Background: Most people who collect and hoard, and then have difficulty discarding items, do not live in squalor, even though accumulation of hoarded items can make cleaning very difficult. Commonly, people living in squalor accumulate garbage, but relatively few fulfill proposed criteria for “hoarding disorder.” We examined the overlap between hoarding and squalor among people referred because of unacceptable living conditions.

Methods: Ongoing collection of data by a Squalor Project team, including ratings on the Environmental Cleanliness and Clutter Scale (ECCS), allowed (1) description of characteristics of cases and (2) examination of ratings of uncleanliness, and of the effect of accumulation of items or material on access within dwellings. Principal component analysis was used to examine latent variables underlying the ECCS.

Results: The mean age of the referred occupants (108 male, 95 female) was 61.9 years. The mean ECCS score in 186 rated cases was 18.5. Factor analysis of ECCS data showed a two-factor solution as the most plausible. Factor 1, comprising seven squalor items, accounted for 33.7% of the variance. Factor 2 comprised reduced accessibility and accumulation of items of little value (variance 17.6%). Accumulation of garbage loaded equally on the two factors. High levels of squalor and/or accumulation were recorded in 105 (56%) of the 186 dwellings. One-third scored high on accumulation/hoarding, while 38% scored high on squalor; 15% scored high on both squalor and accumulation. A quarter of those scoring high on squalor scored low on hoarding/accumulation.

Conclusions: The ECCS is useful when describing whether referred cases show high levels of squalor, hoarding, or both.

Background: Patients living in squalor have a wide range of psychiatric diagnoses, but these may have a common neural basis involving frontal systems. This study investigated frontal executive function, theory of mind, emotional processing including disgust, and appreciation of squalor in elderly patients found living in squalor.

Methods: Six patients referred to an old age psychiatry service underwent a battery of neuropsychological tests, assessment of living conditions and awareness of self and others’ squalor.

Results: All six patients showed impairment in frontal executive function, typically accompanied by amnesic deficits. Theory of mind and emotional processing were surprisingly preserved. While five of the patients could recognize severely unclean or cluttered living conditions in newspaper photographs, more than half did not appreciate that their own living conditions were squalid.

Conclusion: Deficits in frontal executive function appear important in the genesis of squalor although functions linked to orbito-frontal ability appear preserved.

Background: Although community psychiatric services commonly encounter cases where intervention is needed due to persons’ unclean or cluttered living conditions, evidence concerning the referral rate and prevalence of severe domestic squalor is sparse.

Methods: Between 2000 and 2009, ratings of cleanliness and clutter have been made in all cases of people living in squalor who have been referred to an old age psychiatry service in Central Sydney. Where possible, one-year follow-up was arranged.

Results: 173 persons aged 65 years or more were referred to the service during the ten years and assessed as living in squalor (120 moderate or severe, two thirds of whom showed a moderate or severe degree of hoarding/clutter). Of 157 followed up after one year, 47% were still at home, 32% were in long-term care homes, 12% had moved elsewhere, and 9% had died. The annual new referral rate was close to 1 per 1000 elderly people in the catchment area, and of moderate or severe squalor was 0.66 per 1000. Limiting follow-up to those in moderate or severe squalor, 41% were still at home one year later. Current findings suggest that the minimum prevalence in the community of older people living in moderate or severe squalor in Sydney is 1 per 1000.

Conclusions: The costs of intervening in cases of severe domestic squalor are considerable. Increased attention and funding are warranted, as the incidence and prevalence are higher than had previously been estimated.

Over the past 50 years, self-neglect among older people has been conceptualised in both social policy and the academy as a social problem which is defined in relation to medical illness and requires professional intervention. Few authors, however, have analysed the concept of self-neglect in relation to critical sociological theory. This is problematic because professional judgements, which provide the impetus for intervention, are inherently influenced by the social and cultural context. The purpose of this article is to use critical theory as a framework for interpreting the findings from a qualitative study which explored judgements in relation to older people in situations of self-neglect made by professionals. Two types of data were collected. There were 125 hours of observations at meetings and home assessments conducted by professionals associated with the Community Options Programme in Sydney, Australia, and 18 professionals who worked with self-neglecting older people in the community gave in-depth qualitative interviews. The findings show that professional judgements of self-neglect focus on risk and capacity, and that these perceptions influence when and how interventions occur. The assumptions upon which professional judgements are based are then further analysed in relation to critical theory.

Background: Development of a scale to rate the degree and various aspects of uncleanliness will facilitate description and research in cases of severe domestic squalor.

Methods: Discussion with representatives of relevant agencies led to selection of various aspects of domestic uncleanliness and clutter to be assessed when describing cases of squalor. Rooms and areas with varying functions (toilet, kitchen, bedroom, etc.) were all to be rated, along with other indicators of squalor (e.g. odor, vermin). Trial use and further discussion resulted in reduction to ten items, each rated on a four-point scale, with succinct descriptions of anchor-points. Two experienced psychogeriatricians then used this new Environmental Cleanliness and Clutter Scale (ECCS) to rate independently 55 dwellings which had been reported by Aged Care staff as cluttered or unclean, and also rated overall degree of squalor. Reliability and indications of validity were analyzed.

Results: The inter-rater reliability for the ten items was considered satisfactory (κ 0.48, varying from 0.31 to 0.58). Cronbach's α for the new scale was 0.94, demonstrating high internal consistency. Each author's ratings of degree of squalor (none to severe) matched well with the other's ratings on the scale; a score of >12 usually indicated moderate or severe squalor.

Conclusion: The ECCS proved reliable and useful in rating cases where elderly people were living in severe domestic squalor.

Our objective in writing this paper was to present a case of Diogenes' syndrome and to examine the evolution of thinking about the phenomenon. To do this we looked at original case material and then carried out a literature review, the results of this showed the syndrome has been reported most often in the elderly and in higher socio-economic groups. It represents a non-specific final common pathway for many interacting variables.

In our conclusion we found that a detailed multidisciplinary assessment is indicated in all cases. Further work is required to estimate the role of personality disorder and organic frontal lobe dysfunction in the aetiology of this syndrome. A multiaxial approach to diagnosis should be employed. Intervention should be based on objective findings and risk-assessment, rather than on ideological grounds. Irish law does not allow a large variety of options to the helping professions.