Hoarding Disorder: Telephone Shopping, Unsafe Home

Hoarding Disorder Case Background

A family expressed concerns over their mother, who had become increasingly isolated and confused. She fed her “needs” by buying throughout the night on QVC. During a home visit, we observed hundreds of unopened yellow QVC bags and the contents of many additional QVC purchases strewn across the home. There were pathways going between doors and several rooms, with large stacks of items (5 feet+) along the paths. Two bedrooms were closed off; the doors would only open a few inches due to floor-to-ceiling contents stacked from wall-to-wall. The floor of the master bedroom was covered with items, and only a tiny portion of the bed was available for sleeping. The client had several cats who were using the few open spaces as litter boxes.

How did this case of hoarding disorder get referred for help?

The family came to town to visit when the client’s sister died. Her sister also had hoarding disorder and had purchased hundreds of items from QVC. Her body was found in her home amidst the clutter and it took firefighters six hours to remove her body from the home because stacks of items had to be removed first. The family was distressed by their Mom’s living situation, especially in light of her sister’s death. They asked the client’s financial planner for a referral to get some help.

What problems was the hoarding disorder causing?

The client’s problems were numerous: isolation, loneliness, confusion, and depression. She was suffering from malnutrition, and bruises and broken bones from falling in the home. Her environment had become increasingly unsafe. The family was suffering from fear, anger, frustration and overwhelming stress.

As is common in cases of hoarding disorder, the client would not see a professional and did not feel she had a problem. She rationalized each and every purchase. She could not allow any item to be moved, none of the empty bags could be tossed (She would say, “I might need the packing slip inside to return it.”). Any attempts to move items or declutter caused her great distress.

Initially, her family felt that cleaning up would be sufficient. Later, they began to understand the nature of the hoarding disorder and her depression and dementia. In cases of hoarding disorder, simply cleaning and decluttering typically won’t resolve the problem long-term. The client had only one friend, a financial planner, who did not “see a problem” and reinforced client’s right to live as she chose.

Hoarding Disorder Case Approach

An initial meeting was set up by the family via the referral from the financial planner, with the thought that an assessment was needed to identify services that could allow the client to remain in her home.

The care manager did a full assessment on the client and home environment, with a review of medical records and discussion with primary care physician. The care manager showed photos of the house to the physician, who had initially stated there were no concerns, no dementia, and no hoarding disorder. Once the physician saw the photos and discussed the situation with the client, he gave a diagnosis, started medication, and recommended that the client should not remain in the home.

During this process, the care manager took the client to her physician for a routine exam. He discovered she had an infection from one of her cats and she was hospitalized for treatment. During her stay at a rehabilitation facility after the hospitalization, the care manager helped the family to set up an independent living apartment for her. This provided an opportunity for cleaning out the home (the family arranged to change the locks and items were packed up for donation, sale, etc.).

Fortunately, the client was successful in the apartment for a few years. The care manager helped to arrange for the shopping channels to be blocked from her TV, and outgoing long-distance calls blocked on her phone. Her Power of Attorney helped manage the situation and safeguard her credit cards. The POA paid the bills and provided limited funds for spending money, to halt excessive purchasing.

What were the biggest challenges in this hoarding disorder case?

The biggest challenge was the client’s dementia. While not severe, it was enough to keep her from moving forward with any treatment. She was also easily manipulated, and her one friend became overly involved in her situation. He took her to an attorney to appoint a new Power of Attorney (DPOA) and Healthcare Surrogate (HCS).

Once the new DPOA/HCS was in place, her friend hired a new company to oversee things and she became estranged from her family. The new arrangement only worked out for a few months, and then the friend began overseeing everything personally. He eventually moved her to an assisted living facility, where she died following a fall. Unfortunately, the client never reconciled with her family.

What lessons can we learn about hoarding disorder from this case?

Patience, patience, patience! Family members need to understand that hoarding disorder is not about “the stuff.” It is about control and feelings. If there is no dementia present, there is potential for therapy and support to move a person along. It is a long, slow process, and therefore can be quite expensive.

It is important to have planning documents in place (DPOA and HCS). The DPOA/family can help situations of hoarding disorder by restricting access to credit cards and cash available for purchases. But, as this case shows, those documents can be changed. Hoarding disorder can be very persistent and many clients will undo the efforts.

If there is dementia present, the likelihood of any successful resolution in the home is minimal. If dementia is present and the person is at risk due to safety issues in the home, it may be necessary (and quickest) to contact Department of Children and Families (DCF). If they find the client is in danger, they can get the client out of the home and into a supervised, restricted setting. If safety is not an issue, and if the person is eccentric but not demented, there is little that one can do. People have a right to make bad decisions, and families may have to wait until the situation becomes worse.