Hoarding by Elderly Long-Term Care Residents: Page 3 of 3
Issues With Hoarding Behavior in LTC Facilities
If hoarding behaviors are not treated, costly medical and emergency department visits may be incurred. Anxiety related to hoarding activities may precipitate suicidal ideation or attempts.25 Additionally, hoarding may pose a grave threat to physical and emotional well-being as well as social functioning and quality of life.25 Hoarding presents physical health threats, including fire hazards, risk of falls, and unsanitary living conditions.26,27 These conditions affect not only the hoarder, but also those around him or her, including family, friends, and other persons.7
In nursing homes, residents have limited space for storing personal items and important legacy and family memorabilia. Compared with living spaces in apartments and single-dwelling homes, an LTC resident’s bedroom and living area are small (a few dozen square feet) and restricted. With regulatory requirements imposing strict guidelines for fire and safety codes and infection control, nursing home staff are challenged to balance requirements for a clean and organized living environment with residents’ needs. It is not always clear that a resident’s desire to retain possessions perceived as excessive is the underpinning of hoarding behavior. To highlight the dilemma for nursing home staff, Cermele and associates28 described an experimental case study conducted by Hartl and Frost29 that calculated square footage of clutter in relation to square footage of living space. The establishment of a clutter ratio allowed the researchers to demonstrate significant decreases in clutter in personal space and to compare clutter ratios for hoarders with expected disorganization of personal items for nonhoarders. This clutter ratio was used for research purposes and was not translated into a tool to be used by administrators, although it appears it would be of value to them. Future pilot studies to refine and/or examine how this tool could be used in practice would be beneficial.
It is no surprise that in an institutionalized setting, a hoarder’s activities may result in conflict with other residents, personnel, and visitors, and consequently result in administrative issues. This is especially true when the hoarding habit is associated with paranoia. Attempts to confront the situation can result in retaliatory accusations, building resentment and frustration toward the very people who are providing care.2
Treatment of Compulsive Hoarding
Treating hoarding poses a considerable challenge for a variety of reasons, including hoarders not recognizing that they have a problem and a paucity of studies on proper treatments, including in special patient populations, such as LTC residents. Treatments that have been used in the general population include medications, cognitive-behavioral therapy, education, social support, or a combination of these approaches.
The most common pharmacologic treatments that have been explored to treat hoarding are agents that are typically used to treat OCD. These include selective serotonin reuptake inhibitors (SSRIs), particularly paroxetine, as well as other drugs that affect serotonin, such as tricyclic antidepressants (eg, clomipramine).25 SSRIs tend to be preferred over other agents because of their low risk of side effects; however, as with any pharmaceutical agent, side effects and complications from medication interactions can occur. This risk is especially high in elders because they tend to be on more medications and metabolize drugs differently than younger persons, leading to a higher risk of disease-drug and drug-drug interactions. One study reported that the average US nursing home resident uses seven to eight different medications each month.30 Because adding another pharmaceutical increases risk, and current serotonergic medications for OCD have been found to be largely ineffective for treating hoarding,7 pharmacological treatment should likely be avoided in this population.
In contrast, there is some indication that cognitive-behavioral therapy, a form of mental health counseling that focuses on examining the relationships between thoughts, feelings and behaviors, may provide some benefit.7,31 However, most older adults with a mental disorder do not receive the mental health services they need,32 and in LTC settings, patients’ physical health needs are often so pronounced that they take precedence over any mental health problems. Therefore, even if compulsive hoarding were considered a distinct mental disorder or if a resident was found to hoard because of an underlying mental disorder, it is unlikely that he or she would have the opportunity to receive and potentially benefit from a service like cognitive-behavioral therapy.
Although the LTC setting renders the use of pharmaceuticals and mental health services problematic, this unique setting may lend itself to other interventions. Marx and Cohen-Mansfield18 speculated that monitoring by staff in the nursing home, as well as limited access to items commonly hoarded from the controlled environment, decreased the elderly residents’ ability to hoard. Such monitoring and restricted access to goods would not be possible outside of this type of setting, but because it has been reported that hoarders derive emotional comfort from their possessions,4 it can be postulated that limiting access to goods might become distressing to residents who are accustomed to hoarding. Therefore, when limiting residents’ ability to hoard, increased social interaction and participation in activities should be encouraged to help fill their emotional needs and potentially reduce the desire for acquisition. In addition, families should be encouraged to visit these residents more frequently, but should be advised by staff not to encourage hoarding behaviors, such as by bringing these residents requested or desired possessions to hoard.
There are no definitive answers in the literature when it comes to treating compulsive hoarding, and further studies are needed to guide evidence-based practice. Studies examining specific patient populations, such as LTC residents, are clearly needed.
To date, few studies have been published that thoroughly examine hoarding activity in elderly persons residing in nursing homes. Hoarding behaviors in LTC settings require investigation by nurse researchers. With the dearth of currently available nursing literature pertaining to this topic, there is little, if any, guidance available to drive management of this aspect of care in nursing homes. Given the physical safety and mental well-being issues that are associated with compulsive hoarding, future studies need to more closely examine evidence-based interventions to address the management of hoarding in the LTC setting.
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The authors report no relevant financial relationships.
Address correspondence to:
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Florida Atlantic University
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