Hoarding in Late Life: Implications for Clinicians
by M. E. Dozier and C. Ayers, PhD; http://www.psychiatrictimes.com; 10/30/2014
Hoarding Hoarding disorder (HD), a newly released addition to DSM-5, is characterized primarily by difficulty in discarding current possessions, urges to avoid wasting items, and excessive clutter in the home. In addition to HD, hoarding behaviors may derive from obsessive- compulsive disorder (OCD), schizophrenia, depression, as well as some eating disorders. DSM-5 criteria for HD necessitate that the hoarding behaviors cause clinically significant impairment inside patient’s capacity to function and the symptoms are not the consequence of either a condition or other psychiatric disorder.
Prevalence of HD in older adults
Epidemiological reports of hoarding inside community derive from the estimated prevalence of an individual with some amount of hoarding behaviors, not of men and women meeting criteria for HD. Estimates of hoarding symptoms in nongeriatric community dwellers cover anything from 2% to.3%. One major confound from a review with the literature on HD prevalence is the lack of consistent measurement of hoarding symptom severity, which greatly limits comparisons between studies. In addition, the insufficient rigorous inclusion criteria in determining the prevalence of HD severely limits the generalizability of any prevalence study to date.
Clinicians should look into the demographic traits of older adults who may present with HD. The characteristics of older adults with HD can be generalized from the individuals who present for treatment. 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. Older adults with HD who live alone reported significantly higher degrees of clutter, but no difference in their urges to save lots of or difficulty in discarding. Assessments that depend on clutter levels might be misleading in case you live with a roommate or partner, because that person could be artificially deflating the physical manifestation in the hoarding symptoms. When assessing for hoarding symptoms, it is important to inquire about living spaces which can be solely controlled by the individual, like personal sleeping space or study, together with communal apartments, like the lounge or kitchen.
Onset and length of HD
Knowledge of the common age of onset of hoarding behaviors in older adults with HD will help clinicians struggling with a differential diagnosis. Research for the progression of hoarding behaviors could possibly be generalizable to adults with HD. Studies from the reported age of start hoarding symptoms in older adults who either have self- identified as having hoarding problems or have met criteria for HD report an even pattern of onset: hoarding symptoms generally appear before age 20, and not enough people experience onset of problems after the day of 40. During intake, take time to conduct a complete history from the individual’s life and also the progression with the symptoms, including if they have ever experienced a moment in which they did not battle with clutter.
There offers some debate about the growth of hoarding symptoms through the life span. Individuals who self-report as having hoarding problems report that symptom severity tends to stabilize after middle age and remains steady into old age. On the other hand, individuals who meet criteria for compulsive hoarding report that their hoarding symptoms increased in severity with time, including into older adulthood. This may be the result of the accumulation of objects over time, even though it is also possible that individuals with HD experience a “ceiling effect” on his or her amount of clutter.
A study that contrasted hoarding symptom severity in middle-aged and older adults who met DSM-5 criteria for HD figured there are no age-related differences in hoarding symptoms. However, it is possible that there are cohort differences in hoarding that may confound any cross-sectional investigations of symptom severity across the life span. Older adults can be reporting an increase in hoarding symptoms. Because of decreased mobility and also other effects linked to the aging process, the results of hoarding be evident. Longitudinal studies of hoarding symptoms and behaviors are essential to make any definitive conclusions with the progression of hoarding symptoms.
Be mindful associated with a cycles inside the patient’s symptoms, and help the patient recognize the patterns within their behavior. For example, if the patient is often a teacher who reports that his urges to avoid wasting increase every spring in the event the school year ends, help him understand the causes for saving certain objects, which may be tied to emotional context (eg, saving the job of a favorite student).
Impact on well-being
While many in the risks connected with hoarding behaviors are prevalent over the life span, hoarding symptoms may have a particularly devastating impact for the well- being of geriatric populations. Older adults with HD are near increased risk for falling, fires and mold in your 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 may also be problems with older adults who are compulsive hoarders. Dust or insect/rodent infestations may aggravate existing health problems. Because much of the current research on risks linked to clutter levels relies on patient self-reporting, it is possible the risks associated with HD may be underreported due to low comprehension of consequences of hoarding.
Older adults with HD also report having health concerns at a significantly higher rate than older adults without HD, which could possibly be due partly to the increased health risks associated with hoarding. The most common health 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 visit their house; how often with which older adults with HD have visitors to their residence is significantly linked to symptom severity.
Findings declare that homelessness may be more prevalent in older adults with HD than inside general population and that HD may be more prevalent in older adults facing imminent homelessness. Normative life transitions, such as moving because with the need for a higher level of medical treatment or relocation to be closer to family, may create high levels of distress for folks with HD. Consider utilizing a task-force approach that features a social worker or a case manager when working with a geriatric patient with HD.
During the intake session by having an older adult in whom HD is suspected, it's important to assess for other psychiatric disorders which could affect the presentation and treatments for symptoms. The most common comorbid disorders in geriatric patients with HD are MDD, OCD, generalized anxiety, and dysthymia. Presence of the comorbid disorder significantly predicts symptom severity in geriatric patients, with the exception of drinking alcohol. Symptoms of anxiety and depression were found to be predictive of core hoarding symptoms linked to urges to avoid wasting and difficulty with discarding.
Problems in connection with executive functioning are already observed in middle-aged adults with compulsive hoarding, older adults with hoarding symptoms, and older adults with HD. Problems with organization and categorization, key elements of executive functioning, may play a critical part within the development and repair off hoarding symptoms in older adults with HD and so should be thoroughly evaluated when treatment solutions are being planned.
Assessment and treatment strategies
Diagnosis of HD might be made while using the Structured Interview for Hoarding Disorder (SIHD), which assesses to the DSM-5 criteria for HD. The SIHD also queries for virtually any diagnostic specifiers, for example low insight or excessive acquisition. Several well- validated self-report measures will also be available for assessing HD symptom severity, such as the Clutter Image Rating Scale (CIRS) and also the Saving Inventory-Revised (SI-R). For people who have suspected HD, administer the SIHD to initially assess for HD criteria, and consider administering the CIRS and also the SI-R weekly or semi-weekly to assess for alterations in symptom severity after a while.
Both psychotherapy and medication-based interventions have demonstrated positive results to the treatment of compulsive hoarding and HD. The most promising psychotropic intervention is extended-release venlafaxine, an antidepressant that works well through the inhibition of serotonin-norepinephrine reuptake. Venlafaxine is proven to decrease HD symptoms by as much as 36% after 12 weeks. However, older participants inside the study improved significantly less than the younger cohort. There are actually 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 well through the inhibition of serotonin reuptake, has also been found to be effective in reducing hoarding symptoms but, unfortunately, it might not be well tolerated in hoarding samples.
The Steketee and Frost15 cognitive-behavioral therapy (CBT) protocol could be the only manualized answer to HD currently available to clinicians in private practice. CBT for HD is often a lengthy undertaking (26 sessions) and involves heavy use of motivation interviewing and cognitive restructuring. Its focus is about the distorted thinking connected with hoarding behaviors, like the person’s specific causes of saving certain objects. Cognitive restructuring can be used to help patients alter their associations using their possessions, using the hypothesis that this act of sorting and discarding can become easier when the patient carries a more realistic view about the need to avoid wasting objects.
The validation with the protocol has become limited to mid-life compulsive hoarding samples. Investigation of CBT for HD in older adults is bound primarily to case studies or open trials. Two pilot studies of CBT for older adults with compulsive hoarding found decreases in hoarding symptom severity. Unfortunately, participants’ severity of symptoms remained clinically significant where there was hardly any change inside clutter levels.
A novel intervention uses a combination treatment consists of compensatory cognitive training skills as being a work-around towards the executive functioning problems often noticed in older adults with HD paired with exposure therapy for acquiring/discarding.18 The compensatory cognitive training includes sessions focused on skills training related to by using a calendar, composing to-do lists, problem solving, flexible thinking, and planning. The exposure portion with the intervention is dependant on underlying principles similar to those for exposure therapy for obsessive -compulsive–, anxiety-, and trauma- related disorders, that's considered essentially the most evidence-based behavioral treating OCD in older adults. Following a 26-week protocol, participants’ hoarding symptoms had improved by about 41% along with the majority of participants had subclinical levels of hoarding symptom severity.
Richard is a 67-year-old widower. He presents with severe hoarding symptoms which might be assessed with all the SI-R and a visual inspection of his home. Over 85% of Richard’s home is stuffed with clutter; he includes a large storage unit that also is full. Richard has hypertension; he mismanages his medications and it is largely immobile as a result of excessive clutter. In addition to excessive acquiring of newspapers, Richard keeps magazines and also other informational mail items.
Richard includes a high a higher level insight into the effects of his diagnosis (eg, financial strain, lack of visitors), and the man displays a willingness to commit towards the treatment intervention. He is able to develop an exposure hierarchy for not acquiring (ie, likely to book store rather than purchasing magazines) and then for discarding (ie, sorting and discarding newspapers). After 26 sessions, including 4 home visits, Richard demonstrates a 35% decrease in hoarding symptoms.
HD is often a chronic and progressive disease, and it might be a challenge to take care of, even for more experienced clinicians. Often, the best length of action would be to focus around the safety of the individual as well as a mitigation from the most severe problems linked to hoarding (eg, clearing away fire hazards, fall risks). However, many people with HD are wanting to receive evidence-based strategy for their symptoms, and substantial progress may be made using either pharmacotherapy or psychotherapy.