The Impact and Management of Mental Health Comorbidity
Mrs. Bennett is a 72-years-old female with history of Parkinson’s disease that has been well controlled with medication for the last five years. Mrs. Bennett lives in a two-story home independently. Although her Parkinson’s disease has been managed well with medication, Mrs. Bennett has had multiple incidents of fall with one incident leading to broken wrist. Mrs. Bennett is at risk for fall related to hoarding disorder per her daughter’s report. The items that Mrs. Bennett’s accumulates in her house include newspapers, totting food and some other items not specified. The main purpose of this paper is to explore and to take into consideration the impact of comorbid Hoarding disorder in management of Parkinson’s disease and how to manage hoarding in an older adult with Parkinson’s.
Epidemiology of Hoarding Disorder
Adults 65 years and older have a mental disorder with estimated number of 8.6 million (Flood & Buckwalter, 2009). In an epidemiological study conducted in London using1698 participants 19 subjects screened positive for hoarding using DSM-V diagnosis criteria. The study concluded that the prevalence being 1.5%. This study also found that hoarding was correlated with old age and being unmarried (67%) and having comorbid physical health condition (Nordsletten et al., 2013). This evidence can be related to Mrs. Bennett who is older adult, unmarried with Parkinson’s and a comorbid hoarding disorder. Currently, hoarding disorder prevalence is 6% in American in older adults (Mathews, 2014). Some number of patients diagnosed with Parkinson’s disease who receives dopamine-replacement therapy also develop compulsive behaviors such as hoarding. This can lead to challenging therapeutic treatment and cause psychosocial impairment in patients (Ferrara & Stacy, 2008).
Mostly hoarding disorder assessment is not easily revealed in family medicine. Patients with hoarding disorder present in primary care setting with an incident of fall (Frank & Misiaszek, 2012). This is true in Mrs. Bennett’s case; the hoarding disorder would have been hidden if her daughter fails to report to the physician. Hoarding include the compulsive urge and failure to discard huge amount of belongings that takes over the living area of the home and causes the individual a serious distress, health and safety risk (Frost & Hristova, 2011).
The symptoms of hoarding disorder has been under consideration in Diagnostic and Statistical Manual of Mental Disorder 5th Edition (DSM-V) for a while (Frost & Hristova, 2011). Finally, in 2014, hoarding disorder was included in DSM-V as a mental disorder. The diagnostic criteria of hoarding disorder in DSM-V include: Difficulty in discarding or separating self from possessions as a result of urge to keep useless items. The accumulation of items clutters the active living area in different settings such home, office, car. The action of accumulation of possessions causes distress that is clinically significant and causes risk for unsafe environment for self and others. To make the diagnosis of hoarding disorder, medical and mental disorders, neurologic conditions that can cause the individual accumulate items need to be ruled out. Once it is confirmed that the disorder is not related to medical condition or mental disorder, hoarding disorder can be made (Mataix-Cols, 2014). In hoarding disorder, paperwork, newspapers, old clothing, books, and bags are some of the most commonly saved possessions. In Mrs. Bennet’s case newspapers seem to be the number one item she seems to have difficulty discarding.
Several useful assessment questionnaires and interviews have been used to screen for hoarding disorder. These include: general obsessive compulsive disorder (OCD) measure with hoarding subscales such as Yale-Brown Obsessive Compulsive Scale (Y-BOCS), which is an interview with two parts. The first one requires patients indicate OCD symptoms that are divided into compulsions and obsessions and participant is required to answer more than 50 being present. The list include hoarding as both a compulsion and obsession. The second part requires patients to list three obsessions and compulsion that is most frequent and rate them using things such as time, distress. Based on the addition of 10 ratings, the index of OCD severity such as hoarding can be assessed. Although this has been used a lot in early studies, the specificity of this tool is low and has serious problems. First, thoughts that associated with obsessive behavior and hoarding are not the same. Second the experience of hoarding and compulsion are different and may be recorded inaccurately. Third, the Y-BOCS hoarding questions do not correlate with the severity of hoarding behavior (Frost & Hristova, 2011).
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Saving Inventory-Revised (SI-R) is another assessment tool composed of self-report questionnaire that is used mostly. SI-R is s elf-report that includes 23-item questionnaire with a score of 0 to 4 with total score range of 0 to 92 that includes three subscales to measure hoarding disorder main character. Based on evidence SI-R is a reliable and valid assessment tool for hoarding disorder (Frost & Hristova, 2011).
Hoarding Rating Scale –Interview (HRS-I) is one of the most valid and specific assessment used to screen hoarding disorder. HRS-I is composed of semi-structured interview of five-question that assess unique features of hoarding such as clutter, excessive accumulation of things, difficulty discarding, distress, and interference. The score ranges from 0 (not at all) to 8 (extreme). HRS-I has high sensitivity in measuring changes in hoarding treatment (Frost & Hristova, 2011).
Similarly, UCLA Hoarding Severity Scale (UHSS) is also semi-structured of 10-item questionnaire. On the other hand, UHSS includes slowness of task completion, procrastination, and indecisiveness, which makes the tool broader measure compare to HRS-I and other assessment tools. The validity and reliability of UHSS was not discussed but the interview correlates with treatment outcomes (Frost & Hristova, 2011).
For Mrs. Bennett safety evaluation should also be include using Tinetti balance and gait evaluation that assess balance in sitting, standing position, arising attempt, and coordination. Get up and go test for fall prevention also needs to be included by having Mrs. Bennett first to sit in a chair whit her back straight comfortably, stand up from chair, walk, turn around, and walk back to the chair at her normal pace and then finally sit down again (Mathias, Nayak, & Isaacs, 1986).
Evidence Based Treatment
A research reviews showed that treatment of hoarding disorder is best delivered by a multidisciplinary team approach including accessing local resources to manage hoarding disorder (Frank & Misiaszek, 2012). More than just using one treatment method is required to intervene in hoarding disorder; using local resources from multiple public agencies helps in improvement of services. For instance some communities have developed multiagency hoarding team (Chapin et al., 2010).
The treatment should start with evaluating the person and assessing the degree and risk of hoarding disorder. Assessment and evaluation will lead the clinician to provide appropriate management to each individual diagnosed with the hoarding disorder. Primary Care Nurse Practitioners can use the diagnostic interview to assists in evaluating the risk of hoarding such as risk for fall due to clutter, potential fire hazards, risk to health due to unsanitary living conditions, and risk of potential rodent or insect infection by directly interviewing the person (Mataix-Cols, 2014). In Mrs. Bennet’s case, the clutter is causing her to have unsafe environment, which leads to her to falling multiple times. Unfortunately, due to recent recognition of hoarding disorder, there is no evidence based professionally recognized management guideline for clinicians currently. The only evidence-based treatment is cognitive behavior incorporated with hoarding disorder education (Mataix-Cols, 2014).
Geriatric hoarding behavioral treatment in adults with average age of 66 was conducted. The treatment included 24 sessions with psychotherapy of cognitive rehabilitation focusing on discard exposure and executive functioning. The post treatment result was statistically and clinically significant for improved changes in hoarding symptoms. This treatment targets neurocognitive deficits of hoarding disorder (Ayers et al., 2014).
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Pharmacotherapy treatment of hoarding disorder includes selective serotonin-reuptake inhibitors (SSRIs) and Serotonin-norepinephrine reuptake inhibitors (SNRIs). Evidence shows that patients with hoarding disorder had improve with use of paroxetine (Mataix-Cols, 2014). 70 % of patients diagnosed with hoarding disorder had significant symptom improvement using venlafaxine extended–release for 12 weeks (Saxena & Sumner, 2014).
Initial Plan of Care
The major concern of treatment of Hoarding for Mrs. Bennett is safety issue related to the seriousness of Parkinson’s disease and Hoarding. Parkinson’s disease is associated with postural instability, increased resting tremors, bradykinesia, and rigidity. Safety remains as the main issue due to hoarding disorder. Mrs. Bennett’s living arrangement is not suitable for someone with comorbid Parkinson’s disease. The plan of care for Mrs. Bennett should include treatment using pharmacology and non-pharmacology, education on hoarding disorder, and follow-up for monitoring and evaluating treatment response.
Pharmacological treatment for Mrs. Bennett can be started with Paroxetine 20 mg by mouth every morning, increase dose by 10 mg per day every week, with maximum dose of 40 mg per day. Evidence shows that Patients with hoarding disorder who were treated with 40-60 mg of paroxetine showed symptom improvement after 12 weeks (Mathew, 2014). Since Mrs. Bennett is elderly, starting low and going slow with medication dose should be considered.
Refer Mrs. Bennett to geriatric psychiatrist for cognitive behavioral therapy. Ayers et al. (2014) showed that cognitive and behavioral therapy treatment is effective for treating hoarding disorder in older adult. Looking at local resources of public agencies to clear the clutters in Mrs. Bennett’s house by involving a social worker or case manager is also necessary to help her navigate through her house while she is on pharmacological and/or non-pharmacological treatment for hoarding disorder. Hoarding in Parkinson’s disease can be attributed to multiple factors such as being physical unable to discard items. Evidence shows that inability to discard items correlates with obsessive-compulsive disorder in patients who have a comorbid hoarding disorder with Parkinson’s disease (O’Sullivan et al., 2010).
Monitoring Treatment Response
Improvement in hoarding severity will be measured using SI-R, UHSS and HRS-I before and after treatment for monitoring the effect of Paroxetine for Mrs. Bennett. Based on evidence treatment response takes 6-12 weeks. There fore, post treatment severity improvement should be assessed at 12 weeks (Mataix-Cols, 2014). Safety evaluation screening with Tinetti and get up and go will also be performed during pre and post treatment in order to evaluate safety due to Parkinson’s disease. If Mrs. Bennett does not respond to treatment management, placing her in assisted living or nursing home can also be used as a last resort. Every effort should me bade to keep Mrs. Bennett at her home.
The ethical issue in Mrs. Bennett’s case is that although she has a compulsive hoarding disorder that puts her at risk for fall and many other health conditions; the daughter was the one who reported Mrs. Bennett’s hoarding disorder. The ethical dilemma in this case would be autonomy, Mrs. Bennet’s decision to live at home versus safety risk, ethics of forcing her into nursing home. Despite Mr. Bennett’s hoarding disorder, assessment of elder abuse should also be considered.
As a Primary Care Nurse Practitioner (PCNP), one is expected to be able to address the issue of hoarding by using DSM-V screening criteria and using screening assessment tools to correctly diagnose and treat hoarding. The assumption with this Mrs. Bennett is that she probably wants to continue living at her house and getting her house free of clutter is very important. The house needs to be cleaned. With Mrs. Bennett’s Parkinson’s disease she will continue to have
fall incident and injure herself further therefore, safety is a major concern and issue for her.
PCNP can also incorporate teaching on hoarding disorder to Mrs. Bennett and her daughter. As it has been mentioned in evidence based treatment-involving family helps in managing hoarding. The burden for the daughter will be enormous, social support other than Mrs. Bennett’s daughter should also be considered. Evidence shows that the functional impairment involved in hoarding affects both the patient and their families with increasing level of burden associated with caring for individuals with hoarding disorder. Increasing support would benefit the family member in dealing with the individual with hoarding disorder. On the other hand, the study findings also showed that involving family members in treatment of hoarding disorder would be beneficial to the individual with hoarding disorder. This will help in understanding the severity and the etiology of hoarding disorder (Drury, Ajmi, Fernandez de la Cruz, Nordsletten, & Mataix-Cols, 2014). For maintaining ethical principles Nurse Practitioners must take into consideration elder abuse, Mrs. Bennett’s wish and safety risk in providing suggestion to the daughter for the living arrangement of Mrs. Bennett to avoid family influence in living arrangement.
In summary, hoarding disorder is one of the mental disorders that has been recognized recently and included in DSM-V recently. Review of research shows that evidence is limited on the management of hoarding disorder. Future research is needed on treatment management of hoarding disorder (Mataix-Cols, 2014). Hoarding disorder puts burden not only on the person who is being evaluated for hoarding or has been diagnosed with hoarding but also on families of the patient with hoarding disorder just like any other mental disorders. Mrs. Bennet’s hoarding disorder is causing her to fall and putting distress on her daughter.
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