Hoarding by Elderly Long-Term Care Residents: Page 2 of 3
Prevalence of Hoarding by Elders and LTC Residents
Without accepted diagnostic criteria for hoarding, the prevalence of this behavior in elderly individuals or in LTC residents is not well known, indicating that large-scale studies should be conducted within these specific patient populations. In a 1981 Canadian study of hoarding by elders, Rudnick2 noted that hoarding is not an uncommon trait in institutionalized elderly persons; based on nurses’ reports, the incidence of hoarding was estimated at 11% to 13% in standard and chronic nursing care settings, and 53% in special care setting (ie, patients with dementia or other cognitive disabilities).
In 1993, Hogstel13 became the first nurse to publish a hoarding behavior review article in the nursing literature. While providing consultation to psychiatric hospitals, Hogstel performed nursing assessments of geriatric patients referred by nursing home staff, families, neighbors, or legal guardians concerned that hoarding behaviors interfered with care. Most patients she evaluated had no acute medical problems and were found to be alert, ambulatory, and openly communicative. The topic of hoarding was easily broached during interviews and revealed common themes, such as loneliness and having few close family members or visitors. Patients were aware of having a hoarding “habit” but had no insight as to how hoarding related to abnormal behavior. Hogstel’s observations led to a number of questions: Why do older women hoard more than men? At what point are hoarding behaviors pathological and require interventions? When does the hoarding behavior interfere with normal everyday functioning? We still do not have evidence-based answers to these complex questions, despite two decades having passed.
In a 1998 study by Hwang and colleagues,14 approximately 23% of 133 patients in a geropsychiatric ward exhibited hoarding behaviors, suggesting that hoarding is a common symptom in persons with dementia. Kim and associates15 reported a 40% complaint rate with health departments for hoarding issues, and most studies found the individuals involved were significantly older. This might be because hoarding has been shown to increase in severity with each decade of life.16 In 2002, Saxena and colleagues17 reported that compulsive hoarding syndrome is associated with older age, anxiety, impaired coping and adaptation, and poor personal insight into the condition.
Most recently, Marx and Cohen-Mansfield18 investigated hoarding by nursing home residents and senior day care participants. The authors conducted interviews with family and staff caregivers and reviewed medical charts, patient histories, and physical examination findings reported by the treating healthcare provider. These sources of data were reviewed for documentation of hoarding behaviors, demographic and health information, level of cognitive functioning, ability to perform activities of daily living (ADLs), signs of depression, ability to function socially, agitated behaviors, and evidence of previous stressful life experiences. Results of this research showed that 15% of the nursing home residents and 25% of the senior day care participants exhibited hoarding behaviors with a frequency of several times a week. Marx and Cohen-Mansfield concluded that in nursing home residents, significant associations were observed between hoarding behaviors and a larger appetite, taking fewer medications, higher social functioning, minimal ADL impairment by comparison with others, and fewer manifestations of physically nonaggressive, agitated behaviors.18
Psychology of Hoarding: The Meaning of Possessions
Although recent research has investigated the pathophysiology and neuropathology of hoarding, scant current research has examined hoarding as it relates to elderly individuals’ ability to function in an LTC nursing home setting. Thus, our examination of research on hoarding was expanded to include research on the meaning of possessions and the psychology behind hoarding behavior.
In 1978, Furby19 provided early research into the meaning of possessions, establishing that the saving behaviors of hoarders were motivated by perceived use of a possession and emotional attachment to a possession. Furby linked hoarding of possessions to emotional “sentimental saving.” A subsequent study by Frost and Gross20 in 1993 provided further insight into the nature of hoarding behavior. It did not establish a significant relationship between hoarding and OCD, but did show similar characteristics between persons exhibiting hoarding behaviors and those with OCD. Frost and Gross described both groups as being perfectionists, indecisive, and fearful of making a wrong choice or mistake when deciding to keep or throw away an item. These individuals possessed characteristics integral to the development and maintenance of the hoarding behavior; hoarding enabled them to establish a perception of control and avoid the emotional discomfort associated with “wrongly” discarding an item.
In their 1995 study, Frost and colleagues4 examined the usage pattern of hoarded objects and the associated emotional attachment to the objects. They postulated that items seldom or never used were retained to exert control over the possessions, a trait that was not established in the earlier Frost and Gross study.20 They hypothesized that hoarding is associated with a great sense of responsibility for being prepared and for ensuring the well-being of a possession. The hoarders seemed to have a heightened sense of responsibility for being prepared to meet a future need (ie, each possession is seen as having functional utility under certain circumstances; while the utility is not pertinent to the moment, it may be in the future). If a solution, embodied in the object, is discarded and a problem occurs, harm has been done. It is this harm that the compulsive hoarder seeks to avoid. The nature and severity of this harm are vague and unspecified, and hoarders cannot accurately specify what the harmful consequences may be, other than having to get back something that had been discarded. Hoarders also seek to prevent harm to the possession itself, as though it has human-like qualities and therefore must be protected. This behavior is consistent with the observation that hoarders tend to view their possessions as extensions of themselves.10,21
In 2001, a series of telephone interviews with elder care services agencies conducted by Kim and colleagues15 revealed that few of elderly clients with hoarding behavior showed deficits in cognitive functioning, according to provider observations. The findings suggested that hoarding behaviors frequently occur among older adults in the absence of dementia and that hoarding is not specifically a function of dementia. Kim and colleagues also found that hoarders tended to live alone, be women, and unmarried.
A 2008 study by Anderson and colleagues22 used an ethnographic research design as an exploratory method to gain a deeper understanding of emotional issues that underpin hoarding behaviors by older people. Ethnography is a form of qualitative research that interweaves looking, listening, and asking.23 The Anderson study was described as “focused ethnography” because it was of a small scale and had as a focal point a distinct group of people to be studied.24 The sample consisted of eight older adults who received home care and exhibited compulsive hoarding behaviors. Participants had a deeply rooted need to acquire and hold onto excessive possessions; acquisition was noted in the form of stockpiling, impulsive buying, and actively seeking out free things from friends and neighbors. Descriptive, detailed, computer-generated field notes were recorded after each visit had concluded and chronicled what the researcher had seen and heard. The data revealed that the act of acquiring possessions was reassuring for older hoarders; stockpiled possessions relieved anxiety and helped hoarders feel connected, socially engaged, needed by others, proud, productive, and in control. The actual act of acquiring possessions gave hoarders a sense of purpose and meaning to their lives. The findings from this study suggest older hoarders’ judgments and tolerance levels are different from those of the majority of older people. As such, they perceive order within their disordered environment, and they do not perceive that they live amid clutter, garbage, and filth.24