Hoarding Behavior in Dementia
A Preliminary Report
Jen-Ping Hwang, M.D., Shih-Jen Tsai, M.D.
Chen-Hong Yang, M.D., King-Ming Liu, M.D.
Jiing-Feng Lirng, M.D.
Hoarding behavior has been reported in several mental disorders and is occasionally reported by the caregivers of dementia patients. Such behavior may have adverse effects on
the patients and increase the burden of the caregivers. This
study was conducted to investigate the prevalence of hoarding behavior in patients with dementia and identify the
characteristics and psychiatric symptoms associated with it.
The sample was 133 dementia patients admitted to a geropsychiatric ward. Of the 133 dementia patients, 30 (22.6%)
showed hoarding. Hoarding was found in various types of
dementia. Patients with hoarding had a higher prevalence
of repetitive behaviors, hyperphagia, and pilfering. Results
suggested that hoarding behavior is a common symptom
in dementia patients and a complex phenomenon. Better
understanding of the underlying pathogenesis may highlight specific pharmacological or behavioral methods for
treatment of the behavior. (Am J Geriatr Psychiatry 1998;
6:285–289)

H

oarding—collecting a large number of
unneeded objects—is commonly
found in the general population1 and in a
variety of mental disorders, including
schizophrenia,2–4 dementia,2 obsessivecompulsive disorder,2 and eating disorders.5 Greenberg et al.2 proposed that
when hoarding is the main symptom, it is
the final common pathway for a spectrum
of different processes. At one end of the

spectrum is obsessive-compulsive disorder; at the center, paranoid disorders, and
at the other end, organic mental disorders.
Hoarding behavior has long been recognized as a feature of dementia2 and is
frequently noted by the caregivers of dementia patients. It can interfere with the
hygienic management and health of patients, and patients may become extremely
agitated and even violent when family

Received March 24, 1997; revised August 10, 1997, December 24, 1997; accepted January 15, 1998. From the
Department of Psychiatry, Veterans General Hospital–Taipei, Republic of China. Address correspondence to Dr.
Tsai, Department of Psychiatry, Veterans General Hospital–Taipei, No. 201, Shih-Pai Road Sec. 2, Taipei, Taiwan,
Republic of China.
Copyright ᭧ 1998 American Association for Geriatric Psychiatry
THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY

285

Hoarding in Dementia

members threaten to discard their possessions.2,6 Also, many nurses view hoarding
as negative and assume that the patient is
a bit “strange” or psychotic.7 A search of
the MEDLINE database revealed only one
case report concerning hoarding in dementia patients.2 Our study was designed
to investigate the prevalence of hoarding
behavior in dementia patients admitted to
the geropsychiatric ward of a general hospital. We also made an attempt to identify
the characteristics and psychiatric symptoms that are associated with hoarding behavior.

METHODS
The sample population consisted of 133
consecutive dementia patients admitted to
the geropsychiatric ward of Veterans General Hospital–Taipei between August 1989
and February 1996. Most of the patients
were admitted because of violence, inappropriate behaviors, or emotional problems. All patients met the criteria for dementia set by the Diagnostic and Statistical
Manual of Mental Disorders (DSM-III-R).8
Those with Dementia of the Alzheimer’s
type (DAT) met DSM-III-R criteria for primary degenerative dementia as well as the
diagnostic criteria developed by the National Institute of Neurological and Communicative Disorders and Stroke and the
Alzheimer’s Disease and Related Disorders
Association (NINCDS-ADRDA).9 All patients with multi-infarct dementia met the
DSM-III-R criteria for multi-infarct dementia. The other nonspecific dementias were
defined on the basis of their etiologies, according to the DSM-III-R criteria. Diagnosis
was based on a complete medical and neuropsychiatric examination, including history, physical examination, ECG, EEG,
blood count, biochemistry (electrolytes,
liver and renal function, vitamin B12, folic
acid), thyroid function tests, and a serological test for syphilis. Computed tomo286

graphic scans of the brain were available
for all patients.
Patients were divided into two groups,
based on the presence or absence of hoarding. Hoarding was defined as repeatedly
collecting mostly useless or unneeded objects during some time from the onset of
the illness. Such behaviors were indiscriminate and developed after the onset of dementia.
All demographic data were supplied
by caregivers. Psychotic symptoms and behavioral problems were assessed by a
checklist adapted from the Behavioral Pathology in Alzheimer’s Disease Rating Scale
(BEHAVE-AD) by Reisberg et al.,10 with
some modifications. In each case, the patient, as well as at least one caregiver familiar with the behaviors of the patient,
was interviewed by a geriatric psychiatrist.
Symptoms were evaluated and classified as
dichotomous variables. Dementia severity
was assessed on admission by use of the
Folstein Mini-Mental State Exam (MMSE);
scores ranged from 0 to 30.11
Data were analyzed by use of SPSS for
Windows. Two-tailed t tests were used to
compare the differences between the
means of continuous variables. The chisquare test was used to compare differences in dichotomous variables. A P value
less than 0.05 was considered to be statistically significant.

RESULTS
The mean age of these patients was
74.1‫ 3.6ע‬years (range: 65–91), and the
mean MMSE score was 11.6‫( 2.6ע‬median:
11). There were 98 men and 35 women;
the large male predominance is characteristic of a veterans’ hospital. Of the 133 dementia patients, 30 (22.6%) showed hoarding. Patients with hoarding were found in
various types of dementia classifications:
Alzheimer’s dementia (24 of 75), multiinfarct dementia (4 of 40), and dementia
VOLUME 6 • NUMBER 4 • FALL 1998

Hwang et al.

not otherwise specified (NOS; 2 of 18).
The items patients hoarded included daily
necessities (10), food (7), garbage (6),
newspapers or magazines (6), broken umbrellas or electrical items (6), plastic bags
(4), old clothes (4), and cigarette butts (1).
Patients in the hoarding group stored their
objects around their apartment, in closets,
in drawers, under pillows or bedclothes,
under trash cans, under the bed, or in
boxes, or carried the items with them. Reasons given by patients for hoarding included “It will come in handy or can be
sold.”, “This object belongs to me.”, “It will
be stolen.”, “It is too good to throw away.”,
“I don’t want to be caught without a
needed item.”, “Even though the food is
outdated, it is still edible.”, and “I usually
feel hungry.”
There were no significant differences
between the two groups in regard to age,
age at onset, gender, educational level, or
MMSE score. Table 1 summarizes the frequency of psychiatric symptoms in the two
TABLE 1.

groups. The prevalence of repetitive behaviors was significantly higher in the
hoarding group. Also, patients with hoarding were more likely to have hyperphagia
and to pilfer other people’s possessions.

DISCUSSION
The prevalence of hoarding (22.6%) in dementia in this study was high. In a study of
behavioral complications of dementia, the
prevalence of hoarding was 1.9%.12 The
discrepancy in these two studies may stem
from the differences in the definition of
hoarding and the sample source. In the
previous study, the patients were in the
community, and their disease severity varied widely. Behavior was assessed for only
one week. The sample in our study was
patients with moderate-to-severe dementia
admitted to a geropsychiatric ward. The
duration being assessed was from the onset

Prevalence of psychiatric symptoms in patients with and without hoarding behavior,
n (%)

Characteristics
Delusions
Theft
Persecutory
Jealousy
Hallucinations
Auditory
Visual
Misidentifications
Phantom boarders symptoma
Residence is not home
Mirror signb
Caregiver is impostor
Other disturbances
Repetitive behaviors
Day/night disturbance
Aggressiveness
Agitation
Wandering
Hyperphagia
Pilfering

Hoarding
(n؄30)

Nonhoarding
(n؄103)

v2[1]

21 (70.0)
16 (53.3)
5 (16.7)
3 (10.0)
9 (30.0)
5 (16.7)
7 (23.3)
14 (46.7)
8 (26.7)
7 (23.3)
3 (10.0)
2 (6.7)

67 (65.0)
56 (54.4)
30 (29.1)
18 (17.5)
37 (35.9)
19 (18.4)
27 (26.2)
30 (29.1)
15 (14.6)
15 (14.6)
5 (4.9)
11 (10.7)

0.254
0.010
1.860
0.977
0.360
0.050
0.101
3.229
2.380
1.294
1.080
0.424

0.614
0.920
0.173
0.405
0.548
0.823
0.750
0.072
0.123
0.271
0.379
0.732

24 (80.0)
8 (26.7)
18 (60.0)
18 (60.0)
15 (50.0)
18 (60.0)
15 (50.0)

55 (53.4)
28 (27.2)
48 (46.6)
49 (47.6)
44 (42.7)
24 (23.3)
26 (25.2)

6.817
0.003
1.668
1.435
0.499
14.482
6.678

0.009
0.955
0.196
0.231
0.480
Ͻ0.001
0.010

P

a

the belief that other (imaginary) people are in the house.
the inability to recognize one’s own mirror reflection (or statements such as “Someone else is in the
mirror.”)
b

THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY

287

Hoarding in Dementia

of illness. Our study found that hoarding
occurred in Alzheimer’s dementia, multiinfarct dementia, and dementia NOS; this
finding suggests that hoarding is a universal
problem in various kinds of dementia.
It was believed that older women
hoard more than older men,7 but our study
showed no sex differences. We also did not
find a difference in the MMSE score between groups. This finding may be because
our study group was more homogenous,
with most patients having moderate-tosevere dementia. Homma et al.12 reported
that hoarding was found in 5.3% of patients
with moderate dementia but was not
found in those with mild dementia. Persons suffering from cognitive impairment
may be unable to determine the relative
importance of articles, so they tend to save
everything, resulting in “conditions of
hoarding and filth.” Some patients in this
study tended to save everything they considered valuable even before disease onset.
Initially, they stored their collection well,
but it eventually became disorganized as
their dementia progressed.
Analysis of the psychiatric symptoms
showed that patients who hoarded had a
higher prevalence of repetitive behaviors,
hyperphagia, and pilfering. Hoarding has
been classified with repetitive behaviors
and has been postulated to involve hippocampus dysfunction.3,4 In a recent report,
magnetic resonance imaging (MRI)
showed some atrophy of the hippocampus
in both Alzheimer’s dementia and multiinfarct dementia patients.13 Alteration of
eating habits has been found in dementia
patients, and one study demonstrated that
26% of patients had eaten significantly
more at some stage since the onset of dementia.14 One patient in this study stored
spoiled food, which caused gastrointestinal problems. He insisted that he was hungry and the food was still edible. Some patients with hyperorality stored food around
their bedside during hospitalization. During hospitalization, some hoarders took objects from the ward or from other patients.
288

Often these patients failed to discriminate
and claimed that these objects belonged to
them. Newspapers, magazines, food, soap,
and toilet paper were stored under the
bed, in the bedclothes, or in the closet.
Greenberg et al.2 also reported this phenomenon.
One study reported that some patients
carried or stored their hoarded items out
of fear of theft.2 We also found this to be
true in our patients, but in this study, the
delusion of theft was not significantly different in the two groups. It is possible that
the delusion of theft is common in dementia and explains hoarding behavior in only
some patients.
Hoarding sometimes is a safety hazard
and can damage health. Patients may collect dangerous objects, newspapers may
cause a fire, and outdated food spoils. Intervention is needed in these circumstances. However, the causes of hoarding
vary from individual to individual. Before
there is intervention, the underlying etiology must be explored. For example, dementia patients with hyperphagia who
store food may benefit from drugs such
as fluvoxamine.15 Phenylpropanolamine,
which has been reported to inhibit feeding
and hoarding in rats, may also help these
patients.16 Patients who exhibit hoarding
because of delusion of theft may respond
to antipsychotic treatment. Also, Hogstel7
has proposed some nonpharmacological
interventions for hoarding in elderly patients, such as distraction, limiting opportunities, behavioral therapy, group discussion, and removing potentially dangerous
objects.7
This is a preliminary report of hoarding behavior in dementia patients. There
were two limitations in this study. First,
because of the protean expression of
hoarding behavior, it is difficult to clearly
define such behavior. Second, the population in this study consisted of inpatients
with moderate-to-severe dementia. Further
study is needed to identify hoarding behavior in a community-based population. Also,
VOLUME 6 • NUMBER 4 • FALL 1998

Hwang et al.

it would be of interest to compare transnational and cross-cultural differences in
hoarding behavior among dementia patients.

CONCLUSION
Hoarding is common in patients with dementia of various etiologies, particularly in
those who exhibit repetitive behaviors, hy-

perphagia, and pilfering. The pathogenesis
of hoarding is complex. The underlying etiologies must be clarified before there is intervention.
The authors are indebted to the geropsychiatric staff at Veterans General
Hospital–Taipei for their assistance in this
study.
This study was supported by Veterans
General Hospital–Taipei, Grant VGH-85150.

References
1. Warren LW, Ostrom JC: Pack rats: world-class savers. Psychology Today 1988; 22:58–62
2. Greenberg D, Witztum E, Levy A: Hoarding as a
psychiatric symptom. J Clin Psychiatry 1990;
51:417–421
3. Luchins DJ: A possible role of hippocampal dysfunction in schizophrenic symptomatology. Biol
Psychiatry 1990; 28:87–91
4. Luchins DJ, Goldman MB, Lieb M, et al: Repetitive
behaviors in chronically institutionalized schizophrenic patients. Schizophr Res 1992; 8:119–123
5. Frankenburg FR: Hoarding in anorexia nervosa. Br
J Med Psychol 1984; 57:57–60
6. Greenberg D: Compulsive hoarding. Am J Psychother 1987; 41:409–416
7. Hogstel MO: Understanding hoarding behaviors in
the elderly. Am J Nurs 1993; 93:42–45
8. American Psychiatric Association: Diagnostic and
Statistical Manual of Mental Disorders, 3rd Edition, Revised. Washington, DC, American Psychiatric Association, 1987
9. McKhann G, Drachman D, Folstein M, et al: Clinical diagnosis of Alzheimer’s disease: reports of the
NINCDS-ADRDA Work Group under the auspices
of the Department of Health and Human Services
Task Force on Alzheimer’s Disease. Neurology
1984; 34:939–944

THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY

10. Reisberg B, Borenstein J, Salob SP, et al: Behavioral
symptoms in Alzheimer’s disease: phenomenology and treatment. J Clin Psychiatry 1987;
48(suppl):9–15
11. Folstein MF, Folstein SE, McHugh PR: Mini-Mental
State: a practical method for grading the cognitive
state of patients for the clinician. J Psychiatr Res
1975; 12:189–198
12. Homma A, Ishii T, Niina R: Relationship of behavioral complications and severity of dementia in
Japanese elderly persons. Alzheimer Dis Assoc Disord 1994; 8:46–53
13. Matsuzawa T, Hishinuma MT, Matsui H, et al: Severe atrophy of amygdala and hippocampus in
both Alzheimer’s disease and multi-infarct dementia. Scientific Reports of the Research Institute, Tohoku Univ. (Med.) 1990; 37:23–25
14. Morris CH, Hope RA, Faiburn CG: Eating habits in
dementia: a descriptive study. Br J Psychiatry
1989; 154:801–806
15. Hope R, Allman P: Hyperphagia in dementia: fluvoxamine takes the biscuit. J Neurol Neurosurg
Psychiatry 1991; 54:88
16. Wellman PJ, Levy A: lnhibition of feeding and
hoarding behaviors by phenylpropanolamine in
the adult rat. Pharmacol Biochem Behav 1988;
29:79–81

289