Physical Function Decline and the Risk of Elder Self-neglect in a Community-Dwelling Population

Elder self-neglect is a common and important public health issue across all sociodemographic socioeconomic strata and across all locale in the United States. Elder self-neglect has great relevance not only to health care professional and social services agency but also to public health professionals, community organizations, and other relevant disciplines. Evidence suggests that there are about 1.2 million cases of elder self-neglect in the United States (National Center on Elder Abuse, 1998). A recent study suggests that elder self-neglect reported to social services agency is associated with increased risk of mortality, and there is a gradient relation between greater self-neglect severity and higher risk for mortality (Dong, Simon, Mendes de Leon, et al., 2009). Moreover, evidence indicates that reports of elder self-neglect to social services agencies are on the rise (Teaster, 2002). As our aging population increases rapidly, elder self-neglect will likely become an even more pervasive public health issue. The National Centers on Elder Abuse defines elder self-neglect as “ … as the behavior of an elderly person that threatens his/her own health and safety. Self-neglect generally manifests itself in an older person as a refusal or failure to provide himself/herself with adequate food, water, clothing, shelter, personal hygiene, medication (when indicated), and safety precautions” (National Center on Elder Abuse Website, 2006). There have been a number of conceptual frameworks postulated for the syndrome of elder self-neglect (Choi, Kim, & Asseff, 2009; Dyer, Goodwin, Pickens-Pace, Burnett, & Kelly, 2007; Iris, Ridings, & Conrad, 2009; Orem, 1991; Pavlou & Lachs, 2006). This study follows the conceptual framework derived by Dyer and colleagues (2007) from a large cohort of elder self-neglect cases reported to social services agencies. This conceptual framework represents a comprehensive synthesis of elder self-neglect and is widely used by public health workers, clinicians, and researchers to better understand the issues of elder self-neglect (Dong, Mendes de Leon, & Evans, 2009; Dyer et al., 2008; McDermott, 2008; Naik, Burnett, Pickens-Pace, & Dyer, 2008; Paveza, Vandeweerd, & Laumann, 2008; Pickens et al., 2007). In this conceptual framework, the common elements include medical comorbidities (e.g., diabetes, cancer, cerebrovascular disease, cardiovascular disease, etc.), depression, cognitive impairment, executive dysfunction, physical function impairment, lack of social network, and social support. The central hypothesis of this framework suggests that increased burden of medical comorbidities compounded by cognitive impairment and depression may lead to executive dysfunction which in turn could worsen the levels of physical function. In this model, impairment with essential activities of daily living (ADL) and instrumental ADL represent the central event associated with worsening vulnerability in the syndrome of elder self-neglect. In addition, physical function impairment combined with lack of social network and inadequate support services magnify the lack of ability for self-protection, leading to the syndrome of elder self-neglect. Physical function impairment has been associated with substantial morbidity and mortality (Johnson, 2000; Olsen & Jeune, 1980; Wallman et al., 2006). However, our current understanding of the relations between physical function and elder self-neglect has been limited. Prior cross-sectional research found that elder self-neglect was associated with self-reported physical function impairments (Cornwall, 1981; Longres, 1995; Nelson & Farberow, 1980; O’Rawe, 1982; Orrell, Sahakian, & Bergmann, 1989; Pickens et al., 2007). Direct performance testing of physical function may be more accurate, but we found only three cross-sectional studies that have described the lower levels of physical performance testing associated with elder self-neglect (Dong, Mendes de Leon, et al., 2009; Dyer et al., 2007; Naik et al., 2008). Moreover, current knowledge of the temporal relations of physical function and elder self-neglect in a representative population remains limited. This information is critical in ascertaining more precise understanding of risk factors associated with elder self-neglect in order to inform future prevention and intervention strategies. Furthermore, elder self-neglect, like many other geriatric syndromes, manifests along a continuum of severity rather than in discrete categories (Dong & Gorbien, 2005), but our understanding of elder self-neglect is mainly from the most severe cases and from a dichotomous categorization of subjects as “self-neglect” or “no self-neglect.” Improved understand of elder self-neglect and its severity is of enormous public health importance as frontline social services agency deal with the issues of elder self-neglect across the continuum. In this longitudinal study, we aim to expand the prior literature in two ways by examining (a) the relationship between decline in physical function and the risk of self-neglect and (b) the relationship between decline in physical function and the risk of greater self-neglect severity within the context of a prospective population-based cohort. We hypothesize that decline in physical function is associated with increased risk of reported and confirmed elder self-neglect and that there is a linear relation between decline in physical function with greater self-neglect severity.