Hoarding in the Elderly - BGAAAILbgaaail.org/docs/Hoarding.pdf · Hoarding in the Elderly How to Identify & Help with Hoarding in Older Adults

Hoarding in the Elderly

How to Identify & Help

with Hoarding in

Older Adults

Class Overview

Hoarding in Older Adults

Hoarding Overview

About Hoarding in Older Adults

Clutter-Hoarding Scale / Examples

Definition of Hoarding

Changing Diagnosis

Previously the DSM-IV included hoarding as a subset

of OCD (“Compulsive Hoarding”).

Recent changes to the new DSM-V (May 2013)

included separating Hoarding as a completely

separate disorder from OCD (“Hoarding Disorder”).

Potentially: new studies, specialty treatments,

medications, insurance coverage, etc.

Definition of Hoarding

Persistent difficulty discarding; strong urges to save.

Accumulation of a large number of possessions that fill up and clutter the active living areas of the home.

The symptoms cause clinically significant distress or impairment.

Symptoms are not due to a general medical condition.

Symptoms are not restricted to the symptoms of another mental disorder.

New Diagnosis

Co-Morbidities

Hoarding

Disorder

Major Depressive

Disorder (60%) Social Anxiety

Disorder, Social

Phobia (30%)

General Anxiety

Disorder (20%)

Obsessive

Compulsive

Disorder (17%)

ADD / ADHD

(4%)

Statistics

2 – 5% of the American population = 6-15 million (underestimated).

Not limited to age, gender, race, nationality, or socioeconomic class.

Male / Female equal vs. higher in males.

Tends to present during childhood or adolescence in males and during the twenties in females.

Symptoms may be latent, but once triggered usually worsen progressively throughout life.

Increase in severity is equal to dementia.

Statistics – Age of Onset

3.7 % age 0-5

13.8% age 6-10

26.6 % age 11-15

24.2% age 16-20

10.8 % age 21-25

8.1 % age 26-30

4.8% age 31-35

4.4% age 36-40

Statistics

People 65+ equaled

12.4% of the U.S.

population in the

year 2000. 65+

expected to grow to

19%-21% of the

population by 2030

- about 72.1 million

(more than twice the

number in 2000).

New 2012 Statistics

Hoarding in Elderly (Steketee, et al.)

Elderly hoarders saw possessions as self-extensions,

making discarding very distressing.

Experienced higher sense of responsibility for

possessions than non-hoarders.

Believed their clutter level was less severe than friends

and family did.

Reported more problems with function in home.

New 2012 Statistics

In a recent survey of 17,000 people: (Ekerdt, et al.)

60% of respondents age 60 and older said they had

more things than they need = estimated 35 million

people in the United States.

Respondents were gender balanced.

Among wealthier respondents, 75% said they had

more than they need.

New 2012 Statistics

Animal Hoarding (HRS Panel Survey, Ekerdt)

Animal hoarders very often do not restrain animals in

the home, do not use training and do not use cages or

kennels.

Hoarders often attributed human characteristics and

special abilities to their animals.

Overall higher difficulty with daily routines.

New 2012 Statistics

Treatments

Hoarding has poor response to known medications

when used alone. (Muroff)

Bibliotherapy (reading self-help books) showed only

9% reduction in saving rates. (Muroff, et al.)

Cognitive Behavioral Therapy (CBT) has shown only

modest results when administered individually. (Muroff)

New 2012 Statistics

Treatments

GCBT-only treatment showed reduction of around 25%

reduction in saving rates.

Combination of Group Cognitive Behavioral Therapy

(GCBT) and non-clinician home assistant showed the

highest improvement - nearly 30% reduction in saving

rates. (Muroff, et al.)

In-home services may be essential. (Muroff)

What Causes Hoarding?

Instinct


Genetics

Twin studies support a genetic influence of 45-65% in children and 27-47% in adults.

OCD shows 80-87% relation in identical twins; 47-50% relation in fraternal twins.

Several genetic studies have

supported linkages to a variety of

serotonergic, dopaminergic, and

glutamatergic genes.

Causes of Hoarding

Brain Injury


Anterior Cingulate Frontalmarginal Gyrus

Brain Injury



Early Life Events

Parenting not an influencing factor, however,

growing up in a cluttered or disorganized home can

exacerbate an existing tendency.

People born with a tendency but raised in an orderly

environment can be triggered to hoarding later by

life events.

Trigger Events = emotionally traumatic, involving

loss, or creating a long term disruption to

relationships or to the environment.


Early Life Events

New 2012 Statistics for Animal Hoarders (HRS Panel Survey, Ekerdt)

More than one third of animal hoarders described chaotic childhood homes.

Higher levels of childhood stressful events than controls.

88% reported negative family relationships.

Observed failure to develop attachments early in life.


Adult Life Trigger Events Death of loved one

Divorce

Empty nest

Long term or chronic illness

Injury with long term recovery

Chronic pain

Chronic fatigue

Onset of depression or other psychological illness or disorder


Inherent Tendency

Trigger Life Event

Stress Negative Feelings

e.g. Depression, Anxiety

Coping Behavior Release of tension,

“happiness” feels good.

Hypomania “High of the

Buy”

Addiction is Fed

by coping behavior Memory of High and more

negative feelings creates

desire for more

Denial /

Defensiveness

Shame / Guilt

Overwhelm

Contributing Factors

Dementia

Memory loss, mental confusion, disorientation,

impaired judgment and behavioral changes, which

may include hoarding and rummaging through things.

Damage to frontal lobe = Executive Function

impairment


Baby Boomers are Healthiest & Wealthiest

The proportion of people aged 65 and older in poverty decreased from 35 percent in 1959 to 10 percent in 2003 (N.I.H.)

Average life expectancy at birth in 2000 was 76.9 years; females could expect to live an average of 5.4 years longer than men. (N.I.H.)

About 80 percent of centenarians are women (N.I.H.)

About one in five older Americans report having chronic disability as of 2000 (1 in 5) (N.I.H.)


Loss of

Smell: Anosmia

Hyposmia

Specific

Anosmia

Clutter Rating Scale




Areas of Assessment For

Professional Organizers

1. Structure and Zoning

2. Animals and Pests

3. Household Functions

4. Health and Safety

5. Personal Protective Equipment (PPE)


Environmental: Occupant:

Clearance of Paths Through

Rooms

Ages of Occupants (minor or

elderly)

Access to Exits Physical Ability of Occupants

Level of Clutter Mental Soundness of

Occupants

Visible Health and Safety

Issues (Structural, Organic

Waste, Infestations)

Animal Care and Control

Odors and Fumes

ICD Clutter-Hoarding Scale


Level 1

Pathways through rooms are at least 3 feet wide.

All major escape routes are unblocked.

Minimal to moderate excess clutter.

Clutter does not obstruct functional use of room and features.

No evidence of structural decay or damage.

Little to no evidence of insects or rodents.

Household trash within normal levels.

Little to no odor.

Animal care & control is adequate.

Level 1



Level 1


Level 1


Level 1


Level 1


Level 1


Level 1


Level 2


Level 2

Pathways through rooms may be less than 3 feet wide.

One or more major escape exits are blocked or have less than 3 feet clearance.

Debris covers most or all floor space and surfaces; significant trip hazards.

Clutter obstructs many functional areas: furniture, appliances, water fixtures.

Minimal to light evidence of insects or rodents .

Presence of mild odors or fumes or old trash.

Animal care & control may be questionable.

Level 2


Level 2


Level 2



Level 2


Level 2


Level 2


Level 2


Level 2


Level 3


Level 3

Pathways through rooms may be less than 3 feet wide.

One or more major escape exits are blocked or have less than 3 feet clearance.

Height of accumulated clutter reaches the bottom of standard windows.

Infestations may be light to moderate.

Food trash or other rotting organic matter or mild structural damage may be present.

Moderate odors or fumes may be present.

Excessive animals may be present; care and control may be poor.


Level 3


Level 3


Level 3


Level 3


Level 3


Level 3


Level 4


Level 4

Pathways through rooms may or may not exist.

Access to most escape routes blocked.

Height of Accumulated clutter reaches above the bottom of standard windows.

Improper use of electrical items & wiring.

Signs of squalor: rotting food and trash, animal or human excrement, mold, structural damage or decay, infestations.

Strong odors may be present.

Excessive animals may be present; care and control is very poor.


Level 4


Level 4


Level 4


Level 4


Level 4


Level 4


Level 4


Level 4

Level 5



Level 5

Pathways through rooms may or may not exist.

Access to most escape routes blocked.

Height of accumulated clutter reaches more than one foot above the bottom of standard windows.

Hazardous use of electrical items.

Presence of squalor: rotting food and trash, animal or human excrement, mold, structural decay, heavy infestations.

Strong odors or fumes – trash, sewage, etc.

Animals at risk or dangerous to humans.


Level 5


Level 5


Level 5


Level 5


Level 5


Level 5


Level 5

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Recipe for Success

The Five Cs: Speak with Compassion

Require Compliance

Initiate Counteraction

Provide Coaching & Collaboration

How to Talk to Residents

Do: Appear as much as possible to be emotionally

indifferent

Keep facial expression neutral

Make extra effort to keep tone of voice level,

steady, and without emotion


Do: Keep voice volume low and soft to avoid being

perceived as angry or critical

– Women can very easily perceive voices (especially

men’s) as angry, critical or yelling

– Men can perceive voice tone to be challenging or

threatening


Don’t:

Make facial expressions, cover mouth or pinch nose.

Make sounds of disgust, gag, cough, etc.

Say anything negative to the homeowner or each

other about the conditions of the home.

Refer to any of their things as “junk” or “trash” (even if

it is!)

Pick up or move anything without asking or informing

the resident.


Do: Ask or inform the resident before moving any items.

Refer to their possessions as “things,” “items,” or

“belongings” if you need to talk about them. Mirror the

resident’s language.


Don’t:

Make the assumption that the resident knows what

they are doing is “wrong” or dangerous unless they

state it themselves

– Some don’t understand

– Some are in denial

– Some don’t know what to do/frightened


Don’t:

Argue with the resident

– Do not state a case for your point of view using

judgmental language (“this is filthy”)

– Do not refer at all to throwing things away or

reducing the number of items

– Do not put the resident in a position of defending

their position or beliefs


Don’t Ask “Why Do You Have all this Stuff?”

There will always be a reason “why.”


Do: State Factual Information:

– “Keeping things on top of the stove is a fire hazard.

For your safety, we will require those items be

removed and kept at least 12” away from the

stovetop.”

– “The presence of animal feces is a health risk to

humans and it will have to be removed. Any

contaminated items will have to be disposed of as

well.”


Do: Be prepared to present supporting information –

handouts/brochures on environmental health, fire

safety, etc.

– Many extreme hoarders minimize the risks

associated with cluttered or unsanitary conditions.

– They believe they will be able to exit easily during

emergency conditions.

– Many believe that items having been in extended

contact with feces can simply be washed off.

Working with Residents During the Cleanout

Mandated, deadlined clear-outs

don’t work


Usually results in re-hoarding to the same degree or higher in about half the time

Severe psychological scars - feelings of victimization and abandonment.

Increased resentment toward authorities, family, etc.

increased resistance to letting go of objects

Recidivism rate of mandated, deadlined

clearouts is high


30 Days is Not Enough Time

Physical/mental limitations

Cost prohibitive

Doesn’t allow for decision-making process

Creates panic

Unrealistic


Whenever possible, allow unlimited time

Firm compliance with harm-reduction targets

Spreads out the financial cost

The client often becomes more willing to discard with

time

Slower Is Better


Using a “Harm Reduction” Approach

Does not focus on total clear-out.

Focuses on clearing clutter from targeted areas.

Unless the structure is questionable or other health

hazards exist due to clutter.



Target the areas of highest danger to resident and first

responders.

Create a list of requirements (“harm reduction targets”)

that focus on safety and health.



State or list requirements:

– “Pathways through rooms must be a minimum of 36” to prevent trip hazards and allow for emergency personnel and medical equipment.”

– “All combustible liquids, such as propane tanks, must be kept in the garage.”

– All exterior doors must have the floor cleared at least 36” on either side to allow the door to swing completely open and for clear passage

Redefining “Success”

A Caring & Collaborative Effort:

Reduces risk of hoarding-related fire

Reduces cost to the client and family

Keeps residents safe and in their homes

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Documents

Hoarding in the Elderly - BGAAAILbgaaail.org/docs/Hoarding.pdf · Hoarding in the Elderly How to Identify & Help with Hoarding in Older Adults