Hoarding Behavior in Elders
Presented by:
Emily B. Saltz, LICSW
Elder Resources
www.eldres.com
NAPGCM Webinar
January 11, 2012
Definition of Hoarding*
1) The acquisition of, and failure to discard a large number of possessions
that appear to be useless or of limited value.
2) The living spaces in the home are sufficiently cluttered so as to
preclude activities for which those spaces were designed.
3) There is generally significant distress or impairment in functioning
caused by hoarding.
(Adapted from “A Cognitive-Behavioral Model of Compulsive Hoarding” by Randy Frost)
DIAGNOSTIC CRITERIA
Current:

Subset of OCPD in DSMIV

DSM-IV lists hoarding of “worn out or worthless objects
even when they have no sentimental value” as a symptom of
obsessive-compulsive personality disorder (OCPD).
DIAGNOSTIC CRITERIA
Proposed:

Accumulation of clutter

Difficulty discarding/parting with objects

Compulsive acquiring of free or purchased items

Distress or interference

Duration at least 6 months

Not better accounted for by other conditions (OCD, major
depression, dementia, psychosis, bipolar disorder)
(Frost, Steketee, Tolin & Brown, 2006)
Hoarding vs. Collecting

Collecting is a normal and common phenomenon in
children.

Collecting in adulthood can be a pleasurable activity that
does not necessarily include an unwillingness to part with
items.

Clinically significant hoarding is associated with distress and
functional impairment in daily life.

Collectors acquires and discards. Hoarders just acquire and
rarely discard.
Prevalence and Demographics
of Hoarding

Prevalence in general population – 3-5%

Underreported problem –only five percent of cases come to
attention of authorities.

Prevalence among patients with obsessive compulsive
disorder is approximately 20-30 percent.

Prevalence among patients with dementia is approximately
20 percent.

Education – ranged widely

Typical age of onset was during childhood or adolescence.

Strong familial link – 80 percent of hoarders grew up in
house with someone who had hoarded.
Profile of Hoarders
•Female, unmarried, lives alone
•Social Isolation
•Anxiety, depression and/or personality disorder
•Poor insight – denies problem
Co-Morbid Problems Associated With Hoarding
Hoarding is associated with several disorders
including:








Dementia
OCD
ADHD
Depression
Anxiety (PTSD, general)
Schizophrenia /psychotic disorders
Substance abuse
Personality Disorders
Frost & Steketee; Cognitive-Behavioral Model of Compulsive Hoarding; Frost & Steketee; 1998
WHY PEOPLE HOARD

Vulnerabilities

Information processing deficits

Meaning of possessions

Emotional Reactions

Reinforcement
Symptoms of Hoarding

Nearly always accompanied by excessive buying or
acquisition of possessions

Hoarders can collect things or animals – “Specialty
Hoarders”

Many hoarders experience significant depression, social
phobia, and isolation. Hoarders show poor insight into
problems and have poor treatment motivation
Frost & Steketee; Cognitive-Behavioral Model of Compulsive Hoarding; Frost & Steketee; 1998
Symptoms of Hoarding
Hoarding is characterized by problems with:

Acquisition

Discarding

Organization

Beliefs about possessions

Decision-making
Frost & Steketee; Cognitive-Behavioral Model of Compulsive Hoarding; Frost & Steketee; 1998
Deficits Associated With Hoarding
Hoarding Stems from Four Types of Deficits

Information-processing – decision making;
categorization/organization; memory.

Problems with emotional attachments to possessions –
objects as extensions of oneself.

Behavioral avoidance – excessive concern over mistakes.

Erroneous or distorted beliefs about nature and importance
of possessions.
•
•
•
•
Perfectionism
Need for control
Responsibility
Emotional comfort
Frost & Steketee; Cognitive-Behavioral Model of Compulsive Hoarding; Frost & Steketee; 1998
Animal Hoarding
According to HARC (Hoarding of Animals Research
Consortium at Tufts University
Animal Hoarder is someone who:

Accumulates a large number of animals

Fails to provide minimal standards of nutrition, sanitation,
and veterinary care

Fails to act on deteriorating condition of animals

Fails to recognize negative impact of animal collection on
their own health and well being
Characteristics of Animal Hoarders

Believe that they are animals savior

May have grown up in chaotic or abusive
households

Unable to perceive the actual condition of their
animals

View the world as a very hostile place for both
animals and people
Characteristics of Animal Hoarders

More than ¾ of animal hoarders are female

Nearly half are 60 or older; unmarried

Nearly half live alone

Dead or sick animals were found in 80% of
reported cases

Most deny that either the animals or hoarder are
suffering from health problems
Barriers to Effective Treatment
Treatment Interventions

Medications

Psychotherapy

Cognitive Behavioral Therapy

Harm Reduction Model
Barriers to Effective Treatment
with Hoarders

Very little data available regarding treatment outcomes
with hoarders.

Little evidence that antidepressants or other meds used to
treat OCD are effective in treatment of hoarding.

Hoarders have poor insight into nature of problem (denial).

Motivation to change is limited and resistance to treatment
is high.

Treatment is frequently lengthy (one to two years)

Limitations of Cognitive Behavioral Treatment Model
Cognitive Behavioral Therapy
Therapist Guide to Compulsive Hoarding (200&
Frost and Steketee

26 sessions of weekly treatment over 7-12 months

“Field Sessions”

3 office sessions and one home visit/month

Homework each session

Some day long cleanouts with therapeutic team
HARM REDUCTION TREATMENT MODEL
Three levels of harm:

Safety

Health

Comfort
Steps in harm reduction plan:
1. Plan
2. Do
3. Check
HARM REDUCTION TREATMENT MODEL
Appropriate for individuals who:

Are living in unsafe situations

Have little or no insight into problem

Not ready for professional treatment

May have cognitive impairment or dementia
Hoarding and the Elderly Population

Age-related illnesses are not primary cause of hoarding.

Hoarding is a common symptom in dementia patients.

Memory loss: inability to discriminate between relative
importance of articles in home.

Forty percent (40%) of hoarding complaints to local health
departments involved elder service agencies.

Self-neglect associated with hoarding.
Causes of Hoarding in Elderly

Compensation for loss

Grief reaction – death or divorce

Avoiding waste – Depression era

Traumatic event – Holocaust

Social isolation

Finding security

Memory problems

Paranoia or delusions
Dementia and Hoarding
Hoarding is a common symptom in dementia
patients.
Repetitive and ritualistic behaviors associated with
dementia
Symptoms of Dementia
• Hallucinations
• Paranoia
• Delusions
• Misidentification
• False Ideas
Dementia and Hoarding (cont)

Gathering of familiar objects

Attempt to regain control

“Forgetting” what is trash

Inability to sublimate natural drives
• sexuality
• aggression
• acquisition
Clutter and Hoarding
Figure 1: Type and Severity of Clutter (n=62)
Percentage of Cases
50
Substantial
Severe
40
30
20
10
0
Newspaper
Paper
Containers
Clothing
Food
Types of Hoarded Items
Books
Trash
Clutter and Hoarding
Figure 2: Extent to which clutter interferes with
normal life functioning within the home (n=62)
Substantial
Percentage of Cases
50
40
Severe
44
38
38
30
38
26
20
16
12
13
10
0
Inhibition of
Movement
Access to
Furniture
Access to Food
Preparation
Types of Interference
Interference with
Hygiene
Barriers to Effective Treatment
with Elderly Hoarders

Steketee study (1999) showed that after cognitivebehavioral model of therapy for over one year, 43 percent of
subjects had no change after treatment and cleaning out of
clutter; 23 percent relapsed.

Barriers:
• Denial and resistance
• Cognitive impairment/mental illness
• Lack of family support
• Lack of trained staff or staff time
• Client right to self-determination

Forced cleaning and excessive use of reasoning are
frequently unsuccessful with elderly hoarders
Intervention With Elderly Hoarders
•Hoarding is a mental health and a public health issue
•Treatment involves:

Mental and physical health assessment

Risk reduction

Treatment for identified symptoms
Capacity/Risk Model of Intervention
•Concepts

Capacity

Risk
•Three areas of functioning

Physical (activities of daily living)

Psychological

Social (availability of supports, finances)
•Types of risk

Physical/Psychological

To self/To others
**Model developed by Barbara Soniat, MSW, PhD, National Catholic School of Social Service (NCSSS), Washington, DC.
Evaluating Capacity and Risk
Evaluating capacity and risk:

High capacity/High Risk = accept clients right to self
determination

High risk/Low capacity = intervention including legal
(guardianship, etc)

High Risk/Moderate capacity = reduce resistance; reduce
risk; increase capacity
Intervention Guidelines: The “Dos”
•No quick fix
•Establish positive relationship
•Gain person’s trust
•Empathize – see their point of view
•Give choices – help maintain a sense of control
•Help set goals and time frame for getting things
done
•Respect meaning and attachment to possessions
Intervention Guidelines: The “Don’ts”
•Don’t work with hoarders if you feel negatively
about this behavior
•Don’t expect miracles overnight
•Don’t overwhelm or threaten
•Never remove belongings without person being
present
•Don’t do a surprise or forced clean-up if at all
possible
Intervention Guidelines

Hoarding is a mental health and a public health
crisis

Typically NOT an immediate crisis

Interventions without cooperation can be
disastrous
Intervention Guidelines: Collaboration
Development of hoarding task forces
Collaborative intervention:
Mental health
 Adult protective services
 Code enforcement
 Building and safety





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Animal control
Criminal justice
Zoning/Pest Control
Fire prevention
Home Care/VNA
Hoarding: Ethical Issues
•Autonomy vs. beneficence
•Self determination vs. capacity/risk
•Privacy vs. Public Health
•Freedom of choice vs. “resistance”
•Process vs. urgency
•Role as advocate vs. Role as gatekeeper