Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly
Hoarding in Late Life
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).
Assessment
Assessment of HD can be difficult due to patient perceptions.
People have very different ideas about what it means to have a cluttered home. For some, a small pile of things in the corner of an otherwise well-ordered room constitutes serious clutter. For others, only when the narrow pathways makeit hard to get through a room does the clutter register.
Diagnosis of HD can be made using the Structured Interview for Hoarding Disorder (SIHD), which assesses for the DSM-5 criteria for HD (Nordsletten AE, 2013).
The SIHD also queries for any diagnostic specifiers, such as low insight or excessive acquisition.
The SIDH is a somewhat complex tool best left for use by mental health professionals.
Several well-validated tools are available to primary care clinicians for :
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Screening for HD, such as the Clutter Image Rating Scale (CIRS)
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Initial assessment of HD, such as the Saving Inventory-Revised (SI-R).
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Periodic assessment for changes in symptom severity over time, such as the Saving Cognition Inventory (SCI).
The Clutter Image Rating scale (CIR ) consists of three sets of 9 color photographs. Each set depicts a room in the home (living room, bedroom, and kitchen) with varying amounts of clutter (1=least cluttered, 9=most cluttered).
Participants are instructed to rate the level of clutter in the corresponding room in their homes using these photographs.
A score of 4 and above indicates clutter significant enough to warrant clinical attention.
The CIRS has demonstrated good internal consistency, test–retest reliability, and convergent validity, as well as excellent inter-rater reliability (Frost RO, 2008).
Clutter Image Rating scale
The Saving Inventory - Revised (SI-R) is a 23-item self-report measure comprising three subscales: difficulty discarding, clutter, and excessive acquisition (Frost RO, 2004).
Items on the SI-R are scored between 0 and 4, with higher scores indicating greater hoarding severity.
Internal consistency, test-retest reliability, and convergent and divergent validity have been established (Coles ME, 2003).
Saving Inventory - Revised
The Saving Cognitions Inventory (SCI) is a 24-item self-report measure that evaluates maladaptive beliefs about and emotional attachment to possessions.
It is made up of four subscales: emotional attachment, control, responsibility, and memory.
Each item on the SCI represents a thought associated with one of the subscales.
Participants are asked to rate the extent to which they had each thought when deciding whether or not to discard something in the past week, from 1 (not at all) to 7 (very much).
The scale has demonstrated good internal consistency, as well as convergent and discriminant validity (Steketee G, 2003).
Saving Cognitions Inventory
Treatment strategies
Both psychotherapy and medication-based interventions have demonstrated positive results for the treatment of compulsive hoarding and HD.
The most promising psychotropic intervention is extended-release venlafaxine, an antidepressant that works through the inhibition of serotonin-norepinephrine reuptake. Venlafaxine has been shown to decrease HD symptoms by up to 36% after 12 weeks (Saxena S, 2014).
However, older persons with HD taking Venlafaxine improve significantly less than younger persons.
There have been no long-term studies of venlafaxine for HD symptoms nor have there been any comparison studies of venlafaxine against psychotherapy-based interventions of similar durations.
Paroxetine, an antidepressant that works through the inhibition of serotonin reuptake, has also been found to be effective in reducing hoarding symptoms but, unfortunately, it may not be well tolerated (Saxena S, 2007).
The Steketee and Frost cognitive-behavioral therapy (CBT) protocol is the only manualized treatment for HD currently available to clinicians in private practice (Steketee G, 2007).
CBT for HD is a lengthy undertaking (26 sessions) and involves heavy use of motivation interviewing and cognitive restructuring.
Its focus is on the distorted thinking associated with hoarding behaviours, including the person’s specific reasons for saving certain objects.
Cognitive restructuring is used to help patients alter their associations with their possessions, with the hypothesis that the act of sorting and discarding will become easier once the patient has a more realistic view about the need to save objects.
A novel intervention uses a combination treatment composed of compensatory cognitive training skills as a work-around to the executive functioning problems often seen in older adults with HD paired with exposure therapy for acquiring/discarding (Ayers CR, 2014 C).
The compensatory cognitive training includes sessions dedicated to skills training related to using a calendar, composing to-do lists, problem solving, flexible thinking, and planning.
The exposure portion of the intervention is based on underlying principles similar to those for exposure therapy for obsessive-compulsive, anxiety, and trauma-related disorders, which is considered the most evidence-based behavioural treatment of OCD in older adults.
Following a 26-week protocol, participants’ hoarding symptoms had improved by an average of 41% and the majority of participants had subclinical levels of hoarding symptom severity (Ayres CR, 2014 C)
The best approach to therapy is one using a task-force that includes a social worker or a case manager when working with a geriatric patient with HD.
Unless well versed in CBT, the GP will want to refer individuals with high SI-R scores for therapy, yet may utilise the SCI tool for periodic monitoring of the condition.
Conclusions
HD is a chronic and progressive disease, and it can be a challenge to treat, even for more experienced clinicians.
Often, the best course of action is to focus on the safety of the individual and a mitigation of the most severe problems related to hoarding (eg, clearing away fire hazards, fall risks).
However, where the individual with HD is eager to receive evidence-based treatment for their symptoms, substantial progress can be made using either pharmacotherapy or psychotherapy.
This is one of several topics presented in the Thorny Issues sector of this toolkit
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