22Jan

Hoarding Disorder

Hoarding disorder is the accumulation of possessions and persistent difficulty discarding them, regardless of their actual value. Significant distress is associated with attempts to discard possessions, creating a large volume of items that can be associated with functional impairment and compromise the intended use of living areas.

TIPS ABOUT HOARDING DISORDER IN OLDER ADULTS

  • Use standard assessment instruments (Table 2) to determine the presence and severity of hoarding.
  • Involve community agencies to help individuals with hoarding behaviors and environments, with a focus on safety.
  • Refer patients to counselors who have experience with and/or education related to Hoarding Disorder.
  • Identify and treat co-existing mental health problems.

Hoarding disorder is in the DSM-5 as a stand-alone diagnosis. Six criteria are listed to evaluate the presence of hoarding disorder and all six must be present for diagnosis (Table 1). Animal hoarding is not considered part of hoarding disorder; there is not enough research and prevalence data to allow its inclusion.  

Table 1. Summary of DSM-5 Diagnostic Criteria
  • Persistent difficulty parting with possessions, regardless of value
  • Distress associated with discarding possessions
  • Accumulation of possessions that clutter living areas
  • Hoarding causes impairment of social, occupational, or other areas of function, including safety
  • Hoarding not attributable to a medical condition (e.g., brain injury, stroke)
  • Hoarding not better explained by another mental disorder

Hoarding Disorder and Older Adults

Hoarding disorder affects approximately 5% of the U.S. population, roughly 16 million people. The average age of onset is between 11-20, but the average age of patients in treatment is 50. It is estimated that up to 84% of those with hoarding disorder have a first degree family member who exhibits hoarding behaviors, possibly reflecting a genetic predisposition. Hoarding disorder occurs in all cultures and socioeconomic levels. Gender prevalence is unclear, though women are more likely to seek treatment.

Hoarding Disorder and Older Adults
Hoarding Disorder and Older Adults

Depending on its severity, hoarding can present serious health and safety risks for older adults. These include higher rates of falls, infections and respiratory problems; limited ability to move around in, or access parts of, the home; and a higher risk of fire with decreased ability to escape if fire occurs. Deaths have been reported as a result of these problems. Furthermore, hoarding can result in eviction and homelessness. Adult protective service agencies can intervene when individuals demonstrating hoarding behaviors lack decision-making capacity.

Clinical Presentation

Clinical Presentation for Hoarding Disorder
Clinical Presentation for Hoarding Disorder

Patients are often unaware of the severity of their behavior or situation. And if they are aware, they may not believe they need treatment and thus don’t want others to know about their hoarding behavior. As a result, if clinicians do not ask patients (or their families) questions about home safety, general living environment, or emotional well-being, they may not become aware of hoarding. It is important to be alert for clues, such as a patient’s reluctance (or refusal) to accept home health services following hospitalization. Home health personnel are often the first to detect hoarding, before it is apparent to office-based clinicians. Patients or their families may also make comments about possessions or collections, complaints about pest infestations, or delays getting home repairs (out of concern that their hoarding will be detected).

Assessment Instruments for Hoarding

Several tools are available to assess the presence and severity of hoarding behaviors (Table 2). Be sure to include at least one or two questions in every clinical visit that can help indicate if the patient might have mental health issues related to hoarding behaviors and/or an unsafe living environment.

Assessment Instruments for Hoarding
Assessment Instruments for Hoarding

Health care professionals are often the first to begin a dialogue about a hoarding situation and possible interventions. Motivational interviewing is recommended to avoid aggressive or judgmental language.

Table 2. Assessment Instruments for Hoarding
  • Hoarding Rating Scale (HRS) Brief interview, 5 questions, to access compulsive hoarding
  • Clutter Image Rating (CIR) Assesses severity of hoarding through nine photographs of three living spaces
  • Activities of Daily Living for Hoarding (ADL-H) Measures extent to which hoarding interferes with daily functioning
  • Saving Inventory-Revised (SIR) Measures excessive acquisition, difficulty discarding, and clutter
  • HOMES Multidisciplinary Hoarding Risk Assessment Measures health, obstacles, mental health, endangerment, structure, and safety.

Treatment Options

Refer patients to counselors who have experience with and/or education related to hoarding disorder. They will be able to customize cognitive behavioral therapy to include education, goal setting, and exposure to activities focused on reducing acquiring behavior. Other aspects of treatment include a focus on sorting and organizing behaviors, decision-making and problem solving; and new behavior maintenance.

Treatment should also address any co-occurring mental illnesses, even if they are not the cause of hoarding. Such disorders might include depressive disorders, generalized anxiety disorder, social phobias, obsessive compulsive disorder, attention-deficit hyperactivity disorder, posttraumatic stress disorder, and substance use disorders.

Treatment Options
Treatment Options

Structured, facilitated community-based workshops and support groups have also shown some success in helping patients to modify their hoarding behaviors and manage related anxiety. Professional organizers and in-home coaches can also be helpful.

Medications used to treat co-occurring conditions may not directly impact hoarding behaviors, but will improve overall quality of life and function.

Interprofessional Approaches to Hoarding

Given the complexity, time, and resources required to address hoarding, and its intersection with public health and safety, hoarding is often best addressed with an interprofessional and interagency approach, such as a task force. Hoarding disorder task forces usually follow one of three models: education, care coordination, or intervention. Depending on the task force’s mission and funding, some will provide public education, community resource information, case management, and family support. Individual task forces may include representatives from housing, public and environmental health, medicine, behavioral health, child and adult protective services, aging, legal and fiduciary services, fire and police, animal welfare, and related agencies. Some home health agencies will provide home safety assessments that may provide first-hand information about hoarding behaviors.

It is important to note that, in general, forced clean-outs are not an ideal solution as they may cause serious anxiety for individuals with hoarding disorder. Studies have shown the person typically re-acquires items at a rapid pace to fill the void and often within 6 months, they will have reacquired the same or a greater number of possessions.

References and Resources

  • Tolin D, Frost R, Steketee G, Muroff J. (2015). Cognitive behavioral therapy for hoarding disorder: A meta-analysis. Depression and Anxiety, Vol 32(3), 158-166.
  • Samson G. Treatment for Hoarding Disorder: therapist guide (2nd ed.) Gail Steketee and Randy O. Frost New York: Oxford University Press, 2013. pp.276, £32.50 (pb). ISBN: 978-0-19-933496-4
  • Levy H, Worden B, Gilliam C, D’Urso C, Steketee G, Frost R, Tolin D. (2017). Changes in savings cognition mediate hoarding symptom change in cognitive-behavioral therapy for hoarding disorder. Journal of Obsessive-Compulsive and Related Disorders, Vol 14, 112-118.

National Editorial Board: Theodore M Johnson II, MD, MPH, Emory University; Jenny Jordan, PT, DPT, Sacred Heart Hospital, Spokane, WA;  Jane Marks, RN, MS, FNGNA, Johns Hopkins University; Josette Rivera, MD, University of California San Francisco; Jean Yudin, CRNP, University of Pennsylvania

Interprofessional Associate Editors: Carleigh High, PT, DPT; David Coon, PhD; Marilyn Gilbert, MS, CHES; Jeannie Lee, PharmD, BCPS; Marisa Menchola, PhD;  Francisco Moreno, MD; Linnea Nagel, PA-C, MPAS; Lisa O’Neill, DBH, MPH; Floribella Redondo; Laura Vitkus, MPH, CHES

See more: Motivational interviewing with older adults

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