Hoarding Disorder in Elders

At Hoarding Help Central, we believe that the first step in effectively treating hoarding disorder is understanding how it manifests, the barriers associated with treatment, and the ethical and practical dilemmas that geratric care managers face when working with elderly hoarders. Today, we will be looking at each of these areas of interest in order to illustrate the complexity of the problem at hand.

We will also be looking at some intervention guidelines that geriatric care managers (GCMs) should follow in order to effectively assist those affected by hoarding disorder. This is, after all, a particularly vulnerable population and GCMs need all of the information possible to have the best chance of successful intervention. Let’s get started!

Dilemmas Faced When Working With Elderly Hoarders

There are many dilemmas faced when working with elderly hoarders. Time and time again, medical health professionals are faced with barriers to effective treatment when working with elderly hoarders. This includes a long list of questions that have no clear answer including:

What happens if a hoarder refuses assistance?
Should a total cleanout be enacted regardless of the hoarder’s willingness?
Should the hoarder be involved in the cleanout process?
Given a lifelong history of hoarding, is there any chance of lasting success after cleanout

Unfortunately, these questions have no easy answer. This is due to the fact that there are many commonalities associated with hoarders. All too often, those affected by compulsive hoarding disorder fit a classic profile: female, unmarried, and living alone. Often, hoarders are socially isolated and refuse offers of assistance, having poor insight into the problem they are dealing with. This makes it difficult to successfully intervene even when it is a matter of public health and safety.

When trying to assist a hoarder who is refusing treatment, as they often do, GCMs must confront certain difficult ethical issues. After all, how can a GCM protect the autonomy of a hoarder and ensure their fundamental right to live as she chooses while still addressing the public safety concerns caused by their hoarding? When is a hoarder considered legally competent to choose the lifestyle of a hoarder? These are just a few of the many barriers GCMs face when dealing with an elderly hoarder who refuses treatment.

The Diagnostic Criteria of Hoarding Disorder

Compulsive hoarding has long been deemed to be a subset of obsessive compulsive disorder and hoarding behaviors have been observed in 20 to 30 percent of OCD patients. In past versions of the DSM, hoarding has been considered a symptom of other disorders rather than a disorder in itself.

Recent research suggests, however, that hoarding is its own distinct diagnosis consisting of a unique profile of its own symptoms. This led to the DSM-5’s inclusion of hoarding as a unique disorder in itself. So what is the diagnostic criteria of hoarding disorder as highlighted by the DSM-5? According to the DSM-5, there are certain criteria an elderly person must meet to be formally diagnosed with hoarding disorder. Let’s take a look at each of those criteria below:

Persistent difficulty disposing of or parting with items regardless of their actual value
Difficulty due to a perceived need to save the items and due to the distress associated with discarding them
Difficulty disposing of items results in the extreme accumulation of items, leading to clutter in active living areas of the home
Hoarding causes significant distress and/or impairment in either occupational, social, or other areas of life
Hoarding behavior is not attributable to an underlying health condition
Hoarding behavior is not attributable to the symptoms of another psychiatric disorder (OCD, major depressive disorder, schizophrenia, ect.)

Hoarding in the Elderly Population

For a GCM, encountering elderly clients that suffer from profound hoarding problems is far from uncommon. Unfortunately, these cases are often the most difficult to manage. To make matters worse, the current research on dementia, aging, and hoarding is extremely limited. While studies are limited, there is enough evidence to suggest that there is a definite link between hoarding and elders. One such study, named “Hoarding by Elderly People” completed in 2001, found that 40 percent of all calls for hoarding complaints to local health departments involved elder service agencies. This study was also the first to suggest that the forced cleanout of a hoarder’s home was traumatic for the individual and not an appropriate means of intervention.

Grief of Loss

There are a variety of reasons that elders develop or continue with hoarding behavior late in their lives. For one, elderly hoarders that are suffering from some degree of chronic illness and either mental or physical decline are at a particular risk for exhibiting such behaviors. It has been thought, additionally, that hoarding in the elderly population may also be linked to the grief associated with a loss experience. It goes without saying that all elders must face an accumulation of losses in late life and these factors can have profound effects on their hoarding behavior. Such stressors may include the loss of friends or family, retirement, and reduced cognitive or physical skills. Often, elders will use items to “fill up” the emptiness that they are feeling due to this personal grief.

Previous Life Trauma

Another reason that it is thought that hoarding is so common in the elderly population is the presence of previous trauma. After all, generations are defined by the major historical events and cultural values of their lifetime and these factors may have a lot to do with the reason that hoarding behavior emerges in late life. Our current generation of elders lived through major historical events from the Great Depression to the Holocaust. It is possible that the economic travails associated with these times taught the need for great saving and these perceived values may be a major reason that the elderly population hoards.

Social Isolation

Social isolation is yet another reason that the elderly population may hoard. Elderly hoarders, while not always, usually live alone. This means that the formal and informal support systems that they once had are inadequate or nearly non-existent. When there is an absence of connectedness with family and friends, elderly hoarders may sometimes hoard in an attempt to fill up the emptiness of human connection that they are experiencing. Hoarding objects becomes a perceivable way for the elderly person to provide themselves with comfort and security. This is a further reason that it can be so distressing when these elders are faced with an intervention.

Memory Impairment and Dementia

Although the research involving the link between dementia, aging, and hoarding is severely limited, there is some evidence to suggest that a link exists. Many in the GCM community suggest that a link exists. It is a known fact that, for dementia patients, the hoarding instinct is an obstacle to both the hoarder’s safety and health.

To understand why there may be a link between dementia, memory impairment, and hoarding, it is important to remember that dementia causes changes in the brain that can affect mood, behavior, and memory. For this reason, elders with memory loss may be unable to discriminate between items of importance and those of no real value. This may result in the accumulation of items in their homes. Because they can’t distinguish between items of importance and those of no importance, they save everything. This leads to the amount of clutter that would be associated with hoarding disorder.

Hiding behaviors are also common among elders with dementia. These hiding behaviors include hiding objects in order to keep them safe and, due to memory loss, elders may even forget where these items were stored. Another symptom of dementia that may exacerbate the need to hoard is found in the sense of paranoia and mistrust that most dementia patients grapple with. This may make them especially prone to the refusal of treatment as they don’t trust easily and do not understand that they have a problem in the first place.

Elders suffering from dementia often become suspicious and may accuse others of stealing, leading them to hoard their belongings in an attempt to keep others from taking them away. This makes them especially prone to refusing treatment when it is offered to them. This presents yet another barrier that GCMs must consider when effectively trying to intervene in the hoarding behavior presented by elderly patients with memory loss or dementia.

Guidelines for Appropriate Intervention

Working with elderly hoarders presents some of the biggest challenges that GCMs face. That being said, there are some guidelines for appropriate intervention that should be followed in order to experience the best chance of success. Here are the guidelines for appropriate intervention that you should consider when working with elderly hoarders:

Remember that there is no quick fix
Maintain a positive relationship with your client throughout the process
Empathize with your client
Set short-term and long-term goals
If you have negative feelings, you will be ineffective
Never remove belongings without the client present
Collaborate with various agencies and medical health professionals during intervention