A compulsive hoarder collects and is unwilling to discard items of no practical - or even emotional - value. The often massive ensuing accumulation of newspapers, empty food containers, gadgets and other clutter compromises living space and, in some cases, creates unsanitary living conditions.

When the compulsive hoarder is elderly, serious health consequences associated with self-neglect also may emerge. In such cases, geriatric case managers in my area, Northern Virginia, provide the means to administer or access necessary social service and health intervention assistance, and in so doing help to protect these vulnerable individuals from unintentional self-inflicted harm.

A Symptom of OCD
"Compulsive hoarding is not a distinct diagnosis," said Judy Grumbly, ANP, RN, geriatric case manager, Care Options, Falls Church, VA. Compulsive hoarding is an associated symptom of obsessive-compulsive disorder (OCD) that afflicts approximately 25 percent of OCD patients. National Institutes of Mental Health statistics indicate that approximately 2.2 million Americans have been diagnosed with OCD.

According to the Diagnostic Statistical Manual for Mental Health Disorders (DSM) IV, the diagnostic criteria for OCD require that the patient's symptoms cause visible distress and interfere significantly with daily and social functioning. In the case of compulsive hoarding, patients wrongly believe that items that properly should be discarded might, however unlikely, one day be needed, should be fixed if broken, or simply should not be "wasted." In the end, these feelings result in a collection of clutter so overwhelming that the individual's daily and social functions are impaired.

Genetic studies indicate that compulsive hoarding tends to present itself in families with genetic markers on chromosome 4, 5 or 17. The behavior appears to be unrelated to intelligence. In fact, many compulsive hoarders have above average intelligence. It also appears not to be a factor that can be attributed simply to aging. Although compulsive hoarding behavior may initially occur during adolescence, the elderly most frequently come to attention of the health treatment system simply because they are less able to manage their environment.

"For some elderly patients, hoarding is the antidote to loneliness," said Susanna Ryan, MSN, RN psychiatric clinical specialist at the Center for Integrative Psychiatry, Vienna, VA. "With hoarders, oftentimes a spouse may have kept the situation in check by discarding items. When the hoarder's spouse dies, the situation intensifies and the incidence of self neglect climbs."

The behavior of elderly hoarders sometimes is assumed incorrectly to be a symptom of dementia. The hoarder's inability to find among the clutter medications for co-existing chronic conditions such as diabetes, asthma, or hypertension can interfere with essential adherence to prescribed medical regimens.

The Risk of Self-Neglect
A study conducted at the UCLA Neuropsychiatric Institute documents that hoarding constitutes a physical health threat in 81 percent of identified cases.

"Living conditions for those affected with this syndrome are mind-boggling," said Grumbly. "Some patients cannot find needed medication. Falling is a risk. Wheelchair and walker mobility is impaired and . the risk of suffocation from an avalanche of clutter exists."

For those living in apartments or multilevel dwellings, the weight of stockpiled items has, in some documented cases, contributed to the collapse of floors and threatened the safety of neighbors in adjacent dwellings.

During hospital discharge site visits for elderly patients, case nurses may find evidence of self-neglect, poor hygiene, exacerbation of chronic diseases, untreated medical conditions, and/or lack of needed medical supplies or equipment. Examples include:

• Missing dentures
• Glasses
• Hearing aides
• Walkers
• Wheelchairs
• Essential medications

In such discoveries, public health or visiting nurses are required by law to report for investigation cases that meet the criteria of self-neglect to the appropriate adult protective services agency in their jurisdiction.

Nursing Intervention Strategies
Nursing support is vital to preparing the patient for the intrusion of service authorities into the home. Nurses who manage a compulsive hoarding case have an immediate responsibility to the patient to communicate their intended plan of action, assess the patient's level of understanding and provide emotional support.

Long-term case management consists of monitoring adherence to prescribed medication regimens. The medications most commonly used to treat compulsive hoarding are selective serotonin reuptake inhibitors (SSRIs), a type of antidepressant. Long-term intervention also typically consists of intervention cognitive behavioral therapy, the goal of which is to train patients to develop the necessary decision-making skills that empower them to discard nonessential items without remorse.

"The solution is not simply clearing out clutter," said Grumbly.

"If intervention is not collaborative, the patient situation is unresolved," said Henriett Kellum, LCSW, Arlington County Hoarding Task Force.

Nursing intervention connects the patient to vital social service agencies. Nursing compassion helps the elderly hoarder regain control of their environment and their health. Together, the services of nursing, public health, public safety, fire, building code, human services and mental health significantly can improve the likelihood that self-neglect will not threaten the health or welfare of the elderly hoarder.