Mary E. Dozier

The UCLA Hoarding Severity Scale: Development and validation

BACKGROUND Effective management of Hoarding Disorder (HD) must begin with assessment of the severity of hoarding symptoms and functional impairment. We sought to validate the UCLA Hoarding Severity Scale (UHSS), a semi-structured, clinician-administered rating scale that measures the severity of both the core symptoms of HD and the associated features of indecisiveness, perfectionism, task prolongation, and procrastination, which are significantly associated with the diagnosis and impairment of HD. METHODS Hoarding symptom severity was measured in 62 patients who met DSM-5 diagnostic criteria for HD and 65 normal controls, using the UHSS and the Saving Inventory-Revised (SI-R), a well validated self-report measure of hoarding symptoms. RESULTS The UHSS showed significant internal consistency (Cronbach׳s α=.70). Principal components analysis revealed three factors that accounted for 58% of the variance: 1) associated features and functional impairment, 2) clutter volume and social impairment, and 3) difficulty discarding, urges to save, and excessive acquisition. UHSS and SI-R scores were significantly correlated. UHSS and SI-R total and factor scores of HD patients were all significantly different from those of controls. LIMITATIONS Inter-rater and test-retest reliability were not assessed. The initial version of the UHSS did not contain rater instructions, so it lacked quantifiable anchor points for ratings. CONCLUSIONS The UHSS showed internal consistency, construct validity, convergent validity, and known groups discriminant validity. The UHSS validly measures the core symptoms, associated features, and functional impairment of patients with HD. Utilizing a valid clinician-administered scale will provide a more comprehensive and accurate clinical assessment of patients with HD.

Validation of the Clutter Image Rating in older adults with hoarding disorder.

BACKGROUND The Clutter Image Rating (CIR) was created to meet a gap in the research on compulsive hoarding: how to ascertain clutter level in an individuals home without a home visit, as not all clinicians have the ability to conduct a home visit. The CIR has proven itself to be both reliable and valid for use in adults with compulsive hoarding symptoms. However, there is currently a dearth of information on performance of the CIR in older adults diagnosed with hoarding disorder (HD). Because older adults have increased medical issues, including fall risks, evaluating the level of clutter in the house is especially critical in geriatric populations. METHOD The current study was an investigation of the reliability and validity of the CIR in assessing late life HD. The internal consistency, convergent and divergent validity, and norms of the CIR were investigated in a large geriatric HD sample and compared with a midlife sample of individuals with HD. Criterion validity of the CIR was investigated through the comparison of participant ratings conducted in the clinic and clinician ratings conducted in the home. RESULTS The current study found similar levels of reliability and validity in a late life sample as in previous studies conducted in mid-life adults. CONCLUSIONS Unlike previous studies, the current study did not find a significant relationship between the CIR and the non-clutter related subscales of the Savings Inventory-Revised. The CIR appears to be both reliable and valid for assessing clutter levels in older adults diagnosed with HD.

Hoarding Disorder in Older Adulthood

OBJECTIVE Hoarding disorder (HD) is a chronic condition associated with moderate to severe impairment in health and functioning. HD has been primarily studied in midlife adults, and there is limited research on HD in late life. METHODS In this review, we summarize research on the presentation and characteristics of HD and hoarding symptoms in older adults, including evidence for associated impairment in daily functioning, physical health, and cognitive function. Finally, we review the evidence available for intervention outcomes for treating HD in older adults. RESULTS Geriatric HD is characterized by severe functional impairment, medical and psychiatric comorbidities, and cognitive dysfunction. CONCLUSION There is a lack of randomized controlled trials investigating evidence-based treatments for geriatric HD.

Age of onset and progression of hoarding symptoms in older adults with hoarding disorder

Objectives: We investigated (1) age of onset of hoarding disorder (HD) symptoms and diagnosis, (2) late-onset HD, (3) progression of HD symptoms, and (4) association between demographics and hoarding progression. Method: Eighty-two older adults with HD provided retrospective ratings of their hoarding symptoms for each decade of life. Age of onset of symptoms (saving, difficulty discarding, and clutter) was operationalized as the first decade in which the participant reported at least minor symptom severity, and age of onset for possible HD diagnosis was operationalized as the first decade in which the participant reported all three symptoms. We used mixed effects modeling to examine the progression of HD symptoms. Results: The median age of onset for symptoms was between 10 and 20 years, and the median age of onset for possible HD diagnosis was between 20 and 30 years. Twenty-three percent of participants reported onset of possible HD diagnosis after the age of 40. All HD symptoms increased in severity over time. Men reported higher initial clutter and a slower increase in hoarding severity for all symptoms. Increased education was associated with slower increase in saving. Having at least one parent with hoarding tendencies was associated with higher initial hoarding symptoms. Conclusion: Generally, symptoms of HD begin relatively early and worsen across the lifespan. However, approximately one fourth of older adults with HD reported a possible onset after the age of 40.

Executive Functioning in Participants Over Age of 50 with Hoarding Disorder

OBJECTIVES The current investigation utilized mid-life and late-life participants diagnosed with hoarding disorder (HD) to explore the relationship between executive functioning and hoarding severity. DESIGN Correlational analyses were used to investigate the associations between executive functioning and hoarding severity in nondemented participants. Multiple regression was used to determine if executive functioning had a unique association with HD severity when accounting for depressive symptoms. SETTING Participants were recruited from the San Diego area for HD intervention studies. PARTICIPANTS Participants were 113 nondemented adults aged 50-86 years who met DSM-5 criteria for HD. The mean age of the sample utilized in the analyses was 63.76 years (SD, 7.2; range, 51-85 years). The sample was mostly female (72%), Caucasian (81.4%), and unmarried (78%). MEASUREMENTS Hoarding severity was assessed using the Saving Inventory-Revised and the Clutter Image Rating and depression was assessed using the Hospital Anxiety and Depression Scale. Executive functioning was assessed using the Wisconsin Card Sorting Test (WCST-128) and the Trail Making and Verbal Fluency subtests of the Delis-Kaplan Executive Function System. RESULTS Executive function (operationalized as perseveration on the WCST-128) was significantly associated with Clutter Image Ratings. In a multivariate context, executive function and depressive symptom severity were both significant predictors of variance in Clutter Image Rating. CONCLUSIONS Our results suggest that executive function is related to severity of HD symptoms and should be considered as part of the conceptualization of HD.

The relationship between age and neurocognitive and daily functioning in adults with hoarding disorder

Given the increase in hoarding symptoms with age, there is a pressing need for understanding the clinical features as they relate to potential interventions for older adults with hoarding disorder (HD). The aim of the current investigation was to explore age‐related differences in the level of functional and cognitive impairment in individuals with HD.

Psychometric Evaluation of the Saving Inventory-Revised in Older Adults

ABSTRACT Objectives: Hoarding disorder (HD) is a chronic condition characterized by severe impairment in health and functioning for older adults. Researchers and clinicians commonly use the Saving Inventory-Revised (SI-R), a self-report measure validated for the assessment of HD, to establish symptom severity. This study represents the first evaluation of the psychometric properties of the SI-R in a sample of older adults with HD. Methods: Participants were 156 older adults with HD and 23 older adults with no psychiatric diagnoses. Demographic and HD symptom severity measures were compared between the two samples. Convergent and discriminant validity was examined in the HD sample. A confirmatory factor analysis was used to test the replicability of the three-factor structure observed in the original sample. Results: Participants in the HD sample scored significantly higher on the SI-R than did the non-psychiatric sample. The SI-R was significantly correlated with clutter level and symptoms of anxiety and depression. A three-factor model demonstrated poor fit in the HD sample. Conclusions: The SI-R can be used to validly assess hoarding severity in geriatric populations.Clinical Implications: Clinicians working with geriatric patients should consider refraining from use of the SI-R subscales as they may be less theoretically distinct in older adults.

Predictors of hoarding severity in older adults with hoarding disorder

BACKGROUND The recent addition of hoarding disorder (HD) to the Diagnostic and Statistical Manual of Mental Health Disorders, 5th edition, has highlighted the dearth of information about the demographic, sociologic, and medical predictors of HD severity, particularly in older adults. Although there have been several previous studies examining the characteristics of older adults with HD, and one investigation of psychiatric correlates of hoarding symptom severity in non-clinical older adults, there has been little investigation about which characteristics predict hoarding symptom severity in older adults with HD. METHODS Participants were 71 older adults who were enrolled for one of the two studies of HD at the VA San Diego Healthcare System between January 2010 and January 2014. RESULTS There were multiple differences in the predictive ability of patient characteristics between the more cognition-related symptoms of HD and the more concrete measure of clutter, including gender-based differences and anxiety severity. Further, married participants were more likely to report lower hoarding severity, and there was no significant relationship between hoarding severity and intervention attempts or hoarding and reported falls in the past three years. CONCLUSIONS Multiple predictive factors have been presented, which may result in further studies to investigate possible predictive differences in cognition and clutter symptoms of HD. Future studies should examine the possibility of the predictive factors also identified to be moderators of treatment outcomes.

Treatment Recruitment and Retention of Geriatric Participants With Hoarding Disorder

This study describes the initial contact of 255 potential participants, recruitment of 63 participants, and retention of 57 participants from three geriatric Hoarding Disorder (HD) studies. Patients with HD were easily recruited from the community, primarily through the use of clinician referrals and posted flyers, as evidenced by steady patient flow despite lack of compensation for participation. Contrary to treatment outcomes of late life mood and anxiety disorders, geriatric HD patients are largely retained in clinical research treatment studies. Results demonstrate that older adults with HD can be engaged in treatment. Participants often needed the study staff to provide substantial support, including informal motivational interviewing and problem solving, in scheduling and attending the initial visit.

Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST) for Hoarding Disorder in Older Adults: A Randomized Clinical Trial

OBJECTIVE To compare the efficacy of Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST) with geriatric case management (CM) in a sample of older adults meeting DSM-5 diagnostic criteria for hoarding disorder (HD). METHODS Fifty-eight older adults with HD were enrolled in a randomized controlled trial between December 2011 and March 2014. Thirty-one participants received CREST, and 27 participants received CM. Both interventions consisted of 26 individual sessions over a period of 6 months and included several home visits by the study therapists (CREST) or nurses (CM). The Saving Inventory-Revised (SI-R) and the UCLA Hoarding Severity Scale (UHSS) were the main outcome measures. RESULTS Participants in the CREST condition had significantly greater improvement on the SI-R than participants in the CM group (group × time interaction: β = 3.95, SE = 1.81, P = .029), with participants who completed the CREST condition averaging a 38% decrease in symptoms and participants who completed the CM condition averaging a 25% decrease in symptoms. In contrast, there was not a significant group × time interaction effect on the UHSS (β = 1.23, SE = 0.84, P = .144), although participants did report greater improvement in symptoms in the CREST condition (35%) than in the CM condition (24%). Treatment gains were maintained at 6-month follow-up. CONCLUSIONS CREST appears to be an efficacious treatment compared to CM for older adults, but CM also showed meaningful benefits. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01227057​.