Another Eldercare Issue: Hoarding
What is hoarding?
According to Dr. Randy Frost (which has become "the definition" of hoarding) states that clinically significant hoarding can be characterized by three criteria:
- The acquisition of and failure to discard possessions which appear to be useless or of limited value
- Living spaces so cluttered, their use is impaired or impossible, and
- Significant distress or impairment in functioning as a result of the clutter
Cluttered conditions in a senior's home can result from a variety of causes including, but not limited to, physical frailty, disability, dementia, and can look like "minor hoarding" behavior. In my experience, clutter seems to be identified by lack of surface space and "piles" - of paper, magazines, clothes, etc. Hoarding involves much more mass or volume and can appear significantly more overwhelming - a lot more is involved than just surfaces. We're talking more "floor to ceiling". Hoarding can be identified by collecting items that often don't serve a purpose, collecting but not discarding, and such attachment to objects that there's a huge amount of anxiety and stress caused by parting with them.
What are some reasons people hoard?
It's hard to provide any one reason or answer. The most widely held thought comes from the cognitive behavioral model of hoarding which suggests that individuals who hoard have problems with information processing, emotional attachments to possessions, strong beliefs about the nature of possessions, motivational issues and behavioral avoidance. Individuals experience fear of getting rid of something that might be important or necessary later on, something that might be irretrievable, the fear of making a mistake (hoarders are often perfectionists). "Depression-era mentality" is another commonly held belief; individuals who grew up in the depression are thrifty, frugal and fearful of wasting anything that they might later need. Physical infirmity (arthritis, deteriorating vision, etc.) can also play a role. Individuals who live in walkup buildings or who need to negotiate stairs and live alone can also find it difficult to get rid of things. Then it can become a spiral: things pile up, become messy; there's a sense of shame, fear of being found out, all of which serve to isolate the person further. Depression also contributes to hoarding behavior and the literature suggests that this may be a more significant cause than initially thought. Dementia, too, can play a role - with the person not being able to distinguish between useful and non-useful things.
What are some indications that a person might have a problem with hoarding?
These are by no means hard and fast rules but one telltale sign might be that they won't let you into their home; they prefer to meet you elsewhere. They might not be able to locate important papers. They might appear in the same outfit for days at a time, or appear unkempt. Or you might see them around town toting lots of shopping bags or using a shopping cart. Sometimes the person will come to senior centers or social service organizations presenting with a housing or neighbor problem, or some other non-hoarding related matter.
What are some questions that might help determine if a person has a problem with hoarding?
It's important, first and foremost, to convey interest and a non-judgmental attitude. The NYC Task Force on Hoarding came up with a number of suggestions. You can ask questions like "Are you uncomfortable having people come over because of the clutter in your home?" or "Can you use your kitchen and/or bathroom appliances?" or "Do you have to move things off the furniture to sit or sleep?"
What's the best way to engage a person who hoards?
It's a good idea to convey interest, be open, have a non-judgmental attitude, and express concern, if appropriate. Ask them how they view their situation; what can they see themselves accepting in the way of help, curiosity, how do they plan to use any available space. It's generally not helpful to come across as overly professional or controlling as this won't get you very far. It's better to be flexible and patient.
What if they refuse to allow a cleaning of their apartment or house?
It's first important to determine their level of capacity or awareness of their situation. Do they have the ability to make an informed decision; are they aware of the consequences or ramifications of their actions? Are they aware there might be legal repercussions... It's helpful to take inventory of their support network - who is available to help, family, friends? Unfortunately, sometimes cleaning up only comes after a mandate or legal action that comes from the outside or is externally imposed. What one can do until that time is to explore options available to them, provide alternatives, and review the need for adherence to minimum safety guidelines.
If they do allow cleaning, what's the best way to go about this task?
- Engage the hoarder, confer with them, let them have some degree of control over the clean-up, if possible.
- Allow them to be present and determine who else will be present.
- Try to do as much organizing and sorting beforehand as this tends to save both time and money. (If the client is not in a position to assume the cost of cleaning, oftentimes Adult Protective Services or the Triple A's may help out. Sometimes social service agencies have access to charitable grants for financial assistance.)
- Determine whether the presence of friends and/or family will be helpful or will deter the process. (Sometimes their presence feels too intimate or personal. Often it's better to have an impartial crew along with a professional organizer.)
Again, it depends on the individual and his/her specific situation. The advantages of a cleaning crew - preferably with an overseer - are that they are familiar with what is needed for a cleaning and can access such things as dumpsters, containers, can facilitate transportation and arrangements for storage if needed, supplies - all of which become essential for cleaning up a hoarding situation. There's enough resistance to a clean-up from the "get-go," so any impediment or glitch that presents itself can be reason enough for the individual to call the whole thing off. The fewer potential impediments, disruptions, reasons to stall, the better!
What about the risk of recidivism?
The risk of recidivism or reverting back to the hoarding situation is always present. Without fairly intensive cognitive behavioral treatment and training - not so popular or successful with the older populations I've dealt with - it's likely the hoarding tendencies will resurface. It's not unusual for individuals to go out and attempt to retrieve the items recently discarded - referred to as "dumpster diving." Hence the reason it's so important for any dumpsters or containers to be removed the same day.
What about pets?
Pets are sort of a special category - they can be considered the same as others or "family," like children or spouses - with the hoarding exerting a negative impact on them as well. For example, the pets are living in squalor, unable to access litter boxes, resting places, clean feeding area. This would apply more to one, two or three animals. Then there's Animal Hoarding which is a subdivision of regular hoarding.
Are there any safeguards that can be put into place to prevent this from occurring?
- Removal of dumpsters the same day.
- Schedule periodic checks to make sure the environment is maintained according to individual state/city guidelines or "codes."
- If possible, implement of some housekeeping or homecare services. For those without an involved support network, there are always case or care managers or social workers who can visit every so often and can check the premises. In fact, this might be one of the pre-conditions established at the outset that - following the cleaning - periodic visits will be made to insure the apartment or home is maintained.
Eldercare Issues Resolved by Choice, Not Crisis