Upload
hahuong
View
220
Download
0
Embed Size (px)
Citation preview
Hoarding in the Elderly
How to Identify & Help
with Hoarding in
Older Adults
Class Overview
Hoarding in Older Adults
Hoarding Overview
About Hoarding in Older Adults
Clutter-Hoarding Scale / Examples
Definition of Hoarding
Changing Diagnosis
Previously the DSM-IV included hoarding as a subset
of OCD (“Compulsive Hoarding”).
Recent changes to the new DSM-V (May 2013)
included separating Hoarding as a completely
separate disorder from OCD (“Hoarding Disorder”).
Potentially: new studies, specialty treatments,
medications, insurance coverage, etc.
Definition of Hoarding
Persistent difficulty discarding; strong urges to save.
Accumulation of a large number of possessions that fill up and clutter the active living areas of the home.
The symptoms cause clinically significant distress or impairment.
Symptoms are not due to a general medical condition.
Symptoms are not restricted to the symptoms of another mental disorder.
New Diagnosis
Co-Morbidities
Hoarding
Disorder
Major Depressive
Disorder (60%) Social Anxiety
Disorder, Social
Phobia (30%)
General Anxiety
Disorder (20%)
Obsessive
Compulsive
Disorder (17%)
ADD / ADHD
(4%)
Statistics
2 – 5% of the American population = 6-15 million (underestimated).
Not limited to age, gender, race, nationality, or socioeconomic class.
Male / Female equal vs. higher in males.
Tends to present during childhood or adolescence in males and during the twenties in females.
Symptoms may be latent, but once triggered usually worsen progressively throughout life.
Increase in severity is equal to dementia.
Statistics – Age of Onset
3.7 % age 0-5
13.8% age 6-10
26.6 % age 11-15
24.2% age 16-20
10.8 % age 21-25
8.1 % age 26-30
4.8% age 31-35
4.4% age 36-40
Statistics
People 65+ equaled
12.4% of the U.S.
population in the
year 2000. 65+
expected to grow to
19%-21% of the
population by 2030
- about 72.1 million
(more than twice the
number in 2000).
New 2012 Statistics
Hoarding in Elderly (Steketee, et al.)
Elderly hoarders saw possessions as self-extensions,
making discarding very distressing.
Experienced higher sense of responsibility for
possessions than non-hoarders.
Believed their clutter level was less severe than friends
and family did.
Reported more problems with function in home.
New 2012 Statistics
In a recent survey of 17,000 people: (Ekerdt, et al.)
60% of respondents age 60 and older said they had
more things than they need = estimated 35 million
people in the United States.
Respondents were gender balanced.
Among wealthier respondents, 75% said they had
more than they need.
New 2012 Statistics
Animal Hoarding (HRS Panel Survey, Ekerdt)
Animal hoarders very often do not restrain animals in
the home, do not use training and do not use cages or
kennels.
Hoarders often attributed human characteristics and
special abilities to their animals.
Overall higher difficulty with daily routines.
New 2012 Statistics
Treatments
Hoarding has poor response to known medications
when used alone. (Muroff)
Bibliotherapy (reading self-help books) showed only
9% reduction in saving rates. (Muroff, et al.)
Cognitive Behavioral Therapy (CBT) has shown only
modest results when administered individually. (Muroff)
New 2012 Statistics
Treatments
GCBT-only treatment showed reduction of around 25%
reduction in saving rates.
Combination of Group Cognitive Behavioral Therapy
(GCBT) and non-clinician home assistant showed the
highest improvement - nearly 30% reduction in saving
rates. (Muroff, et al.)
In-home services may be essential. (Muroff)
What Causes Hoarding?
Instinct
What Causes Hoarding?
Genetics
Twin studies support a genetic influence of 45-65% in children and 27-47% in adults.
OCD shows 80-87% relation in identical twins; 47-50% relation in fraternal twins.
Several genetic studies have
supported linkages to a variety of
serotonergic, dopaminergic, and
glutamatergic genes.
Causes of Hoarding
Brain Injury
What Causes Hoarding?
Anterior Cingulate Frontalmarginal Gyrus
Brain Injury
What Causes Hoarding?
What Causes Hoarding?
Early Life Events
Parenting not an influencing factor, however,
growing up in a cluttered or disorganized home can
exacerbate an existing tendency.
People born with a tendency but raised in an orderly
environment can be triggered to hoarding later by
life events.
Trigger Events = emotionally traumatic, involving
loss, or creating a long term disruption to
relationships or to the environment.
What Causes Hoarding?
Early Life Events
New 2012 Statistics for Animal Hoarders (HRS Panel Survey, Ekerdt)
More than one third of animal hoarders described chaotic childhood homes.
Higher levels of childhood stressful events than controls.
88% reported negative family relationships.
Observed failure to develop attachments early in life.
What Causes Hoarding?
Adult Life Trigger Events Death of loved one
Divorce
Empty nest
Long term or chronic illness
Injury with long term recovery
Chronic pain
Chronic fatigue
Onset of depression or other psychological illness or disorder
What Causes Hoarding?
Inherent Tendency
Trigger Life Event
Stress Negative Feelings
e.g. Depression, Anxiety
Coping Behavior Release of tension,
“happiness” feels good.
Hypomania “High of the
Buy”
Addiction is Fed
by coping behavior Memory of High and more
negative feelings creates
desire for more
Denial /
Defensiveness
Shame / Guilt
Overwhelm
Contributing Factors
Dementia
Memory loss, mental confusion, disorientation,
impaired judgment and behavioral changes, which
may include hoarding and rummaging through things.
Damage to frontal lobe = Executive Function
impairment
Contributing Factors
Baby Boomers are Healthiest & Wealthiest
The proportion of people aged 65 and older in poverty decreased from 35 percent in 1959 to 10 percent in 2003 (N.I.H.)
Average life expectancy at birth in 2000 was 76.9 years; females could expect to live an average of 5.4 years longer than men. (N.I.H.)
About 80 percent of centenarians are women (N.I.H.)
About one in five older Americans report having chronic disability as of 2000 (1 in 5) (N.I.H.)
Contributing Factors
Loss of
Smell: Anosmia
Hyposmia
Specific
Anosmia
Clutter Rating Scale
Clutter Rating Scale
Clutter Rating Scale
Clutter Rating Scale
Areas of Assessment For
Professional Organizers
1. Structure and Zoning
2. Animals and Pests
3. Household Functions
4. Health and Safety
5. Personal Protective Equipment (PPE)
Clutter Rating Scale
Environmental: Occupant:
Clearance of Paths Through
Rooms
Ages of Occupants (minor or
elderly)
Access to Exits Physical Ability of Occupants
Level of Clutter Mental Soundness of
Occupants
Visible Health and Safety
Issues (Structural, Organic
Waste, Infestations)
Animal Care and Control
Odors and Fumes
ICD Clutter-Hoarding Scale
ICD Clutter-Hoarding Scale
Level 1
Pathways through rooms are at least 3 feet wide.
All major escape routes are unblocked.
Minimal to moderate excess clutter.
Clutter does not obstruct functional use of room and features.
No evidence of structural decay or damage.
Little to no evidence of insects or rodents.
Household trash within normal levels.
Little to no odor.
Animal care & control is adequate.
Level 1
ICD Clutter-Hoarding Scale
ICD Clutter-Hoarding Scale
Level 1
ICD Clutter-Hoarding Scale
Level 1
ICD Clutter-Hoarding Scale
Level 1
ICD Clutter-Hoarding Scale
Level 1
ICD Clutter-Hoarding Scale
Level 1
ICD Clutter-Hoarding Scale
Level 1
ICD Clutter-Hoarding Scale
Level 2
ICD Clutter-Hoarding Scale
Level 2
Pathways through rooms may be less than 3 feet wide.
One or more major escape exits are blocked or have less than 3 feet clearance.
Debris covers most or all floor space and surfaces; significant trip hazards.
Clutter obstructs many functional areas: furniture, appliances, water fixtures.
Minimal to light evidence of insects or rodents .
Presence of mild odors or fumes or old trash.
Animal care & control may be questionable.
Level 2
ICD Clutter-Hoarding Scale
Level 2
ICD Clutter-Hoarding Scale
Level 2
ICD Clutter-Hoarding Scale
ICD Clutter-Hoarding Scale
Level 2
ICD Clutter-Hoarding Scale
Level 2
ICD Clutter-Hoarding Scale
Level 2
ICD Clutter-Hoarding Scale
Level 2
ICD Clutter-Hoarding Scale
Level 2
ICD Clutter-Hoarding Scale
Level 3
ICD Clutter-Hoarding Scale
Level 3
Pathways through rooms may be less than 3 feet wide.
One or more major escape exits are blocked or have less than 3 feet clearance.
Height of accumulated clutter reaches the bottom of standard windows.
Infestations may be light to moderate.
Food trash or other rotting organic matter or mild structural damage may be present.
Moderate odors or fumes may be present.
Excessive animals may be present; care and control may be poor.
ICD Clutter-Hoarding Scale
Level 3
ICD Clutter-Hoarding Scale
Level 3
ICD Clutter-Hoarding Scale
Level 3
ICD Clutter-Hoarding Scale
Level 3
ICD Clutter-Hoarding Scale
Level 3
ICD Clutter-Hoarding Scale
Level 3
ICD Clutter-Hoarding Scale
Level 4
ICD Clutter-Hoarding Scale
Level 4
Pathways through rooms may or may not exist.
Access to most escape routes blocked.
Height of Accumulated clutter reaches above the bottom of standard windows.
Improper use of electrical items & wiring.
Signs of squalor: rotting food and trash, animal or human excrement, mold, structural damage or decay, infestations.
Strong odors may be present.
Excessive animals may be present; care and control is very poor.
ICD Clutter-Hoarding Scale
Level 4
ICD Clutter-Hoarding Scale
Level 4
ICD Clutter-Hoarding Scale
Level 4
ICD Clutter-Hoarding Scale
Level 4
ICD Clutter-Hoarding Scale
Level 4
ICD Clutter-Hoarding Scale
Level 4
ICD Clutter-Hoarding Scale
Level 4
ICD Clutter-Hoarding Scale
Level 4
Level 5
ICD Clutter-Hoarding Scale
ICD Clutter-Hoarding Scale
Level 5
Pathways through rooms may or may not exist.
Access to most escape routes blocked.
Height of accumulated clutter reaches more than one foot above the bottom of standard windows.
Hazardous use of electrical items.
Presence of squalor: rotting food and trash, animal or human excrement, mold, structural decay, heavy infestations.
Strong odors or fumes – trash, sewage, etc.
Animals at risk or dangerous to humans.
ICD Clutter-Hoarding Scale
Level 5
ICD Clutter-Hoarding Scale
Level 5
ICD Clutter-Hoarding Scale
Level 5
ICD Clutter-Hoarding Scale
Level 5
ICD Clutter-Hoarding Scale
Level 5
ICD Clutter-Hoarding Scale
Level 5
ICD Clutter-Hoarding Scale
Level 5
Recipe for Success
The Five Cs: Speak with Compassion
Require Compliance
Initiate Counteraction
Provide Coaching & Collaboration
How to Talk to Residents
Do: Appear as much as possible to be emotionally
indifferent
Keep facial expression neutral
Make extra effort to keep tone of voice level,
steady, and without emotion
How to Talk to Residents
Do: Keep voice volume low and soft to avoid being
perceived as angry or critical
– Women can very easily perceive voices (especially
men’s) as angry, critical or yelling
– Men can perceive voice tone to be challenging or
threatening
How to Talk to Residents
Don’t:
Make facial expressions, cover mouth or pinch nose.
Make sounds of disgust, gag, cough, etc.
Say anything negative to the homeowner or each
other about the conditions of the home.
Refer to any of their things as “junk” or “trash” (even if
it is!)
Pick up or move anything without asking or informing
the resident.
How to Talk to Residents
Do: Ask or inform the resident before moving any items.
Refer to their possessions as “things,” “items,” or
“belongings” if you need to talk about them. Mirror the
resident’s language.
How to Talk to Residents
Don’t:
Make the assumption that the resident knows what
they are doing is “wrong” or dangerous unless they
state it themselves
– Some don’t understand
– Some are in denial
– Some don’t know what to do/frightened
How to Talk to Residents
Don’t:
Argue with the resident
– Do not state a case for your point of view using
judgmental language (“this is filthy”)
– Do not refer at all to throwing things away or
reducing the number of items
– Do not put the resident in a position of defending
their position or beliefs
How to Talk to Residents
Don’t Ask “Why Do You Have all this Stuff?”
There will always be a reason “why.”
How to Talk to Residents
Do: State Factual Information:
– “Keeping things on top of the stove is a fire hazard.
For your safety, we will require those items be
removed and kept at least 12” away from the
stovetop.”
– “The presence of animal feces is a health risk to
humans and it will have to be removed. Any
contaminated items will have to be disposed of as
well.”
How to Talk to Residents
Do: Be prepared to present supporting information –
handouts/brochures on environmental health, fire
safety, etc.
– Many extreme hoarders minimize the risks
associated with cluttered or unsanitary conditions.
– They believe they will be able to exit easily during
emergency conditions.
– Many believe that items having been in extended
contact with feces can simply be washed off.
Working with Residents During the Cleanout
Mandated, deadlined clear-outs
don’t work
Working with Residents During the Cleanout
Usually results in re-hoarding to the same degree or higher in about half the time
Severe psychological scars - feelings of victimization and abandonment.
Increased resentment toward authorities, family, etc.
increased resistance to letting go of objects
Recidivism rate of mandated, deadlined
clearouts is high
Working with Residents During the Cleanout
30 Days is Not Enough Time
Physical/mental limitations
Cost prohibitive
Doesn’t allow for decision-making process
Creates panic
Unrealistic
Working with Residents During the Cleanout
Whenever possible, allow unlimited time
Firm compliance with harm-reduction targets
Spreads out the financial cost
The client often becomes more willing to discard with
time
Slower Is Better
Working with Residents During the Cleanout
Using a “Harm Reduction” Approach
Does not focus on total clear-out.
Focuses on clearing clutter from targeted areas.
Unless the structure is questionable or other health
hazards exist due to clutter.
Working with Residents During the Cleanout
Using a “Harm Reduction” Approach
Target the areas of highest danger to resident and first
responders.
Create a list of requirements (“harm reduction targets”)
that focus on safety and health.
Working with Residents During the Cleanout
Using a “Harm Reduction” Approach
State or list requirements:
– “Pathways through rooms must be a minimum of 36” to prevent trip hazards and allow for emergency personnel and medical equipment.”
– “All combustible liquids, such as propane tanks, must be kept in the garage.”
– All exterior doors must have the floor cleared at least 36” on either side to allow the door to swing completely open and for clear passage
Redefining “Success”
A Caring & Collaborative Effort:
Reduces risk of hoarding-related fire
Reduces cost to the client and family
Keeps residents safe and in their homes
Before & After
Before
Before & After
After
1st
4 hrs
Before & After
After
2nd
4 hrs
Before & After
After
Before & After
After
Before & After
Before
Before & After
After
1st
4 hrs
Before & After
After
2nd
4 hrs
Before & After
After 3rd 4 hrs
Before & After
After
Before & After
Before
Before & After
After
Before & After
Before
Before & After
After
Before & After
Before
Before & After
After
1st
4hrs
Before & After
After 2nd 4hrs
Before & After
After
Before & After
Before
Before & After
After
1st
4 hrs
Before & After
Before
Before & After
After
1st
4 hrs