On November 18th, 2014, a female 87 years old (I.E.) was once more admitted to our Geriatric Rehabilitation Unit-Nursing home accompanied by a social worker and the city police of Brescia. The social worker insisted on the need of her institutionalization (even if it was against the patient’s will) due to the fact that her living conditions for the second time in a few months had returned to being unhealthy and unhygienic: a new accumulation of useless objects, food, and trash that took this time only 4 months to make. The photographs taken (see below) show a tendency of excessive acquisition of and the inability to discard objects, also the incapacity of programming and planning the typical activities of house cleaning and tidying up. (Fig. 1)

Fig. 1
figure 1

Interior of the house dominated by the disorderly accumulation of various objects and junk

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I.E. was single, who was in the past employed in a big national public company; she lived alone in an elegant building. In January 2014, she was hospitalized in an acute care hospital for cachexia and recurring falls. She was discharged with the following diagnosis: vascular ischaemic encephalopathy, moderate cognitive impairment, accidental fall with compound fracture of the eighth rib, malnutrition and dehydration, recurrent ulcer of the left leg with infection, abdominal aorta aneurysm (diameter 6 cm), sever reflux esophagitis, hiatal hernia Permagna with peptic ulcer, chronic gastritis, moderate anemia, igg lambda monoclonal component, and severe hearing impairment. In the patient’s clinical records emerged an important problem regarding her home and her unhealthy living conditions. The photographs obtained by the social service showed the complete disorder and the cluttering of various objects, wasted food, and trash inside the patient’s apartment, underlying the total lack of hygiene. The final impression that the viewer receives is that of a person who lacks in goodhouse keeping and an uncontrollable need to accumulate large quantities of useless objects.

The female cousin of the patient during an interview, described her aunt’s life before the hospitalization: she lived in a well-defended state of voluntary isolation for quite a long time (at least 2 years); the cousin recalls the conversations she had on the phone with her and stated that her aunt’s intellect was intact and active (the patient conserved interests in music, botany, trekking stories, politics, current events); the cousin used a curious statement to describe the situation that had been created “my aunt, it seems, turned the pyramid of Maslow upside down”.

The patient did not realize the dangerous situation she’s gotten herself in: she blames the disorder of her apartment due to her reduced mobility prior to a recent and painful ulcer of the leg.

After discharge from the hospital she was transferred for the first time to our Geriatric Rehabilitation Unit-Nursing Home. At her arrival a MMSE screening valuation was given resulting in a score of 14/30, that was interpreted as the consequence of the recent hospitalization and to the transfer to an unknown environment. In fact, after a period of proper assistance, appropriate hydration, and regular meals, the patient flourished with good health and returned to cultivating her many interests (music, botany, etc.). Stunning how, from hereinafter, the patient regained a huge improvement in intellect. The psychologist, during the interviews with the patient would describe her to be clearminded, cooperative, and showing but a little confusion when it came to talking about her problems with the state of her home. In the meantime, the cousin informs us that a legal order was given to eliminate all the useless material from the patient’s apartment otherwise the apartment would be confiscated. A total of 80 sacks of garbage were taken away.

The patient passes calmly 6 months at our Nursing Home where she spent most of her time alone in the garden cultivating her interests in botany. She refused indignated in participating in any of the various activities proposed by the Nursing Home and did not socialize with any of the other patients, granting audience only and exclusively to doctors and to the psychologist.

Her MMSE score was: 24/30.

On the 9th of July, the patient, after a lot of insistence, returns to her home declaring that she will get help in keeping her apartment from her neighbors and friends.

One day the patient goes to her pharmacy to buy items for medicating a wound on her leg. The pharmacist after taking a good look at this wound informed the social service that immediately hospitalized the patient once more for an ulcer of the right leg. It was on the 6th of November 2014. The patient was discharged on the 18th of November 2014 and returned to our Geriatric Rehabilitation Unit-Nursing Home Nursing Home. The patient of course was annoyed and troubled by this forced institutionalization that she did not agree upon. On the first day, the patient appeared clearminded, not cooperative, partially orientated, talkative, oppositional, and irritated by the decision taken by the social service to institutionalize her against her will. Her postural steps and walking without aid was done in autonomy. In agreement with the social service, was the will to call upon a judge to designate a tutor. The patient agrees to undergo the various tests necessary for this procedure: Neuropsychological evaluation by a geriatric specialist, brain MRI, and blood tests (TSH, vitB12, folates, calcium, and phosphate).

On the 27th of November 2014, the patient underwent the neuropsychological evaluation that revealed only an isolated mild executive function deficit (Trial Making Test below normal range); on the contrary, verbal memory, language, abstraction, reasoning, and constructional praxia were all in the normal range for her age and education. Her MMSE score was: 25.7/30.

After obtaining the results from this valuation, from the brain MRI (showing subcortical–periventricular ischemic vascular damage), from the blood tests (normal values), the viewing of the photographs that had been taken of her apartment and the long interviews done between the patient and her psychologist, the medical consultant formulated the following diagnosis: “hoarding behavior and isolated executive function impairment in person affected by subcortical ischemic vascular disorder”.

The patient died in our Nursing Home at the age of 89; she lived until her death cultivating her botanical and musical interests alone and engaging discussion with psychologists and doctors.

Hoarding disorder is a mental disorder that has been newly included in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). According to the DSM-5 criteria hoarding disorder is an early-onset disorder which appears to cause (early in life and persistently) significant impairment in the individual’s everyday functioning, persistent difficulty in discarding or parting with possessions; these difficulties result in the disorganized accumulation of possessions that clutter active areas, substantially compromising their intended use [1]. Hoarding disorder should not be diagnosed if the symptoms are judged to be a direct consequence of a typical obsessive compulsive disorder. Moreover, hoarding disorder should not be diagnosed if the symptoms are judged to be a direct consequence of an organic brain disorder such as major neurocognitive disorder (i.e., dementia), traumatic brain injury, brain tumor, cerebrovascular disease, or infection of the central nervous system.

As to our clinical case, being the behavioral disorder secondary to an organic disease the diagnostic definition of “hoarding behavior” rather than “hoarding disorder” seems therefore to be more correct.

In conclusion, the described patient suggests that even very mild, isolated, neurocognitive impairment involving the frontal lobe function can be the cause of an hoarding behavior.