Hoarding Older Adults

Research has shown that hoarding disorder (HD) is debilitating chronic and progressive
condition that has significant public health implications. Older adults represent the largest
group of HD suffers due to increasing severity with age. Often, Veterans with HD are seen in
the VA system and the status of their hoarding is never assessed. Providers are treating
patients for other health and social service issues yet missing an important source of
disability and distress. This insidious, often undetected condition leads to greater medical
and social disability and is costly to the VA system as patients continue to decompensate.
When HD is even detected, patients in the VA receive indefinite case management and
inadequate treatment. The cases the investigators know about have caused significant
financial burden to the investigators' system. Most importantly, HD causes significant
impairment and poor quality of life for the Veterans, particularly older Veterans.
Unfortunately, the investigators know nothing about how to treat late life HD. Nor do the
investigators know how neurocognitive features impact treatment response, which the
investigators strongly suspect influence treatment outcome. HD is a potentially treatable
source of disability in the VA system - one that the VA must research and treat. This study
represents the first randomized controlled trial of a novel intervention for the treatment of
HD in older Veterans. The main objective of this proposal is to further refine and test a new
treatment for hoarding in older Veterans (age 60-85) which will be accomplished through a
series of treatment development phases (case series, open labeled trial) and a randomized
controlled trial. The new treatment (Cognitive Remediation and Exposure Therapy for hoarding;
CogRET) is hypothesis driven and based on late life anxiety literature, consultation with
mentors, results of the pilot study using a standard cognitive-behavioral intervention, and
several case series that will be completed prior to the start of the Career Development Award
(CDA). The first draft of CogRET is complete and is currently being used with several case
studies. The research and training plan is divided into 5 phases; 1) training and preparation
2) training, further case studies using CogRET, further modification of CogRET 3)training,
open label trial of CogRET, further modification of CogRET 4) randomized controlled trial and
5) presenting, publishing, dissemination of results and submission of a VA Merit grant.
Primary hypotheses include 1) when randomized to CogRET, older Veterans with HD will show
significant decreases in acquisition, difficulty discarding, and excessive clutter compared
to those randomized to case management and 2) executive functioning (EF) is a significant
moderator of treatment response. Other mediators and moderates of treatment response
(psychiatric, medical, demographic, etc.) will be explored.

Inclusion Criteria:

Participants must be between the ages of 60 - 85 years old and meet clinical criteria for
Compulsive Hoarding (CH) developed by the Steketee and Frost (2000) research group. These
criteria include:

- significant amount of clutter in active living spaces

- the urge to collect, buy, or acquire things

- an extreme reluctance to part with items

- clutter accumulation that causes distress or interferes with functioning

- symptom duration of at least 6 months

- the reluctance to part with items is not accounted for by other psychiatric
conditions.

To be enrolled, patients must have:

- a score of 20 or greater on the University of California, Los Angeles Hoarding
Severity Scale (UHSS)

- 40 or greater on the Savings Inventory-Revised (SI-R)

- severity rating of 4 or higher on the Anxiety Disorders Interview Schedule (ADIS-IV)
rating scales for clutter and difficulty discarding

- and diagnosis confirmed at a consensus conference including at least two licensed
professionals with expertise in CH (myself and at least one mentor).

Exclusion Criteria:

- Individuals with moderate to severe cognitive deficits (scores below 23 on the MMSE)
will be excluded.

- Prospective participants must not have active substance abuse problems.

- Participants will also be excluded if they are currently in other forms of
psychotherapy.

- Participants must have no change in any psychotropic medications for at least three
months prior to the initial assessment.

- Patients with current psychosis or mania will be excluded.

- Mood and anxiety disorders are permitted as long as compulsive hoarding is the primary
diagnosis.

- Participants will are not eligible if they have active suicidal ideation, those
participants will be given immediate medical or mental health attention.