Article Archive
January/February 2020

Hoarding — A Hazard for Older Adults
By Lindsey Getz
Today’s Geriatric Medicine
Vol. 13 No. 1 P. 10

Hoarding—estimated to affect between 2% and 5% of the population—can be dangerous to anyone, particularly when it spirals out of control. But for certain groups, it can create dire circumstances. In fact, the risks associated with hoarding are more likely to be a serious threat to the health and safety of older adults.

There are a number of potential risks associated with hoarding, some of which seem to be exacerbated by age, says Catherine Ayers, PhD, ABBP, an associate clinical professor of psychiatry at the University of California, San Diego, and a leading researcher on hoarding. The primary problem, Ayers says, is that hoarding creates mobility risks—difficulty moving around the residence because of the accumulation of items. Since physical mobility may already be an issue for older adults with health concerns such as arthritis or back problems, hoarding compounds it.

“In particular, late-life hoarding poses a significant fall risk by creating trip-and-fall hazards throughout the home,” Ayers says. “Other risks include fire hazards, poor hygiene and nutrition, and poor sanitary conditions. Hoarding can make it challenging to move around the home, and, therefore, the use of basic facilities can be impeded. Individuals might no longer have easy access to their bathtubs or showers or even to their refrigerators. Hoarding sometimes makes it impossible to open doors or windows, which is when fire hazards become a serious risk.

“There have been reports of first responders who have not been able to gain easy access to a victim due to hoarding,” Ayers adds.

Additional Risks to Older Adults
Hoarding also can lead to disorganization or an increased likelihood of losing things, says Gail Steketee, PhD, dean emerita and a professor emerita of Boston University School of Social Work and coauthor of Stuff: Compulsive Hoarding and the Meaning of Things. “For an older adult, this can create a serious issue if they lose medications or misplace important medical or household bills in the many piles of belongings they have created,” Steketee says. “Oftentimes, people with hoarding problems save almost everything, so it becomes quite difficult for them to distinguish items that are important from those that are not. Something as simple as sorting mail becomes an overwhelming task,” she says.

To put it simply, hoarding can make the home environment hazardous—even if the individual was once able to manage it just fine, says Monika Eckfield, PhD, RN, an assistant professor of nursing at the California State University, East Bay, whose primary areas of expertise are gerontology, mental health, and hoarding disorder. Those piles and piles of newspapers were once easy to step over but now pose a serious threat, Eckfield adds. “It’s important to recognize that hoarding can affect men and women of all ages,” she continues. “The trouble with older adults is that the hoarding disorder is exacerbated by issues relating to their age, such as changes in vision, a decline in their energy level, or even the onset of chronic health problems. Whereas they were once able to still function with their hoarding tendencies, their age has now made it increasingly hazardous to their well-being.”

A Hoarding Diagnosis
According to the American Psychiatric Association, people with hoarding disorder excessively save items that others may view as worthless. They have persistent difficulty getting rid of possessions, with distress linked to parting with items. This leads to clutter that disrupts their ability to use their living or work spaces.

The cause of hoarding remains unclear. However, genetics, brain functioning, and stressful life events are all being studied as possible causes. “It’s not a problem that starts when the individual is older,” Steketee says. “Most people can trace behaviors back as far as childhood or their teenage years.” While some experts say it is unclear whether the hoarding habits themselves worsen with age or simply that the individual’s ability to cope with the hoarding habits worsens, there’s no question that the disorder has a greater impact on older adults.

A study published in The American Journal of Geriatric Psychiatry found that the prevalence of provisional hoarding disorder diagnoses increased linearly by 20% with every 5 years of age.

People with hoarding disorder are also likely to experience other mental health disorders including depression, anxiety, obsessive-compulsive disorder, and ADHD. According to the Mayo Clinic, there are also risk factors that may make hoarding more likely. These include the following:

• Personality. Many people who have hoarding disorder have a temperament that includes indecisiveness.

• Family history. Development of the problem is more likely when a family member also has a hoarding disorder.

• Stressful life events. Some people develop hoarding disorder after experiencing a stressful life event that they’re struggling to cope with, such as death, divorce, or losing possessions in a fire.

More Than Just Messy
Of course, many may wonder where exactly the line is drawn between messiness and hoarding. After all, household clutter is a common problem, and even when older adults aren’t necessarily struggling with hoarding, they may still tend to keep more than perhaps they should.

Like every other mental health issue, hoarding is on a continuum, Eckfield says, and the line at which a disorganized person actually becomes a hoarder isn’t exactly black and white.

“Where we would think about hoarding as a clinical concern is the point at which it causes impairment,” Eckfield says. “If it is interfering with the individual’s ability to function in their home or to use the spaces in their home to the fullest, then we would think of that as more than just messy or disorganized living, but as something that is creating a problem.”

Ayers adds that it also has a lot to do with the behaviors associated with keeping the items. In other words, she says, there could be someone who has “a lot of stuff,” but isn’t necessarily compelled by any strong urges to hold on to it.

“Where we start to think of the threshold shifting toward hoarding behavior is when the individual experiences great distress over even the thought of discarding items,” Ayers continues.

An important distinction is that hoarding disorder is different from “collecting.” According to the Mayo Clinic, people who have collections—eg, stamps or model cars—deliberately search for specific items, categorize them, and carefully display them. Although collections can be large, they aren’t usually cluttered and don’t cause distress and impairments that are associated with hoarding.

“There is very commonly a strong disorganized component to hoarding,” Steketee says. “The vast majority are somewhat challenged in regard to that particular cognitive capacity. They feel overwhelmed by the prospect of organizing things and wind up with massive amounts of clutter—unable to find where items are located.”

That’s not to say there isn’t a sentimental attachment to these items, Steketee adds.”People with hoarding are incredibly attached to items,” she continues. “They might call them beautiful or important or useful. They are excessively attached, so much so that the idea of getting rid of anything is devastating.”

Over the years, Eckfield has interviewed numerous individuals with hoarding disorder and says that many have said their behavior had manifested from being “frugal” or “resourceful.”

“Many of these folks are living on a fixed income and find it difficult to get rid of something that is still perfectly useful for the fear that once they get rid of it, they’ll need it,” she says. “They may worry that if they need the item again in the future, that they won’t have the funds.”

The Social Factor
The experts agree that beyond health impairments, those who cross the hoarding threshold also experience significant social impairments.

“Hoarding has an incredible impact on social functioning,” Ayers says. “There is shame and embarrassment associated with the state of their home and they stop inviting people over. Sometimes it also causes problems within families when someone steps in and tries to help. More often than not, these individuals are living alone.”

The fact that many individuals with hoarding behavior live alone can actually lead to additional problems. For one, Eckfield says, older adults who have lost a spouse to divorce or death may see their hoarding tendencies spiral out of control once they’re on their own. “Perhaps this individual has always had hoarding tendencies, but a spouse was able to keep it in check,” she continues. “They may have been able to keep at least the common areas tidy or might have been the one to sort the mail and prevent paperwork from piling up. But once this person is gone, those hoarding tendencies may become a significant problem.”

Given the probability that these individuals live alone, it’s quite common for hoarding to be done completely in secret.

“It’s usually a relative that helps bring the problem to light,” Steketee says. “But sometimes, if the person is in public housing, an inspection might reveal the problem. If a pipe bursts or a serviceperson has to check on the oil, the problem may ultimately get reported to the Department of Aging over the concern that this person is at risk. Unfortunately, the person is often reluctant to bring the problem to light him- or herself.”

Treatment Options
The main treatment for hoarding disorder is cognitive behavioral therapy, which can be quite effective.

Steketee says the first approach to treatment generally focuses on reducing any excessive acquiring that’s still taking place. For example, if the individual is still purchasing or picking up free items at a regular rate, the first goal would be to stop that behavior. Then, a therapist would also focus on helping clients develop some organizing skills and systems that work for them in regard to the items that they want to keep.

“Moving on to the phase of discarding is the most challenging step,” Steketee says. “For someone with a serious hoarding problem, it’s a lengthy process that needs to be done with a clinician or peer support group involved. It involves difficult emotional decisions and the individual will need a lot of support.”

Steketee says that in her treatment experiences in working with patients with hoarding, this process has commonly taken six months to a year.

Eckfield agrees that the discarding process will require support. She recommends starting in a common area and going for the “low-hanging fruit” before tackling more difficult matters.

“Maybe someone is willing to start by discarding newspapers that are from the 1990s or earlier,” she says. “As the individuals start making decisions to discard those items, they often see that it’s not as bad as they thought it would be. Take time to reflect on the process and see how the person is doing. Then keep moving from there.”

Eckfield says that most people tend to find the bedroom to be the hardest space to work on, so it should not be the place in which the process begins. Instead, she suggests starting in common areas such as the kitchen or bathroom—spaces that are also often most vital for the person to be able to use.

“Help the person envision their goal and come up with small, achievable steps they can take to get there,” she says. “Gentle nudges are helpful but be careful not to make the process more stressful than it has to be.”

Treatment—specifically the discarding phase—requires a group of people and often multiple agencies.

“For us, as we would gain momentum with older adults in treatment for hoarding, we would bring out a team of students to the house—generally young undergrads studying hoarding—and they would do the heavy lifting,” says Ayers of her work on hoarding at the University of California, San Diego. “It’s important that the older adult is the one making the decisions, but in terms of the physical labor, a young person is handling that. The key is that it’s a client-driven approach.”

According to Ayers, the good news is that it works.

“Treatment can absolutely be successful,” she says. “But it’s important that the individual is willing to engage in the treatment. Once they start to learn new skills and participate in daily discarding, the success builds and they start to see real results. We’ve had great outcomes with older adults.”

As mental health in general is getting more attention, Ayers adds that she’d like to see increased awareness of hoarding disorder. She says it’s important that providers and others involved in the care of older adults are on the lookout for hoarding behaviors.

“Compared to other mental health disorders like anxiety, the prevalence rate for hoarding is actually higher, and yet it seems to not be on everyone’s radar,” Ayers adds. “We need to be asking the proper questions, the three most important being: Do you have a lot of items in your home? Does the number of items in your home make it difficult for you to use your home? And, do you have a difficult time discarding items? If the answers to those questions is yes, then I would advise that providers pursue the issue further. If we can increase awareness, it could make a big difference in the lives of older adults living with hoarding disorder.”

— Lindsey Getz is an award-winning freelance writer in Royersford, Pennsylvania.