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Hoarding Hazards
By Barbara Worthington

Imagine a dwelling piled floor to ceiling with trash and garbage to the extent that it’s possible to navigate from room to room only through a series of tunnels carved through the debris. Inconceivable? Difficult as it may be to envision, such living conditions exist—and likely more extensively than we realize.

In fact, this scenario characterizes precisely the way a 74-year-old man met his demise in England in early January, according to the Daily Telegraph. When neighbors expressed concern about not having seen their aging friend for several days, police forcibly entered the man’s home. The scene they encountered personified hoarding at its most frightening extremes.

A specialty search and recovery team was required to locate the body of the eccentric man who apparently died of dehydration amid the cardboard boxes and litter that made it a challenge to move around within the house, according to the newspaper account. The occupant’s disorientation likely had prevented him from satisfying his own basic needs.

The septuagenarian kept mostly to himself, his neighbors noted, and had recently become a bit of a hermit. The house’s rubbish was reportedly visible from the street and attracted rodents to the site.

The hoarding pattern, often attributed to eccentricity, is becoming more familiar. But experts acknowledge that hoarding in older adults can escalate to the point where it creates living conditions that are isolating and dangerous.

What Causes Hoarding?
Hoarding in older adults doesn’t suddenly begin as elders pass into their later years. “Hoarding or cluttering begins many decades earlier,” says Patrick Arbore, EdD, director of the Center for Elderly Suicide Prevention and Grief Related Services Institute on Aging in San Francisco. “Older adults hoard because it is a pattern that began years ago in response to some experience that was not discussed or resolved.”

It’s estimated that nearly 1 million Americans exhibit hoarding behaviors, according to Arbore. “Because of the tendency for people who hoard to hide their behavior, the actual numbers are hard to define,” he says.

Items older adults accumulate, sometimes to excess, include newspapers, magazines, clothes, and even trash. “Some things are saved for sentimental or emotional reasons,” says Randy O. Frost, PhD, a professor in the department of psychology at Smith College in Northampton, MA. “They remind them of important people, places, or events. They can also serve as parts of their identity.”

“Many people who hoard feel like they are losing a part of themselves when they get rid of things,” Frost adds. “Some things are kept because they are signals of safety in a threatening world.” He says some hoarders save items because they believe they need them, while others take to excessive collecting for emotional reasons.

Incidents or circumstances that trigger hoarding in older adults “vary according to the problems that individuals experience as children and adolescents,” says Arbore. He notes three particular characteristics that contribute to hoarding: compulsive acquisition, difficulty discarding possessions, and disorganization in many areas of an individual’s life.

Research shows that older adults with tendencies toward hoarding don’t fit a particular profile, according to Arbore. “Any person can become a hoarder,” he says. Although men can become excessive hoarders, statistically, women are more likely to hoard things, Arbore says. That may be because women live longer than men, allowing their excessive collecting to grow out of control, he speculates. Additionally, he says, “Hoarding behavior increases due to a senior’s physical frailty or features of dementia.”

Frost agrees that there’s no single personality or type of person who’s likely to tend toward hoarding. But, he says, “Many hoarders have certain characteristics that are associated with the behavior.” One of them is difficulty making decisions. “It takes them long periods of time to make decisions of any kind,” he says. Another characteristic is perfectionism. “They [hoarders] are driven by the fear of making mistakes,” he adds.

Although some older adults with dementia have tendencies toward hoarding various items, “The vast majority of people who hoard do not have dementia,” says Frost. Many people who hoard things don’t look on excessive accumulations of items or trash as problematic. “Some complain about the clutter but insist that it is reasonable to acquire and save all the things they do,” he says.

“Hoarding is a compulsive, repetitive behavior that people appear to have an inability to curb,” says Arbore. He acknowledges that most hoarders are competent. However, most older adults with dementia symptoms may develop an increase in their hoarding because their short-term memory has been affected.

Potential Consequences
The most serious results and frightening consequences of older adults’ hoarding are related to health and safety issues. Stacks of newspapers or magazines or rooms stacked with boxes or trash present hygiene and safety issues, in addition to creating fire hazards. Items littering the floor in hallways and various rooms increase the possibility of injury due to falls.

“The deaths that are attributable to hoarding usually occur because of fire fed by newspapers in homes where egress is difficult,” says Frost. “In a study of hoarding complaints to health officers in Massachusetts, 6% of the cases resulted in death in house fires.”

“When fire codes are ignored, this is a serious problem for people who live in buildings and communities with people who hoard,” says Arbore. Hoarding puts not only the hoarder’s personal safety at risk but also that of neighbors who may be unaware of an existing hazard or problem.

Additionally, the accumulated clutter in the homes of older adults who hoard may contribute to their increased isolation, as family members and friends hesitate or refuse to visit an unwelcoming environment that offers no place to walk or sit down.

Treatment for Hoarders
Among the most significant barriers to treatment of hoarders, according to Arbore, is the fact that in most cases, the hoarding behavior isn’t discovered until the individual has reached his or her later years. Initially, it’s essential to identify the hoarding behavior, keeping in mind that most hoarders are competent, Arbore says, which means individuals can live the way they choose. “If they meet safety codes or guidelines,” he says, “it’s difficult to force treatment because they clutter their homes or yards.”

The greatest challenge lies in getting older adults with hoarding tendencies to recognize their hoarding as a problem and seek help, according to Frost. “This is not always easy,” he says. “We encourage family and friends to focus on what things the [older adult] cannot do or no longer does because of the hoarding.”

Frost says he has had some success using a cognitive behavioral treatment for hoarding. “Right now, there are no medications that are clearly helpful, though new research may point us in some directions with regard to medication,” he notes.

Lack of insight on the hoarder’s part creates the single greatest barrier to successful treatment, Frost indicates. “In addition, very few mental health professionals have had much experience with hoarding,” he says. “Unless they know what to do, treatment is likely to be ineffective.”

Even when hoarders are identified, their resistance to treatment often creates a barrier, according to Arbore. A lack of treatment options also makes it difficult to address the difficulties associated with hoarding, he says. He suggests a team approach as the basis for treatment strategy.

“A caring counselor, case manager, and representative from public health or housing can join forces to help support the person with hoarding behavior to find another way to live their life,” he says. “Groups such as Clutterers Anonymous can also be a supportive environment.”

Professionals best equipped to treat older adults who hoard items to excess and to their own detriment with respect to older adults’ safety are those who specialize in treating obsessive-compulsive disorder (OCD), says Frost. “Most of the research on treating hoarding has been published in the OCD treatment literature, and these folks are the most likely to have read it.”

Arbore believes a coalition of individuals and organizations in communities gathering to discuss various approaches to hoarding constitutes the optimal strategy for combating this complex public health problem.

— Barbara Worthington is editor of Aging Well.