JAGP61041S1064-7481(12)61041-010.1097/00019442-199800640-00003American Association for Geriatric PsychiatryTABLE 1Prevalence of psychiatric symptoms in patients with and without hoarding behavior, n (%)CharacteristicsHoarding(n = 30)Nonhoarding (n = 103)χ2[1]PDelusions21 (70.0)67 (65.0)0.2540.614 Theft16 (53.3)56 (54.4)0.0100.920 Persecutory5 (16.7)30 (291)1.8600.173 Jealousy3 (10.0)18 (17.5)0.9770.405Hallucinations9 (30.0)37 (35.9)0.3600.548 Auditory5 (16.7)19 (18.4)0.0500.823 Visual7 (23.3)27 (26.2)0.1010.750Misidentifications14 (46.7)30 (291)3.2290.072 Phantom boarders symptoma8 (26.7)15 (14.6)2.3800.123 Residence is not home7 (23.3)15 (14.6)1.2940.271 Mirror signb3 (10.0)5 (4.9)1.0800.379 Caregiver is impostor2 (6.7)11 (10.7)0.4240.732Other disturbances Repetitive behaviors24 (80.0)55 (53.4)6.8170.009 Day/night disturbance8 (26.7)28 (27.2)0.0030.955 Aggressiveness18 (60.0)48 (46.6)1.6680.196 Agitation18 (60.0)49 (47.6)1.4350.231 Wandering15 (50.0)44 (42.7)0.4990.480 Hyperphagia18 (60.0)24 (23.3)14.482<0.001 Pilfering15 (50.0)26 (25.2)6.6780.010athe belief that other (imaginary) people are in the house.bthe inability to recognize one's own mirror reflection (or statements such as “Someone else is in the mirror.”)Received March 24, 1997; revised August 10, 1997, December 24, 1997; accepted January 15, 1998.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-85-150.Regular ArticlesHoarding Behavior in Dementia: A Preliminary ReportJen-PingHwangM.D.Shih-JenTsaiM.D.*Chen-HongYangM.D.King-MingLiuM.D.Jiing-FengLirngM.D.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 ChinaHoarding 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.Hoarding—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 obsessive-compulsive 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 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.METHODSThe 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 tomographic 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 30.11Data 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 chi-square test was used to compare differences in dichotomous variables. A P value less than 0.05 was considered to be statistically significant.RESULTSThe mean age of these patients was 74.1±6.3 years (range: 65–91), and the mean MMSE score was 11.6±6.2 (median: 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), multi-infarct dementia (4 of 40), and dementia 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 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.DISCUSSIONThe 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 of illness. Our study found that hoarding occurred in Alzheimer's dementia, multi-infarct 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-to-severe 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 multi-infarct 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. 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.7This 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, it would be of interest to compare transnational and cross-cultural differences in hoarding behavior among dementia patients.CONCLUSIONHoarding is common in patients with dementia of various etiologies, particularly in those who exhibit repetitive behaviors, hyperphagia, and pilfering. The pathogenesis of hoarding is complex. 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