The Complexities of Hoarding Among Older Adults

It wasn’t what I had expected to walk into. I had been called in to help an academically distinguished older woman find the best senior living option to meet her needs. All I had known about her prior to this meeting were two things: 1) Her home was worth $1.5M and 2) She was professionally successful but personally drowning under the physical and mental clutter that surrounded her. I was not prepared, emotionally or physically, for what I was about to experience. I knew in that moment I needed to partner with a tribe of experts who understood the sensitive and psychological challenges she was experiencing. I am happy to say that with a lot of time, patience and ongoing support, my client is now thriving in her new setting! 

If you are reading this, you may be personally supporting someone with Hoarding Disorder (HD) or professionally providing services to the elder population. There is still very little known about this disorder, but this article aims to provide the basics and outline some available resources.

Many people living in deplorable conditions are able to keep their circumstances a secret from the world for a very long time. The causes and symptoms of Hoarding Disorder typically have been with someone for most of their life. 

Hoarding is certainly not a new phenomenon, affecting approximately 2-5% of today’s adult population. It was only in 2013 that the Disorder was classified as a distinct mental disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V, 2013). Hoarding Disorder is assigned to individuals who excessively save items and have great difficulty parting with these items, so much so that it may impair functioning and create health and safety risks. 

While hoarding is a complex disorder that requires dynamic interventions, the literature is clear on what a successful intervention does not look like. Evidence indicates that one-time forced removal of clutter, or “clean sweeps”, may actually exacerbate and perpetuate hoarding because it does not address the underlying causes. However, home clean-out remains the most commonly sought form of help, especially for non-extreme cases. And although mental health treatments such as cognitive behavioral therapy are highly recommended, they are used in fewer than 20% of cases. The best approach is to use a collaborative, multi-disciplinary, community hoarding task force that includes mental health support which is true for all populations, including older adults and individuals who resist the help.

Understand the Hoarder’s History, Behaviors and Relationships

PHYSICAL APPEARANCE OF PERSON OR HOME – Do you notice a body odor or unkept clothing/hair? Or, do you visit the home and notice from the outside that it seems unmaintained?

BEHAVIORS – When you ask to visit the individual’s home or refer to services, are you consistently turned away or told they are not in need of assistance? Take notice of habits outside the home (i.e. visiting the Senior Center for many meals or use of bathroom for personal care).

CHANGE IN SOCIALIZATION – Look for changes in the engagement of the individual (someone who was once social is now self-isolating).

TAKE THE TIME – Since the common denominator in many cases is a lack of personal relationships, trust is going to need to be built over time with the person in order for them to let you in to help them both physically and emotionally.

PHYSICAL DANGER – Look for increased risk of falls or inability to move around due to extreme clutter. Keep note of a lack of durable medical equipment (DME). 

REFUSING HELP – Observe resistance to allowing anyone visit their home, whether family, professionals, or services like VNAs, Meals on Wheels or Elder Services.

HEALTH – Signs of injury such as lacerations, bruising, skin conditions, scalp/hair condition, overall weakness and cognitive decline are all signs of deteriorating health.

MEDICATIONS – How are they being stored, organized, consumed and managed? Notice the potency of medications being taken. 

INFLUENCERS – Ask if there are other key influencers in this person’s life such as providers, friends, community support, church members, family or other professionals you can connect with to learn more about this individual’s baseline behavior and hear of any recent changes in personality or health. 

Common Characteristics of Hoarding Disorder:

• Over-generalizing
• All-or-nothing thinking
• Emotional reasoning vs. logic
• Perfectionism
• Avoidance 
• Indecisiveness 
• Exaggeration
• Procrastination
• Jumping to conclusions
• Moral reasoning

There are two main treatments for Hoarding Disorder

Motivational Interviewing is a collaborative person-centered therapy with the goal of inspiring and strengthening motivation for change. This treatment imposes a change that matches the individual’s own values & concerns, rather than contradicting them. The counselor or therapist uses a foundation of trust and empathy to help the individual explore why they feel “stuck” or unable to change their behavior. The ultimate goal is to help someone realize their own personal and genuine motivation for changing problem behaviors. Argument and confrontation are avoided, as these are counterproductive to gaining the person’s trust and improving their symptoms.

Cognitive Behavioral Therapy: This treatment works by changing people’s attitudes and behavior by focusing on their thoughts, images, beliefs & attitudes, particularly when the individual is responding to an emotionally difficult situation. For example, you could identify and challenge the thoughts and beliefs related to acquiring and saving items. This approach will help the person learn to resist the urge to collect more objects, while developing the decision-making skills needed to discard items and organize what is left.

GOALS of CBT:

• De-clutter the home during in-home visits by a therapist, coach or professional organizer
• Learn to reduce isolation & increase social involvement with more meaningful activities
• Learn ways to enhance motivation for change
• Attend family or group therapy
• Periodic & ongoing treatment to maintain positive progress.

Hoarding Disorder is a complicated diagnosis with the need for ongoing clinical support. If you know someone suffering from HD and want additional information, please visit www.dovetailcompanies.com or call 617-227-1600 to learn more about available resources.