their careers
seemed to have been successful and they had enjoyedsound family backgrounds, education, and social
standing in earlier life.
Admission and Presentation
Two were compulsorily admitted (under Section 47of the Mental Health Act), the rest voluntarily; eighthad previously refused until the point where illnessbecame critical. A fall or collapse (seventeen) was themost common presentation.
DiagnosisAll were acutely ill, and the principal diagnoses
were congestive heart-failure (eight), cerebrovasculardisease (seven), bronchopneumonia (four), malignantdisease (two), Parkinsons disease (two), osteoarthritis
(two), and leukaemia, gangrene, cervical spondylosis,pulmonary embolism, and renal failure were presentin single cases.
Pathological InvestigationsThese revealed the presence of anaemia and multiple
deficiencies including sideropenia, changes in the
serum-proteins, low folate and vitamin-B]2 levels,deficiencies of vitamins C and D, and water deprivation(see table).
Intelligence and Personality Assessment
This was studied in fifteen patients,- several weeksafter admission, to allow treatment to take effect andfor them to settle in new surroundings. The strikingfinding was the high l.Q., ranging from 97 to 134,the mean (115) being in the top quarter of the popula-tion at this age. A mean I.R.S. of 14 (range 10-5-17)indicated a high level of intellectual preservation(maximum possible score 17).
No gross deviation of personality was found whenthe personality-testing scores were compared with
general population norms despite striking age differ-
ences, and the patients showed a closer correspondencewith normal than abnormal personality. However,they seemed more aloof, detached, shrewd, suspicious,and less well integrated. Other less significant traits
showed them to be less stable emotionally, more
serious, aggressive, and group-dependent, with a
tendency to distort reality.
Progress and AftercareFour men (average age 85) and ten women (aver-
age age 81) died. The death-rate for women is strikingand significantly greater (P
8/8/2019 Diogenes Lancet 1975
There are two possible explanations why intelligenteducated individuals descend to such .debased stan-
dards of living. One might be a lifelong proclivityto give personal and domestic care a low priority-a disorganised style of life becoming exaggerated byageing and physical infirmity-or it might be areaction to stress in an elderly person with certain
personality characteristics. Sometimes previouslystable old people develop neurotic breakdown with-out previous history,17 due to social, economic, and
declining health factors with predisposing featuresin the personality (e.g., being aloof, moody, andanxious). A vicious circle of increasing anxiety, help-lessness, and anger is accentuated by inadequacy tomaster everyday problems, producing a further ineffici-ency.18 Social, psychological, and economic stress
produce mental illness in old age 19 and invoke defencemechanisms of withdrawal and denial of need." Our
patients seem to need social contact whic