Evaluating Dispositional Capacity in Patients With Late-Life Hoarding Disorder

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ACADEMY OF CONSULTATION LIAISON PSYCHIATRY

Hoarding disorder is a type of obsessive-compulsive and related disorder, defined by DSM-5-TR as persistent difficulty discarding or parting with possessions due to the perceived need to save the items and distress associated with discarding them. The accumulation of possessions congests and clutters active living areas and substantially compromises their intended use, causing clinically significant distress or impairment in functioning.¹ Community epidemiological reports estimate prevalence rates of clinically significant hoarding symptoms from 2.0% to 5.3%.²

For older adults, hoarding disorder can have serious consequences, such as increased fall risk, fire hazards, poor hygiene, and poor nutrition, all of which can lead to patient morbidity. Other serious consequences of hoarding disorder in older adults include food contamination, social isolation, and medication mismanagement, leading to medical problems and problems in daily functioning.³ One study showed that older adults with compulsive hoarding behaviors have significantly higher rates (90% vs 40%) of self-reported general medical comorbidities, such as hypertension, stroke, sleep apnea, and seizures, than older adults without hoarding disorder.⁴ Kim et al reported that many older adults with hoarding symptoms experienced substantial impairment in daily living (Table 1).⁵ Moreover, older adults with hoarding disorder may struggle with eviction and homelessness.⁶

Table 1. Impairments in Daily Living for Older Adults With Hoarding Symptoms

Consultation psychiatrists practicing in the general medical hospital are routinely asked to evaluate the decisional capacity of hospitalized patients with psychiatric disorders. While traditional decisional capacity evaluations pertain to a single decision and follow the doctrine of informed consent,⁷ a dispositional capacity evaluation determines the patient’s capacity for self- care post-discharge. The dispositional capacity assessment is multifactorial and prospective, requiring psychiatrists to envision the patient’s ability to care for themselves in the community and in the future.⁸ Factors such as cognitive impairment and psychiatric illness influence both decisional and dispositional capacity. Per Appelbaum, neurocognitive disorders are most commonly associated with impaired decisional capacity.⁹ However, psychotic, bipolar, depressive, adjustment, and other psychiatric disorders may impair decisional capacity, even in the absence of cognitive impairments.

Literature concerning the impact of hoarding disorder or hoarding behaviors on decisional or dispositional capacity is limited. There is also a lack of consensus about the significance or relevance of hoarding disorder when assessing dispositional capacity. Patients with hoarding disorder often exhibit neurocognitive impairments and deficits in self-control, particularly among children and older adults.^10,11 Additionally, numerous case studies have demonstrated that the relationship between hoarding behavior and deficits in self-control. Especially in elderly patients with severe hoarding disorder, the combination of self-control deficits and refusing to seek help can lead to acute illness and extreme self-neglect, suggesting a potential influence on dispositional capacity.^12,13 Here, we present a case in which our consultation psychiatry service was asked to evaluate dispositional capacity in a hospitalized patient with late-life hoarding disorder.

Case Vignette

Our service was asked to evaluate, “Margaret,” a patient for an involuntary psychiatric commitment upon completion of treatment for acute hypoxic respiratory failure due to chronic obstructive pulmonary disease exacerbation and obstructive sleep apnea in the setting of medication nonadherence. Margaret is a 77-year-old woman with a history of hypertension, pulmonary embolism, and major depressive disorder (MDD). She presented to the hospital after her friend requested a welfare check on her for an uninhabitable living situation and not responding to her telephone for a couple of days.

Per records, emergency medical services (EMS) could not get the gurney into her house due to multiple hazards caused by the accumulation of her belongings. EMS placed Margaret on an involuntary psychiatric commitment order for grave disability because they deemed her home uninhabitable with a report that the local government may condemn her home. A condemned property is a property or building that local authorities—typically municipal—have closed, seized, or imposed restrictions on for various reasons, such as public safety and public health.¹⁴

During the initial psychiatric evaluation, Margaret reported worsening depressive symptoms for many years in the setting of multiple losses, social isolation, physical disability, and nonadherence to her antidepressant medications (venlafaxine and bupropion). The medical team became concerned about hoarding disorder, given the information from EMS about the accumulation of belongings posing a health hazard, a friend’s report on the patient’s impulsive shopping, a family member’s report on the patient’s decades-long hoarding behavior, and Margaret’s fear of losing her belongings. Evaluation of medical causes of hoarding included cognitive assessment (normal MoCA score of 29/30) and CT brain imaging, which was significant for subtle areas of white matter hypodensity, likely a sequelae of mild chronic microvascular angiopathy.

Margaret additionally presented with severe deconditioning, malnutrition [hyponatremia, hypokalemia, hypophosphatemia, and low vitamin C (<5mol/L), vitamin B12 (171pg/mL), and folate (<3.5ng/mL)], and inability to perform activities of daily living, likely as a result of both her psychiatric illnesses as well as mobility issues. She denied any substance use, and there was no evidence of a substance use disorder (negative urine drug screens). Margaret exhibited impaired insight, as she was unable to verbalize how her hoarding behaviors affected her home environment—which was on the brink of being condemned—and thus her own safety. She declined to contact available family or friends to help provide alternative housing options, stating she preferred to return to her own home. As a result, the team had concerns that Margaret was unable to provide a plan for self-care, including shelter and food, due to her severe hoarding behavior. She was thus placed on an involuntary psychiatric commitment for grave disability.

Over the next couple of days, while searching for an inpatient psychiatric hospital, Margaret was linked to outpatient follow-up regarding her depressive and hoarding disorders. She resumed a regular diet and received intravenous fluids and supplementation with vitamin B12 and folate. Her depressive symptoms improved and her electrolytes normalized. The hospital social work team confirmed that Margaret’s house was not condemned, though initial reports had indicated otherwise. Margaret seemed to demonstrate improved insight into her hoarding behaviors by verbalizing plans to organize and declutter her house with support (eg, friend, cleaning services). She agreed to adhere to treatment recommendations, such as taking medications, showing up to outpatient appointments, and improving her diet, with home health support. Given her verbalized plans to provide care for herself and her improved insight, the psychiatric team discontinued her involuntary psychiatric commitment order.

During discharge planning, the social work team learned that law enforcement had filed a report to Adult Protective Services (APS) for her self-neglect after the initial welfare check. Her son, who lived far away, became involved in her care during discharge planning and stated that she should not return home to her unsafe living environment. He shared that his mother had a chronic history of severe hoarding and numerous incidents of not following through with her plans of decluttering, eventually requiring her relatives to travel across the country to clean the home. He stated that the family would not be able to declutter her home this time. Given this new information, the primary hospital medicine team did not believe Margaret had the capacity to make decisions regarding a safe discharge plan and asked the psychiatric team to evaluate her for dispositional capacity.

When the psychiatry team reapproached her, it was clear that Margaret did not understand the risks of returning home. She was unable to verbalize the consequences of her continuous hoarding, such as the risk of falls, infections, infestations, self-neglect, and fire hazards. She had a history of self-neglect leading to her admission and possibly also falls related to hoarding behaviors. She ultimately demonstrated poor insight and judgment regarding her safety. Therefore, the psychiatry team decided that Margaret lacked dispositional capacity and suggested that the primary medical team consider the role of a surrogate decision-maker. Margaret’s son became her surrogate decision-maker and was involved in formulating an alternative discharge plan. The medical team eventually found her a board and care facility (ie, nonmedical custodial care provided in a single-family residence, a retirement residence, or in any appropriate care facility, including nursing homes), to where Margaret agreed to be discharged, and family members flew to her home to assist with property restoration.

Discussion

When considering the prospective behavior of a patient with hoarding disorder, multiple factors must be taken into account.⁸ Demographic factors such as age, income level, employment status, location, and homeownership can significantly influence the patient’s ability to adhere to recommended treatments and maintain a habitable living environment. Medical factors, including comorbid medical conditions, sensory capacities, and mobility, can impact overall health and ability to provide self-care. Psychological factors, such as the severity of hoarding behaviors, ongoing treatment modalities like cognitive-behavior therapy or psychiatric medication, neurocognitive status, and other cooccurring psychiatric disorders, play a crucial role in predicting future behavior. Additionally, social factors, such as housing status and the availability of a supportive social network, can greatly affect the patient's ability to maintain their living environment and engage in activities of daily living and instrumental activities of daily living. Ultimately, assessing these factors collectively provides insight into how the patient may behave in the future, including their ability to adhere to treatment recommendations and maintain a safe and functional home environment.

Concluding Thoughts

While patients with hoarding disorder may not routinely seek psychiatric care, hoarding disorder affects 2.0% to 5.3% of the population and can have serious health impacts, particularly for older adults (Table 2).^2,3 Despite self-care risks, there is a scarcity of literature regarding the potential impact of severe hoarding behaviors on dispositional capacity. We introduced a case that demonstrated all these potential risks and illustrated how we approached the dispositional capacity evaluation and assisted with a safe discharge plan for an older patient with severe hoarding disorder in an inpatient setting. We emphasize considering multiple factors in evaluating self-care in hoarding disorder. An interdisciplinary approach—including social work, occupational therapy, neuropsychology testing if available, physical therapy, and APS assessment of the home environment if possible—can be instrumental in the evaluation process.

Table 2. Examples of Significant Health Consequences in Older Adults With Hoarding Disorder

Furthermore, obtaining pertinent information from family members, friends, and caregivers can provide valuable insights. Given the progressive nature of hoarding disorder and the relatively new established treatments, there is a growing number of elderly patients with severe hoarding disorder experiencing critical health consequences. Therefore, future studies will be necessary to determine how to effectively work with late-life hoarding disorder patients in various settings.

Acknowledgment

We would like to thank our UC Davis Internal Medicine team and the patient for letting us participate in the patient’s care and giving us an opportunity to investigate the presented issue further.

Dr Kim is a resident in psychiatry. Dr Dutta is a resident in neurology. Dr Reddy is an associate physician diplomate. Dr Bourgeois is vice chair of Hospital Psychiatry Services. All authors are at the University of California, Davis Medical Center, Sacramento, California.

References

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14. Condemned property. Wikipedia. April 27, 2024. Accessed August 21, 2024. https://en.wikipedia.org/wiki/Condemned_property