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DIOGENES SYNDROME* order and squalor, is not uncommon, yet has attracted
A CLINICAL STUDY OF GROSS NEGLECT little study.2,3 Such people pose serious problems in
terms of community care and sometimes need urgent
IN OLD AGE
hospital admission. We describe here the back-
A. N. G. CLARK G. D. MANKIKAR ground, presentation, psychiatric factors, and out-
IAN GRAY come in thirty such cases and investigate the sugges-
Department of Geriatric Medicine, Brighton General tionthat this social and clinical picture might repre-
Hospital, Brighton BN2 3EW sent a syndrome.
Patients and Methods
Summary
study of elderly patients (fourteen
A
men, sixteen women) who were ad- Thirty patients (foutteen male, sixteen female) aged
mitted to hospital with acute illness and extreme self- 66-92 (average 79) were seen. All lived in a desperate
state of domestic disorder, squalor, and self-neglect, and
neglect revealed common features which might be they were referred for urgent admission to the geriatric
called Diogenes syndrome. All had dirty, untidy unit between October, 1972, and July, 1973. The social
homes and a filthy personal appearance about which and environmental background was examined in every
they showed no shame. Hoarding of rubbish (syllo- case, together with conventional medical examination and
gomania) was sometimes seen. All except two lived investigations on admission. Comprehensive intelligence
alone, but poverty and poor housing standards were and psychometric testing were assessed by the intellectual
not a serious problem. All were known to the social- rating scale (I.R.S.), intelligence quotient by Wechsler
services departments and a third had persistently adult intelligence scale,4 and by Cattell’s methodfor
refused offers of help. An acute presentation with personality.
falls or collapse was common, and several physical Results
diagnoses could be made. Multiple deficiency states Social and Environmental Factors
were found—including iron, folate, vitamin B12, vita-
min C, calcium and vitamin D, serum proteins and All patients lived in
a state of domestic squalor, dis-
albumin, water, and potassium. The mortality, order, and self-neglect. Their homes were
extreme
especially for women, was high (46%); most of the filthy on the outside-peeling paintwork and dirty,
survivors responded well and were discharged. Half often broken, windows with dingy net curtains serv-
ing as external markersto conditions within. Inside
showed no evidence of psychiatric disorder and
there characteristic strong, stale, and slightly
was a
possessed higher than average intelligence. Many
had led successful professional and business lives, suffocating smell. The patients were usually dressed
with good family backgrounds and upbringing. Per- in’layers of dirty clothing sometimes covered by an
old raincoat or overcoat, and, when confined to bed,
sonality characteristics showed them to tend to be
aloof, suspicious, emotionally labile, aggressive, they lay beneath a pile of ragged blankets, clothing,
group-dependent, and reality-distorting individuals. or newspapers. They never appeared to undress or
It is suggested that this syndrome may be a reaction wash, the hair being long and unkempt, with exposed
late in life to stress in a certain type of personality. surfaces of skin deeply engrained with dirt. Only
two patients apologised about their personal or domes-
*
DIOGENES (4th century B.C.). Greek philosopher, the first of
Family and Home Support
the cynics. Supplied his needs in food and clothing, which Twenty-eight lived alone-one man lived with a
he kept to the minimum, by begging.... His ideals were son and grandson, and one lived with his unmarried
" "
" life according to nature ", self-sufficiency ", freedom
from emotion ", " lack of shame ", "
daughter; seventeen had relatives (eight in the Brigh-
outspokenness ", and ton area) while thirteen had none. Every patient had
" contempt for social organisation ".1
been known to the community authorities for several
weeks to years, and the domestic predicament was
well recognised. Twelve had home services (home
19. Estrada-Parra, S., Olguin-Palacios, E. in Nucleic Acids in Immuno- help, nursing, and meals) while ten repeatedly de-
logy (edited by O. J. Plescia and W. Braun); p. 96, New York, clined offers of help, sometimes refusing to open the
1968.
Acad. Sci. U.S.A. 1969,
door to callers.
20. Schur, P. H., Monroe, M. Proc. natn. 63,
1108.
21. Talal, N., Steinberg, A. D., Daley, G. G. J. clin. Invest. 1971, 50, Nutrition
1248. Little food was to be found in the house, and old
22. Epstein, W. V., Tan, M., Easterbrook, M. New Engl. J. Med.
1971, 285, 1502. dishes and mouldy scraps were often seen. Tea,
23. Koffler, D., Carr, R., Agnello, V., Thoburn, R., Kunkel, H. G. bread, biscuits, cakes, and tinned food seemed to be
J. exp. Med. 1971, 134, 294.
24. Stollar, D., Levine, L. Archs Biochem. Biophys. 1963, 101, 417. the staple diet.
25. Stollar, D., Levine, L., Lehrer, H. I., Van Vunakis, H. Proc. natn.
Acad. Sci. U.S.A. 1962, 48, 874. Finance
26. Arana, R., Seligmann, M. J. clin. Invest. 1967, 46, 1867. All the patients received the old-age pension and
27. Erickson, E., Braun, W., Plescia, O. J., Kwiatokowski, Z. in Nucleic
Acids in Immunology (edited by O. J. Plescia and W. Braun); six had supplementary pension; two had savings of
p. 201. New York, 1968. E2600 and E5000, and seven owned their homes. No-
28. Tanenbaum, S. W., Karol, M. H. ibid. p. 222.
29. Leroy, E. C. J. clin. Invest. 1974, 54, 880. one complained of shortage of money, and poverty
367
did not seem to be a feature. Food and clothing were No gross deviation of personality was found when
sometimes accepted from sympathetic neighbours. the personality-testing scores were compared with
general population norms ’despite striking age differ-
Professions ences, and the patients showed a closer correspondence
Three men had held Service commissions; two had with normal than abnormal personality. However,
been journalists; one had been a dentist, and one a they seemed more aloof, detached, shrewd, suspicious,
professional violinist. Three women had been school- and less well integrated. Other less significant traits
teachers, one a West-End fashion designer, one a showed them to be less stable emotionally, more
music teacher, one an opera singer (Covent Garden), serious, aggressive, and group-dependent, with a
and one a teacher of needlework. Their careers tendency to distort reality.
seemed to have been successful and they had enjoyed
sound family backgrounds, education, and social Progress and Aftercare
standing in earlier life. Four men (average age 85) and ten women (aver-
Admission and Presentation age age 81) died. The death-rate for women is striking
and significantly greater (P<0-05) than that seen in
Two were compulsorily admitted (under Section 47 our unit 8; the death-rate for men is in keeping with
of the Mental Health Act), the rest voluntarily; eight routine experience. The patients either responded
had previously refused until the point where illness well or died shortly after admission.’
became critical. A fall or collapse (seventeen) was the Thirteen were discharged: home (one man, four
most common presentation. women), welfare home (six men, one woman), private
Diagnosis home (one man). Only three were placed in long-
All were acutely ill, and the principal diagnoses stay wards. Follow-up visiting showed that those at
were congestive heart-failure (eight), cerebrovascular
home were in a reasonable, yet untidy, state; those in
welfare homes settled well and voiced no regrets.
disease (seven), bronchopneumonia (four), malignant
disease (two), Parkinson’s disease (two), osteoarthritis
Discussion
(two), and leukaemia, gangrene, cervical spondylosis,
pulmonary embolism, and renal failure were present This study reveals sufficient common features to
in single cases. confirm the suggestion that severe self-neglect in old
age is a syndrome.’ Common features include domes-
Pathological Investigations tic and personal dirt and squalor,2 poor housing stan-
These revealed the presence of anaemia and multiple dards not seeming to be important. They were all
deficiencies including sideropenia, changes in the known to authority, and a third caused problems by
serum-proteins, low folate and vitamin-B]2 levels, refusing help.9 All required urgent hospital admis-
deficiencies of vitamins C and D, and water deprivation sion, and a presentation with falls and collapse was
(see table). common. A variety of diseases and deficiency states
were diagnosed, and anxmia, sideropenia, and folate,
Intelligence and Personality Assessment
vitamin-C, and vitamin-Bl2 deficiencies were more
This was studied in fifteen patients,- several weeks common than in routine admissions.’°°" Dietary
after admission, to allow treatment to take effect and vitamin-D deficiency was present, and is well recog-
for them to settle in new surroundings. The striking nised in old age.12,13 The plasma-protein changes were
finding was the high l.Q., ranging from 97 to 134, probably due to nutritional inadequacy, and we found
the mean (115) being in the top quarter of the popula- four examples of hypokalxmia, which has been
tion at this age. A mean I.R.S. of 14 (range 10-5-17) ascribed to poor nutrition."
indicated a high level of intellectual preservation
Psychological assessment (on those patients who
(maximum possible score 17). could be tested) revealed good intellectual preserva-
LABORATORY FINDINGS tion and higher than average intelligence. Several
isolated themselves in the ward, others avoided group
activities, and some displayed outbursts of temper
when discussing future care. The tendency to dis-
tort reality might explain the lack of concern about
living standards. Poverty was not a serious factor;
several owned their own homes and two had capital
assets. Two previous examples, living as paupers,
were of a man with E’2 million and a woman with
30,000 accepting food and clothing from neighbours.
This may be a delusion of inability to afford necessi-
ties 15 or the result of a long tendency to save rather
than to spend.
The syllogomania may have been a distortion of
an instinctive drive to collect things.16 Some have
a compulsive habit to hoard objects which might be
management. If they recover, their freedom to decide ABOUT 3 % of the general population are mentally
their future should be respected. retarded, with i.Q. values below 70, and in about
We thank Dr N. I. Condon, Dr W. S. Parker, and Dr J. A. 0-4% of the population the i.Q. is less than 50 when
Whitehead, and the health visitors and social workers for their measured at the age of seven years.1,2 If the mental
interest and help in this study. Prof. J. F. Scott gave statisti- retardation can be shown to be linked with a specific
cal advice. biochemical abnormality, it may be possible to improve
Requests for reprints should be addressed to A. N. G. C. the situation by specific treatment or by developing
methods of prenatal diagnosis upon which to base
REFERENCES appropriate genetic counselling, with the option of
1. Chambers Encyclopædia; vol. IV, p. 533. Oxford, 1966. aborting an affected fetus.
2. Stevens, R. S. Br. J. geriat. Pract. 1963, 2, 88.
3. MacMillan, D., Shaw, P. Br. med. J. 1966, ii, 1032.
Many inherited metabolic diseases that manifest as
4. Britton, P. G., Savage, R. D. Br. J. Psychiat. 1966, 112, 417. an organic aciduria include mental retardation among
5. Cattell, R. B., Stice, G. F. Handbook of the Sixteen Personality their symptoms. Previous work has concentrated on
Factor Questionnaire; and handbook supplement for form C.
Institute for Personality and Ability Testing, Illinois, 1957. aminoacidopathies and certain other disorders for
6. Payne, R. B., Little, A. J., Williams, R. B., Milner, J. T. Br. med. J. which relatively simple screening methods are avail-
1973, iv, 643. able. Although isolated examples of organic acid-
7. Harris, L. J., Abbasy, M. A. Lancet, 1937, ii, 1429.
8. Clark, A. N. G. Publ. Hlth, Lond. 1973, 88, 11. urias associated with mental retardation are known,3
9. Rudd, T. N. Br. J. clin. Pract. 1960, 14, 345. there are no previous reports of comprehensive meta-
10. Powell, D. E. R., Thomas, J. H., Mills, P. Geront. clin. 1968, 10,
21. bolic screening for abnormal non-amino organic
11. Hurdle, A. D. F., Picton Williams, T. C. Br. med. J. 1966, ii, 202. acidurias. New quantitative methods H have now
12. Anderson, I., Campbell, A. E., Dunn, A. Scott. med. J. 1966, 11, 429.
13. Chalmers, J. Jl R. Coll. Surg. Edinb. 1968, 13, 225.
enabled this to be undertaken, and we describe here
14. Judge, T. G. Geront. clin. 1968, 10, 102. a study of the incidence of metabolic disorders associ-
15. Beatson, A. W. Br. med. J. 1960, ii, 468. ated with an organic aciduria in mentally defective
16. James, W. Principles of Psychology. London, 1901.
17. Slater, E., Rother, M. Clinical Psychiatry; p. 117. London, 1969. adults and children.
18. Freedman, A. M., Kaplan, M. D. Comprehensive Textbook of The analytical methods used permit the quantitative
Psychiatry. Baltimore, 1967.
19. Padmore, F. B. in Mental Illness in Later Life (edited by E. Pfeiffer analysis of one approximately 5 ml. urine sample
and E. W. Busse); p. 46. American Psychiatric Association, 1973.
20. Pfeiffer, E., Busse, E. W. (editors). Mental Illness in Later Life;
(equivalent to 3 mg. creatinine) for any acidic com-
p. 110. American Psychiatric Association, 1973. pound with a pKa value less than about 5-5. Prior
21. Kinsey, E. W. Times, Jan. 9, 1973. knowledge of the likely acidic metabolites is not
515
the agreed 4% annual increase in consultant establishment and domestic factors carefully, he will usually take the
and when, because of the continued effect of the Willink action which is in the patient’s best interests.
recommendation, the hospital service is more dependent Department of Community
on overseas doctors than at any time in its history ? The Medicine,
Ruchill Hospital,
principles behind the Secretary of State’s proposals Glasgow G20 9NB. H. MACANESPIE.
remain and it is for this reason that impasse has been
reached.
Editorial pens move people. Perhaps yours can be LEVAMISOLE
instrumental in urging the Government and profession
to jointly seek a judicial definition of what the consultant
SIR,—Your editorial (Jan. 18, p. 151) calls for controlled
clinical trials of levamisole, and at least two centres are
contract really means.
already using it in the treatment of human malignancies.I,2
Hellingly Hospital, We wish to support the caution sounded by Dr Hopper and
Hailsham, RONALD MAGGS,
Sussex BN27 4ER. Whole-time consultant. others,3 regarding the experimental evidence for tumour
inhibition by levamisole.
In our experience with levamisole (L-tetramisole), and
SiR,-In view of the escalating and irresponsible sanctions with the racemic mixture (D-L-tetramisole) to which greater
by some N.H.S. consultants, I call upon my fellow retired activity has been attributed,4the drug did not stimulate
consultants to report for unpaid part-time duty, either at
humoral or cellular immune responsiveness. We found no
their former place of work or at the nearest hospital that
evidence of altered humoral antibody response to sheep
needs them. In this way we may hope to salvage what is
left of our reputation at home and abroad and to break the erythrocytes injected in groups of mice receiving 1-25 mg.
per kg. body-weight intraperitoneally of levamisole over
stranglehold that threatens our patients. various time schedules.- We did not observe either immuno-
llA Acol Road,
London NW6 3AA. L. S. MICHAELIS. suppression associated with drug therapy before antigen
challenge, or immunostimulation associated with drug
administration with or soon after antigen challenge, as
SIR,-It is with interest that we read Mr Robinson’s reported by others.4 Similarly, we found no evidence of
letter (March 15, p. 626). Do you, Sir, regard The Lancet accelerated rejection of tail skin grafts in mice treated by
"
as essentially a consultants’ journal "? similar schedules, which also failed to inhibit growth of a
M. G. BAMBER transplanted fat tumour. In this last experiment, rats
H. R. L. BISHOP-CORNET immunised with irradiated Walker 256 tumour cells or
Medical Students’ Residence, A. F. MANLEY inoculated with viable tumour received the drug (2-5 mg.
Alder Hey Hospital,
West Derby, SUSAN M. MURRAY per kg. body-weight) intraperitoneally. In-vitro assays
Liverpool 12. M. WARMINGER. showed no increase in serum-antibody potency or spleen-
cell cytotoxicity at different times following tumour
"
** *No: we do not look upon this journal as being
essentially " for (or against, for that matter !) any parti- 1. Webster, D. J. T., Hughes, L. E. Lancet, Feb. 15, 1975, p. 389.
cular group of readers.-ED. L. 2. Amery, W. ibid.
3. Hopper, D. G., Pimm, M. V., Baldwin, R. W. ibid. March 8, 1975,
10. Pattengale, P. K., Smith, R. W., Gerber, P. Lancet, 1973, ii, 93. p. 574.
11. See Lancet, Jan. 11, 1975, p. 92. 4. Renoux, G., Renoux, M. J. Immun. 1974, 113, 779.