Tales of elder abuse are not uncommon, and the most prevalent stories seem to have similar roots. Older adults with cognitive issues being financially swindled, immobile seniors being neglected in nursing homes—but one area of elder abuse walks a delicate line and receives far less attention, though the stories are just as horrifying: seniors who self-harm.

The type of self-harm in these cases isn’t usually deliberate but stems from a lack of proper care. Seniors who may be on the cusp of cognitive difficulties but still able to live on their own are at the highest risk of falling victim to their own neglect. Lack of medical care, for example, is all too common for seniors living on their own. In other cases, independent elderly people may be unable or unwilling to keep up with their homes—sometimes to the point of living in squalor. It’s not exactly surprising that the majority of reported cases of elder abuse are rooted in self-harm, but what is surprising is how difficult an area this can be to treat.

There is something of a catch-22 in cases of self-harm. On one hand, living in a space where your safety and hygiene is negatively affected is never a good thing, but do we have the right to intervene if that is the way these seniors choose to live? For those who are cognitively able to live on their own, there is little that can be done. In some cases, when interventions are made, they are only successful for a limited amount of time. Consider, for example, that an individual is deemed unfit to care for themselves—they are removed from their home, placed in a structured setting where they are taking the proper medication, being bathed and cleaned up after, and fed well. Progress is made—often to the point where the individual is fit to return to their home. Unfortunately, that is usually the point where the downward spiral begins again, and so the cycle continues.

We have to ask ourselves about cause and effect as well. Are these people engaging in harmful habits because of an underlying condition, like depression? Or is depression the result of their choices? The answer will be different on an individual basis, so coming up with treatment options can be tricky. As can determining that self-harm is occurring in the first place. Many older adults who are allowing their lives and health to fall to disarray appear outwardly normal. They may visit their doctor regularly but fail to take the proper medication–wear clean clothes every day but live in a home infested with vermin. Often they are comfortable in their own pattern, harmful or not, and will go to great lengths to hide their behavior from others.

Fortunately this is an issue that will be receiving a lot more attention, and there is hope that more successful intervention tactics will be devised in the near future. This month, the American Society on Aging will be holding a conference in San Francisco to address some of these questions and give the very real issue of self-abuse in seniors the attention it needs.