Hoarding in the Elderly

[Audio] "Welcome, and thank you for joining this presentation on Hoarding in Aging Adults: How It Relates to Self-Neglect. Today, we'll explore the connection between hoarding behaviors and self-neglect in older adults. While hoarding is often portrayed in the media as an extreme or unusual habit, the reality is that it can be a gradual, hidden problem with serious health, safety, and social consequences. We'll look at how to recognize the warning signs, understand the risk factors, and respond in a way that respects the individual while protecting their well-being. This discussion will be especially relevant for health professionals, first responders, and caregivers, because you are often the first to encounter these situations — whether during a wellness check, a home visit, or while providing ongoing care. Let's begin by understanding what self-neglect actually means in this context." "To do that, we'll start by defining self-neglect in aging adults, so we have a clear foundation for everything else we'll cover.".

[Audio] "Self-neglect occurs when an older adult, or an adult with disabilities, is unable to meet their own essential needs. This includes physical needs — like food, clothing, and shelter — as well as psychological and social needs, such as maintaining relationships or seeking medical care. When these needs go unmet, the person's health, safety, and overall well-being are put at risk. Importantly, self-neglect can happen even when resources are available — it's not always a result of poverty or lack of access. Sometimes, the barriers are physical, like mobility limitations, or emotional, like depression or grief. In some cases, self-neglect is linked to hoarding behaviors. The person may prioritize keeping possessions over keeping their home safe or sanitary. Over time, clutter and disorganization can make it even harder for them to care for themselves. Understanding this link is key — because identifying self-neglect early can prevent dangerous situations from escalating." "Now that we've defined self-neglect, let's take a closer look at the factors that put older adults at risk of developing unsafe living conditions.".

[Audio] "Unsafe living conditions in older adults often don't appear overnight — they develop over time, and there are common risk factors we should be aware of. Some of the most significant include: Cognitive decline, such as dementia or Alzheimer's disease, which affects judgment and decision-making. Loss of a spouse or loved one, which can lead to profound grief, decreased motivation, and social withdrawal. Worsening medical problems or physical disabilities, which can make tasks like cleaning or organizing difficult or impossible. Social isolation, where the person rarely interacts with friends or family and may go unnoticed for long periods. Lack of a careiver, leaving no one to notice changes in their living environment. "When multiple risk factors are present, the likelihood of unsafe living conditions — and potentially hoarding — increases significantly. For professionals, recognizing these early warning signs can prompt timely intervention before the situation becomes severe." "Let's now examine what unsafe living conditions can look like in real-world settings.".

[Audio] "When we talk about unsafe living conditions, we're referring to situations that pose direct threats to a person's health, hygiene, or safety. For example: Dirt and dust — Some dust is normal, but widespread buildup can indicate declining mobility or neglect. Improper disposal of pet waste — This can lead to strong odors, bacterial growth, and pest problems. Infestations — Recurring issues with insects or rodents may stem from improper food storage or unsanitary conditions. Unmanaged laundry, dishes, and garbage — Overflowing or unwashed items suggest the person is unable to keep up with basic household care. While any one of these signs could be temporary, a pattern or combination of them should prompt concern. They may point to self-neglect, caregiver neglect, or the beginning stages of hoarding behavior." "But to address these issues effectively, we need to understand why they develop in the first place.".

[Audio] "There are several reasons why a home can become unsanitary for an older adult, and these reasons often overlap. One is hoarding — where items accumulate to the point of blocking pathways, exits, and essential living spaces. This goes beyond collecting; it creates hazards and interferes with daily life. Another is depression, which affects a person's energy and motivation. They may spend long periods sitting or sleeping, neglecting personal hygiene and household tasks. And finally, mobility issues — physical limitations can make even simple chores like vacuuming or taking out the trash physically exhausting or impossible. In cases where the person has a caregiver, these conditions may point to neglect by that caregiver. For someone living alone, they may simply be the result of physical or emotional barriers. Knowing the root cause is critical, because the solutions — whether medical, social, or environmental — need to match the underlying issue." "Now that we've explored the causes of unsanitary conditions, let's focus more closely on hoarding itself — what it is, how it develops, and why it's especially concerning in older adults.".

[Audio] In the United States, hoarding is estimated to affect around 2% of the population, but the percentage is higher among older adults, especially those living alone. The main signs of hoarding include: Excessive accumulation of items that have little to no use or value. Cluttered living spaces where it becomes difficult — or impossible — to use rooms as intended. Significant distress or impairment in daily functioning, such as trouble cooking because the kitchen is filled with clutter. Hoarding can be connected to anxiety, depression, or obsessive-compulsive tendencies, but it's also influenced by life experiences — especially for seniors. Emotional attachments to possessions, the belief that something will be useful later, or the thought that discarding an item means losing part of their past can make it very difficult to let go. For older adults, mobility issues and isolation can accelerate the problem. As the clutter grows, the risks grow too — from tripping hazards and fire danger to blocking access for emergency responders." "Let's look specifically at how hoarding shows up in older adults' homes and why it can be especially dangerous for them.".

[Audio] "Hoarding is a common occurrence in older adults due to longevity and emotional attachment to items. The emotional reasons for this behavior vary. For some, it's tied to cherished memories. For others, it's a practical fear — the belief they might need the item someday. And in some cases, it's a reflection of identity, such as saving items from a career or hobby. Aging adults often face mobility issues that may make it more challenging to manage clutter. Over time, piles can block walkways, doors, and even access to essential areas like the bathroom or kitchen. Unfortunately, the consequences can be severe, including increased risk of falls, fire hazards, difficulty for first responders to navigate the home, and unhygienic conditions that can lead to illness. The longer the clutter builds, the harder it is to address without outside help. To better visualize the problem, let's walk through what hoarding in the elderly can actually look like.".

[Audio] "In elderly populations, hoarding often centers around certain types of items: Newspapers and magazines, Clothing, Plastic bags and containers, and food. Hoarding can transform a home's layout and functionality. You might see: Narrow, winding pathways between piles of possessions. Rooms that can't be used for their intended purpose — like a kitchen that no longer functions for cooking, or a bathroom that's inaccessible. Furniture covered with stacks of items, leaving nowhere to sit or rest. Bags, boxes, and clutter blocking windows and doors, limiting light, ventilation, and escape routes in an emergency. This environment doesn't just impact safety — it affects mental health and social life. Many people in this situation stop inviting others over, leading to further isolation. And without intervention, these conditions tend to worsen over time.".

[Audio] ""To help professionals assess the severity of a hoarding situation, there's a useful classification system from The Institute for Challenging Disorganization that breaks hoarding into five distinct levels." Level 1 – Low Severity: Minimal clutter, no odors, and all doors and windows accessible. Level 2 – Mild Severity: One major exit might be blocked, there are inconsistent cleaning habits, noticeable odors, and early signs of pests. Level 3 – Moderate Severity: Clutter interferes with daily activities, at least one room is non-functional, pests are present, and hygiene may begin to decline. Level 4 – High Severity: Multiple inaccessible areas, mold and mildew, rotting food, and critical spaces are unusable. Level 5 – Extreme Severity: Structural damage, major infestations, and most appliances unusable. Understanding these levels is helpful not only for documenting conditions but also for prioritizing interventions. For example, Level 5 requires urgent safety action, while Level 2 might allow for gradual, collaborative cleanup.".

[Audio] "Now that we've covered the general signs and levels of hoarding, let's look at some real-world examples.".

[Audio] "Let's start with our first case. Mrs. Thompson is an 81-year-old widow who has lived alone in her two-bedroom home for 45 years. She's alert and oriented, so there's no cognitive impairment, but a visiting nurse reports that stacks of old newspapers, magazines, and junk mail cover every surface. In fact, two doorways are completely blocked. When asked, she says she plans to 'go through them one day' because the information is too valuable to throw away. From a professional standpoint, this is a classic case of paper hoarding with a sentimental or informational component. The items are kept because she believes they have future value, not because she's forgotten about them. Based on the clutter blocking exits and interfering with daily function, this is likely a Level 3 hoarding situation — moderate severity. The safety concerns here are serious: Piles of paper are highly flammable and block exits, creating a fire hazard. Obstructed pathways increase her fall risk. Emergency services may have trouble reaching her in a crisis. Social isolation can worsen because she no longer invites people into her home. In approaching Mrs. Thompson, the goal is not to shame or criticize but to build trust. We focus on safety first: for example, clearing at least one safe pathway, checking smoke detectors, and removing items that block emergency exits. The conversation should be collaborative: start with one pile, ask her input, and emphasize that you want to help her meet her own goal of staying safe and independent.".

[Audio] "Let's walk through the answers for Mrs. Thompson's case. First, the type of hoarding we're seeing is paper hoarding — newspapers, magazines, and junk mail — and it looks like a mix of sentimental or information-related hoarding. In other words, she believes the material has future value or meaning. Given the blocked doorways and functional impairment of rooms, this most closely fits a moderate level of hoarding. From a safety standpoint, the immediate risks are clear: piles of paper are a fire hazard, obstructed walkways increase the chance of trips and falls, and blocked exits or doorways can prevent emergency responders from reaching her quickly. There's also a social consequence: people may stop visiting, which increases isolation and can worsen mental health. How to approach it: communication must be nonjudgmental and respectful. Open with empathy — acknowledge what she values about the papers ("I can see they're important to you") — and frame the goal as safety, not criticism. Practical steps include starting extremely small: agree to sort one box together, identify a single safe pathway or escape route, and make sure smoke detectors are functional while you work. If there's an immediate fire risk, involve the fire department for a safety check. For follow-up, consider involving local services: a hoarding task force if available, mental health services familiar with older adults, and peer support programs. If the living conditions reach a level that threatens her health or safety and she can't or won't accept help, Adult Protective Services (APS) should be contacted so professionals can make a formal assessment.".

[Audio] "Our next case focuses on a man whose hoarding is tied to his work identity — which can be particularly challenging to address. Mr. Garcia is a 76-year-old retired mechanic who lives with his daughter and grandchildren. Over the years, he's filled the garage and backyard with tools, broken appliances, and car parts, all kept with the intention of using or repairing them 'someday.' His daughter reports that he becomes angry and defensive when she suggests throwing anything away. The family is concerned about possible pest problems and local code violations. This case highlights the importance of understanding the difference between collecting and hoarding: Collecting is organized, purposeful, and typically safe. Hoarding creates hazards, limits function, and causes distress when discarding is suggested. In Mr. Garcia's situation, these items are tied to his identity as a skilled worker and provider. This emotional connection makes the idea of getting rid of them feel like losing a part of himself." "Let's review the recommended approach for Mr. Garcia's case in more detail.".

[Audio] "Here's how we can think through this case: Collecting vs. Hoarding: Organized collecting is not inherently harmful. Hoarding, on the other hand, disrupts living spaces, causes safety hazards, and sparks conflict when others suggest discarding. Identity factor: Mr. Garcia's tools represent his skills, usefulness, and history. Removing them without understanding this connection can feel like erasing his past. Constructive family involvement: Validate his feelings and memories, set boundaries like 'tools stay in the garage only,' and offer alternative roles — for example, mentoring grandchildren in basic repairs. Resources: Family counseling or caregiver support groups, mediation services, and aging services to develop a safety plan. Code enforcement should be a last resort, used only if safety risks persist despite efforts to collaborate.".

[Audio] "Our third case focuses on a woman whose hoarding is directly connected to her past trauma and fear of scarcity. Ms. Lee is 79 years old and has a history of food insecurity earlier in her life. A caseworker visiting her home found the kitchen overflowing with expired canned goods, dry food, and plastic containers. Many items were several years past their expiration dates. She insists on keeping it all 'in case things get bad again.' This is a clear example where trauma-informed care is essential. Her behavior isn't just about clutter — it's rooted in fear and a desire to avoid the hardship she's faced before. That means our approach has to address both safety and her sense of security. Let's review the recommended steps for Ms. Lee's case.".

[Audio] For Ms. Lee, the approach should look like this: Acknowledge her history without judgment. Her actions make sense in the context of her past. Avoid triggering language — don't call her a hoarder or her home a mess. Step-by-step strategy: Start with items that are clearly unsafe, like infested or spoiled food. Suggest donating safe but excess items she's willing to part with. Mental health referrals: A geriatric therapist with trauma experience, hoarding-specific support groups, and possibly psychiatric care if obsessive behaviors are present. Balancing safety with autonomy: Focus on immediate hazards, involve her in every decision, and highlight her strengths — such as resourcefulness and caring for others. This approach reduces health risks while preserving trust.".

[Audio] "Now that we've seen what hoarding can look like in real homes, let's talk about tools that can help assess the severity and guide intervention".

[Audio] "When we're working with someone who hoards, one of the challenges is simply describing the severity in a way that everyone understands — the person themselves, family members, and other professionals. That's where the Clutter Image Rating Scale, or CIR, comes in. Instead of relying on words like 'messy' or 'cluttered,' which can be vague or even feel judgmental, the CIR uses a set of pictures of real rooms — living rooms, kitchens, bedrooms — each shown at different stages of clutter, from perfectly tidy to completely unusable. Here's how it works: You look at the room in question and match it to the photo that's the closest fit. A Level 1 room is neat and functional. Around Level 4 or 5, clutter starts to interfere with how the space is used — maybe you can't sit on the couch or easily reach the bed. By Level 7 or higher, the room might be almost impossible to use at all — pathways are blocked, furniture is buried, and safety hazards are everywhere. The image scale shown here is for the bedroom.".

[Audio] "This is the image scale for the living room area.".

[Audio] "Lastly, here is the image scale for the kitchen. The advantage of using the CIR is that it creates a shared, visual reference. It's not about blaming; it's about having an agreed-upon starting point. It also makes it easier to track progress. For example, moving a room from a Level 8 to a Level 5 is a clear improvement, even if it's not perfect yet. For first responders, APS workers, and caregivers, this tool also helps with documentation and communication — you can literally show where things stand and how they've changed over time.".

[Audio] "Another tool you might come across is the Hoarding Rating Scale, which is a quick screening questionnaire designed to measure the severity of hoarding behaviors. It's different from the Clutter Image Rating Scale because it's not just about the appearance of the home — it's about understanding the person's behaviors, feelings, and difficulties related to acquiring and discarding items. The Hoarding Rating Scale typically covers five key areas: Clutter in living spaces — How much clutter is there, and how much does it limit use of the rooms? Difficulty discarding — How hard is it to get rid of things, regardless of their actual value? Acquiring — Is there a strong urge to acquire items, whether through buying, collecting free things, or picking them up elsewhere? Distress — How much emotional discomfort does the person feel about their living situation? Impairment — How much does the hoarding interfere with daily life — things like cooking, sleeping, socializing, or moving safely around the home? Each area is scored from 0 to 8, and the total score helps professionals determine whether hoarding is mild, moderate, or severe. This scale is quick to use, works well alongside the Clutter Image Rating Scale, and gives a fuller picture — not just what the home looks like, but how the behavior is impacting the person's life. In practice, the two tools complement each other: one tells you what you see, and the other tells you how it's affecting the person and their daily function. With these tools in mind, we can move toward making informed decisions about when and how to approach interventions in a way that's respectful and effective.".

[Audio] Next, let's briefly discuss when and how to have an intervention with an elder adult who is exhibiting hoarding behavior.".

[Audio] "When you're dealing with hoarding in an older adult, deciding when and how to intervene is one of the most delicate steps. First, timing matters. An intervention is appropriate when the hoarding is creating unsafe living conditions — for example, blocked exits, mold, pest infestations, or structural damage. It's also needed when the person's physical health is being affected — like falls, respiratory issues, or infections linked to the environment. Other signs it's time to act include: Emotional stress so severe that it interferes with daily functioning. Financial strain — bills aren't being paid, or the home is at risk of condemnation. Impact on others — family members, roommates, or even neighbors are being affected. How you approach the intervention is just as important as knowing when to start. It needs to be grounded in respect, empathy, and a clear focus on safety. The goal isn't to clean the home overnight — it's to start a process where the person feels supported, not attacked. This often means starting with immediate hazards and working outward, giving the individual time to adjust to changes. And when possible, involve them in setting the priorities — this preserves dignity and builds trust. "To make sure those conversations go well, let's review some specific do's and don'ts when approaching someone about hoarding.".

[Audio] "When it comes to intervention, the way you approach the conversation can determine whether it succeeds or fails. Let's start by discussing what we should do in this situation: First, we want to be respectful and acknowledge their feelings. Next, we want to ask "why?" to try to understand why the individual is hoarding items. It's important to keep talking with empathy to avoid the individual shutting down. We then focus on fixes or finding a positive solution. We also want to be patient, as hoarding typically occurs over several years and can be very frustrating for the individual. It's also important to address the underlying mental health issue that is causing the person to hoard. We also want to involve the individual in any decisions, particularly when getting rid of items. This will make them feel more confident about giving up items that need to be discarded. Finally, many hoarding situations require expertise in the removal and cleanup process, so it's important to hire professionals to help you during this process. Next, let's discuss what we should not do when helping a hoarder: First, be dismissive – you should acknowledge their feelings and treat them with respect. Assume you understand – making them feel understood increases the likelihood they will agree to a solution. Get angry – these situations are frustrating, and you want to avoid shutting down. Focus on fault – we never want to blame the individual. We want to focus on finding a way forward. Rush the process – hoarding occurs over several years, so it will take time for change. Next, we don't want to deny the underlying issues – It's important to recognize that hoarding often relates to deeper mental health issues, and addressing these can help foster positive change. Act without permission – we never want to exclude the hoarder from any discussions or tasks, as this will create resistance in their participation and behavior change. Lastly, feel like you're on your own – it's important to hire professionals who are respectful to help with the situation. By sticking to these principles, you create an environment where the individual feels respected and heard — and that makes them far more likely to engage with the process. Now let's look at what caregivers — whether family members or professionals — can do to support someone through this process while still protecting their own well-being.".

[Audio] "For caregivers, working with someone who hoards can be both emotionally and physically challenging. That's why it's important to approach the situation with a clear plan. Effective caregiver behaviors include: Choose the right time and place — have conversations in a private, calm setting without distractions. Include them in discussions — especially if you need to involve outside authorities. This keeps the process transparent and reduces feelings of being ambushed. Maintain a supportive relationship — show patience, listen to their reasons for keeping items, and avoid judgmental reactions. Designate a family point person — this prevents mixed messages and keeps communication consistent. Respect their pace — change can be overwhelming. Allow them to set achievable goals rather than imposing unrealistic timelines. These steps help reduce conflict and keep the relationship intact, even during difficult cleanups or interventions. In some situations, however, the conditions you see will require a formal report — especially if you're in a state like Michigan with clear rules for mandated reporters.".

[Audio] "In Michigan, certain professionals are legally required to report suspected abuse, neglect, or self-neglect of vulnerable adults. This includes many of you in this room — health professionals, first responders, and social service workers. Reports go to Adult Protective Services (APS), which will assess the situation and decide the next steps. APS investigations are designed to determine whether intervention is necessary and what kind of support or services might help. It's important to remember: you don't have to have all the details or proof before making a report. If you see conditions that could pose a danger, it's better to err on the side of caution. APS is trained to evaluate and respond appropriately. The bottom line is — in Michigan, if you are a mandated reporter and you believe a vulnerable adult is at risk, you must report it. It's both a legal requirement and a way to connect that person to help they may urgently need. And for both mandated and non-mandated reporters, knowing where to find support services can make a big difference — not just for the person who hoards, but also for their caregivers.".

[Audio] "There are several excellent resources in Michigan that can help both caregivers and older adults dealing with hoarding or self-neglect: AgeWays (800-852-7795) – Connects older adults and caregivers with in-home care, Meals on Wheels, adult day services, respite care, and classes on caregiving. Trualta (800-214-5085) – A free online platform with short lessons, videos, and articles to guide caregivers through common challenges. Alzheimer's Association – Michigan Chapter (800-272-3900) – Support, education, and resources for dementia care, including a 24-hour helpline. Area Agencies on Aging Association of Michigan (517-886-1029) – A network that links caregivers with services like nutrition programs, senior centers, and in-home support. Michigan Department of Health & Human Services – Adult Protective Services (855-444-3911) – For investigating suspected abuse, neglect, or exploitation. Michigan Department of Health & Human Services – Aging Services (517-241-4100) – Connects residents to local aging programs and services. These resources can provide everything from emotional support to hands-on assistance with daily living, helping to ease the burden on caregivers and improve safety for the person at risk. Next, we'll wrap things up with the key takeaways from everything we've covered today — and outline when to contact APS even if you're not completely sure what's happening.".

[Audio] "Let's summarize the most important points from today's discussion. Hoarding is the persistent difficulty discarding possessions, regardless of their actual value. It's more common in older adults, especially those living alone, and it can be considered a form of self-neglect when it leads to unsafe conditions. Causes often include emotional or psychological challenges, past trauma, mobility limitations, or isolation. Risks include increased likelihood of falls, fire hazards, and difficulty accessing medical care or emergency services. Hoarding also places strain on relationships and can reduce overall quality of life. If there's one takeaway from this slide, it's that hoarding is rarely just about 'too much stuff.' It's about the person's safety, dignity, and ability to live well. We also need to remember that in some cases, intervention is not just helpful — it's necessary to prevent serious harm. Let's go over a few more reminders about that.".

[Audio] "When hoarding behavior creates unsafe or unsanitary living conditions — or puts the individual or others at risk — intervention becomes essential. Approach the situation in a safe and private environment to preserve dignity. Maintain a supportive and nonjudgmental relationship to encourage cooperation. Adult Protective Services is available to assess and respond to dangerous conditions. Many free and low-cost resources for caregivers and families can help address both the immediate risks and the root causes. It's also important to remember: change can be slow, and that's okay. Success isn't always about an entirely clean home — sometimes it's about making the space safe enough to prevent accidents and allow the person to remain in their home. So, what if you're concerned about self-neglect but you're not sure you have enough information? Let's cover that next.".

[Audio] "If you suspect an older adult is experiencing self-neglect, but you aren't certain or can't verify every detail, you should still reach out to Adult Protective Services (APS). APS professionals are trained to assess situations and determine the appropriate response. Your role is to provide the facts as you see them — you don't need to make a final judgment about whether neglect is happening. The National Adult Protective Services Association has a tool on their website to connect you with APS agencies in your area. Even if it turns out the situation doesn't meet the criteria for intervention, making the call ensures that someone evaluates the circumstances and offers resources. In short — if you see something that could be putting someone at risk, it's better to call and let APS decide the next steps. Finally, let's talk briefly about how to access that APS resource and close with some final thoughts. To connect with an APS agency in your area, visit www.napsa-now.org/help-in-your-area. You'll find a directory that lists contact information for every state, along with instructions on how to make a report. In Michigan, you can call 855-444-3911 to report suspected abuse, neglect, or exploitation of a vulnerable adult. This line is available 24/7, and your call can be anonymous if needed. Remember — making a report doesn't mean you're accusing someone. It simply means you're alerting trained professionals to check on a potentially dangerous situation.".

[Audio] "Using evidence-based resources ensures that our approach to hoarding in older adults is safe, effective, and respectful. It also means we can make informed decisions — and connect individuals and families to the right help at the right time. Hoarding in older adults is a complex issue, but with empathy, the right tools, and coordinated support, we can help people live more safely and with greater dignity. Thank you for your commitment to this work, and for the difference you make in the lives of the people you serve.".