Domestic squalor: Who should take responsibility?

To the Editor

People living in severe domestic squalor present a range of clinical, ethical, social and management challenges. A squalid environment is generally regarded as one in which an accumulation of rubbish over time results in a living situation which is regarded as undesirable by others (Snowdon et al., 2012). The prevalence of squalor has been estimated to be as high as one in 700 community-dwelling older persons living alone (Snowdon et al., 2012), making this a major public health issue.

When faced with squalor, practitioners have two broad options: intervening, often against the strenuous objections of the patient; or declining to act. As the former option is generally regarded as unacceptably paternalistic, most practitioners will default to the latter path, possibly stating a belief that each individual has the right to live in whatever environment they choose, even if that environment is something that others would find unpalatable.

Whether squalor has arisen via a passive decline in functioning or through an accumulation of material through hoarding, recent research suggests that impaired frontal lobe function is almost invariably present (Lee et al., 2014).

Clinical impairments in the frontal lobes can often be difficult to detect as clinicians are frequently unfamiliar with their assessment. The Folstein Mini-Mental State Examination (MMSE) (Folstein et al., 1975) has gained widespread acceptance as the standard screen for cognitive impairment, yet it is insufficient to reliably identify frontal impairment as the tool was primarily geared to the detection of temporal lobe pathology. Our data have revealed an average MMSE score of over 26 in the squalor living group, whose verbal skills are often well preserved (Lee et al., 2014). Thus, affected individuals can score highly on the MMSE, whilst presenting well and retaining a veneer of capacity.

Psychiatrists have tended not to view squalor as a psychiatric issue, yet we are often best placed to assess executive function and to advise on appropriate management strategies. Individuals who degenerate into squalor as a result of frontal lobe pathology are likely to have diminished capacity, and may be managed by the provision of home help services and community assistance. In extreme cases, more assertive paternalistic approaches, such as guardianship, may well be appropriate. In view of the increasing evidence for high-level executive impairment in this vulnerable patient group, it is no longer acceptable to invoke respect for a right to autonomy in order to excuse clinical inaction.