Hoarding disorder (HD), a recent addition to DSM-5, is characterized primarily by difficulty in discarding current possessions, urges to save items, and excessive clutter in the home.

DSM-5 criteria for HD necessitate that the hoarding behaviours cause clinically significant impairment in the patient’s ability to function and that the symptoms are not the result of either a medical condition or other psychiatric disorder.

In addition to HD, hoarding behaviors may result from obsessive-compulsive disorder (OCD), schizophrenia, depression, and even some eating disorders.

 

 

Prevalence of HD in older adults  

Estimates of hoarding symptoms in non-geriatric community dwellers range from 2% to 6% (Mueller A, 2009), though figures may be higher among clinical samples due to the significant psychiatric comorbidity associated with HD (Frost RO, 2011 B)

In a large study of older adults who met DSM-5 criteria for HD, 69% were women and 85% were white, unmarried, and lived alone (Ayers CR, 2014 A)

Assessments that rely on clutter levels may be misleading for individuals who live with a roommate or partner, because that partner may be masking the physical manifestation of the hoarding.

When assessing for HD, it is important to inquire about living spaces that are solely controlled by the individual, such as personal sleeping space or study, in addition to communal living spaces, such as the living room or kitchen.

 

 

Onset and course of HD

Hoarding symptoms generally appear before age 20, and few individuals experience onset of problems after the age of 40.

Symptom severity tends to stabilize after middle age and remains steady into old age (Tolin DF, 2010).

 

Because of decreased mobility and other effects associated with the aging process, the consequences of hoarding become more evident, and older adults may consequently report an increase in hoarding symptoms

 

Be mindful of any cycles in the patient’s symptoms, and help the patient recognize the patterns within his or her behavior.

For example, if a patient is a teacher who reports that his urges to save increase every spring when the school year ends, help him understand the reasons for saving certain objects, which may be tied to emotional context (eg, saving the work of a favourite student).

 

 

Impact on well-being

While many of the risks associated with hoarding behaviours are prevalent across the life span, hoarding symptoms may have a particularly devastating impact on the well-being of geriatric populations.

Older adults with HD are at increased risk for falling, fires and mould in the home, poor hygiene and nutrition, and medical problems.

The level of perceived risk increases with hoarding symptom severity.

Food contamination, social isolation, and medication mismanagement are also problems with older adults who are compulsive hoarders.

Dust or insect/rodent infestations may aggravate existing health problems.

 

The higher incidence of medical conditions on older adults with HD may be due in part to the increased health risks associated with hoarding (Ayers CR, 2014 B).

The most common medical conditions reported by older adults with HD include hypertension, high cholesterol levels, arthritis, and sleep apnea.

 

The majority of older adults with HD report never having friends or family visit their home; the frequency with which older adults with HD have visitors to their home is significantly related to symptom severity.

 

Homelessness may be more prevalent in older adults with HD than in the general population and that HD may be more prevalent in older adults facing imminent homelessness (Rodriguez CI, 2012)

Normative life transitions, such as moving because of the need for a higher level of medical care or relocation to be closer to family, may create high levels of distress for individuals with HD.

 

 

Psychiatric comorbidities

When dealing with an older adult in whom HD is suspected, it is important to assess for other psychiatric disorders that may affect the presentation and treatment of symptoms.

The most common comorbid disorders in geriatric patients with HD are Major Depressive Disorder (MDD), Obsessive Compulsive Disorder (OCD), Generalized Anxiety Disorder (GAD), and dysthymia.

There is a more robust relationship between hoarding and depression than between hoarding and anxiety (Frost RO, 2011 A).

 

Presence of a comorbid disorder significantly increases symptom severity in geriatric patients.

 

Obsessive–compulsive disorder (OCD) patients who hoard experience higher levels of psychopathology (e.g., anxiety symptoms, lifetime suicidal attempts), worse functioning, and greater disability than patients with only OCD symptoms (Chakraborty V, 2012)

Furthermore, among patients with anxiety disorders, hoarding symptoms are significantly correlated with family impairment, above and beyond the effects of depression (Tolin DF, 2011).  

Hoarding/collecting compulsions also predicted worse psychotic symptoms (e.g., bizarre delusions, disorganization) in patients with schizophrenia (Guillem F, 2009).