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Hoarding in the Elderly: A Challenge to Home Care

Hoarding in the Elderly: A Challenge to Home Care. Mary Ann Forciea MD, FACP Associate Professor of Clinical Medicine Division of Geriatric Medicine UPHS. Why am I (or my team) here?. This is a common and frustrating problem for us Hoping to learn some diagnostic tips

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Hoarding in the Elderly: A Challenge to Home Care

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  1. Hoarding in the Elderly: A Challenge to Home Care Mary Ann Forciea MD, FACP Associate Professor of Clinical MedicineDivision of Geriatric Medicine UPHS

  2. Why am I (or my team) here? • This is a common and frustrating problem for us • Hoping to learn some diagnostic tips • Hoping to learn some management tips • Want a chance to vent frustration at the system of care available to these patients. • Like to see my colleagues. • Always wanted to try this restaurant

  3. Why am I (or my team) here? • This is a challenging problem for us • Want a chance to vent about these patients • Like to see my colleagues • Always wanted to try this restaurant • Want to see if UPHS has any better ideas than we do

  4. Key questions for this seminar • Is hoarding in older patients different than in younger patients • What are the critical clinical questions in the evaluation of patients with hoarding? • What treatment strategies can be attempted? • What resources are available in the Delaware Valley?

  5. Case- DR • 78 yr old lady, widow with 2 children • Living in Senior housing • Call from facility SW (Friday at 4PM) • Increasing complaints from neighbors about ‘cleanliness’ of apartment • Apartment visit that day • Toilet overflow, clutter, attire • Home health aide refusing to return • Facility considering eviction

  6. Case continues 2 • >40 yr history of bipolar disorder • Has medications • Multiple barriers to ongoing psychiatric care • Diabetes mellitus with peripheral neuropathy] • Venous stasis • DJD of knees, hips, LS spine – increasing immobility

  7. Case 3 – prior history • Third dwelling while part of our primary care program (8 yrs) • ‘Clutter’ an issue in each site • Mania associated with requests for DME • Progressive mobility dependence • Third move precipitated by loss of driving privileges

  8. Added information • Visited patient one week ago • Called patient after SW call • Admits to overwhelming apartment ‘situation’ • Blame exclusively on building management • Admits to progressive URI over past week • Reluctant to agree to ED or hospital visit • Home care team urgent conference call

  9. Living room(close to hers –google images)

  10. Bedroom(close to hers – google images)

  11. Options • Sign out to weekend covering partner • Temporize by offering a Monday medical house call visit by your team • Arrange transport to ED for evaluation • Directly admit to your inpatient service

  12. Hoarding – DefinitionSaxena 2007 • Collecting • excessive quantities of • Poorly useable items • Of little value • Failing to discard items • Interference with function

  13. Excessive acquisition • Buying • Accumulation of ‘free’ things • Received • Sought out (dumpster diving • Motivation • “thrill” • ‘therapy’ for unpleasant feelings (?‘retail’ therapy) • Fear of missed opportunities

  14. Failure to discard • Most easily recognized • Motivation • Sentimental value • Wasteful to discard • Might be useful in the future • Decreased ability to group/sort items • Poor organizational skills

  15. Interference with function • Clutter – cannot use space or object for its intended purpose • Functional status – cannot walk through apartment, bathe, cook\ • Consequences • Eviction, health concerns, fire risks

  16. Risks of hoarding • Social dysfunction • Functional disability • Falls • Fires • Unsanitary conditions

  17. Is hoarding a psychiatric disorder? • Associations: • OCD • Schizophrenia • Dementia (especially fronto-temporal) • Mood Disorders • Not currently listed in DSM-IV, will likely be listed in DSM-V • Little attention to older patients with hoarding behaviors

  18. FTD vs ADMiller et al Neurology 1997

  19. Natural history of hoarding • Chronic problem with gradual worsening across lifespan • 80% of patients report symptoms by age 18 • Late onset patients more often have a stressful life event at initiation • Familial component • 85% of hoarders describe a 1st degree relative as a ‘packrat’

  20. Distinctions in Older Patientswith ‘Terrible Decline” • Hoarding versus self care deficit? • Or both • Long term or acute? • Decisional capacity? • Severe enough to warrant coercive action?

  21. Assessment tools Clutter Hoarding Scale Institute for Challenging Disorganization

  22. In treating these patients, we have tried: • SSRIs • Cholinesterase Inhibitors • Cognitive/behaviroal therapy • Occupational therapy consultation

  23. I have been satisfied with the outcomes of my therapy • Yes • No

  24. My patients have been happy with the outcomes of therapy • Yes • No

  25. Treatment • Medications • SSRI – possibly less effective in older patients • Cognitive behavioral therapy • Information processing deficits • Help sort into larger clusters • Maladaptive beliefs • I am a craftsman because I own tools • Attachment to possessions • Sentiment, control • Interprofessional team management

  26. Self care deficit “The result of an adult’s inability due to diminished capacity to perform essential self-care tasks such as providing essential food, clothing, shelter, and medical care; obtaining goods and services necessary to maintain physical health, mental health, emotional well-being and general safety; and/or manage financial affairs.” -APS

  27. Self-Neglect – DefinitionPavlou and Lachs JGIM 2008 • A Self-neglector is a person who exhibits 1 or more of the following: • 1) persistent inattention to personal hygiene and/or environment • 2) repeated refusal of some/all indicated services which can reasonably be expected to improve quality of life • 3) self endangerment through the manifestation of unsafe behaviors (e.g. persistent refusal to care for a wound, creating fire hazards in the home)

  28. Self-neglect • Annual incidence: 5.2 per 1000 elders • Self-neglect 50-75% of elder mistreatment • 90% of all self-neglect APS ≥ 65y/o • ♀ > ♂ • Decreased survival 40.3% died within 13 years follow-up • Self-neglect patients more likely to die in NH Lachs et al. JAMA 1998

  29. Clinical evaluation • Dementia • Depression • If acute, look for medical problem • Stroke, infection, medication effect • Determination of decisional capacity

  30. Treatment • Often emergency-related • Hip fracture, pneumonia, police incident • If incapable of decisions • Refer for competency determination and guardianship • Placement likely • If capable • Inform of helpful services • Documentation of preferences for Advance Directive

  31. Assessment tools Self neglect severity scale -Houston Geriatrics group

  32. Personal appearance of subjectHair

  33. Nails

  34. House

  35. Home Environment

  36. Bathroom

  37. Self Neglect Severity Scale

  38. Decisional capacity • Competence – a legal determination in court • Appointment of a guardian • Of the person (medical decisions) • Of finances • Decisional capacity – a clinical decision • Decision specific • “Hierachies” of decisions • Most basic decisions honored even in presence of some impairment • May make ‘low stakes’ decisions even if unable to make ‘high stakes’ decisions

  39. Elements of Decision Making • Ability to communicate a choice • Ability to understand and retain relevant information • Ability to appreciate the situation and consequences for oneself • Ability to manipulate information rationally

  40. Ability to appreciate situation for oneself • Acknowledge that condition is present • Realizes that risks and benefits apply to him/her • May involve understanding of motives for choices • What will happen if you refuse treatment? If you accept?

  41. Manipulates information rationally • Reaches conclusions that are logically consistent with starting premises • Again, may involve description of motives • Please help me to understand why you decided to accept/refuse treatment

  42. Summary • Older patients with hoarding behaviors have higher likelihood of co-existing dementia • Time course of progression is critical information • Hoarding and self neglect frequently co-exist in older patients • Assessment tools can help guide team planning and follow-up • The determination of decisional capacity is often critical • Local regulation about safety standards is important in action steps

  43. The Eye of the Beholder

  44. Resources/References • The Institute for Challenging Disorganization: • www.challengingdisorganization.org • Valente, Sharon. The Hoarding Syndrome. Home Health Care Nurse 27:432. 2009 • WWW.homehealthcarenurseonline.com • Guilliam, CM and Tolin, DF. Compulsive Hoarding. Bulletin of the Menniger Clinic 74:93. 2010. • Dyer, CB et al. Self-neglect among the elderly; Am J of Public Health 97:1671.2007

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