Hoarding: Advice for the Fall Prevention Clinician

Posted Le 26 août 2016

Even seasoned health professional can experience strong reactions when entering the home of someone who hoards, and frequently describe feelings of distress in light of the serious and pernicious safety concerns that they observe for their patients. Inaccessible or unusable living spaces, impaired ADL functioning, as well as a heightened risk for adverse events like fires, falls, floods, or infestations are common to the cluttered environments that hoarding can create. 

Hoarding Disorder (HD) is a mental health condition characterized by significant difficulty with discarding, due to strong urges to save belongings and the distress that is evoked by letting them go. Challenges with managing possessions for persons with HD are often compounded by tendencies of compulsive acquisition, as well as information processing difficulties, particularly in regards to decision-making and attentional control.

While it has only recently been classified within the DSM-V, Hoarding Disorder is not a new condition, nor an uncommon one: estimates suggest that approximately 5% of the adult population hoards¹. The frequency of HD, as well as the serious nature of health, safety, and functional impairment so often seen with this condition, underscores the value for health professionals from all disciplines to understand this disorder and the strategies that are available to effectively support our patients.

In fact, clinicians who work in falls prevention are uniquely situated to identify and respond to patients with HD. Not only can the clutter itself create trip hazards, narrowed walkways, stairs or floorcovering that are in disrepair, etc., but conditions in the home can impact the implementation of other falls prevention interventions. Consistently locating medications, eye glasses, or hearing aids within disorganized piles, or using a gait aid in inaccessible pathways, for example, can become demanding tasks for patients with HD.  Moreover, there is a striking correlation between HD and the co-occurrence of physical health conditions. While the directionality and full nature of this relationship remains under investigation, it has become evident that adults with HD experience significantly more comorbid health conditions, including obesity sleep apnea, diabetes, arthritis, and other hematologic, cardiovascular or lung conditions^2,3. People with HD also seem to be less likely to engage in regular physician visits and maintenance of chronic medical conditions².  

How to Help

Cognitive Behavioural Therapy which incorporates strategies from motivational interviewing and organizational skills training is a best-practice approach for patients ready to engage with formal psychotherapy. For others who are not expressing interest a strong interest in therapy, yet who live in an environment which is detrimental to their health, a harm reduction approach aimed at reducing the problematic effects of hoarding behaviour, if not necessarily the behaviour itself, may be of greatest benefit. Premature or overemphasis on the clearing out of a home, often performed as an “extreme clean,” is best avoided except in the most severe of safety or eviction risks, as it can create distrust within the therapeutic relationship and may potentially exacerbate hoarding symptoms.

Assisting in Home Safety: How-to Step by Step

STEP 1: Safeguard yourself in the home

• Take only essential items with you.


• Place personal belongings into a plastic bag, seal it, and leave it near the door, to be picked up when exiting the home. Consider bringing a change of clothes in more severe circumstances.


• Avoid wearing loose fitting clothing, open-toed shoes, or shoes with deep treads that could hold pests or unsanitary debris. Consider using protective equipment (gloves, boots, gown, mask) in more concerning environments while weighing the impact this may have on the therapeutic alliance.


• Avoid sitting, particularly on soft-covered furniture.


• Do not lift, carry, or walk into areas you do not feel comfortable accessing.


• Be aware of your exits and paths. Avoid areas where piles can easily topple.

STEP 2: Safety Assessment

• Identify specific risks in the environment and rate the severity of each: falls, access to emergency services, fire hazards, infestations, unsanitary conditions, elderly dependents, children, or pets in the home adversely affected by clutter. Standardized assessments can assist: The Home Environment Index (Rasmussen et al, 2014), HOMES Multidisciplinary Hoarding Risk Assessment (Bratiotis, 2009).


• Educate your client about these risks; discuss potential consequences and collaborate on options available to address the concerns.


• Document your concerns and discussion with your client.

STEP 3: Prioritize Intervention Goals

• Use data from safety assessment to prioritize goals: address most critical issues first.


• Strategize safety solutions that do not solely involve discarding. For example, relocate possessions from key walkways/stairwells to less accessed areas; facilitate access to a pharmacy-filled blister pack for medication management; install a personal medical alarm, etc.


• Consider the feasibility and scope of the goals and scale to manageable & achievable levels.

STEP 4: Assemble a Team

• Coordinate service with local community supports. Consider linking to mental health or seniors case management and outpatient services. Legal aid/services can aid in situations of eviction risk.


• Provide access to good health education. Examples: Buried in Treasures: Help for Compulsive Acquiring, Saving and Hoarding (Tolin, Steketee, Frost); IOCDF fact sheets: hoarding.iocdf.org


• Weigh issues of health information privacy when considering involving agencies like Fire Services.


• Draw on natural support networks for hands-on sorting assistance: adult children, friends, church associates, extended family, emotional support, and/or financial support.

References

1. Samuels, Bienvenu, Grados, Cullen, Riddle, Liang, Eaton, Nestadt. 2008. Prevalence and Correlates of Hoarding Behaviour in Community-based Sample. Behaviour Research and Therapy, 46(7): 836-844.


2. Ayers, Iqbal & Strickland. 2014. Medical Conditions in Geriatric Hoarding Disorder Patients. Aging and Mental Health, 18(2): 148-151.


3. Timpano, Exner, Glaesmer, Rief, Keshaviah, Brahler, Wilhelm. 2011. The Epidemiology of the Proposed DSM-5 Hoarding Disorder. The Journal of Clinical Psychiatry, 72: 780-786.