Diogenes Syndrome is a syndrome of extreme selfneglect,
domestic squalor, excessive hoarding, social
withdrawal and refusal of all help and lack of concern
regarding one’s personal residential situation. A case report
of an 83 year old lady with mild dementia and Diogenes
Syndrome is described.peer-reviewe

Ferry, Peter

English

OAR@UM

The Journal of the Malta College of Family Doctors  VOLUME 02 issUE 03 DECEMBER 2013 29aBsTRaCTDiogenes Syndrome is a syndrome of extreme self-neglect, domestic squalor, excessive hoarding, social withdrawal and refusal of all help and lack of concern regarding one’s personal residential situation.  A case report of an 83 year old lady with mild dementia and Diogenes Syndrome is described.KEY wORDsDiogenes, syndrome, senile, dementiainTRODUCTiOnDiogenes Syndrome (DS), also known as Senile Squalor Syndrome, is a complex spectrum of behaviours found in persons who are living reclusively.  It is characterized by an extreme self-neglect of environment, health and hygiene, combined with compulsive hoarding of refuse and the patient’s complete denial of his or her surroundings or symptoms (Iqbal et al., 2010).DS was named after Diogenes the Cynic (412 - 323 BC), the Greek philosopher who was best known for wandering the streets of Athens in the daylight with a lamp in search of an honest man.  Diogenes slept in a barrel, was often found begging and engaged in forbidden public habits.  DS was first described as a geriatric syndrome in 1966 because of its multifactorial aetiology and association with functional decline.  Most patients are single or widowed and live alone, and their decline tends to be lengthy in duration.  There is an association with falls, incontinence and increased mortality.  These reclusive patients present with some form of physical illness such as cutaneous ulcers or neuropathy or malnutrition.  The incidence is 5 per 10,000 in patients 60 years and over.  Some patients with DS have a prior psychiatric history; most of them have above average intelligence, work histories, stable family backgrounds and adequate social resources (Reyes-Ortiz, 2001).Diogenes Syndrome is often identified by chance (e.g. a person collapses, trapped in rubbish, etc.), by having recurrent visits to hospital for self neglect, or through a trigger by public health after complaints from neighbours. One should suspect Diogenes Syndrome in a filthy patient who is unkempt and malodorous with neglected feet and poor dentition.  The patient’s family may raise issues Dr Peter FERRYCasE sTUDYA case of Diogenes Syndromeof hoarding behaviour and self neglect.  The differential diagnosis is elder abuse, mental illness, delirium, dementia, poverty or alcohol abuse.Clinical features of Diogenes Syndrome may include self neglect, lack of self-consciousness about their personal habits, hoarding of rubbish, aloofness, suspiciousness, emotional lability, aggressiveness, distortion of reality and nutritional deficiencies.Multiple deficiency states have been associated with DS including deficiencies of iron, folate, vitamin B12, vitamin C, calcium and vitamin D, serum proteins and albumin, water and potassium (Clarke, Mankikar and Gray, 1975).The purpose of this case report is to demonstrate how such a well described syndrome may be neglected by both doctors and social workers unless it is recognized as a clinical entity and diagnosed.CasE REPORTA consultant geriatrician was contacted by the nephew of an 83 year old spinster to visit her at home as he noted that she was becoming a bit forgetful, may not have been taking her chronic medication and has had a couple of falls recently.  She is an independent lady who lives in a large house in the village core, surrounded by neighbours.Before the geriatrician stepped into the house, the nephew warned him that her house, which was actually a mansion, was “in a bit of a mess” as she would not accept anyone to help keep it clean and that she has “a habit of collecting all sorts of rubbish”.  As soon as he entered the house, the stench of rotting garbage hit him, and it was unbelievable that this poor lady could live in such unhygienic conditions.  There was household waste all over the place, including on the floor, on furniture and in every room including the kitchen (see Photo 1), bedroom and living room (see Photo 2).  The garden was overgrown and also contained mounds of rubbish.The lady was lacking insight about her social situation. When confronted with the problem, she could not understand what the fuss was about, saying she “collected stuff which she would find handy in time of need.”During the visit, the lady sustained a near fall on an empty plastic bottle which was lying on the floor. It became obvious that this lady’s condition was a medical health 30 VOLUME 02 issUE 03 DECEMBER 2013 The Journal of the Malta College of Family Doctors emergency, although this would not have been so obvious had she been seen in a clinic or hospital situation.Her nephew stated that the Public Health Department was already informed about the case as the patient’s next door neighbours had complained about the smells and pests coming from this lady’s house.  When she was confronted as to whether she was experiencing any problems with the neighbours, she expressed surprise as to why recently her neighbours were slightly aloof as she did not feel that she had offended anyone!A quick elective admission to the Rehabilitation Hospital Karin Grech (RHKG) with the patient’s consent was organized, the purpose of which was to perform a comprehensive geriatric assessment on her and also to give enough time for her nephew to clean her house and make it habitable once again.  Her nephew recounted that this was not the first time that he had to clean the house and that a few years previously he had spent 4000 Euros in skip hire to get rid of all the rubbish she had accumulated.The lady was admitted to RHKG a couple of days later as the nephew preferred to postpone admission after a family occasion.  In the meantime, the patient scalded her foot with hot water and this resulted in a grade 2 burn on the dorsal aspect of her left foot.Her burn was attended to with local therapy and systemic antibiotics for associated cellulitis.  Her cognition was assessed and, as this showed mild cognitive impairment with a Mini Mental State Examination (MMSE) of 21/30, she was started on Donepezil 20mg daily.  She was also assessed by a psychogeriatrician, who confirmed the diagnosis of Diogenes Syndrome and confirmed that her Donepezil and Paroxetine 20mg daily should be continued. A blood workup was done including a haematinic screen and vitamin C and D levels. As the latter were found to be deficient, she was started on Vitamin C and D supplements as well as on calcium.On the ward, her foot wound infection and burn recovered; however she continued to manifest compulsive hoarding behaviour by collecting objects of no value from the ward environment and storing them in her bedside locker.Discussions with the patient and her nephew resulted in a decision to re-home her in a smaller house, also belonging to her, in the hope that once she returns home it would be more manageable in the future to have it re-cleaned rather than her original mansion. The discharging interdisciplinary team recommended regular visits by community nurses, the psychiatric outreach team and community liaison nurses to try to prevent the situation recurring quickly.  The Telecare system was also installed in her house. DisCUssiOnDiogenes Syndrome is often characterized by a tendency to hoard excessively.  This syndrome may be due to a reaction to stress in older people with certain personality characteristics or as the end stage of a personality disorder. However in the case described above the patient manifested dementia, which may also have triggered the disorder.Studies on Diogenes Syndrome describe the following common clinical features:  poor personal hygiene, hoarding of litter, very poor surroundings with filth in or around the house, resistance to offers of help, social withdrawal and a shameless attitude (Reyes-Ortiz, 2001).The patient described in this case report satisfies all the clinical features described above.  She also had an associated dementia.  It must be noted that half to two-thirds of patients with Diogenes Syndrome have an underlying psychiatric disease, mostly dementia (Wrigley and Cooney, 1992).Dr Peter FERRY  MS, MSc (Keele), FRCP (Lond), PG Dip Ger, Dip ORT (Dundee), Cert Med Ed (Dundee)Consultant Geriatrician, Ministry for HealthSenior Lecturer Medicine and European Centre of Gerontology, University of MaltaPostgraduate Coordinator Training in Geriatric MedicineEmail: peter.g.ferry@gov.mtThe Journal of the Malta College of Family Doctors  VOLUME 02 issUE 03 DECEMBER 2013 31Although it may be argued that this lady’s problem with compulsive hoarding has not been reversed and that she may be at risk at home, it was agreed by both the geriatric and psychogeriatric teams that she carried enough mental capacity to return home, once she accepted regular community care visits.  She definitely did not want to be admitted to a 24 hour residential institution and thus her autonomy had to be respected.referencesClark, A.N., Mankikar, G.D. and Gray, I., 1975. Diogenes syndrome: a clinical study of gross neglect in old age. Lancet; 1: 366-368.Iqbal, J., Haghour-Vwich, M., Badr, A., Baron, N. and Fletcher, E., 2010. A Look at Diogenes Syndrome. Clinical Geriatrics; 18: 45-46.Reyes-Ortiz, C., 2001. Diogenes syndrome: the self-neglect elderly. Comprehensive Therapy; 27: 117-121.Wrigley, M. and Cooney, C., 1992. Diogenes Syndrome – An Irish Series. Ir J. Psych Med; 9(1): 37-42.For these reasons, the Council has decided to open applications as follows:1. From trainers for the following sub-committees:•	 Trainer CPD•	 Curriculum Review Board•	 Specialist Training Programme Committee•	 Trainers Accreditation Board•	 Trainer Appeals Board•	 AKT Group•	 CSA Group•	 Psychometric Group•	 Examiner Training•	 CME for members•	 Logistical support group•	 Secretarial and Administrative Support Group2. From trainees for the following sub-committees:•	 Curriculum Review Board•	 Specialist Training Programme Committee3. From graduates of the MMCFD/MRCGP[Int] programme for the following sub-committees:•	 Curriculum Review Board•	 AKT Group•	 CSA Group•	 Psychometric Group•	 Trainers Accreditation Board•	 Trainers Appeals Board•	 Examiners Training•	 CME for members•	 Logistical support group•	 Secretarial and Administrative Support Group4. From the general membership for the following  sub-committees:•	 AKT Group•	 CSA Group•	 Psychometric Group•	 Examiner Training•	 CME for members•	 Logistical support group•	 Secretarial and Administrative Support GroupApplications should include a clear indication of the area/s of interest. Applicants will need to satisfy the following criteria:•	 Possess good team working skills,•	 Be professional and meticulous in their work,•	 Have a sound IT knowledge,•	 Be able to attend to any necessary meetings,•	 Be able to work against deadlines,•	 Have academia at heart,•	 Be fully paid up members of the Malta College  of Family Doctors MALTA COLLEGE OF FAMILY DOCTORS 127, Professional Centre, Sliema Road, Gzira, GZR 1633 MALTA (Europe)  |  Email: contact@mcfd.org.mtwww.mcfd.org.mtJoint call for applicationsThe Council reserves the right to conduct interviews. The choice of applicants by the Council is final. Applications, accompanied by a Curriculum Vitae, should be sent by Friday 27th December 2013 to:The Honorary Secretary of the MCFD CouncilMalta Federation of Professional Bodies127, Sliema Road, Gzira GZR 1633Prof. P. Mallia President MCFDDr. J. Bonnici Honorary Secretary MCFD In its quest to balance the ever growing educational needs with the sustainability of active human resources, and to increasingly involve the membership in active participation, the Council of the Malta College of Family Doctors is currently seeking to gauge the interest of the College’s members to participate in a number of subcommittees which are planned to be set up to oversee the various educational needs of our Specialty.nOTiCE

A case of Diogenes Syndrome

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A case of Diogenes Syndrome

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