Compulsive Hoarding
Conditions
Keywords
exposure therapy, case management, older adults, cognitive rehabilitation
Brief summary
The purpose of this investigation is to examine treatment outcome of a new intervention for hoarding in older adults compared to standard case management for hoarding. The new intervention combines exposure therapy and cognitive remediation.
Detailed description
Research has shown that hoarding disorder (HD) is debilitating chronic and progressive condition that has significant public health implications. Older adults represent the largest group of HD suffers due to increasing severity with age. Often, Veterans with HD are seen in the VA system and the status of their hoarding is never assessed. Providers are treating patients for other health and social service issues yet missing an important source of disability and distress. This insidious, often undetected condition leads to greater medical and social disability and is costly to the VA system as patients continue to decompensate. When HD is even detected, patients in the VA receive indefinite case management and inadequate treatment. The cases the investigators know about have caused significant financial burden to the investigators' system. Most importantly, HD causes significant impairment and poor quality of life for the Veterans, particularly older Veterans. Unfortunately, the investigators know nothing about how to treat late life HD. Nor do the investigators know how neurocognitive features impact treatment response, which the investigators strongly suspect influence treatment outcome. HD is a potentially treatable source of disability in the VA system - one that the VA must research and treat. This study represents the first randomized controlled trial of a novel intervention for the treatment of HD in older Veterans. The main objective of this proposal is to further refine and test a new treatment for hoarding in older Veterans (age 60-85) which will be accomplished through a series of treatment development phases (case series, open labeled trial) and a randomized controlled trial. The new treatment (Cognitive Remediation and Exposure Therapy for hoarding; CogRET) is hypothesis driven and based on late life anxiety literature, consultation with mentors, results of the pilot study using a standard cognitive-behavioral intervention, and several case series that will be completed prior to the start of the Career Development Award (CDA). The first draft of CogRET is complete and is currently being used with several case studies. The research and training plan is divided into 5 phases; 1) training and preparation 2) training, further case studies using CogRET, further modification of CogRET 3)training, open label trial of CogRET, further modification of CogRET 4) randomized controlled trial and 5) presenting, publishing, dissemination of results and submission of a VA Merit grant. Primary hypotheses include 1) when randomized to CogRET, older Veterans with HD will show significant decreases in acquisition, difficulty discarding, and excessive clutter compared to those randomized to case management and 2) executive functioning (EF) is a significant moderator of treatment response. Other mediators and moderates of treatment response (psychiatric, medical, demographic, etc.) will be explored.
Interventions
BEHAVIORALCognitive Rehabilitation and Exposure Therapy for Compulsive Hoarding
The intervention includes cognitive remediation for deficits in executive functioning and exposure therapy for discarding/acquiring.
BEHAVIORALCase Management
Case management
Sponsors
VA Office of Research and Development
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
60 Years to 85 Years
Healthy volunteers
No
Inclusion criteria
Participants must be between the ages of 60 - 85 years old and meet clinical criteria for Compulsive Hoarding (CH) developed by the Steketee and Frost (2000) research group. These criteria include: * significant amount of clutter in active living spaces * the urge to collect, buy, or acquire things * an extreme reluctance to part with items * clutter accumulation that causes distress or interferes with functioning * symptom duration of at least 6 months * the reluctance to part with items is not accounted for by other psychiatric conditions. To be enrolled, patients must have: * a score of 20 or greater on the University of California, Los Angeles Hoarding Severity Scale (UHSS) * 40 or greater on the Savings Inventory-Revised (SI-R) * severity rating of 4 or higher on the Anxiety Disorders Interview Schedule (ADIS-IV) rating scales for clutter and difficulty discarding * and diagnosis confirmed at a consensus conference including at least two licensed professionals with expertise in CH (myself and at least one mentor).
Exclusion criteria
* Individuals with moderate to severe cognitive deficits (scores below 23 on the MMSE) will be excluded. * Prospective participants must not have active substance abuse problems. * Participants will also be excluded if they are currently in other forms of psychotherapy. * Participants must have no change in any psychotropic medications for at least three months prior to the initial assessment. * Patients with current psychosis or mania will be excluded. * Mood and anxiety disorders are permitted as long as compulsive hoarding is the primary diagnosis. * Participants will are not eligible if they have active suicidal ideation, those participants will be given immediate medical or mental health attention.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Hoarding Symptom Severity as Measured by the Saving Inventory-Revised (SI-R) at 6 Months | 6 months | Hoarding symptom severity (primary outcome) will be measured using the Savings Inventory-Revised (SI-R), a 23-item self-report measure used to assess common hoarding symptoms. Subtests include excessive clutter, compulsive acquisition, and difficulty discarding. The SI-R has demonstrated good internal consistency, divergent validity, concurrent validity, divergent validity, test-retest reliability in clinical samples with hoarding. The total score will be used for analyses. The range of the total score is 0-92, with higher scores indicating worse hoarding severity. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| The Activities of Daily Living in Hoarding (ADL-H) | 6 months | The Activities of Daily Living in Hoarding (ADL-H) was used to assess functional impairment. Higher scores represent increased impairment. Mean score is 1-75, with higher scores indicating worse impairment due to hoarding. |
| Executive Functioning as Measured by the Delis Kaplan Executive Functioning System (D-KEFS) at 6 Months | 6 months | The D-KEFS Trail Making Test Condition 4: Number-Letter Switching Scaled Score was used to assess executive functioning. Scaled scores range from 1-19. Higher scores represent less impairment. |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Arm 1: Cognitive Rehabilitation Cognitive rehabilitation and exposure therapy for hoarding
Cognitive Rehabilitation and Exposure Therapy for Compulsive Hoarding: The intervention includes cognitive remediation for deficits in executive functioning and exposure therapy for discarding/acquiring. | 31 |
| Arm 2: Case Management Case Management: Case management | 27 |
| Total | 58 |
Baseline characteristics
| Characteristic | Total | Arm 2: Case Management | Arm 1: Cognitive Rehabilitation |
|---|---|---|---|
| Activities of Daily Living - Hoarding | 31.31 units on a scale STANDARD_DEVIATION 11.23 | 31.90 units on a scale STANDARD_DEVIATION 13.53 | 30.85 units on a scale STANDARD_DEVIATION 9.3 |
| Age, Continuous | 66.95 years STANDARD_DEVIATION 6.48 | 64.19 years STANDARD_DEVIATION 5.35 | 69.35 years STANDARD_DEVIATION 6.49 |
| Clinician Global Improvement - Severity scale | 3.81 units on a scale STANDARD_DEVIATION 1.06 | 3.96 units on a scale STANDARD_DEVIATION 1.19 | 3.67 units on a scale STANDARD_DEVIATION 0.92 |
| Clutter Image Rating | 4.24 units on a scale STANDARD_DEVIATION 1.89 | 4.33 units on a scale STANDARD_DEVIATION 2.11 | 4.15 units on a scale STANDARD_DEVIATION 1.71 |
| Hospital Anxiety and Depression Hospital Anxiety and Depression - Anxiety | 9.56 units on a scale STANDARD_DEVIATION 3.98 | 10.15 units on a scale STANDARD_DEVIATION 3.41 | 9.06 units on a scale STANDARD_DEVIATION 4.39 |
| Hospital Anxiety and Depression Hospital Anxiety and Depression - Depression | 7.79 units on a scale STANDARD_DEVIATION 4.16 | 8.56 units on a scale STANDARD_DEVIATION 4.97 | 7.13 units on a scale STANDARD_DEVIATION 3.23 |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 2 Participants | 0 Participants | 2 Participants |
| Race (NIH/OMB) Black or African American | 1 Participants | 0 Participants | 1 Participants |
| Race (NIH/OMB) More than one race | 3 Participants | 3 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 1 Participants | 0 Participants | 1 Participants |
| Race (NIH/OMB) White | 51 Participants | 24 Participants | 27 Participants |
| Region of Enrollment United States | 58 participants | 27 participants | 31 participants |
| Saving Inventory Revised | 58.34 units on a scale STANDARD_DEVIATION 12.08 | 59.48 units on a scale STANDARD_DEVIATION 14.01 | 57.35 units on a scale STANDARD_DEVIATION 10.23 |
| Sex: Female, Male Female | 41 Participants | 17 Participants | 24 Participants |
| Sex: Female, Male Male | 17 Participants | 10 Participants | 7 Participants |
| University of California, Los Angeles Hoarding Severity Scale | 27.52 units on a scale STANDARD_DEVIATION 5.65 | 28.85 units on a scale STANDARD_DEVIATION 5.82 | 26.35 units on a scale STANDARD_DEVIATION 5.31 |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 0 / 31 | 0 / 27 |
| serious Total, serious adverse events | 0 / 31 | 0 / 27 |
Outcome results
Primary
Hoarding Symptom Severity as Measured by the Saving Inventory-Revised (SI-R) at 6 Months
Hoarding symptom severity (primary outcome) will be measured using the Savings Inventory-Revised (SI-R), a 23-item self-report measure used to assess common hoarding symptoms. Subtests include excessive clutter, compulsive acquisition, and difficulty discarding. The SI-R has demonstrated good internal consistency, divergent validity, concurrent validity, divergent validity, test-retest reliability in clinical samples with hoarding. The total score will be used for analyses. The range of the total score is 0-92, with higher scores indicating worse hoarding severity.
Time frame: 6 months
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Arm 1: Cognitive Rehabilitation | Hoarding Symptom Severity as Measured by the Saving Inventory-Revised (SI-R) at 6 Months | 35.44 units on a scale | Standard Deviation 15.48 |
| Arm 2: Case Management | Hoarding Symptom Severity as Measured by the Saving Inventory-Revised (SI-R) at 6 Months | 44.68 units on a scale | Standard Deviation 13.29 |
Comparison: Linear mixed models with random intercepts were used to evaluate the change in primary and secondary outcome variables over time, the effect of group, the effect of treatment, and the treatment group by time interaction, both for the treatment phase (0-6 months) and follow up phase (6-12 months). All analyses (0-6 months) were conducted first using observed data only (i.e., completer analysis) and then using an intent to treat (ITT) sample.p-value: 0.029Mixed Models Analysis
Secondary
Executive Functioning as Measured by the Delis Kaplan Executive Functioning System (D-KEFS) at 6 Months
The D-KEFS Trail Making Test Condition 4: Number-Letter Switching Scaled Score was used to assess executive functioning. Scaled scores range from 1-19. Higher scores represent less impairment.
Time frame: 6 months
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Arm 1: Cognitive Rehabilitation | Executive Functioning as Measured by the Delis Kaplan Executive Functioning System (D-KEFS) at 6 Months | 10.8 units on a scale | Standard Deviation 3.67 |
| Arm 2: Case Management | Executive Functioning as Measured by the Delis Kaplan Executive Functioning System (D-KEFS) at 6 Months | 10.8 units on a scale | Standard Deviation 3.11 |
p-value: >0.1ANOVA
Secondary
The Activities of Daily Living in Hoarding (ADL-H)
The Activities of Daily Living in Hoarding (ADL-H) was used to assess functional impairment. Higher scores represent increased impairment. Mean score is 1-75, with higher scores indicating worse impairment due to hoarding.
Time frame: 6 months
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Arm 1: Cognitive Rehabilitation | The Activities of Daily Living in Hoarding (ADL-H) | 21.09 units on a scale | Standard Deviation 6.67 |
| Arm 2: Case Management | The Activities of Daily Living in Hoarding (ADL-H) | 27.81 units on a scale | Standard Deviation 14.29 |
Comparison: Linear mixed models with random intercepts were used to evaluate the change in primary and secondary outcome variables over time, the effect of group, the effect of treatment, and the treatment group by time interaction, both for the treatment phase (0-6 months) and follow up phase (6-12 months). All analyses (0-6 months) were conducted first using observed data only (i.e., completer analysis) and then using an intent to treat (ITT) sample.p-value: 0.04Mixed Models Analysis