Hoarding Disorder in Older Adulthood

doi:10.1016/j.jagp.2014.05.009

The American Journal of Geriatric Psychiatry

Volume 23, Issue 4, April 2015, Pages 416-422

https://doi.org/10.1016/j.jagp.2014.05.009 Get rights and content

Objective

Hoarding disorder (HD) is a chronic condition associated with moderate to severe impairment in health and functioning. HD has been primarily studied in midlife adults, and there is limited research on HD in late life.

Methods

In this review, we summarize research on the presentation and characteristics of HD and hoarding symptoms in older adults, including evidence for associated impairment in daily functioning, physical health, and cognitive function. Finally, we review the evidence available for intervention outcomes for treating HD in older adults.

Results

Geriatric HD is characterized by severe functional impairment, medical and psychiatric comorbidities, and cognitive dysfunction.

Conclusion

There is a lack of randomized controlled trials investigating evidence-based treatments for geriatric HD.

Section snippets

Prevalence of HD in Late Life

Prevalence rates of HD should be interpreted cautiously as the DSM-5 HD criteria are relatively new and so studies prior to 2013 did not have the advantage of utilizing formal criteria. Community epidemiological reports estimate prevalence rates of clinically significant hoarding symptoms from 2%¹¹ to 5.3%¹⁵ in non-geriatric populations. Results are mixed with respect to an increase in hoarding symptoms with age. One study reported that hoarding symptoms were three times more likely to occur in

Treatment

Studies examining the efficacy of medications in midlife compulsive hoarding patients have yielded mixed results,⁴⁰ with the exception of a recent report showing that extended-release venlafaxine administered over the course of 12 weeks may have decreased hoarding symptom severity in 24 adults with HD (mean age: 51.8 years, range: 33–61) by up to 36% on clinician-administered measures and up to 32% on self-reports.⁴¹ Unfortunately, age was negatively correlated with improvement in hoarding

Conclusion and Future Implications

Hoarding disorder in late life is characterized by severe functional impairment, medical and psychiatric comorbidities, and cognitive dysfunction. There are currently no published randomized controlled trials investigating late-life hoarding treatments. Future studies should examine the efficacy of such interventions using randomized controlled trials with the eventual goal of bringing treatments to community settings with a focus on functional outcomes.

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Cited by (22)

Rates of diagnosis and service utilization in veterans with hoarding disorder
2024, Psychiatry Research
Hoarding Disorder (HD) is a prominent and disabling neuropsychiatric condition defined by the inability to discard objects resulting in impairing levels of clutter. The prevalence rate is 2–6 % and increases with age. The aging Veteran population is a high risk group for impairment associated with HD. Medical and psychiatric comorbidities as well as associated rates of disability and poor quality of life are very common in both HD and the related disorder of OCD. We examined rates of HD and OCD diagnoses at the VA San Diego Healthcare System. Data were obtained from medical records for all Veterans with these diagnoses over 8-years and included information on medical and psychiatric care, homelessness services, and Care Assessment Needs (CAN) scores. Rates of diagnosis for both HD and OCD were well below epidemiological estimates. Veterans with HD were older, had higher rates of medical hospital admissions with longer stays; had more cardiac, neurological, and acquired medical conditions; had more psychiatric comorbidities; had more interactions with the suicide prevent team and homelessness services; and had higher CAN scores than Veterans with OCD. The low rate of diagnosis and high services utilization of Veterans with HD demonstrates an area of unmet need.
The speed of progression towards obsessive-compulsive disorder
2020, Journal of Affective Disorders
Citation Excerpt :
In the present case-control study, we were interested in investigating the speed of progression from subclinical obsessive-compulsive symptoms to clinically significant OCD and its correlates in a large sample of Brazilian OCD patients. Based on the existing literature linking faster progression of illness (“telescoping” effect) to increased severity of the overall clinical picture in the context of substance (Hernandez-Avila et al., 2004), and behavioral addictions (Tavares et al., 2003), we predicted that faster conversions from subthreshold to clinical OCD would be associated with younger age at assessment (Geller et al., 2001); male gender (Taylor, 2011); more reports of streptococcal infections before the onset of OCD symptoms (Jaspers-Fayer et al., 2017); increased comorbidity with and/or severity of depression and anxiety (de Mathis et al., 2008; Wang et al., 2012); greater severity of and worse insight into OCD symptoms (Post and Weiss, 1998; Ravi Kishore et al., 2004; Taylor, 2011); less hoarding (Ayers et al., 2015) and more sexual/religious (Ferrao et al., 2006; Geller et al., 2001) and aggressive (Geller et al., 2001) symptoms; a positive family history of OCD (potentially greater family accomodation; Delorme et al., 2005); and increased resistance to serotonin reuptake inhibitors (Ferrao et al., 2006; Post and Weiss, 1998). One thousand and one OCD patients were enrolled in seven different treatment centers from 5 different Brazilian states between 2003 and 2009 as a part of the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders (CTOC), a research initiative supported by Brazilian Government Grants.
There is current interest in the elaboration of early intervention programs for obsessive-compulsive disorder (OCD). To this end, it is important to investigate the speed of progression from subthreshold symptoms to diagnosable OCD. In this study, we have retrospectively investigated the speed of progression towards full-blown OCD and sociodemographic and clinical factors associated with a faster transition.
Patients enrolled in the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders (N = 954) were interviewed with a comprehensive assessment battery that included the interval (in years) between the onset of subthreshold OCD symptoms and the onset of full-blown OCD.
It took a median of 7 years (interquartile range: 2–13 years) for subthreshold symptoms to convert to diagnosable OCD. Faster OCD onset was associated with lower age at the time of assessment, male gender, being in new romantic states as precipitants for compulsions, greater severity of sexual/religious symptoms and lower severity of hoarding and YBOCS compulsions severity scores, greater rates of generalized anxiety disorder and agoraphobia without panic disorder, and negative family history for OCD.
The retrospective design of this study allowed for susceptibility to memory bias about age at onset of OCD symptoms. We were unable to capture progressions taking less than 12 months.
We could identify a specific phenotype that was more likely to escalate rapidly to clinical levels within this large clinical sample. This phenomenon may be particularly relevant in the context of selecting individuals for early intervention initiatives in situations when resources are scarce.
Interpersonal attachment insecurity and emotional attachment to possessions partly mediate the relationship between childhood trauma and hoarding symptoms in a non-clinical sample
2019, Journal of Obsessive-Compulsive and Related Disorders
Citation Excerpt :
Studies have indicated that hoarding disorder may be more prevalent than OCD (Adam, Meinlschmidt, Gloster, & Lieb, 2012; Ruscio, Stein, Chiu, & Kessler, 2010), estimated to affect between 1.5% and 6% of the population (Iervolino et al., 2009; Nordsletten et al., 2013). Hoarding tends to take a more chronic course than OCD, with symptoms increasing rather than fluctuating over time (Ayers, Najmi, Mayes, & Dozier, 2015; Grisham & Barlow, 2005; Tolin, Meunier, Frost, & Steketee, 2010). A number of biopsychosocial risk factors for hoarding have been identified, including genetic vulnerability (Iervolino et al., 2009; Lochner et al., 2005; Zilhão, Smit, Boomsma, & Cath, 2016), emotional coping style (de la Cruz et al., 2013; Timpano, Shaw, Cougle, & Fitch, 2014), suboptimal attachment history (Chen et al., 2017; Frost, Kyrios, McCarthy, & Matthews, 2007; Kyrios et al., 2018; Neave, Tyson, McInnes, & Hamilton, 2016) and adverse life events, particularly in childhood (Cromer, Schmidt, & Murphy, 2007; Frost, Steketee, & Tolin, 2011; Landau et al., 2011; Samuels et al., 2008; Tolin et al., 2010).
Previous studies have indicated that childhood adversity and emotional attachment difficulties are common in hoarding disorder. The aim of this cross-sectional study was to explore whether current insecure attachment style, operationalized as insecure attachment to romantic partners, and emotional over-attachment to objects might be one mechanism linking the experience of early adversity to later hoarding tendencies. Data was gathered using an online survey from 463 adult participants; n = 216 scored in the clinical range for hoarding. The experience of two types of childhood trauma (emotional abuse and physical neglect) predicted higher levels of hoarding symptoms. Attachment anxiety and avoidance were positively correlated with hoarding symptoms and with emotional attachment to possessions. Current attachment insecurity and emotional attachment to objects partly mediated the relationship between childhood trauma and hoarding symptoms, after controlling for anxiety and depression. This study provides evidence for a novel way by which traumatic life events may influence hoarding symptomatology via attachment to significant others and object attachment. The findings are limited by the use of a cross-sectional design; however, they support the growing body of research which points to the importance of early adverse events and attachment difficulties in the aetiology of hoarding.
Comparing clinical characteristics and treatment outcomes between Veterans and non-Veterans with hoarding disorder
2018, Comprehensive Psychiatry
Citation Excerpt :
Because Veterans have higher rates of mental health conditions [15] and both physical and mental health comorbidities are known to affect treatment outcomes [16], Veterans may be less likely to respond to treatment for HD. Furthermore, given the deleterious effects of HD observed in community-dwelling samples [5–9], Veterans with HD may be particularly susceptible to the psychosocial and functional impairments associated with hoarding. The main purpose of this investigation was to compare the rates of treatment barriers between Veterans and non-Veterans with HD.
Because Veterans have higher rates of mental health conditions and both physical and mental health comorbidities are known to affect treatment outcomes, the purpose of this investigation was to compare the rates of risk factors for poor hoarding treatment outcomes between Veterans and non-Veterans with hoarding disorder (HD). This is the first study to investigate differences between Veterans and non-Veterans with HD.
Baseline data were used from three different treatment studies of adults with hoarding disorder (n = 159). Demographic characteristics, baseline hoarding symptom severity, baseline medical and psychiatric comorbidities, and treatment attrition and response were compared between Veterans and non-Veterans.
Veterans were significantly less likely to be employed than non-Veterans. Veterans did not report significantly more severe hoarding symptoms at baseline when compared to non-Veterans. Veterans reported having a greater mean number of overall medical and psychiatric comorbidities. Veterans were more likely than non-Veterans to meet criteria for major depressive disorder and post-traumatic stress disorder. There was no significant difference in the rate of attrition between Veterans and non-Veterans and Veterans were not significantly more likely to be classified as treatment responders.
Many similarities were observed between the two groups, including demographic characteristics, hoarding symptom severity, and rates of treatment response. Given that Veterans with HD may suffer from greater medical and psychiatric comorbidities, clinicians should ensure that their clients are receiving adequate medical care and that any other psychiatric comorbidities should be addressed in conjunction for treatment with HD.
Presidential Address: Team Science Across Disciplines: Advancing CBT Research and Practice on Hoarding
2018, Behavior Therapy
Citation Excerpt :
I have time only for a brief mention of some of the features associated with hoarding that we have studied in order to explain why people hoard and build models to guide interventions. Common features include medical illnesses accompanying hoarding, such as hypertension, bronchial conditions, and arthritis (Ayers, Najmi, Mayes, & Dozier, 2015; Tolin, Frost, Steketee, & Fitch, 2008). Neurocognitive problems with attention, concern about memory (although relatively little actual memory problems), and executive functioning undoubtedly contribute to the disorganization and perhaps to other perceptual biases (Frost et al., 2011; Grisham, Norberg, Williams, Certoma, & Kadib, 2010; Tolin, Frost, Steketee, Gray, et al., 2008; Tolin et al., 2012).
This presidential address focuses on the recent history of research and practice on hoarding disorder (HD) as a potential model for coordinating interdisciplinary teams of professionals within and outside mental health fields to advance scientific efforts to understand and resolve mental health problems. To identify, assess, and intervene with clients who have HD, psychologists, social workers, psychiatrists, and other service professionals are needed, including those in public health, housing, medicine, aging and protective services, fire, safety, and animal protection. Research findings and practice methods developed by many of my colleagues highlight the various skills of these diverse disciplines and fields. Of particular interest are multimethod assessments and CBT interventions that span individual, group, and family treatments, delivered in the office, at home and via the web by mental health and other professionals, as well as peers. Outcomes are positive, but there remains much work to do to improve understanding and intervention outcomes.
Hoarding in the elderly: A critical review of the recent literature
2017, International Psychogeriatrics

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Regular Research ArticleHoarding Disorder in Older Adulthood

Objective

Methods

Results

Conclusion

Section snippets

Prevalence of HD in Late Life

Treatment

Conclusion and Future Implications

Am J Geriatr Psychiatry

Clin Psychol Rev

Clin Psychol Rev

Behav Res Ther

J Obsessive Compuls Relat Disord

Behav Res Ther

J Affect Disord

Behav Res Ther

J Anxiety Disord

Am J Geriatr Psychiatry

Behav Res Ther

Cog Behav Pract

J Obsessive Compuls Relat Disord

J Anxiety Disord

Behav Res Ther

Behav Res Ther

Behav Res Ther

Behav Res Ther

Am J Geriatr Psychiatry

Behav Res Ther

J Psychiat Res

Age at onset and clinical features of late life compulsive hoarding

Int J Geriatr Psychiatry

The prevalence of elder self-neglect in a community-dwelling population: hoarding, hygiene, and environmental hazards

J Aging Health

Diagnostic and Statistical Manual of Mental Disorders

Hoarding: A symptom, not a syndrome

J Clin Psychiatry

Regular Research Article
Hoarding Disorder in Older Adulthood