Alicia Ault

March 29, 2016

WASHINGTON ― Exposure therapy combined with some training in problem solving appears to lessen the severity of hoarding symptoms, according to a small, randomized controlled trial.

Researchers from the San Diego State University (SDSU)/University of California, San Diego (UCSD) joint doctoral program in clinical psychology compared a program they devised, called Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST), with case management in a group of older hoarders.

The study found "that the treatment works — and I think that's incredible," said discussant Julie Wetherell, PhD, professor in residence in psychiatry at UCSD, who is also a staff psychologist in the Veterans Affairs (VA) San Diego Healthcare System Home-Based Primary Care program.

Case management is a "powerful control condition, and yet [CREST] was more effective." The results add "to my conviction that cognitive change, at least formal cognitive restructuring, is not necessarily that helpful" when it comes to older people with hoarding disorder, she said.

The findings were presented here at the American Association for Geriatric Psychiatry (AAGP) 2016 Annual Meeting.

Hoarding disorder is defined in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as "persistent difficulty discarding or parting with possessions" regardless of their value, extensive clutter in the home and workplace, and symptoms that impair function, including "maintaining a safe environment."

Older adult hoarders have problems with executive function and may not manage their diet or medications, leading to a worsening of any comorbid chronic conditions, said study investigator Mary Dozier, a doctoral candidate at the SDSU/UCSD program who presented the data. The disorder may also significantly impair the individual's ability to conduct activities of daily living, she added.

Hoarding in the geriatric population has also been linked to a risk for eviction and homelessness, said Dozier, who presented the findings on behalf of lead author Catherine Ayers, PhD, assistant professor of psychiatry at UCSD.

The CREST study included persons aged 60 years or older who met the DSM-5 criteria for hoarding disorder and had significant symptoms, as defined by a score of 20 or more on the UCLA Hoarding Severity Scale and the Saving Inventory–Revised (SIR). Individuals with severe cognitive impairment, bipolar or psychotic disorder, and active substance use were excluded, as were those in psychotherapy. For patients who were receiving psychotropic medications, the dosing of those medications had to be stable.

More than 120 individuals expressed interest in participating, but the study included 58 patients ― 41 women, and 17 men (mean age, 67 years). The patients were primarily white; almost a third had never been married, and another third were married or living with someone. Sixty percent were retired.

Thirty-one patients were enrolled in CREST; 27 were enrolled in case management. By the study's end, at 6 months, 21 patients remained in the CREST arm, and 18 were in case management. Patients were dropped from the study for various reasons, including health problems. One patient was dropped for behavioral reasons, and another for starting psychotherapy, said Dozier.

Forty percent of the patients were taking psychotropic medications. A quarter had obsessive compulsive disorder, 28% had a separate anxiety disorder, and 39% had a mood disorder.

Patients received CREST or case management in weekly sessions over 26 weeks. The CREST was delivered by two doctoral-level therapists and a master's-level therapist who had training in hoarding disorder. Geriatric nurses delivered the case management.

Superior to Case Management

The first six sessions focused mostly on delivering compensatory cognitive training, which consisted of training in prospective memory, prioritizing, problem solving, planning, and cognitive flexibility. For example, patients were given calendars and were taught how to use them, or they were provided with strategies for linking tasks, such as putting keys in the same place every day.

In one of the first sessions, a brief introduction to exposure therapy is presented to help prepare patients for a home visit.

"Just the act of having someone coming to their home can be an exposure in itself," said Dozier.

When exposure therapy begins, patients are asked to bring to the clinic a box of items to sort, the idea being that they will be keeping some of the items but disposing of the rest. The box cannot contain things they have already decided to throw away, Dozier said. If patients want to recycle or give away any items, those things must be placed into a box that will be immediately disposed of — it cannot be a box that they will take with them to keep at home, she said.

As the therapists and helpers — usually undergraduates — go into the home, items are removed, but the decision as to which items are to be removed is up to the individual with the hoarding disorder.

"Ultimately, the goal here isn't to get the house clean by the end of the treatment," said Dozier. "It's to teach them the skills and have them maintain the skills so they can clean out the home themselves and maintain that."

By the end of the study, patients who received CREST demonstrated a 38% decline in scores on the SIR, compared with a 25% decline for patients receiving case management. The case management result was similar to what has been observed with cognitive-behavioral therapy for geriatric hoarding, said Dozier.

Patients receiving CREST also did better on secondary measures, such as the Clutter Image Rating scale. CREST recipients had a 40% decline in scores on that measure, compared with a decline of just under 16% for those receiving case management. The CREST patients had a 31% decline in scores on the Activities of Daily Living–Hoarding scale (ADL-H), compared with 13% for the case management group.

Overall, "we found that CREST works pretty well," said Dozier, and that it was superior to what most geriatric hoarders receive — case management.

It is not clear whether the study results would be similar for hoarders who are much older than the study population or for people who are living with children or in a nursing home, Dozier said.

She and her colleagues are now exploring how CREST compares with exposure therapy only. The study, which is still recruiting patients, is sponsored by the Department of Veterans Affairs and will be conducted in veterans aged 45 to 85 years at the VA San Diego Healthcare System. It began in October 2015 and will be completed in 2020.

Mary Dozier and Dr Wetherell report no relevant financial relationships.

American Association for Geriatric Psychiatry (AAGP) 2016 Annual Meeting: Session 205, presented March 18, 2016.

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