Download Abstract ONE SUMMER AFTERNOON, Mr. M, age 72, was brought

Abstract
ONE SUMMER AFTERNOON, Mr. M, age 72, was brought to the ED with a
possible fractured left hip.* He said he'd been lying on the floor for about 3
hours after tripping over one of his dogs. Emergency medical service (EMS)
personnel who brought him to the hospital reported that Mr. M had many
animals; authorities later determined that 38 dogs and 12 cats lived with
him in a house with no electricity or running water. EMS personnel had to
move piles of bags and papers to reach him, and animal feces were
everywhere. They'd called state authorities to the scene.On Mr. M's initial
assessment, he was covered with feces from head to toe. He had bilateral
lower extremity cellulitis due to multiple scratches, and his skin assessment
revealed fleabites as well as urine burns. Described as very anxious, he
constantly asked about his pets without expressing concern for himself. Mr.
M was identified as a person who hoards. That evening, the local TV news
program showed animal control officers removing animals from his
house.Hoarding is a psychiatric disorder that also involves medical and, at
times, legal issues. A complex and perplexing disorder, hoarding was
previously classified as an obsessive-compulsive disorder (OCD). In the fifth
edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
issued in May 2013, hoarding disorder was reclassified as a diagnostic
disorder.1The diagnostic criteria for hoarding disorder set forth in the DSM-5
describe persistent difficulties discarding or parting with possessions,
regardless of their actual value. Some people hoard animals or food as well
as inanimate possessions. They fill up or clutter living areas until the space
can't be used as intended.People who purposely hoard experience distress
when faced with the prospect of discarding items. The behavior causes
significant impairment in social, occupational, or other areas of functioning,
including maintaining a safe environment for self or others.1 For a diagnosis
of
Keywords
Article Content
ONE SUMMER AFTERNOON, Mr. M, age 72, was brought to the ED with a
possible fractured left hip.* He said he'd been lying on the floor for about 3
hours after tripping over one of his dogs. Emergency medical service (EMS)
personnel who brought him to the hospital reported that Mr. M had many
animals; authorities later determined that 38 dogs and 12 cats lived with
him in a house with no electricity or running water. EMS personnel had to
move piles of bags and papers to reach him, and animal feces were
everywhere. They'd called state authorities to the scene.
Figure. No caption available.
On Mr. M's initial assessment, he was covered with feces from head to toe.
He had bilateral lower extremity cellulitis due to multiple scratches, and his
skin assessment revealed fleabites as well as urine burns. Described as very
anxious, he constantly asked about his pets without expressing concern for
himself. Mr. M was identified as a person who hoards. That evening, the
local TV news program showed animal control officers removing animals
from his house.
Hoarding is a psychiatric disorder that also involves medical and, at times,
legal issues. A complex and perplexing disorder, hoarding was previously
classified as an obsessive-compulsive disorder (OCD). In the fifth edition of
the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) issued in
May 2013, hoarding disorder was reclassified as a diagnostic disorder.1
The diagnostic criteria for hoarding disorder set forth in the DSM-5 describe
persistent difficulties discarding or parting with possessions, regardless of
their actual value. Some people hoard animals or food as well as inanimate
possessions. They fill up or clutter living areas until the space can't be used
as intended.
People who purposely hoard experience distress when faced with the
prospect of discarding items. The behavior causes significant impairment in
social, occupational, or other areas of functioning, including maintaining a
safe environment for self or others.1 For a diagnosis of hoarding disorder,
the symptoms can't be attributable to a medical condition (for example,
brain injury or cerebrovascular disease) or another mental disorder (for
example, obsessions in OCD or delusions from a psychotic disorder such as
schizophrenia).1
Hoarding is a common psychiatric condition that affects an estimated
700,000 to 1.4 million Americans, but few receive adequate treatment.2 It
presents significant risks to the individual and family, ranging from health
issues associated with unsanitary conditions to fire hazards. The goal of this
article is to provide nurses with insight into hoarding disorder to guide
clinical practice.
Who hoards?
Hoarding seems to be interconnected with other psychiatric disorders, such
as social phobias, schizophrenia, bipolar disorder, dementia, attachment
disorder, autism, impulse control disorders, brain injury, and depression.3
(See A closer look at those who hoard.) Many legal, medical, mental health,
and animal rights agencies are attempting to develop strategies to help
people who hoard.
Although hoarding behavior is found in both men and women regardless of
socioeconomic status, some patterns are common. Symptom onset occurs
at, on average, ages 11 to 15.1 Hoarding onset occurs in childhood more
often in boys. Older people have a high incidence of hoarding, especially if
they have a concurrent diagnosis of dementia.5
Frost suggests that 1 in 20 people has a significant hoarding problem.6
Although about 18% to 40% of those with OCD report significant hoarding
symptoms, these aren't usually the person's main problem. Perhaps 80% or
more of those with hoarding disorder don't have symptoms of OCD.7 (See Is
it OCDor hoarding disorder?) Dementia and hoarding may be the only
psychiatric disorders that increase in severity throughout the life cycle.6
Food hoarding in foster children has been traced back to lack of food from
neglect or abuse during childhood. It can occur in adults who experienced
trauma when food and daily necessities were withheld; for example, in
concentration camps or during wartime.5
Dangers of hoarding
Hoarding has serious ramifications for both the patient and his or her family.
Environmental dangers. One study that reviewed 54 cases of animal
hoarding found these problems within the households:
* 32% had no working bathrooms
* more than 20% had no working cooking facilities or refrigerator
* 3% had no electricity
* 25% had human or animal feces and urine on the bed
* 32% had dead animals on the premises.8
People living in homes cluttered with hoarded objects may navigate their
surroundings through narrow trails, if they can move at all. Some rooms
may be so completely filled that they can't be entered. Excessively cluttered
bathrooms and kitchens can cause hygiene, food preparation, and storage
problems. The weight of collected items can cause structural problems, with
collapse a real possibility.
Large amounts of clutter are also a fire hazard, especially if the objects are
jammed against outlets or if appliances are used with things piled on or in
them. In an emergency, the clutter may prevent those in the house from
escaping and emergency personnel from getting in.9
Health dangers. Health issues for those who hoard and family members
who live with them include injuries from tripping or falling over the clutter or
animals, or slipping in animal urine or feces. When homes are infested with
fleas, rats, mice, or bed bugs, extermination is difficult or impossible.
Objects falling from piles can injure or kill people. Dust accumulated from
clutter, animal dander, mold, mildew, and high ammonia levels from animal
waste can cause respiratory problems.
Parasites and food-related illnesses are linked to poor sanitation. Those who
hoard animals also risk zoonotic diseases, such as bubonic plague, caused
by infectious agents transmitted between or shared by animals and
humans.10 Rabies, salmonellosis, cat scratch fever, Lyme disease,
roundworm, and ringworm may result from close contact with dogs, cats, or
rodents.11
Those who hoard tend not to accept home care after an illness, or may leave
against medical advice or refuse rehab. They want to return to the items or
animals they've left at home as quickly as possible.
Effects on children. Besides physical risks, children of those who hoard
have unique psychological problems, including isolation and depression.
They're usually too embarrassed to invite friends over, or they're not allowed
to do so. At risk for poor hygiene, they may not be able to wash their
clothing, causing further isolation and even making them a target for
bullying. They may resent the person who hoards and may have to compete
with the hoarded objects for their parent's affection. They live with the fear
of being removed from their home.
Adult children of those who hoard are at risk for other disorders due to their
childhood's unstable environment and relationships. They may exhibit
symptoms of depression, anxiety, or OCD, or they may develop hoarding
disorder themselves.12 Adult children may be afraid to bring their own
children to visit, further isolating the person who hoards.
Financial consequences. Those who hoard may spend all of their money
on their possessions. They may have the added expense of eating out or
having food delivered because they can't cook in their own cluttered
kitchens. They may neglect paying routine monthly bills. This may result in
utilities being cut off and illnesses related to poor hygiene, lack of heat in
winter, or excessive heat in the home during hot weather. Those who hoard
animals may spend excessively on food for their many animals.
Legal consequences. Those who hoard risk homelessness if they're evicted
or their home is condemned as a public safety hazard. They risk having their
children removed from the home by child protective services or being
charged with child neglect. Those who hoard animals may be charged with
animal cruelty, which in some states is a felony.
Identifying patients who hoard
Signs and symptoms vary among patients. Hoarding causes more distress to
loved ones than to those who hoard because they don't identify their own
behavior as a problem.13 Some report the disorder by explaining how it
interferes with their daily life and functioning. They also begin to isolate
themselves from family and friends due to guilt and embarrassment. The
person may have difficulty with interpersonal relationships and experience
family tension and low self-esteem.
When those with health problems seek medical treatment, outpatient
providers may be able to explore their circumstances. Nurses need to ask
about and listen to family concerns about the patient's condition and living
environment. Observe the patient's behavior in the hospital: Some collect
everything from used food trays to medicine cups to dressings.
Nurses can incorporate questions such as these into assessments to alert
them to the need for further discussion:
* What do you collect? Do others believe your collections are valuable?
* Do you store your collections inside or outside the house? Can these areas
be used for their intended purpose?
* Do you find it difficult or impossible to discard your collections or
possessions?
* Is it hard to organize the things you've collected?
* How do you feel about others touching items you've collected?14
Although those who hoard need care for physical problems, psychosocial
issues should also be addressed. Nurses can share their concerns with other
caregivers to initiate the systems needed to help the patient return to a safe
home and maintain a state of well-being.
In Mr. M's case, identifying his hoarding behavior wasn't difficult. The
challenge was to understand him and his needs, starting with dealing with
the unwelcome news coverage. When Mr. M saw his animals being removed
and heard them described as abused and neglected on the news, he became
inconsolable, saying repeatedly that they were going to kill all of his pets
and he wanted to die with them. He wouldn't participate in any treatment
and refused to take his medications. Looking for family support, his nurses
discovered he had a daughter, although they hadn't spoken for 2 years.
The second day postop, Mr. M's daughter Ms. J came to the hospital to offer
her support. In addition to educating Mr. M and his daughter about postop
care and resources, his nurses used a window of opportunity to help the
family understand the hoarding disorder and its health consequences. In the
end, Mr. M went to a long-term-care facility for rehab, and with his
daughter's support, both agreed to counseling. Ms. J would help with the
house while giving her father some say about its cleaning.
Treatment and interventions
Although no "cure" for hoarding exists and the problem is chronic and often
intractable, nurses can help those who hoard transition effectively to
healthier behaviors and live more contentedly.3 Assessing those who hoard
is challenging. Although Mr. M had been stabilized medically, his hoarding
symptoms remained. A substantial psychological or emotional component to
his illness requires a trusting therapeutic alliance to open the door to
treatment.
Although researchers and clinicians don't agree on the most effective
treatment modality, the key to successful treatment is for those who hoard
to recognize they have a problem so early interventions are possible.2
Nurses must begin to ask questions and make referrals during
hospitalization. With continued outpatient treatment, behaviors may
improve.
Recovery from animal hoarding is less likely to be successful. Animal
hoarding experts have known for years that recidivism can be up to 100%.
Some who hoard animals have even picked up an animal on their way home
from the court proceedings related to the hoarding or shortly afterwards.15
Change is slow and the relapse rate is high, with patients showing various
levels of understanding about their hoarding behaviors.2 Those who hoard
consider their possessions to be an extension of themselves. Many resist
change or procrastinate. Nurses are instrumental in assessing the patient's
level of insight to determine if they recognize that their collecting is a
problem.
When someone who hoards is referred to outpatient treatment, nurses need
to establish a therapeutic relationship to encourage the patient's
participation. Nurses should be aware of the patients' need for control and
their emotional attachment to their objects or animals. Recognize that just
as hoarding behavior took time to develop, change also takes quite some
time. Don't give up on patients. Offer them respect while they're searching
for solutions. Use a nonconfrontational approach when teaching patients
about safety hazards and impairment and isolation resulting from their
disorder.
The treatment needs to be multimodal because a one-dimensional approach
(such as therapy or medication only) hasn't proven to be effective.8
Nursing interventions
Once those who hoard have been identified, nurses can initiate therapeutic
nursing interventions and collaborate with a multidisciplinary team for a
treatment plan.
* Build trust with patients by showing a caring attitude, show respect for
their independence, and communicate that they aren't being judged.
* Encourage patients to verbalize their feelings about their hoarding's
effects.5 Realize that they may see only the comfort they receive from
collected items. Nurses need to recognize and examine their own feelings
and biases about this behavior.
* Display empathy while understanding that everyone has some attachment
to belongings. Try to understand items' importance to those who hoard.9
* Describe and discuss potential consequences of hoarding behaviors, such
as eviction or loss of children, with patients.5 Include the benefits of change,
such as being able to use rooms for their intended use and reestablishing
relationships with children and grandchildren.
* Encourage patients to think of ideas to make their home safer, such as
moving clutter from doorways and halls.9
* Offer support and discuss relaxation techniques.5 Some are anxious when
their collections are out of their sight.
* If authorities get involved, encourage a family member or social service
worker, or offer yourself, to sit with them while the authorities explain their
plan or actions.
* Assess patients' level of understanding of their situation and offer support.
* Encourage consults with professionals who have experience and expertise
with those who hoard, including psychiatrists, psychiatric NPs, and home
organizers. Offer a list of treatment providers who've expressed an interest
in treating people who hoard.
* Encourage family members to be involved in counseling or learning about
hoarding. (For more information, see Resources on the web.)
* With families, discuss local resources for help with those who hoard.
Discourage families from emptying the home while patients are in the
hospital. Doing so risks patients becoming very upset and cutting off contact
with the family. They need to work with patients to remove the items:
Involving those who hoard in decisions about what to remove helps them
regain a sense of control over their environment and ultimately their lives.
* Upon discharge, ask social service agencies to identify local visiting nurse
services that have experience with those who hoard.
* To help patients return to a safe and healthy environment upon discharge,
connect them with social services agencies such as public safety, fire,
building code, and public health.5
* Prepare patients and families for long-term interventions, such as
medication management, cognitive behavioral therapy (CBT), and
interactions with multiple agencies. (See How does CBT help?)
Besides CBT therapy, psychopharmacology with selective serotonin reuptake
inhibitors, such as paroxetine, sertraline, and fluvoxamine, is effective.2
These medications cause few adverse reactions, helping with adherence.2
These medications may also be prescribed for certain comorbid disorders,
such as social phobia, depression, and anxiety.2
These therapies can reduce hoarding symptoms by about 40%, but when
patients stop medications, symptoms return.2 Due to these medications'
effects on anxiety and cognitive distortions, patients respond better to CBT.
Patients' social support systems and home healthcare must also be mobilized
along with these two major outpatient therapies. Support groups can help
patients understand they're not alone in this process. These groups can
teach them about their behavior and how to reduce the symptoms. Some
communities offer resources to assist those who hoard.
Free treatment may be available to patients participating in clinical studies
about hoarding behaviors. Home healthcare can support patients by helping
with realistic and achievable goals to retake living space and reduce clutter.
Home healthcare can offer positive feedback about the treatment and
positive changes that are demonstrated, such as retaking living space by
reducing the clutter or improvements in social functioning.
Be aware that those who hoard animals, like Mr. M, believe that when
animal control authorities get involved, their animals will die. (Although this
isn't always the case, animals are sometimes euthanized because of severe
health problems and because there are so many of them.) Fortunately,
recidivism rates decrease when people who hoard and authorities work
together.8 The treatment plan includes letting the person keep a few
animals while agreeing not to take in any more as well as accepting
unannounced visits from animal control. These visits need to go on as long
as the person who hoards lives where the behavior could return.
There are no winners in hoarding cases, but there are many losers: those
who hoard, family members, neighbors, animals, and society itself. Hoarding
disorder is an illness that takes a community of participants to produce a
good outcome for all involved.
Mr. M returned to the hospital twice during his 2-month rehabilitation.
Although he had a very hard time accepting the loss of his pets, with his
daughter's help the house was professionally cleaned of animal waste, and
Mr. M could return home at last. Ms. J's support and understanding were
most important, not only for her father to return home but to help him to
have a more healthy and happy future. A few days after his return home,
one of his cats (lucky number 13) showed up on his doorstep and ultimately
the authorities let him keep that one cat.
Ongoing care
Long-term case management includes the following:
* With family participation, patients can be encouraged to keep a daily log of
items acquired. This helps them recognize triggers that lead to collecting
items.5
* With patient permission, have family take photos of the rooms before,
during, and after therapy.5
* Set small realistic goals; for example, removing clutter from one area for
15 minutes a day or learning and practicing a relaxation technique in 1
week.2
* Provide positive feedback for each small step toward the ultimate goal of
removing clutter.
Nurses need to not only recognize those who hoard but to also remember
that their "collections" comfort them. They may not recognize the negative
effects of their hoarding, but with appropriate medication, counseling,
support, and long-term follow-up, those who hoard can lead a life in which
they begin to establish control over the hoarding and reverse the isolation
and damage it engenders.
A closer look at those who hoard
According to R.O. Frost, a pioneering authority on hoarding disorders,
hoarding is multidimensional, with these four characteristics:
* The patient, who has a high level of perfectionism, has exhibited
symptoms of anxiety and depression. The patient may have a family history
of hoarding.
* The patient has difficulty processing information, having problems with
attention, memory, categorization, and decision making. The region of the
brain that influences these functions activates differently in people who
hoard than in those who don't have the disorder.
* Someone who hoards builds intense emotional attachments to a wider
range of objects than people who don't hoard.
* The patient has opinions about the necessity of conserving items or
missing opportunities based on a distortion of the item's importance.
Katherine J.Vanderhorst ,RN,BSN
Vice-President
C&V Senior Care Specialists, Inc.
95 Oakgrove Drive
Williamsville, NY 14221
716-863-0743
[email protected]
www.cvseniorcare.com