Diogenes the Cynic was an ancient Greek philosopher, often pictured by later artists as living in a barrel. His lifestyle was ascetic, characterised by his rejection of every comfort... hence his rather restrictive living accommodation. Rightly or otherwise, his name has been applied to a phenotype of dementia associated with social isolation, hoarding and squalor.

For the immediate avoidance of doubt, ‘squalor’ and its derivatives is defined as ‘repulsively dirty’. ‘Squalor’ describes the horrified reaction elicited in an observer. No reasonable criticism may be made of the patient who is suffering such wretched distress. It is for this reason that squalor is such a significant clinical sign. The patient needs help.

Given the profound effect that this clinical picture has both on the patients and those who care for them, it is surprising how little attention the clinical phenotype has received in the common law; it seems to have been cited solely as an inappropriate and belittling dismissal; ‘…a misuse of language to describe Diogenes as having occupied this accommodation within the meaning of the (Housing) Act’.

By contrast, the Department of Clinical Law has received four enquiries relating to ‘Diogenes syndrome’ in the last 15 years; in each case relating primarily to the vulnerability of the patient; but also to the risks that the squalid conditions pose to health professionals seeking to conduct home visits. Both of these elements must be considered.

It seems that hoarding is an integral part of the clinical syndrome; a significant contributor to the hazards in the home, and a severe distraction for the patient. The compulsion to obtain and maintain a stock of physical items overrides inclinations to eat, drink and remain warm; or live in a degree of comfort. Hoarding has recently been characterised as ‘…an extreme difficulty to get rid of any belongings…the ability to weigh relevant information is overwhelmed by the extreme anxiety triggered by the hoard being diminished to any meaningful degree’. In the case of AC, 92 years old, and GC her son, living together, the court found that AC lacked capacity to make decisions about her residence or her care and support; and that GC lacked capacity to make decisions about either his own items and belongings, or those of his mother. The house was sufficiently cluttered, dirty, and disordered to pose sanitary, fire and electrical risks to the health and safety of both the residents and the district nursing and occupational therapy services; as well as the electricians and fire and rescue services involved.

These risks were made clear when the court set out the information relevant to making decisions in the respect of one’s items and belongings:

Volume of belongings and impact on use of rooms; relating to the degree to which these items impair the usual function of rooms; is the bathroom available for sanitation, or the kitchen for the preparation of food?
Safe access and use; can the patient (and other residents) safely gain access to and use rooms?
Creation of hazards due to accumulated items. Can utilities function, such as heat and light and water? Is there potential for or actual vermin infestation and a risk of causing fire, or blocking escape routes from fire?
Safety of the building. Will inaccessibility due to the accumulated clutter compromise the structural integrity (and thus safety) of the building?
Is safe and effective removal and/or disposal of hazardous accumulations of possessions possible and desirable?

On the basis of these objective criteria, it was found to be in both mother’s and son’s best interest to have house-clearing and cleaning services enter the building on sufficient occasions to dispose of perished items and remove or dispose of hazardous belongings.

This guidance is immediately helpful for clinicians who manage patients who arrive in hospital from scenes of squalor. The five categories set out by the court allow us to articulate the risks which the patient may return to, and which may confront our colleagues in the community, if a home visit is planned.

Re AC & GC (Capacity: Hoarding: Best Interests) [2022] EWCOP 39

Mr Robert Wheeler
Department of clinical law

The personal and professional faces of Diogenes