Impairments in Executive and Everyday Function in Older Adults with Hoarding Disorder

Hoarding Disorder Diagnosis and Treatment
Hoarding Disorder Diagnosis and Treatment
A study investigated age-related differences in the level of functional and cognitive impairment in 122 adults with hoarding disorder.

Older adults with hoarding disorder (HD) experience increased impairments in skills related to executive and daily functioning, compared with younger adults with HD, according to new research published in the December 31, 2016 issue of International Journal of Geriatric Psychiatry.1

Catherine R. Ayers, PhD, ABPP, from the Joint Doctoral Program in Clinical Psychology at San Diego State University/University of California, the VA San Diego Healthcare System, and the San Diego School of Medicine, and colleagues investigated age-related differences in the level of functional and cognitive impairment in 122 adults with HD. The mean age of the participants was 62.5 years (SD = 9.3, range 29-85). 

To measure hoarding severity, the researchers used the Saving Inventory-Revised (SI-R) and the Clutter Image Rating (CIR) scales. The Hospital Anxiety and Depression Scale (HADS) was used to measure mood. Cognition was measured using the Wisconsin Card Sorting Test (WCST), the Delis-Kaplan Executive Function System (D-KEFS), and the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV). Behavior was measured using the Frontal System Behavior Scale (FrSBe), and daily functioning was measured with the Activities of Daily Living Scale in Hoarding (ADL-H).

The University of California San Diego (UCSD) Performance-Based Skills Assessment (UPSA) was utilized to measure skills related to daily functioning, including finances, communication, comprehension/planning, transportation, and household skills. 

The researchers found that all participants reported high hoarding symptom severity on the SI-R and the CIR. More than 90% of all participants reported behavioral dysfunction in the clinically severe range, as measured by the FrSBe (total: 98%; apathy: 98%; disinhibition: 92%; executive dysfunction: 97%).

The majority of participants’ scores were in the average range for all neurocognitive assessments. Only 16% of participants or less demonstrated impaired performance on each cognitive variable. 

Age was not significantly correlated with the majority of the hoarding severity measures; in fact, older participants reported significantly fewer symptoms related to urges to save (P <.01). Scores on the HADS depression scale decreased with age (P <.05) and there was no significant association between age and the HADS anxiety scale (P <.05). Age was not significantly correlated with most FrSBe total or subscale scores or with the ADL-H. 

Age was significantly correlated with the UPSA total score, suggesting that impairment in daily tasks increases with the age of the participant.

The researchers noted that 90% of participants reported clinically severe behavioral disturbances consistent with frontal lobe impairment on the FrSBe total and subscale scores. However, participants overall actually demonstrated average performance on the neurocognitive tests. “There may be little relationship between actual and perceived difficulties with executive functioning problems in adults with HD,” the researchers wrote. 

An alternative explanation is that “the available executive functioning tests may not be sensitive enough to accurately capture the experience of individuals with HD.”

Older adults, however, did perform worse on other neuropsychological measures, notably the D-KEFS Tower Test and the Letter-Number Sequencing Subtest of the WAIS-IV, “suggesting an association between age and increased impairment in skills related to executive functioning.”

The researchers concluded that their findings “suggest that older HD patients may experience increased levels of impairment in skills related to executive functioning and daily functioning, when compared [with] younger HD patients” since “older participants performed worse on a test of skills related to comprehension/planning, communication, financial skills, and transportation, even when controlling for premorbid IQ.”

The investigators encourage clinicians to “follow up patient reports of executive dysfunction with formal neuropsychological testing,” warning, however, that performance-based tests may not “illuminate the actual experience of patient.”

“Geriatric HD adults may be less able to attend to and process new information,” the researchers noted. They advise clinicians to “consider including compensatory cognitive training or more behavioral interventions that require less attention and cognitive flexibility than more traditional cognitive therapies.”

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Dozier ME, Wetherell JL, Twamley EW, Schiehser DM, Ayers CR. The relationship between age and neurocognitive and daily functioning in adults with hoarding disorder. Int J Geriatr Psychiatry. 2016 Dec;31(12):1329-1336.