Hoarding Behavior in Elders
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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.

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Definition of hoarding

Hoarding Behavior in EldersPresented by:Emily B. Saltz, LICSWElder Resourceswww.eldres.comNAPGCM WebinarJanuary 11, 2012


Definition of hoarding

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

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 criteria1

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

    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 and Demographicsof 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

    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

    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

    WHY PEOPLE HOARD

    • Vulnerabilities

    • Information processing deficits

    • Meaning of possessions

    • Emotional Reactions

    • Reinforcement


    Symptoms of hoarding

    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 hoarding1

    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

    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

    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

    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 hoarders1

    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

    Barriers to Effective Treatment


    Treatment interventions

    Treatment Interventions

    • Medications

    • Psychotherapy

    • Cognitive Behavioral Therapy

    • Harm Reduction Model


    Barriers to effective treatment with hoarders

    Barriers to Effective Treatmentwith 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

    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

    HARM REDUCTION TREATMENT MODEL

    • Three levels of harm:

      • Safety

      • Health

      • Comfort

    • Steps in harm reduction plan:

    • Plan

    • Do

    • Check


    Harm reduction treatment model1

    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

    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

    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

    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

    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

    Clutter and Hoarding

    • Figure 1: Type and Severity of Clutter (n=62)

    Percentage of Cases

    Types of Hoarded Items


    Clutter and hoarding1

    Clutter and Hoarding

    • Figure 2: Extent to which clutter interferes with normal life functioning within the home (n=62)

    Percentage of Cases

    Types of Interference


    Barriers to effective treatment with elderly hoarders

    Barriers to Effective Treatmentwith Elderly Hoarders

    • Steketee study (1999) showed that after cognitive-behavioral 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

    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

    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

    • 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

    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

    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

    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

    Intervention Guidelines: Collaboration

    • Development of hoarding task forces

    • Collaborative intervention:

      • Mental health

      • Adult protective services

      • Code enforcement

      • Building and safety

      • Animal control

      • Criminal justice

      • Zoning/Pest Control

      • Fire prevention

      • Home Care/VNA


    Hoarding ethical issues

    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


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