Hoarding in the Elderly: A
Challenge to Home Care
Mary Ann Forciea MD, FACP
Associate Professor of Clinical Medicine
Division of Geriatric Medicine
UPHS
Why am I (or my team) here?
• This is a common and frustrating problem for
us
• Hoping to learn some diagnostic tips
• Hoping to learn some management tips
• Want a chance to vent frustration at the
system of care available to these patients.
• Like to see my colleagues.
• Always wanted to try this restaurant
Why am I (or my team) here?
1.
2.
3.
4.
5.
This is a challenging
problem for us
Want a chance to vent
about these patients
Like to see my colleagues
Always wanted to try this
restaurant
Want to see if UPHS has
any better ideas than we
do
20%
1
20%
2
20%
20%
3
4
20%
5
Key questions for this seminar
• Is hoarding in older patients different than in
younger patients
• What are the critical clinical questions in the
evaluation of patients with hoarding?
• What treatment strategies can be attempted?
• What resources are available in the Delaware
Valley?
Case- DR
• 78 yr old lady, widow with 2 children
• Living in Senior housing
• Call from facility SW (Friday at 4PM)
– Increasing complaints from neighbors about
‘cleanliness’ of apartment
– Apartment visit that day
• Toilet overflow, clutter, attire
– Home health aide refusing to return
– Facility considering eviction
Case continues 2
• >40 yr history of bipolar disorder
– Has medications
– Multiple barriers to ongoing psychiatric care
• Diabetes mellitus with peripheral neuropathy]
• Venous stasis
• DJD of knees, hips, LS spine – increasing
immobility
Case 3 – prior history
• Third dwelling while part of our primary care
program (8 yrs)
• ‘Clutter’ an issue in each site
– Mania associated with requests for DME
• Progressive mobility dependence
– Third move precipitated by loss of driving
privileges
Added information
• Visited patient one week ago
• Called patient after SW call
– Admits to overwhelming apartment ‘situation’
– Blame exclusively on building management
– Admits to progressive URI over past week
– Reluctant to agree to ED or hospital visit
• Home care team urgent conference call
Living room
(close to hers –google images)
Bedroom
(close to hers – google images)
Options
1.
2.
3.
4.
Sign out to weekend
covering partner
Temporize by offering a
Monday medical house
call visit by your team
Arrange transport to ED
for evaluation
Directly admit to your
inpatient service
25%
1
25%
25%
2
3
25%
4
Hoarding – Definition
Saxena 2007
• Collecting
– excessive quantities of
– Poorly useable items
– Of little value
• Failing to discard items
• Interference with function
Excessive acquisition
• Buying
• Accumulation of ‘free’ things
– Received
– Sought out (dumpster diving
• Motivation
– “thrill”
– ‘therapy’ for unpleasant feelings (?‘retail’ therapy)
– Fear of missed opportunities
Failure to discard
• Most easily recognized
• Motivation
– Sentimental value
– Wasteful to discard
– Might be useful in the future
• Decreased ability to group/sort items
• Poor organizational skills
Interference with function
• Clutter – cannot use space or object for its
intended purpose
• Functional status – cannot walk through
apartment, bathe, cook\
• Consequences
– Eviction, health concerns, fire risks
Risks of hoarding
•
•
•
•
•
Social dysfunction
Functional disability
Falls
Fires
Unsanitary conditions
Is hoarding a psychiatric disorder?
• Associations:
– OCD
– Schizophrenia
– Dementia (especially fronto-temporal)
– Mood Disorders
• Not currently listed in DSM-IV, will likely be listed in
DSM-V
• Little attention to older patients with hoarding
behaviors
FTD vs AD
Miller et al Neurology 1997
Symptom
Insidious onset
Early loss of personal &
social awareness
hyperorality
Perseverative behavior
Emotional unconcern
Progressive reduction in
speech
Stereotypy of speech
Praxis
FTD +/30
29
22
22
19
24
24
20
29
AD +/30
30
1
0
1
6
0
2
5
NS
<0.0001
“
“
“
“
“
“
Natural history of hoarding
• Chronic problem with gradual worsening
across lifespan
– 80% of patients report symptoms by age 18
• Late onset patients more often have a
stressful life event at initiation
• Familial component
– 85% of hoarders describe a 1st degree relative as a
‘packrat’
Distinctions in Older Patients
with ‘Terrible Decline”
• Hoarding versus self care deficit?
– Or both
• Long term or acute?
• Decisional capacity?
• Severe enough to warrant coercive action?
Assessment tools
Clutter Hoarding Scale
Institute for Challenging
Disorganization
In treating these patients, we have
tried:
1. SSRIs
2. Cholinesterase
Inhibitors
3. Cognitive/behaviro
al therapy
4. Occupational
therapy
consultation
25%
1
25%
25%
2
3
25%
4
I have been satisfied with the
outcomes of my therapy
1. Yes
2. No
50%
1
50%
2
My patients have been happy with the
outcomes of therapy
1. Yes
2. No
50%
1
50%
2
Treatment
• Medications
– SSRI – possibly less effective in older patients
• Cognitive behavioral therapy
– Information processing deficits
• Help sort into larger clusters
– Maladaptive beliefs
• I am a craftsman because I own tools
– Attachment to possessions
• Sentiment, control
• Interprofessional team management
Self care deficit
“The result of an adult’s inability due to
diminished capacity to perform essential
self-care tasks such as providing essential
food, clothing, shelter, and medical care;
obtaining goods and services necessary
to maintain physical health, mental
health, emotional well-being and general
safety; and/or manage financial affairs.”
-APS
Self-Neglect – Definition
Pavlou and Lachs JGIM 2008
• A Self-neglector is a person who exhibits 1 or
more of the following:
– 1) persistent inattention to personal hygiene
and/or environment
– 2) repeated refusal of some/all indicated services
which can reasonably be expected to improve
quality of life
– 3) self endangerment through the manifestation
of unsafe behaviors (e.g. persistent refusal to care
for a wound, creating fire hazards in the home)
Self-neglect
•
•
•
•
•
Annual incidence: 5.2 per 1000 elders
Self-neglect 50-75% of elder mistreatment
90% of all self-neglect APS ≥ 65y/o
♀>♂
Decreased survival 40.3% died within 13 years
follow-up
• Self-neglect patients more likely to die in NH
Lachs et al. JAMA 1998
Clinical evaluation
• Dementia
• Depression
• If acute, look for medical problem
– Stroke, infection, medication effect
• Determination of decisional capacity
Treatment
• Often emergency-related
– Hip fracture, pneumonia, police incident
• If incapable of decisions
– Refer for competency determination and guardianship
• Placement likely
• If capable
– Inform of helpful services
– Documentation of preferences for Advance Directive
Assessment tools
Self neglect severity scale
-Houston Geriatrics group
Personal appearance of subject
Hair
Nails
House
Home Environment
Bathroom
Self Neglect Severity Scale
Decisional capacity
• Competence – a legal determination in court
– Appointment of a guardian
• Of the person (medical decisions)
• Of finances
• Decisional capacity – a clinical decision
– Decision specific
– “Hierachies” of decisions
• Most basic decisions honored even in presence of some
impairment
• May make ‘low stakes’ decisions even if unable to make
‘high stakes’ decisions
Elements of Decision Making
• Ability to communicate a choice
• Ability to understand and retain relevant
information
• Ability to appreciate the situation and
consequences for oneself
• Ability to manipulate information rationally
Ability to appreciate situation for
oneself
• Acknowledge that condition is present
• Realizes that risks and benefits apply to
him/her
• May involve understanding of motives for
choices
• What will happen if you refuse treatment? If
you accept?
Manipulates information rationally
• Reaches conclusions that are logically
consistent with starting premises
• Again, may involve description of motives
• Please help me to understand why you decided
to accept/refuse treatment
Summary
• Older patients with hoarding behaviors have higher
likelihood of co-existing dementia
– Time course of progression is critical information
• Hoarding and self neglect frequently co-exist in older
patients
– Assessment tools can help guide team planning and
follow-up
• The determination of decisional capacity is often
critical
• Local regulation about safety standards is important
in action steps
The Eye of the Beholder
Resources/References
• The Institute for Challenging Disorganization:
– www.challengingdisorganization.org
• Valente, Sharon. The Hoarding Syndrome. Home
Health Care Nurse 27:432. 2009
– WWW.homehealthcarenurseonline.com
• Guilliam, CM and Tolin, DF. Compulsive Hoarding.
Bulletin of the Menniger Clinic 74:93. 2010.
• Dyer, CB et al. Self-neglect among the elderly;
Am J of Public Health 97:1671.2007