Hoarding as Indicator of Neurocognitive Disorders: A Simple Screening Tool

A single question about clutter, posed to caregivers, may offer a quick and surprisingly effective way to identify potential neurocognitive disorders, including Alzheimer’s disease and frontotemporal dementia. Researchers at Oregon Health & Science University found that asking caregivers about concerns regarding hoarding behavior flagged a significant number of patients who also exhibited more severe neuropsychiatric symptoms and higher levels of depression. This simple screening tool could be particularly valuable in primary care settings where time is limited and comprehensive assessments are challenging.

Identifying Hoarding as a Potential Indicator

The study, published in The Journal of Neuropsychiatry and Clinical Neurosciences, defined hoarding disorder as a “persistent difficulty discarding or parting with possessions, regardless of their actual value.” Lead researcher Peter Pressman, MD, explained that behaviors like hoarding often go unreported unless specifically inquired about. “Many behaviors aren’t described unless you specifically ask, and hoarding often isn’t asked about systematically,” he told Healio. The research team sought a quick, easily implementable method to identify potential hoarding tendencies in a clinical setting.

The observational study retrospectively analyzed data from 135 patients (average age 70.9 years, 39% women, 73% white) seen at an academic memory disorders clinic between October 2018 and August 2021. Diagnoses included Alzheimer’s disease (37%), mild neurocognitive disorder (19%), Lewy body dementia (9%), and other neurocognitive disorders. Caregivers completed the Single-Item Hoarding Screen (SIHS), answering the question: “Is there any concern regarding clutter in the home or possible hoarding behavior?”

Approximately 23% of caregivers expressed concern – 10% answered “yes” and 13% answered “maybe.” Notably, men accounted for 77% of the patients whose caregivers responded “yes.” Those caregivers who indicated concern then completed the five-question Hoarding Rating Scale (HRS). The HRS scores were significantly higher for those who answered “yes” to the SIHS (indicate 12.5) compared to those who answered “maybe” (mean 8.6, P = .042). A score of 11 or higher on the HRS is generally considered indicative of a hoarding problem, and 62% of those in the “yes” group and 44% in the “maybe” group met this threshold.

Linking Hoarding to Underlying Conditions

The study revealed a strong association between hoarding concerns and other neuropsychiatric symptoms. Patients whose caregivers answered “yes” to the SIHS exhibited significantly higher scores on the Patient Health Questionnaire-9 (indicating more severe depression) and the Neuropsychiatric Inventory Questionnaire. Caregiver burden, as measured by the Zarit Scale, was also significantly higher in the “yes” group. These findings align with previous research linking depressive symptoms to increased dementia risk.

Interestingly, the prevalence of hoarding varied depending on the underlying neurocognitive disorder. Patients with behavioral variant frontotemporal dementia (FTD) had the highest rate of hoarding (38%), substantially higher than those with Alzheimer’s disease (10%), Lewy body dementia (17%), or mild neurocognitive disorder (4%). This suggests that the frontal and temporal lobes, which are particularly affected in FTD, may play a crucial role in hoarding behavior. The study authors hypothesize that disruptions in the brain’s salience network – responsible for identifying the importance of objects – or abnormal reward circuitry could also contribute to the behavior.

Implications for Clinical Practice and Future Research

The researchers suggest that the SIHS could serve as a valuable initial screening tool in clinical settings. Its brevity – requiring only seconds to administer – makes it practical for use in busy primary care offices. A positive response to the SIHS could prompt further evaluation, including a more comprehensive hoarding assessment and consideration of underlying neuropsychiatric symptoms. SLACK Incorporated, the publisher of the journal, offers resources for clinicians seeking further information on neuropsychiatric disorders.

However, Pressman emphasizes that this study is preliminary and requires further validation. “These findings are preliminary. This was a single-center retrospective sample, and prospective validation in larger and more diverse populations is the clear next step,” he stated. Future research should focus on assessing the test-retest reliability of the SIHS, examining its performance across different demographic groups, and exploring its correlation with neuropsychological and neuroimaging measures. Longitudinal studies tracking the evolution of hoarding behavior across different stages of disease would also be beneficial.

The Wyanoke Group, parent company to SLACK Incorporated and Healio, continues to support research aimed at improving the diagnosis and management of neurocognitive disorders. More information about their initiatives can be found on their website.

Identifying hoarding early not only offers the potential for improved clinical outcomes but also provides an opportunity to connect caregivers with much-needed support. Given that caregiver burden was significantly elevated in families affected by hoarding, addressing this issue is crucial for improving the well-being of both patients and their loved ones.

Looking ahead, clinicians should consider incorporating the SIHS into routine evaluations, particularly when assessing patients at risk for neurocognitive disorders. Whereas not a definitive diagnostic tool, it can serve as a valuable starting point for further investigation and intervention.