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Understanding Hoarding in Older Adults

Learn about the core features, nature, and causes of hoarding in older adults, and discover strategies for addressing this issue. Presented by Dr. Peggy M.A. Richter, an expert in OCD and related disorders.

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Understanding Hoarding in Older Adults

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  1. Hoarding in Older Adults: What You Need to Know! Peggy M.A. Richter,MD, FRCPC Director, Clinic for OCD and Related Disorders Associate Professor of Psychiatry, University of Toronto Peggy.Richter@sunnybrook.ca

  2. Objectives At the end of this presentation, you will be: • Familiar with the core features of hoarding • Aware of current thinking regarding nature and causes of hoarding • Able to identify appropriate strategies for hoarding

  3. Disclosures In the last 3 years: • On National Advisory Board for OCD for Lundbeck • Honoraria from Lundbeck • Research fellow funded by Eli Lilly • Research studies funded by Lundbeck

  4. The Collyer Brothers

  5. OCD - Diagnosis Obsessions persistent unwanted thoughts, images, or impulses Intrusive, uncontrollable/excessive provoke anxiety Compulsions repetitive behaviours or mental acts performed in response to an obsession, or in ritualistic fashion intended to reduce discomfort or prevent feared event Severity: symptoms must cause marked distress occupy > 1 hour/day OR significantly interfere with functioning

  6. Current Obsessions/Compulsions in 182 patients Aggressive Contamination Symmetry Somatic Hoarding Religious Sexual 68.7% 57.7% 53.2% 34.1% 30.2% 24.2% 19.8% • Checking • Washing • Repeating • Ordering • Counting • Hoarding • Miscellaneous • 80.7% • 63.7% • 55.5% • 40.1% • 35.2% • 28.0% • 59.3% Summerfeldt, Antony, Downie, Richter and Swinson 1997

  7. Is Hoarding OCD? Hoarding ‘Obsessions’ Intense preoccupation with belongings However: Not intrusive Not resisted or unwanted Not distressing Hoarding ‘Compulsions’ Rachman, Elliott, Shafran & Radomsky, BRAT, 2009 • Acquisition/sorting /protection of possessions However: • Acquisition/collecting of things generally enjoyable • Not generally ritualistic • Not distressing

  8. Definition of Hoarding • Persistent difficulty discarding or parting with possessions, regardless of their actual value • A living space sufficiently cluttered in a manner that precludes activities for which the space was designed • Significant distress or impairment in functioning caused by hoarding (including maintaining a safe environment for self and others) • Hoarding not caused by other mental disorders (e.g. dementia, BAD, MDE) or a general medical condition (e.g. brain injury, cerebrovascular disease) Specify: With Excessive Acquisition Insight (Good/poor/absent) Frost & Hartl, 1996; Steketee & Frost, 2003; Grisham et al, 2007; DSM-5

  9. Publication Trends in Hoarding Research Mataix-Cols et al, 2010

  10. The OCD Spectrum Preoccupation with Body Appearance or Sensation Impulse Control Disorders Bulimia Nervosa Pathological Gambling Kleptomania Sexual compulsions Self injury Trichotillomania BDD Anorexia Nervosa Hypochondriasis Obsessive Compulsive Disorder Autism Sydenham's Chorea Tourettes and other tic disorders Huntington's Chorea Hoarding Neurological Disorders

  11. Manifestations of Hoarding: 1. Compulsive Acquiring 2. Saving 3. Disorganization Steketee & Frost, 2007

  12. Manifestations of Hoarding:1. Compulsive Acquiring • Compulsive buying • Retail/discount • Ebay, web shopping • Home shopping network • Compulsive acquiring of free things • Advertising flyers/handouts • Give-aways • Trash picking, dumpster diving Steketee & Frost, 2007, Frost et al, 2009, Koran et al, 2006

  13. Compulsive Buying(compulsive shopping, oniomania) Characterized by: Preoccupation with shopping, or intrusive buying impulses Clearly buying more than is needed/affordable Distress Interference with functioning Prevalence 2-8% in U.S. Women: clothes, shoes, jewellery, makeup Men: electronics, hardware, car products Odlaug & Grant, 2010; Koran et al, 2006; Mueller et al, 2009

  14. Manifestations of Hoarding:2. Saving • Reasons for saving • Sentimental “this helps me remember. This represents my life. It’s part of me. • Instrumental “I might need this. I could fix this. Somebody could use this. Think of the potential!” • Intrinsic “Isn’t this beautiful • Hoarders apply these reasons to more things Steketee & Frost, 2007

  15. Manifestations of Hoarding:3. Disorganization • Condition of the home • Clutter • Mixture of important and unimportant items • Behaviour • Fear of putting things out of sight • Indecisiveness – churning • Categorization problems May be slow at completing tasks, frequently late, use circumstantial/over-inclusive language Steketee & Frost, 2007; Saxena, 2008

  16. Characteristics of Hoarding • Community prevalence 2.3-6% • Prevalence in OCD: 30% • Rate increases with age: 2.3% aged 34-44, 6.2% among age 55 and above • Mean age of onset of hoarding symptoms: 13 • 60% report onset by age 12 • Course of illness: typically chronic • Average age at treatment = 50 • Education ranges widely • Tend to be single, live alone • Low marriage rate, high divorce rate Koran et al, 2006; Mueller et al, 2009; Samuels et al, 2008; Grisham et al, 2006 Steketee & Frost, 2007; Tolin et al, 2010

  17. Characteristics of Hoarders • Squalid conditions uncommon among treatment seekers • Insight is limited; recognition of problem typically develops much later than symptoms • May be precipitated by loss or deprivation • Hartl et al, 2005: hoarders reported greater frequency of traumatic events than controls • Having something taken by force • Rough physical handling • Forced to engage in sexual activity • Cromer et al, 2007: among OCD sufferers, hoarders experienced significantly more traumatic events

  18. Hoarding is associated with childhood adversity... -Community-based study of 742 individuals -prevalence of hoarding was 3.7%, 5.3% weighted prevalence Samuels et al, 2008

  19. From: Anderson et al. Reasons to Accumulate Excess. Home Health Care Services Quarterly, 27(3), 2008

  20. > • N=18 older adults (> 60, mean age 67.5 years)

  21. > • Conclusions: • Hoarding symptoms typically started early, and always before age 30 • Hoarding severity increased with age • ~50% had other psychiatric disorders, but only 16% had OCD • Compulsive hoarding was grossly underdetected and untreated (only 2/13 received tx for hoarding)

  22. Diogenes Syndrome • Also known as • Senile squalor syndrome • Social breakdown syndrome • Syndrome of extreme self-neglect • First recognized in 1966 • Named by Clark et al, 1975 Macmillan & Shaw, BMJ. 1966; Clark et al, Lancet, 1975

  23. Diogenes Syndrome Characterized by: • Domestic squalor • self neglect • Social isolation • Hoarding of rubbish (syllogomania) • Lack of shame Clark et al, Lancet, 1975;Cybulska & Rucinski Br. J Hosp Med. 1986; Rosenthal et al, Isr J Psych Relat Sci 1999

  24. Features of Diogenes Syndrome • Annual incidence: 5-10/10,000 for >60 yr olds • M= F • Majority live alone, but “squalor a deux” also reported • More prevalent in upper social classes • Clark et al: N=30, most highly successful professionals in earlier life • Only 50% have Axis I Disorder • Often associated with frontal lobe dysfunction (Orrell et al, 1989) Clark et al, Lancet, 1975;MacMillan & Shaw, Br Med J, 1996; Reyes-Oritz, Compr Ther, 2001; Snowdon & Halliday, Int Psychogeriatric, 2011

  25. Outcome of Diogenes Syndrome • Most have significant physical illness cardiac failure bronchopneumonia pulmonary embolism Parkinson’s disease osteoarthriitis gangrene malignancy leukemia cervical spondylosis renal failure • Mortality rate following hospitalization: 50% • 5-year mortality rate: 46% • Follow-up studies show little change in living situations after interventions Clark et al, Lancet, 1975; Ngeh, Ger. Psych 2000; Reyes-Ortiz, 2001; Hanon et al, 2004

  26. Grey Garden

  27. Not all hoarders have a mental condition… • Only 50% have an identifiable mental disorder • among cases with severe domestic squalor: dementia (22%) schizophrenia/schizoaffective disorder (21%) substance use disorder (10%) • OCD most common in cases referred to therapists • Frost et al, 2011: studied N=217 hoarders • 18% hoarders had OCD • High comorbidity with depression, anxiety (similar to OCD) • Hoarding associated with ADHD (28% vs. 3% in OCD)

  28. “Organic” hoarding versus Hoarding Disorder Mataix-Cols, Pertusa & Snowdon, J of Clinical Psychology: In Session, 2011

  29. The health burden of hoarding

  30. What is Hoarding??? OCD? complication of multiple aging-related conditions? independent condition?

  31. Why do people hoard? Ethological Cognitive Neurobiology Learning Theory LIFE EXPERIENCE Behavioural Genetic

  32. “Genetics play a large part in it…for example, if your parents didn’t have any children, you won’t either!”

  33. Is Hoarding Genetic? • Hoarding runs in families • 50-85% of hoarders report 1st degree relative who is a “packrat” • 26-54% report family members with OCD • Heritability of hoarding is 71% • In a study of >5,000 twins, genetic factors accounted for 50% of variance, along with nonshared environmental factors, error • Genetic studies suggest hoarding ≠ OCD Saxena, 2008; Mathews et al, 2007; Zhang et al, 2002; Samuels et al, 2007; Iervolino, 2011

  34. - N=3,410 twin participants (2,350 singletons) • completed Hoarding Rating Scale Self-Report • genotyped on Illumina 317 K or 610 K

  35. Brain Structures Central to OCD Striatum: Putamen Caudate Corpus Callosum Thalamus Anterior Cingulate Anterior Cingulate Prefrontal Cortex Thalamus from Rosenberg et al., 2000

  36. Do OCD Dimensions Have Differing Neuroanatomical Correlates? Saxena et al, Am J Psych, 2004

  37. From: Anderson et al. Reasons to Accumulate Excess. Home Health Care Services Quarterly, 27(3), 2008

  38. Treatment of Hoarding • Pharmacotherapy • Cognitive-Behavioural Therapy (CBT) • Combined Multi-Modal Treatment

  39. Meds OR CBT?Issues to Consider in Initiating Treatment Severity Insight Comorbidity Personality factors Motivation Availability of treatment Consider CBT For Every Patient!

  40. OCD: Choice of Medications First Line SSRIs (Prozac, Luvox, Zoloft, Paxil, Celexa, Cipralex) Second Line Clomipramine(Anafranil) Venlafaxine(Effexor) Mirtazepine(Remeron) Adjunctive Therapy Antipsychotics (risperidone, olanzepine, quetiapine, *haloperidol) 2nd Line Adjunctive Therapy Topiramate, Pindolol, Memantine, Riluzole Gabapentin, D-amphetamine, weekly oral morphine, Tramadol, Clonazepam * Only for patients with poor insight, tics, or schizotypal personality

  41. Drug Treatment for Hoarding • ASSUMPTION: • hoarders do less well with tx • EVIDENCE: • results are mixed on OCD-related hoarding (Saxena et al, 2011) • i.e. Saxena et al study • Treated 12 weeks with paroxetine<60 mg daily % Saxena et al, 2007

  42. Pharmacotherapy - General Principles • Treatment goal: improvement, not remission • OCD response may be independent of depression response • Higher dosages better • 6-10 week lag to initial response • Adequate trials require 12-15 weeks • should allow at least 6-10 weeks at maximal dosage

  43. CBT for Hoarding

  44. OCD: Psychological Treatment Fear responses fade over time if there is no real danger Avoiding feared situations makes the fear stronger Rituals make the fear stronger Staying in the feared situation lessens the fear From Swinson, 2001

  45. Reinforcement process • Immediate positive emotions reinforce acquiring and saving • Immediate negative emotions with discarding lead to avoidance • Avoidance prevents • opportunity to test beliefs • development of alternative beliefs Steketee & Frost, 2007

  46. CBT for Hoarding Core components: • Psychoeducation • Cognitive strategies to address hoarding beliefs (meaning of possessions) • Must target 1. Acquiring 2. Discarding 3. Clutter • Organizing/decision making (associated with information processing deficits) Steketee & Frost, 2007; Muroff et al, 2009

  47. Treatment rules • Therapist does not touch possessions without permission • All decisions made by the client • Only Handle It Once • Categories established first • Help client establish own rules for saving and discarding • Clients must think aloud while sorting possessions • Treatment proceeds systematically • In = Out Steketee & Frost, 2007

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