Older Adults and Self-Neglect: the Need for New Strategies to Preserve Housing

Preserving safe housing for elders who experience mental illness or cognitive decline can require collaboration among many parties. If the tenant is motivated, landlord is accommodating, and intervention occurs in time, the tenancy typically can be successfully preserved. During my first year of representing older adults with mental illness and cognitive decline in eviction cases, many of my clients have remained in their apartments with proper supports and/or treatment in place. As described in a previous post, this ideal outcome leads to improved health, decreased frustration on both sides, and lower costs for the state.

In some cases, however, a successful resolution is more difficult to identify. How can a well-meaning team best support an older adult whose condition not only puts his housing at risk, but also prevents him from actively participating in treatment or even recognizing his landlord’s concern? Despite attempted intervention by numerous providers, family members, and friends – and often despite their own strongly expressed desire to do whatever necessary to remain in their current apartment – some individuals continue to engage in behavior that puts themselves or other tenants at risk or in fear. In these cases, landlords feel an understandable need to proceed with the eviction for the protection of their other tenants, especially when other alternatives been unsuccessful. Other providers may cease services, if frequent refusals or behavior challenges make their limited resources better spent on other consumers. The most challenging cases leave concerned family and would-be helpers with few options – while these cases fall under the elder abuse category of self-neglect, if the person is deemed to have capacity to make decisions, the reality may be homelessness. Even if they obtain new housing, if a mental health condition remains unrecognized, the challenges are likely to reoccur.

The difficulties of accessing mental health care, and the need for increased training for many professions who respond to people with mental disabilities, have been addressed recently in the Boston Globe. When it comes to elders with mental health conditions, even systems and centers that are designed for people with mental illnesses, and whose staff are prepared to encounter a variety of conditions, cannot always accommodate their needs. Group homes, homeless shelters, therapy delivery systems, and mental health emergency response teams often are designed and funded for younger, able-bodied populations, rather than older adults who often present with longer histories of trauma, compounded loss, and increased physical needs. Differing manifestations of illnesses in older adults can lead to misdiagnoses of dementia. Just as for younger populations, a lack of culturally competent training for staff and providers can be a barrier to accessing assistance or even exacerbate the issue.

Working with members of this population over the past year, I have gained familiarity with the real-life consequences of barriers to effective assistance for elders with mental health conditions. When a tenant and landlord do not perceive a situation through the same lens, making a feasible agreement impossible to create and/or uphold, there are no simple resolutions and often seem to be more questions than answers. How should capacity be assessed, when the consequence is homelessness? Within our quest to maximize autonomy and avoid overprotectiveness, how can we assess whether a client is making an informed decision? If it becomes clear that a person does not have capacity, how does this change his or her options going forward? For a person whose current housing is in fact inappropriate, what type of housing supports should be sought? Are they currently available, or could they be created, and at what cost?

As our population ages and expands over the next several years and decades, our society must confront these issues. Through blog posts over the next several months, I will attempt to shed light on some of these questions, along with highlighting programs, agencies, and individuals across Massachusetts and elsewhere who are making strides toward closing the gap in services for this population. With the preservation of housing as a focal point, I will aim to show the prevalence and reality of undiagnosed and untreated mental illness in older adults, explore new and innovative approaches to reaching and working with this population, and ultimately advocate for the funding and expansion of successful models.

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One thought on “Older Adults and Self-Neglect: the Need for New Strategies to Preserve Housing

  1. A good many of my associates struggle with down-sizing and re-settling decisions as they continue to mature with ownership or the ability to pay for specialized housing a given. That is, when should we sell the house and move to warmer climates or near a child and grandchildren. For the most part we have a normal range of age related limitations but are otherwise active. We consider what would be best for our quality of life and independence while maintaining a substantive back up. Your post exposes these decisions as an embarrassment of riches when one considers bearing the burden of mental illness and the tenuous nature of rental housing. It also tactfully reveals the very serious considerations of the landlord who needs to consider his other tenants as well as his facility investment at a time when cities are becoming unaffordable for even the middle class, home ownership becomes far harder to achieve and care for the mentally ill remains a national disgrace since the Reagan years. This is a burden that our society has seemingly already rejected in a housing market that predominantly builds rentals and hamstrings ownership. For all too many, decisions will be made for them from limited lesser evil choices.

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