Hoarding in the Elderly: A Challenge to Home Care

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Hoarding in the Elderly A Challenge to Home Care

• Mary Ann Forciea MD, FACP
• Associate Professor of Clinical MedicineDivision
  of Geriatric Medicine
• UPHS

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Why am I (or my team) here?

• This is a common and frustrating problem for us
• Hoping to learn some diagnostic tips
• Hoping to learn some management tips
• Want a chance to vent frustration at the system
  of care available to these patients.
• Like to see my colleagues.
• Always wanted to try this restaurant

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Why am I (or my team) here?

1. This is a challenging problem for us
2. Want a chance to vent about these patients
3. Like to see my colleagues
4. Always wanted to try this restaurant
5. Want to see if UPHS has any better ideas than we
   do

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Key questions for this seminar

• Is hoarding in older patients different than in
  younger patients
• What are the critical clinical questions in the
  evaluation of patients with hoarding?
• What treatment strategies can be attempted?
• What resources are available in the Delaware
  Valley?

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Case- DR

• 78 yr old lady, widow with 2 children
• Living in Senior housing
• Call from facility SW (Friday at 4PM)
• Increasing complaints from neighbors about
  cleanliness of apartment
• Apartment visit that day
• Toilet overflow, clutter, attire
• Home health aide refusing to return
• Facility considering eviction

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Case continues 2

• gt40 yr history of bipolar disorder
• Has medications
• Multiple barriers to ongoing psychiatric care
• Diabetes mellitus with peripheral neuropathy
• Venous stasis
• DJD of knees, hips, LS spine increasing
  immobility

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Case 3 prior history

• Third dwelling while part of our primary care
  program (8 yrs)
• Clutter an issue in each site
• Mania associated with requests for DME
• Progressive mobility dependence
• Third move precipitated by loss of driving
  privileges

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Added information

• Visited patient one week ago
• Called patient after SW call
• Admits to overwhelming apartment situation
• Blame exclusively on building management
• Admits to progressive URI over past week
• Reluctant to agree to ED or hospital visit
• Home care team urgent conference call

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Living room(close to hers google images)
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Bedroom(close to hers google images)
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Options

1. Sign out to weekend covering partner
2. Temporize by offering a Monday medical house call
   visit by your team
3. Arrange transport to ED for evaluation
4. Directly admit to your inpatient service

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Hoarding DefinitionSaxena 2007

• Collecting
• excessive quantities of
• Poorly useable items
• Of little value
• Failing to discard items
• Interference with function

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Excessive acquisition

• Buying
• Accumulation of free things
• Received
• Sought out (dumpster diving
• Motivation
• thrill
• therapy for unpleasant feelings (?retail
  therapy)
• Fear of missed opportunities

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Failure to discard

• Most easily recognized
• Motivation
• Sentimental value
• Wasteful to discard
• Might be useful in the future
• Decreased ability to group/sort items
• Poor organizational skills

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Interference with function

• Clutter cannot use space or object for its
  intended purpose
• Functional status cannot walk through
  apartment, bathe, cook\
• Consequences
• Eviction, health concerns, fire risks

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Risks of hoarding

• Social dysfunction
• Functional disability
• Falls
• Fires
• Unsanitary conditions

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Is hoarding a psychiatric disorder?

• Associations
• OCD
• Schizophrenia
• Dementia (especially fronto-temporal)
• Mood Disorders
• Not currently listed in DSM-IV, will likely be
  listed in DSM-V
• Little attention to older patients with hoarding
  behaviors

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FTD vs ADMiller et al Neurology 1997
Symptom FTD /30 AD /30
Insidious onset 29 30 NS
Early loss of personal social awareness 22 1 lt0.0001
hyperorality 22 0
Perseverative behavior 19 1
Emotional unconcern 24 6
Progressive reduction in speech 24 0
Stereotypy of speech 20 2
Praxis 29 5
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Natural history of hoarding

• Chronic problem with gradual worsening across
  lifespan
• 80 of patients report symptoms by age 18
• Late onset patients more often have a stressful
  life event at initiation
• Familial component
• 85 of hoarders describe a 1st degree relative as
  a packrat

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Distinctions in Older Patientswith Terrible
Decline

• Hoarding versus self care deficit?
• Or both
• Long term or acute?
• Decisional capacity?
• Severe enough to warrant coercive action?

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Assessment tools

• Clutter Hoarding Scale
• Institute for Challenging Disorganization

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In treating these patients, we have tried

1. SSRIs
2. Cholinesterase Inhibitors
3. Cognitive/behaviroal therapy
4. Occupational therapy consultation

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I have been satisfied with the outcomes of my
therapy

1. Yes
2. No

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My patients have been happy with the outcomes of
therapy

1. Yes
2. No

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Treatment

• Medications
• SSRI possibly less effective in older patients
• Cognitive behavioral therapy
• Information processing deficits
• Help sort into larger clusters
• Maladaptive beliefs
• I am a craftsman because I own tools
• Attachment to possessions
• Sentiment, control
• Interprofessional team management

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Self care deficit
The result of an adults inability due to
diminished capacity to perform essential
self-care tasks such as providing essential food,
clothing, shelter, and medical care obtaining
goods and services necessary to maintain physical
health, mental health, emotional well-being and
general safety and/or manage financial
affairs.
-APS
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Self-Neglect DefinitionPavlou and Lachs JGIM
2008

• A Self-neglector is a person who exhibits 1 or
  more of the following
• 1) persistent inattention to personal hygiene
  and/or environment
• 2) repeated refusal of some/all indicated
  services which can reasonably be expected to
  improve quality of life
• 3) self endangerment through the manifestation of
  unsafe behaviors (e.g. persistent refusal to care
  for a wound, creating fire hazards in the home)

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Self-neglect

• Annual incidence 5.2 per 1000 elders
• Self-neglect 50-75 of elder mistreatment
• 90 of all self-neglect APS 65y/o
• ? gt ?
• Decreased survival 40.3 died within 13 years
  follow-up
• Self-neglect patients more likely to die in NH
  
• 
  Lachs et al. JAMA 1998

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Clinical evaluation

• Dementia
• Depression
• If acute, look for medical problem
• Stroke, infection, medication effect
• Determination of decisional capacity

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Treatment

• Often emergency-related
• Hip fracture, pneumonia, police incident
• If incapable of decisions
• Refer for competency determination and
  guardianship
• Placement likely
• If capable
• Inform of helpful services
• Documentation of preferences for Advance Directive

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Assessment tools

• Self neglect severity scale
• -Houston Geriatrics group

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Personal appearance of subjectHair
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Nails
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House
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Home Environment
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Bathroom
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Self Neglect Severity Scale
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Decisional capacity

• Competence a legal determination in court
• Appointment of a guardian
• Of the person (medical decisions)
• Of finances
• Decisional capacity a clinical decision
• Decision specific
• Hierachies of decisions
• Most basic decisions honored even in presence of
  some impairment
• May make low stakes decisions even if unable to
  make high stakes decisions

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Elements of Decision Making

• Ability to communicate a choice
• Ability to understand and retain relevant
  information
• Ability to appreciate the situation and
  consequences for oneself
• Ability to manipulate information rationally

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Ability to appreciate situation for oneself

• Acknowledge that condition is present
• Realizes that risks and benefits apply to him/her
• May involve understanding of motives for choices
• What will happen if you refuse treatment? If you
  accept?

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Manipulates information rationally

• Reaches conclusions that are logically consistent
  with starting premises
• Again, may involve description of motives
• Please help me to understand why you decided to
  accept/refuse treatment

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Summary

• Older patients with hoarding behaviors have
  higher likelihood of co-existing dementia
• Time course of progression is critical
  information
• Hoarding and self neglect frequently co-exist in
  older patients
• Assessment tools can help guide team planning and
  follow-up
• The determination of decisional capacity is often
  critical
• Local regulation about safety standards is
  important in action steps

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The Eye of the Beholder
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Resources/References

• The Institute for Challenging Disorganization
• www.challengingdisorganization.org
• Valente, Sharon. The Hoarding Syndrome. Home
  Health Care Nurse 27432. 2009
• WWW.homehealthcarenurseonline.com
• Guilliam, CM and Tolin, DF. Compulsive Hoarding.
  Bulletin of the Menniger Clinic 7493. 2010.
• Dyer, CB et al. Self-neglect among the elderly
  Am J of Public Health 971671.2007