Cognitive Rehabilitation and Exposure Therapy for Geriatric Hoarding

Project Summary/Abstract
Hoarding disorder (HD) is a chronic, progressive, and debilitating psychiatric condition that leads to
devastating personal and community consequences, particularly for older adults. HD is defined by persistent
difficulty discarding or parting with possessions due to distress associated with discarding, urges to save,
and/or difficulty making decisions about what to keep and what to discard. As a result, clutter accumulates and
fills active living areas, preventing the normal use of space and resulting in distress and disability. Community
epidemiological reports estimate the prevalence of clinically significant hoarding symptoms at 7% in individuals
over age 60 and even higher rates in those over age 70. HD is the only neuropsychiatric condition that
progresses in severity and population prevalence with age apart from dementia.
Inhibition and cognitive switching have been identified as key deficits in older adults with HD. These
executive functioning areas are consistent with the RDoC cognitive control domain and particularly the goal
selection, updating, representation, and maintenance subconstruct. Findings suggest that these deficits may
contribute to the symptomatic expression of HD, degree of functional impairment, and modest responses to HD
treatment. Furthermore, anticipatory and experiential fear and anxiety, consistent with the RDoC constructs of
acute and potential threat, lead to sustained problems with discarding items and clutter accumulation. When
these constructs are targeted, our group has produced clinically and statistically significant outcomes.
Consistent with NIMH strategic goal 3.1, to arrive at effective treatment approaches for unmet therapeutic
domains in behavioral science, this project seeks to conduct the first confirmatory efficacy trial for older adults
with HD. We propose a RCT comparing CREST to a case management control condition for 150 adults age 50
and older with HD. We are examining age as a moderator and will therefore include both midlife and late life
participants. An evaluation of treatment outcome, including hoarding severity and functional outcomes, will be
conducted at baseline (0 months), mid-treatment (3 months), end of treatment (6 months), 3-month (9 months)
and 6-month follow-up (12 months). Participants will receive 26 weekly 60-minute individual sessions over the
course of 32 weeks maximum (6-7.5 months). They will receive 50% in home and 50% office visits. We will
examine factors that mediate improvement in CREST (improved inhibition/cognitive switching and reduction in
fear/anxiety of discarding items) through physiological, behavioral, self-report, and paradigm assessments.
Individual factors (e.g., age and other demographic factors, baseline cognitive control, baseline hoarding
severity) and treatment factors (e.g., session attendance) will be evaluated as moderators. The specific aims
include determining confirmatory efficacy of CREST, mechanisms of CREST effects, and moderators of
CREST. If successful, this project would lead to an effectiveness trial in a real world setting.

Grant Number: 5R01MH127056-04
NIH Institute/Center: NIH
Principal Investigator: Catherine Ayers