Department of Geriatric Medicine Neuropsychological profile of people living in squalor Dr. Sook Meng LEE Western Health
Severe domestic squalor Living environment that are so unclean, messy and unhygienic that people of similar culture and background would consider extensive clearing and cleaning to be essential (Snowdon, Halliday & Banerjee 2012) Living conditions that are filthy and disgusting, not just somewhat unclean or untidy (Snowdon, Shah & Halliday 2007) 2
Reasons for undertaking this study Uncertainty amongst health professionals regarding the management of people who present with squalor People who live in squalor rarely seek help or accept help when offered Clark s paper on Diogenes Syndrome described subjects as having high levels of intellectual preservation 3
Background Up to 50% of people living in squalor were reported to have no underlying psychiatric diagnosis (MacMillan & Shaw 1966, Clark 1975) Epiphenomena in dementia, substance abuse, psychiatric and medical illnesses, and intellectual disability People who live in squalor commonly exhibit features of frontal lobe impairment including apathy, lack of motivation and indifference to their living conditions 4
Objective and hypothesis To characterise the cognitive profiles of a clinical sample of people living in squalor through analysis of neuropsychological reports Frontal executive dysfunction would be almost invariable, regardless of the presence of any underlying psychiatric or medical disorder 10
Method Clinicians were invited to submit reports detailing neuropsychological profiles of patients who live in squalor Reports screened to ensure there was adequate description of squalor and reporting of neuropsychological domains tested Neuropsychological reports, supplemented with information from medical records, underwent analysis 11
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Results Referral source None of the subjects self-referred to health services 72.5% were referred for neuropsychology assessment during their inpatient stay 68% assessed in hospital 95.7% also showed signs of self-neglect 40.5% had evidence of hoarding associated with squalor 13
Demography (1) Age range: 41-96 years with mean age 72.3 years (SD=11.3) 20% of sample (n=14) less than 65 years Similar number of males (n=33, 47.8%) and females (n=36, 52.2%) Only 8 patients (11.6%) were in a relationship Single (34.8%), divorced /separated (31.9%) or widowed (21.7%) 14
Demography (2) 59.4% were owner occupiers 71% lived alone None were in current employment 88.4% on pension 8.7% self funded Education 3 patients had no education 65.2% educated to secondary or tertiary level 15
Neuropsychology assessment 77% had >/= average estimated premorbid intellectual function Mean MMSE of those tested (52/69) was 25.29 (SD=3.96) Neuropsychological domains information processing speed, memory function and executive function 16
Results neuropsychology domains (1) Domains Impaired (%) Information processing speed 61/68 (88.2) Memory function New learning 58/69 (84.1) Retrieval difficulties 56/69 (81.2) Rapid forgetting 24/69 (34.8) 17
Results executive function (dorsolateral) Executive function domains Impaired (%) Abstraction 59/69 (85.5) Verbal fluency 57/68 (82.4) Higher attentional skills 60/69 (87.1) Planning 58/69 (84.1) Organisation 57/69 (82.6) Problem solving 56/68 (82.4) General reasoning 53/69 (76.8) Mental flexibility 60/69 (87.0) 18
Results orbitofrontal Domains n (%) - presumed absent if not specified Impulsivity 29 (42.0) Sexual disinhibition 5 (7.2) Overfamiliarity 17 (24.6) 19
Results neuropsychology domain (3) Domain Normal (%) Impaired (%) Insight 5 (7.2) 64 (92.8) Executive Function 5 (7.2) 64 (92.8) 20
Results neuropsychology opinion Opinion of underlying pathology n (%) 15 patients with mixed causes Normal 1 (1%) Vascular cause 29 (42%) Alcohol related 17 (25%) Psychiatric 11 (16%) Dementia (other than vascular,alc,hiv) 13 (19%) Intellectual impairment 4 (6%) Acquired brain injury 3 (4%) Medical cause 2 (3%) 21
Results neuroimaging for 38 patients 8% (3) vascular changes with atrophy 65% (25) vascular changes 8% (3) general atrophy 8% (3) regional atrophy 3% (1) frontal lobectomy 8% (3) normal 22
Summary of findings Frontal executive dysfunction was a prominent finding regardless of their underlying medical or psychiatric diagnoses Dorsolateral rather than orbitofrontal functions were more likely to be impaired Vascular aetiology was the most commonly implicated cause of cognitive deficits found 23
Discussion (1) Largest study of neuropsychology profile of squalor patients Executive impairment was a prominent finding MMSE insufficient Cognitive assessments that include tests of executive function are needed when assessing patients living in squalor 24
Discussion (2) Limitations Opportunistic study No control group Neuropsychology assessment was requested as per clinical need The majority were assessed as inpatients Results have clinical utility 25
Authors Dr Sook Meng Lee MBBS FRACP 1,2, Dr Matthew Lewis PhD 1, Deborah Leighton 3, Dr Ben Harris PhD 4, Dr Brian Long DPsych (Clin. Neuro.) 5 A/Prof Stephen Macfarlane MBBS FRANZCP 1 Affiliations 1. Aged Psychiatry Service, Caulfield Hospital, Alfred Health 2. Department of Geriatric Medicine, Western Health 3. Neuropsychology, The Royal Melbourne Hospital, Melbourne Health 4. Neuropsychology, Kingston Centre, Monash Health 5. Neuropsychology, Monash Medical Centre, Monash Health 26