Treating Hoarding Disorder in Middle-Aged to Older Adults

At Hoarding Help Central, we believe that understanding the causes and the way that hoarding disorder manifests in middle-aged to older adults is central to defining appropriate treatment methods. Without knowing what lies behind hoarding disorder and how it affects the individual in question, medical help professionals don’t have the necessary tools to treat someone affected by hoarding disorder.

Today, we will be discussing the causes of hoarding disorder, how it manifests, and the treatment methods available to alleviate the symptoms. With this knowledge, it is our hope that those working to intervene and assist those with hoarding disorder to overcome their compulsion to collect will be aided in their pursuits. With that, let’s get started!

The DSM-5 Criteria for Hoarding Disorder

In order to treat hoarding disorder effectively, medical health professionals must have a thorough understanding of the criteria required for an individual to be diagnosed with hoarding disorder. With hoarding disorder added to the DSM-5 as a psychiatric illness, there are certain criteria associated with hoarding disorder. This criterion not only assists medical health professionals in identifying the disorder but, in turn, gives clues as to the best treatment methods available. Let’s take a closer look at the criteria for hoarding disorder as outlined by the DSM-5.

The DSM-5 defines hoarding disorder based on the following criteria:

Persistent, continuous difficulty with parting with or discarding of personal possessions, regardless of their value
The difficulty discarding of items is due to some perceived need to save them and this causes the affected individual a lot of distress
The symptoms of hoarding disorder result in the accumulation of possessions that eventually gets out of control, moving into living areas and restricting their use
Hoarding behavior causes significant distress or impairment of social, occupational, and other important areas of everyday life
Hoarding behavior is not due to some other underlying health condition
Hoarding behavior is not accounted for due to the symptoms of another disorder such as OCD, major depressive disorder, ect.

It is also important when determining whether or not an individual is affected by hoarding disorder to specify if there is:

Excessive Acquisition: It should be determined whether or not symptoms are accompanied by excessive collecting or the buying or stealing of items that aren’t needed and for which there is no available space.
Good/Fair Insight: It should be determined whether the individual recognizes that their hoarding-related beliefs/behaviors are problematic.
Poor Insight: It should be determined whether the individual is unable to recognize that their hoarding-related beliefs/behaviors are problematic.
Absent Insight: It should be determined whether the individual is completely convinced that their hoarding-related beliefs/behaviors are not problematic in any way.

Why Do Those With Hoarding Disorder Collect?

Now that you have an understanding of the criteria associated with hoarding disorder in accordance with the terms outlined by the DSM-5, it is important that we discuss why those with hoarding disorder are driven to collect. In short, there are three main reasons that those with hoarding disorder are driven to collect items in excess. This can be broken down as follows:

Sentimental:The first reasoning that a hoarder uses to justify the collection of items in excess is found in sentimental value. For those operating based on a delusion of sentimental value, they collect items in excess because these items, in their minds, are an extension of them based on personal perceived value.
Instrumental:The next reasoning that a hoarder may use to justify the collection of items in excess is in perceived instrumental value. For this type of hoarder, it is their belief that items should be kept and collected in excess due to the fact that they may need them someday.
Intrinsic:Finally, the third reason that those with hoarding disorder may be driven to collect items in excess is due to perceived intrinsic value. For these hoarders, the items that they collect in excess hold intrinsic value and to get rid of them wouldn’t make any sense.

The Prevalence of Hoarding Disorder in Middle-Aged to Older Adults

Now that we understand what hoarding disorder is as well as the reasons that those who collect and keep in excess may be driven to do so, let’s look at the prevalence of hoarding disorder in middle-aged to older adults. Overall, hoarding disorder has been observed to occur in 2-5 percent of adults. For those affected by hoarding disorder, these symptoms typically appear in early adolescence with a total of 68 percent of onsets occurring before the age of 20. In fact, the late onset of hoarding disorder is extremely rare. Overall, results are mixed as to whether or not the severity of hoarding symptoms increases with age.

According to reports from a study by Marx and Cohen-Mansfield in 2003, 15 percent of nursing home residents and 25 percent of community daycare elder participants hoarded small items. While the overall rate of hoarding among elders in both private and public housing is unknown, there are some frequency counts available from the following sources:

Elders at Risk Program in Boston: 15 percent
Visiting Nurses Association in New York City: 10-15 percent
Community Guardianship in North Carolina: 30-35 percent

Unfortunately, from the time of onset, studies have found that the course of hoarding disorder tends to be chronic with a very small amount of reports of spontaneous remission in those affected by hoarding disorder. This highlights the need for proper intervention and treatment of hoarding disorder for those affected.

The Consequences of Hoarding in Older Adults

As you can see, hoarding behavior is by far the most common in the older population of adults. In order to understand the need for proper treatment methods for these affected individuals, it is crucial that we understand the consequences of hoarding in older adults. For one, older adults affected by hoarding disorder are much more likely to develop chronic and age-related illnesses. Secondly, older adults engaging in hoarding behavior are much more likely to mismanage both their medication and their diet and this can lead to a worsening of their current medical conditions.

Another consequence of hoarding in older adults is found in the fact that hoarding behavior severely impacts their ability to perform their daily activities. This includes the ability to move throughout the home, locate items of importance, use their kitchen sink, eat at their dining room table, and even sleep in their own bed. Unfortunately, hoarding behavior also leads many older adults to be relocated to senior housing prematurely or to be evicted from their homes altogether.

The Barriers in Treating Hoarding Disorder

It is clear that the consequences associated with hoarding behavior calls for effective treatment options. Unfortunately, there are a variety of barriers in treating hoarding disorder in older adults and each of these barriers should be understood in order to form the most effective treatment methods for these individuals. So what are the barriers that medical professionals and families may face when trying to intervene and help their patients, friends, and loved ones get proper treatment for hoarding disorder? Here are just a few that should be considered:

The possibility of cognitive impairment
Daily living activities are impaired
Instrumental activities such as cooking, cleaning, and driving are impaired
Affected individuals may not be familiar or comfortable with psychiatric treatment
The role of family members in the intervention
Fixed or otherwise limited income
Multiple medical providers or medications to consider
Risk of losing independent living status due to hoarding behavior

Each of these barriers should be considered and understood when working with an individual that is hoarding in late life. After all, these barriers are the reason that so many hoarding individuals feel uncomfortable and unwilling to receive treatment. Overcoming these barriers effectively is the first step in helping a hoarding individual to receive the proper treatment methods.

Available Treatment Options for Hoarding Disorder

So what are the available treatment options that those with hoarding disorder can receive? One of the most effective treatment methods for middle-aged to older adults with hoarding disorder is Cognitive Behavioral Therapy (CBT). Specialized Cognitive Behavioral Therapy for hoarding disorder involves education and case formulation, the act of determining the value of hoarded items and setting goals to discard of them appropriately, motivational enhancement, skills training for developing problem-solving skills, organizational skills, and decision-making skills, and practice with the act of discarding and non-acquiring.

Proper Cognitive Behavioral Therapy measures for hoarding individuals includes around 26 sessions or approximately one year of CBT. In especially severe cases, this can sometimes take even longer. CBT also includes either individual or group therapy sessions dependent upon the needs of the individual. There are also both home or in-office appointments available depending upon the needs of the individual. The CBT treatment format for adults also involves cleanouts with trained staff/coach if necessary for excessive clutter. Finally, psychoeducation is also a very important part of the process of treatment for hoarding individuals. This involves education surrounding the cognitive-behavioral model of hoarding, discussion of the treatment model and its intended effects, and personalized model-building for those affected.