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Dobbins SK, Garcia CM, Evans JL, Valle K, Guzman D, Kushel MB. Continued Homelessness and Depressive Symptoms in Older Adults. JAMA Netw Open 2024; 7:e2427956. [PMID: 39145977 PMCID: PMC11327886 DOI: 10.1001/jamanetworkopen.2024.27956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2024] Open
Abstract
Importance Depression is common in adults experiencing homelessness. It is unclear whether continued homelessness is associated with more depressive symptoms. Objective To examine the association between residential status and depressive symptoms in adults aged 50 years or older experiencing homelessness at study entry. Design, Setting, and Participants This cohort study analyzed results from the Health Outcomes of People Experiencing Homelessness in Older Middle Age (HOPE HOME) project, which in 2013 began enrolling adults aged 50 years or older experiencing homelessness in Oakland, California, and conducted structured interviews every 6 months for a mean duration of 5.5 years through 2023 (for this cohort study). Eligible participants included those aged 50 years or older, able to speak English, and experiencing homelessness at enrollment. We analyzed data collected from 2013 to 2023. Exposures The exposure of interest was residential status. At follow-up visits, residential status was categorized as (1) homelessness (meeting the HEARTH [Homeless Emergency Assistance and Rapid Transition to Housing] Act definition) or (2) housed (living in a noninstitutional environment and not meeting the HEARTH Act definition). Main Outcomes and Measures The primary outcome was moderate to severe depressive symptoms (with Center for Epidemiologic Studies-Depression [CES-D] scale score ≥22). The augmented inverse probability of treatment weighting (AIPTW) approach was used to examine the association between continued homelessness and depressive symptoms. The AIPTW adjusted for the following variables: number of chronic health conditions, age, sex, visiting a health care practitioner, receiving outpatient mental health treatment, receiving mental health medication, exposure to abuse, substance use disorder, and binge drinking. Results The cohort was composed of 450 participants, of whom 343 (76.2%) were males, and the mean (SD) age was 58.5 (5.2) years. Participants completed a median (IQR) of 8.9 (8-11) follow-up visits. With 1640 person-years of observation time, participants continued homelessness for 880 person-years (57.1%) and experienced being housed for 715 person-years (44.3%). Many participants (304 [78.0%]) were housed during at least 1 follow-up visit. The odds of a CES-D scale score of 22 or higher was significantly higher among participants who continued experiencing homelessness than among housed participants (marginal causal odds ratio, 1.08; 95% CI, 1.04-1.11; P < .001). Conclusions and Relevance This cohort study found that continued homelessness was associated independently with increased odds of depressive symptoms. Obtaining housing may have a favorable role in depression and overall well-being of older adults experiencing homelessness and may be considered as a mental health intervention.
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Affiliation(s)
| | - Cheyenne M Garcia
- Center for Vulnerable Populations, University of California, San Francisco
- UCSF Benioff Homelessness and Housing Initiative, University of California, San Francisco
| | - Jennifer L Evans
- Center for Vulnerable Populations, University of California, San Francisco
- UCSF Benioff Homelessness and Housing Initiative, University of California, San Francisco
| | - Karen Valle
- Center for Vulnerable Populations, University of California, San Francisco
- UCSF Benioff Homelessness and Housing Initiative, University of California, San Francisco
| | - David Guzman
- Center for Vulnerable Populations, University of California, San Francisco
- UCSF Benioff Homelessness and Housing Initiative, University of California, San Francisco
| | - Margot B Kushel
- Center for Vulnerable Populations, University of California, San Francisco
- UCSF Benioff Homelessness and Housing Initiative, University of California, San Francisco
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Garcia CM, Schrier EF, Carey C, Valle KA, Evans JL, Kushel M. Sleep Quality among Homeless-Experienced Older Adults: Exploratory Results from the HOPE HOME Study. J Gen Intern Med 2024; 39:460-469. [PMID: 37783981 PMCID: PMC10897106 DOI: 10.1007/s11606-023-08429-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 09/13/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Sleep is essential to health and affected by environmental and clinical factors. There is limited longitudinal research examining sleep quality in homeless older adults. OBJECTIVE To examine the factors associated with poor sleep quality in a cohort of older adults in Oakland, California recruited while homeless using venue-based sampling and followed regardless of housing status. DESIGN Longitudinal cohort study. PARTICIPANTS 244 homeless-experienced adults aged ≥ 50 from the Health Outcomes in People Experiencing Homelessness in Older Middle Age (HOPE HOME) cohort. MAIN MEASURES We assessed sleep quality using the Pittsburgh Sleep Quality Index (PSQI). We captured variables via biannual questionnaires and clinical assessments. KEY RESULTS Our sample was predominantly men (71.3%), Black (82.8%), and had a median age of 58.0 years old (IQR 54.0, 61.0). Two-thirds of participants (67.2%) reported poor sleep during one or more study visits; sleep duration was the worst rated subdomain. In a multivariable model, having moderate-to-severe depressive symptoms (AOR 2.03, 95% CI 1.40-2.95), trouble remembering (AOR 1.56, 95% CI 1.11-2.19), fair or poor physical health (AOR 1.49, 95% CI 1.07-2.08), two or more chronic health conditions (AOR 1.76, 95% CI 1.18-2.62), any ADL impairment (AOR 1.85, 95% CI 1.36-2.52), and being lonely (AOR 1.55, 95% CI 1.13-2.12) were associated with increased odds of poor sleep quality. Having at least one confidant was associated with decreased odds of poor sleep (AOR 0.56, 95% CI 0.37-0.85). Current housing status was not significantly associated with poor sleep quality. CONCLUSIONS Homeless-experienced older adults have a high prevalence of poor sleep. We found that participants' physical and mental health was related to poor sleep quality. Poor sleep continued when participants re-entered housing. Access to physical and mental healthcare, caregiving support, and programs that promote community may improve homeless-experienced older adults sleep quality, and therefore, their overall health.
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Affiliation(s)
- Cheyenne M Garcia
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
- UCSF Benioff Homelessness and Housing Initiative, University of California, San Francisco, San Francisco, CA, USA
| | - Elizabeth F Schrier
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Caitlin Carey
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
- UCSF Benioff Homelessness and Housing Initiative, University of California, San Francisco, San Francisco, CA, USA
| | - Karen A Valle
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
- UCSF Benioff Homelessness and Housing Initiative, University of California, San Francisco, San Francisco, CA, USA
| | - Jennifer L Evans
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
- UCSF Benioff Homelessness and Housing Initiative, University of California, San Francisco, San Francisco, CA, USA
| | - Margot Kushel
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA.
- UCSF Benioff Homelessness and Housing Initiative, University of California, San Francisco, San Francisco, CA, USA.
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Blackford K, Crawford G, McCausland K, Zhao Y. Describing homelessness risk among people from culturally and linguistically diverse backgrounds in Western Australia: A cluster analysis approach. Health Promot J Austr 2023; 34:953-962. [PMID: 36764671 DOI: 10.1002/hpja.704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 01/06/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023] Open
Abstract
ISSUE ADDRESSED Housing is a social determinant of health. Migrants are at an increased risk of insecure housing, overcrowding, and homelessness which can lead to poor quality of life and well-being. This study aimed to identify clustering patterns of homelessness risks among people from culturally and linguistically diverse (CaLD) backgrounds in Western Australia (WA). METHODS Participants from CaLD backgrounds (n = 143, 81.8% male) were identified from secondary cross-sectional data sourced from Vulnerability Index Service Prioritisation Decision Assistance Tool (VI-SPDAT) surveys conducted with people experiencing homelessness in Perth, WA, between 2012 and 2020. A two-step cluster analysis was used to identify subgroups within the data, and chi-square tests compared demographic characteristics and drivers of homelessness among the determined clusters. RESULTS Three distinct clusters were identified and labelled as 'high-risk group' (n = 50, 35.0%), 'medium-risk group' (n = 39, 27.3%) and 'low-risk group' (n = 47, 32.9%). The most vulnerable participants (with VI-SPDAT score ≥ 10) were all clustered in the 'high-risk group'. CONCLUSION The analysis identified subgroups within and between CaLD populations and highlighted limitations with data collection instruments for measuring homelessness among these groups. SO WHAT?: To prevent health issues associated with homelessness and improve social determinants of health, improvements in research and service provision are recommended to facilitate equitable access to secure housing for people from CaLD populations.
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Affiliation(s)
- Krysten Blackford
- Collaboration for Evidence, Research and Impact in Public Health, School of Population Health, Curtin University, Australia
- School of Population Health, Curtin University, Australia
| | - Gemma Crawford
- Collaboration for Evidence, Research and Impact in Public Health, School of Population Health, Curtin University, Australia
- School of Population Health, Curtin University, Australia
| | - Kahlia McCausland
- Collaboration for Evidence, Research and Impact in Public Health, School of Population Health, Curtin University, Australia
- School of Population Health, Curtin University, Australia
| | - Yun Zhao
- School of Population Health, Curtin University, Australia
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Rapaport P, Kidd G, Jeraldo RE, Mason A, Knapp M, Manthorpe J, Shulman C, Livingston G. A qualitative exploration of older people's lived experiences of homelessness and memory problems - stakeholder perspectives. BMC Geriatr 2023; 23:556. [PMID: 37700235 PMCID: PMC10498566 DOI: 10.1186/s12877-023-04250-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/23/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND The numbers of older people experiencing both homelessness and memory problems are growing, yet their complex health, housing and care needs remain undelineated and unmet. There is a critical gap in understanding what can improve the care, support and experiences of this group. In this qualitative study we explore how stakeholders understand memory problems among older people in the context of homelessness and consider what they judge gets in the way of achieving positive outcomes. METHOD We conducted reflexive thematic analysis of qualitative interviews (n = 49) using a semi-structured topic guide, with 17 older people (aged ≥ 50 years) experiencing memory problems and homelessness, 15 hostel staff and managers, and 17 health, housing and social care practitioners. We recruited participants from six homelessness hostels, one specialist care home and National Health and Local Authority Services in England. RESULTS We identified four overarching themes. The population is not taken seriously; multiple causes are hard to disentangle; risk of exploitation and vulnerability; and (dis)connection and social isolation. The transience and lack of stability associated with homelessness intensified the disorienting nature of memory and cognitive impairment, and those providing direct and indirect support required flexibility and persistence, with staff moving beyond traditional roles to advocate, provide care and safeguard individuals. Memory problems were perceived by frontline staff and older people to be overlooked, misinterpreted, and misattributed as being caused by alcohol use, resulting in pervasive barriers to achieving positive and desired outcomes. CONCLUSIONS Efforts to meet the needs of older people living with memory problems and experiencing homelessness and future interventions must reflect the complexity of their lives, often in the context of long-term alcohol use and current service provision and we make suggestions as to what could be done to improve the situation.
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Affiliation(s)
- Penny Rapaport
- UCL Department of Mental Health of Older People, Division of Psychiatry, Wing B, Floor 6 Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK.
| | - Garrett Kidd
- UCL Department of Mental Health of Older People, Division of Psychiatry, Wing B, Floor 6 Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK
| | - Rosario Espinoza Jeraldo
- UCL Department of Mental Health of Older People, Division of Psychiatry, Wing B, Floor 6 Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK
| | - Ava Mason
- UCL Department of Mental Health of Older People, Division of Psychiatry, Wing B, Floor 6 Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK
| | - Martin Knapp
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Jill Manthorpe
- NIHR Policy Research Unit in Health and Social Care Workforce, King's College London, London, UK
- NIHR Applied Research Collaboration (ARC) South London, London, UK
| | - Caroline Shulman
- Pathway, London, UK
- Healthy London Partnership, London, UK
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
| | - Gill Livingston
- UCL Department of Mental Health of Older People, Division of Psychiatry, Wing B, Floor 6 Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK
- Camden and Islington NHS Foundation Trust, London, UK
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Abstract
Context In recent years, cities across the world have seen widespread growth in unsheltered homelessness, in which a person sleeps in a place not meant for human habitation such as cars, parks, sidewalks, and abandoned buildings. It is widely understood that people experiencing homelessness have poorer health outcomes than the general population. Less is known about the health of people who are unsheltered, yet they may be exposed to greater health risks than their sheltered counterparts. The purpose of this literature review is to evaluate and summarize the evidence on unsheltered homelessness and health. Evidence Acquisition A literature search was conducted using PubMed to identify publications on unsheltered homelessness and health. A total of 42 studies were included for review. Evidence Synthesis Unsheltered populations experience higher rates of chronic disease, serious mental illness, and substance abuse than sheltered populations. Unsheltered homelessness is strongly associated with chronic homelessness that exacerbates serious mental illness and substance use, which is often co-occurring. Despite having large unmet health needs, unsheltered populations have lower healthcare utilization and often lack health insurance. Conclusions Evaluating the impact of shelter status on health outcomes has important implications for the allocation of housing and health services. Longitudinal studies are needed to examine the relationship between the duration of sheltered and unsheltered homelessness and health outcomes and explore the mediating mechanisms that lead to poor health among unsheltered populations. Despite these limitations, our results also suggest an urgent need to address the unique and severe challenges facing unsheltered populations and the need for intervention approaches that are sensitive to these unique disease burdens.
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Affiliation(s)
- Jessica Richards
- Department of Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
| | - Randall Kuhn
- Department of Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
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Weldrick R, Canham SL, Sussman T, Walsh CA, Cormier É, Mahmood A. Delivering Services to Older Persons Experiencing Homelessness: Providers' Perspectives of What Does and Does Not Work. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2023; 66:29-42. [PMID: 35678024 DOI: 10.1080/01634372.2022.2087128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/03/2022] [Accepted: 06/04/2022] [Indexed: 06/15/2023]
Abstract
Older people with experiences of homelessness (OPEH) tend to experience more complex health, social, and psychological issues than people experiencing homelessness at younger ages. Simultaneously, many housing resources (e.g., shelters, temporary housing) are often ill equipped to meet the needs of OPEH. As such, OPEH are often unable to age in the right place (AIRP) - that is, in a place that supports unique needs and vulnerabilities. However, several promising practices exist that deliver housing and services tailored to OPEH. To investigate the aspects of housing and shelter that both promote and impede AIRP for OPEH, this study examines the delivery of services in three such promising practices from the perspective of service providers. Findings from fifteen qualitative interviews revealed three overarching themes: 1) barriers to providing individualized support (e.g., staff turnover); 2) shifting contexts and structures (e.g., housing market changes); and 3) mechanisms of success (e.g., facilitating smooth transitions into permanent housing). These findings provide evidence to support the refinement of service delivery to promote AIRP for OPEH. In doing so, these insights can help to elevate promising practices to the level of best practice.
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Affiliation(s)
- Rachel Weldrick
- Department of Gerontology, Simon Fraser University, Vancouver, BC, Canada
| | - Sarah L Canham
- College of Social Work, University of Utah, Salt Lake City, UT, USA
- College of Architecture and Planning, University of Utah, Salt Lake City, UT, USA
| | - Tamara Sussman
- School of Social Work, McGill University, Montreal, QC, Canada
| | | | | | - Atiya Mahmood
- Department of Gerontology, Simon Fraser University, Vancouver, BC, Canada
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Semere W, Kaplan L, Valle K, Guzman D, Ramsey C, Garcia C, Kushel M. Caregiving Needs Are Unmet for Many Older Homeless Adults: Findings from the HOPE HOME Study. J Gen Intern Med 2022; 37:3611-3619. [PMID: 35167064 PMCID: PMC8853310 DOI: 10.1007/s11606-022-07438-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 01/26/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The homeless population is aging, with early onset of cognitive and functional impairments. It is unclear whether older homeless adults receive caregiving assistance that could prevent long-term disability. OBJECTIVE We describe characteristics of older homeless-experienced adults with caregiving need and determine factors associated with having unmet need. DESIGN AND PARTICIPANTS Cross-sectional analysis of a longitudinal study, Health Outcomes in People Experiencing Homelessness in Older Middle Age (HOPE HOME), examining health, life course events, and functional status among older homeless-experienced (i.e., currently and recently homeless) adults. We recruited 350 homeless adults (July 2013-June 2014) and an additional 100 (August 2017 to July 2018) in Oakland, California; this study includes 303 participants who completed caregiving interviews. MEASUREMENTS We defined caregiving need as difficulty with activities of daily living (ADLs), instrumental activities of daily living (IADLs), falls, Short Physical Performance Battery (SPPB) score < 10, or Modified Mini-Mental State (3MS) exam impairment. We defined unmet need as having caregiving need and reporting not receiving caregiving assistance in the last 6 months. Using logistic regression, we analyzed associations between respondent characteristics and unmet caregiving need. RESULTS Among 303 participants, the mean age was 61.3 ± 5.0 years; 73% were men and 82% were Black. Eighty-one percent had caregiving needs, and in 82% of those, their caregiving needs were unmet. Better self-rated health (AOR 2.13, CI [1.02-4.46], p = 0.04) and being a man (AOR 2.30, CI [1.12-4.69], p = 0.02) were associated with higher odds of unmet need. Moderate or high-risk substance use (AOR 0.47, CI [0.23, 0.94], p = 0.03) was associated with lower odds of unmet need. CONCLUSIONS Older homeless-experienced adults have high prevalence of unmet caregiving need. Interventions that increase caregiving access for homeless-experienced individuals may help avoid poor health outcomes and costly long-term-care needs due to untreated disabilities.
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Affiliation(s)
- Wagahta Semere
- Division of General Internal Medicine, University of California, San Francisco (UCSF) and Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA. .,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.
| | - Lauren Kaplan
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
| | - Karen Valle
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
| | - David Guzman
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
| | | | - Cheyenne Garcia
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
| | - Margot Kushel
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
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Hargrave AS, Garcia CM, Lightfoot M, Handley MA, Weeks J, Olsen P, Knight KR, Kushel MB. "We Remember the Pain": A qualitative study of intergenerational trauma among older adults experiencing homelessness in the HOPE HOME study. JOURNAL OF SOCIAL DISTRESS AND THE HOMELESS 2022; 33:103-111. [PMID: 38948456 PMCID: PMC11213552 DOI: 10.1080/10530789.2022.2080793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/17/2022] [Indexed: 07/02/2024]
Abstract
Rates of homelessness among adults aged 50 and over are rising. Common strategies for exiting homelessness rely on social and family support. However, intergenerational trauma may disrupt these social support networks and contribute to homelessness. Understanding the impact of intergenerational trauma on living with family or friends may give insight into addressing homelessness among older adults. We purposefully sampled 46 adults who reported living with family or friends from the HOPE HOME study cohort (350 community-recruited adults, ≥ 50 years and experiencing homelessness in Oakland, California) and 19 family/friends who had hosted the participants in their living spaces. We conducted independent, semi-structured interviews and used grounded theory methodologies to analyze data. We identified four major themes from the interviews: (1) Intergenerational trauma was common and made it difficult to stay with family or friends; (2) Participants and hosts sought to protect future generations from intergenerational trauma; (3) Relationships endured despite intergenerational trauma; and (4) social structures exacerbated the impact of intergenerational trauma and played a significant role in perpetuating homelessness. Trauma-informed policies that confront the structures that propagate or exacerbate intergenerational trauma may mitigate their impact and facilitate housing for older adults.
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Affiliation(s)
- Anita S. Hargrave
- University of California, San Francisco (UCSF). 505 Parnassus Ave, San Francisco, CA 94143 USA
| | - Cheyenne M. Garcia
- UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital. 2789 25th St, San Francisco, CA 94110 USA
| | - Marguerita Lightfoot
- Oregon Health & Science University (OHSU). 3181 S.W. Sam Jackson Park Road, Portland, OR 97239
| | - Margaret A. Handley
- University of California, San Francisco (UCSF). 505 Parnassus Ave, San Francisco, CA 94143 USA
- UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital. 2789 25th St, San Francisco, CA 94110 USA
- Department of Epidemiology and Biostatistics, UCSF. 550 16th St 2nd floor, San Francisco, CA 94158 USA
| | - John Weeks
- UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital. 2789 25th St, San Francisco, CA 94110 USA
| | - Pamela Olsen
- UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital. 2789 25th St, San Francisco, CA 94110 USA
| | - Kelly R. Knight
- University of California, San Francisco (UCSF). 505 Parnassus Ave, San Francisco, CA 94143 USA
- Oregon Health & Science University (OHSU). 3181 S.W. Sam Jackson Park Road, Portland, OR 97239
| | - Margot B. Kushel
- University of California, San Francisco (UCSF). 505 Parnassus Ave, San Francisco, CA 94143 USA
- UCSF Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital. 2789 25th St, San Francisco, CA 94110 USA
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Garcia-Grossman I, Kaplan L, Valle K, Guzman D, Williams B, Kushel M. Factors Associated with Incarceration in Older Adults Experiencing Homelessness: Results from the HOPE HOME Study. J Gen Intern Med 2022; 37:1088-1096. [PMID: 34109543 PMCID: PMC8189551 DOI: 10.1007/s11606-021-06897-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND In the US, the median age of adults experiencing homelessness and incarceration is increasing. Little is known about risk factors for incarceration among older adults experiencing homelessness. To develop targeted interventions, there is a need to understand their risk factors for incarceration. OBJECTIVE To examine the prevalence and risk factors associated with incarceration in a cohort of older adults experiencing homelessness. DESIGN Prospective, longitudinal cohort study with interviews every 6 months for a median of 5.8 years. PARTICIPANTS We recruited adults ≥50 years old and homeless at baseline (n=433) via population-based sampling. MAIN MEASURES Our dependent variable was incident incarceration, defined as one night in jail or prison per 6-month follow-up period after study enrollment. Independent variables included socioeconomic status, social, health, housing, and prior criminal justice involvement. KEY RESULTS Participants had a median age of 58 years and were predominantly men (75%) and Black (80%). Seventy percent had at least one chronic medical condition, 12% reported heavy drinking, and 38% endorsed moderate-severe use of cocaine, 8% of amphetamines, and 7% of opioids. At baseline, 84% reported a lifetime history of jail stays; 37% reported prior prison stays. During follow-up, 23% spent time in jail or prison. In multivariable models, factors associated with a higher risk of incarceration included the following: having 6 or more confidants (HR=2.13, 95% CI=1.2-3.7, p=0.007), remaining homeless (HR=1.72, 95% CI=1.1-2.8, p=0.02), heavy drinking (HR=2.05, 95% CI=1.4-3.0, p<0.001), moderate-severe amphetamine use (HR=1.89, 95% CI=1.2-3.0, p=0.006), and being on probation (HR=3.61, 95% CI=2.4-5.4, p<0.001) or parole (HR=3.02, 95% CI=1.5-5.9, p=0.001). CONCLUSIONS Older adults experiencing homelessness have a high risk of incarceration. There is a need for targeted interventions addressing substance use, homelessness, and reforming parole and probation in order to abate the high ongoing risk of incarceration among older adults experiencing homelessness.
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Affiliation(s)
- Ilana Garcia-Grossman
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Lauren Kaplan
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA.,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General (ZSFG) Hospital and Trauma Center, San Francisco, CA, USA.,UCSF Benioff Homelessness and Housing Initiative at ZSFG Hospital and Trauma Center, San Francisco, CA, USA
| | - Karen Valle
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA.,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General (ZSFG) Hospital and Trauma Center, San Francisco, CA, USA.,UCSF Benioff Homelessness and Housing Initiative at ZSFG Hospital and Trauma Center, San Francisco, CA, USA
| | - David Guzman
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA.,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General (ZSFG) Hospital and Trauma Center, San Francisco, CA, USA.,UCSF Benioff Homelessness and Housing Initiative at ZSFG Hospital and Trauma Center, San Francisco, CA, USA
| | - Brie Williams
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA.,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General (ZSFG) Hospital and Trauma Center, San Francisco, CA, USA.,Division of Geriatrics, UCSF, San Francisco, CA, USA
| | - Margot Kushel
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA. .,UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General (ZSFG) Hospital and Trauma Center, San Francisco, CA, USA. .,UCSF Benioff Homelessness and Housing Initiative at ZSFG Hospital and Trauma Center, San Francisco, CA, USA.
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Cai C, Knight KR, Olsen P, Weeks J, Handley MA, Kushel MB. Barriers and Facilitators to Resolving Older Adult Homelessness through Stays with Family: Qualitative findings from the HOPE HOME Study. JOURNAL OF SOCIAL DISTRESS AND THE HOMELESS 2022; 32:200-209. [PMID: 38144397 PMCID: PMC10746129 DOI: 10.1080/10530789.2022.2035128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 01/24/2022] [Indexed: 12/26/2023]
Abstract
Living with family and friends is a common strategy used to prevent or exit homelessness, but little is known about structural barriers that impede family and friends' ability to provide temporary or permanent housing for older homeless adults. We conducted semi-structured interviews with 46 homeless participants from the HOPE HOME study, a cohort of 350 community-recruited homeless adults age 50 or older in Oakland, CA, who reported having stayed with housed family/friends for 1 or more nights in the prior 6 months. We conducted semi-structured interviews with 19 hosts of homeless participants and 11 stakeholders in housing and homelessness. We found that homeless older adults and hosts perceived staying with family or friends as a form of temporary housing rather than as a permanent exit to homelessness. Structural barriers to family and friends providing housing for temporary stays or permanent exits from homelessness included housing regulations restricting visitors and changing rent obligations; decreased eligibility and priority for shelter and permanent housing; geographic and transportation challenges; and environments inconducive to older adults. We suggest four areas for policy reform: providing subsidies to hosts and homeless individuals, removing disincentives for homeless older adults to stay with family, changing lease regulations, and expanding the supply of affordable housing.
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Affiliation(s)
- Christopher Cai
- University of California, San Francisco (UCSF) School of Medicine, 3333 California Street, Suite 485, San Francisco, CA USA 94143
| | - Kelly R. Knight
- Department of Humanities and Social Sciences, University of California, San Francisco, 490 Illinois Street, 7th Floor, San Francisco, CA USA 94143
| | - Pamela Olsen
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, 2789 25th St., Suite 350, San Francisco, CA USA 94110
| | - John Weeks
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, 2789 25th St., Suite 350, San Francisco, CA USA 94110
| | - Margaret A Handley
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, 2789 25th St., Suite 350, San Francisco, CA USA 94110
- Department of Epidemiology & Biostatistics, University of California, San Francisco, 550 16th St 2nd floor, San Francisco, CA USA 94158
| | - Margot B. Kushel
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, 2789 25th St., Suite 350, San Francisco, CA USA 94110
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11
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Recchia DR, Cramer H, Wardle J, Lee DJ, Ostermann T, Lauche R. Profiles and predictors of healthcare utilization: using a cluster-analytic approach to identify typical users across conventional, allied and complementary medicine, and self-care. BMC Health Serv Res 2022; 22:29. [PMID: 34986866 PMCID: PMC8728927 DOI: 10.1186/s12913-021-07426-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 12/17/2021] [Indexed: 01/07/2023] Open
Abstract
Introduction The identification of typologies of health care users and their specific characteristics can be performed using cluster analysis. This statistical approach aggregates similar users based on their common health-related behavior. This study aims to examine health care utilization patterns using cluster analysis; and the associations of health care user types with sociodemographic, health-related and health-system related factors. Methods Cross-sectional data from the 2012 National Health Interview Survey were used. Health care utilization was measured by consultations with a variety of medical, allied and complementary health practitioners or the use of several interventions (exercise, diet, supplementation etc.) within the past 12 months (used vs. not used). A model-based clustering approach based on finite normal mixture modelling, and several indices of cluster fit were determined. Health care utilization within the cluster was analyzed descriptively, and independent predictors of belonging to the respective clusters were analyzed using logistic regression models including sociodemographic, health- and health insurance-related factors. Results Nine distinct health care user types were identified, ranging from nearly non-use of health care modalities to over-utilization of medical, allied and complementary health care. Several sociodemographic and health-related characteristics were predictive of belonging to the respective health care user types, including age, gender, health status, education, income, ethnicity, and health care coverage. Conclusions Cluster analysis can be used to identify typical health care utilization patterns based on empirical data; and those typologies are related to a variety of sociodemographic and health-related characteristics. These findings on individual differences regarding health care access and utilization can inform future health care research and policy regarding how to improve accessibility of different medical approaches.
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Affiliation(s)
- Daniela Rodrigues Recchia
- Chair of Research Methods and Statistics in Psychology, Department of Psychology and Psychotherapy, Witten/Herdecke University, Alfred-Herrhausen-Strasse 50, 58448, Witten, Germany.
| | - Holger Cramer
- Department of Internal and Integrative Medicine, Evang. Kliniken Essen-Mitte, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany.,National Centre for Naturopathic Medicine, Southern Cross University, Lismore, New South Wales, Australia
| | - Jon Wardle
- National Centre for Naturopathic Medicine, Southern Cross University, Lismore, New South Wales, Australia
| | - David J Lee
- Chair of Department of Public Health Sciences, University of Miami, Miami, FL, USA
| | - Thomas Ostermann
- Chair of Research Methods and Statistics in Psychology, Department of Psychology and Psychotherapy, Witten/Herdecke University, Alfred-Herrhausen-Strasse 50, 58448, Witten, Germany
| | - Romy Lauche
- National Centre for Naturopathic Medicine, Southern Cross University, Lismore, New South Wales, Australia
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12
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Tong MS, Kaplan LM, Guzman D, Ponath C, Kushel MB. Persistent Homelessness and Violent Victimization Among Older Adults in the HOPE HOME Study. JOURNAL OF INTERPERSONAL VIOLENCE 2021; 36:8519-8537. [PMID: 31135255 PMCID: PMC8715865 DOI: 10.1177/0886260519850532] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The homeless population is aging; older homeless adults may be at high risk of experiencing violent victimization. To examine whether homelessness is independently associated with experiencing physical and sexual abuse, we recruited 350 adults, aged 50 and older in Oakland, California, who met criteria for homelessness between July 2013 and June 2014. We interviewed participants at 6-month intervals for 3 years in Oakland about key variables, including housing status. Using generalized estimating equations, we examined whether persistent homelessness in each follow-up period was independently associated with having experienced physical or sexual victimization, after adjusting for known risk factors. The majority of the cohort was men (77.4%) and Black American (79.7%). At baseline, 10.6% had experienced either physical or sexual victimization in the prior 6 months. At 18-month follow-up, 42% of the cohort remained homeless. In adjusted models, persistent homelessness was associated with twice the odds of victimization (adjusted odds ratio [AOR] = 2.01; 95% confidence interval [CI]: [1.41, 2.87]). Older homeless adults experience high rates of victimization. Re-entering housing reduces this risk. Policymakers should recognize exposure to victimization as a negative consequence of homelessness that may be preventable by housing.
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Affiliation(s)
- Michelle S. Tong
- University of California, Berkeley, USA
- University of California, San Francisco, USA
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13
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Kaltsidis G, Grenier G, Cao Z, L'Espérance N, Fleury MJ. Typology of changes in quality of life over 12 months among currently or formerly homeless individuals using different housing services in Quebec, Canada. Health Qual Life Outcomes 2021; 19:128. [PMID: 33882927 PMCID: PMC8061013 DOI: 10.1186/s12955-021-01768-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 04/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background In health and social service evaluations, including research on homelessness, quality of Life (QOL) is often used as a key indicator of well-being among service users. However, no typology has been developed on changes in QOL over a 12-month period for a heterogenous sample of homeless individuals. Methods Cluster analysis was employed to identify a typology of change in QOL for 270 currently or formerly homeless individuals using emergency shelters, temporary housing (TH) and permanent housing (PH) services in Quebec (Canada). Participant interviews were conducted at baseline and 12 months later. An adapted Gelberg–Andersen Model helped organize QOL-related sociodemographic, clinical, and service use variables into predisposing, needs, and enabling factors, respectively. Comparison analyses were performed to determine group differences. Results Four groups emerged from the analyses: (1) young women in stable-PH or improved housing status with moderately high needs and specialized ambulatory care service use, with improved QOL over 12 months; (2) middle-age to older men with stable housing status, few needs and low acute care service use, with most improvement in QOL over 12 months; (3) older individuals residing in stable-PH or improved housing status with very high needs and reduced QOL over 12 months; and (4) men in stable-TH or worse housing status, with high substance use disorder, using few specialized ambulatory care services and showing decline in QOL over 12 months. Conclusions Findings suggest that positive change in QOL over 12 months was mainly associated with fewer needs, and stability in housing status more than housing improvement. Specific recommendations, such as assertive community treatment and harm reduction programs, should be prioritized for individuals with high needs or poor housing status, and among those experiencing difficulties related to QOL, whereas individuals with more favourable profiles could be encouraged to maintain stable housing and use services proportional to their needs.
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Affiliation(s)
- Gesthika Kaltsidis
- Department of Psychiatry, McGill University, Montreal, QC, Canada.,Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada
| | - Guy Grenier
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada.
| | - Zhirong Cao
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada
| | - Nadia L'Espérance
- Centre Intégré Universitaire de Santé et de Services Sociaux, Trois-Rivières, Quebec, Canada
| | - Marie-Josée Fleury
- Department of Psychiatry, McGill University, Montreal, QC, Canada.,Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada
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14
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Babayan M, Futrell M, Stover B, Hagopian A. Advocates Make a Difference in Duration of Homelessness and Quality of Life. SOCIAL WORK IN PUBLIC HEALTH 2021; 36:354-366. [PMID: 33722166 DOI: 10.1080/19371918.2021.1897055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Social support is known to protect against homelessness and improve the wellbeing of people experiencing homelessness, but the role of professional versus informal advocates has not been studied in relation to the duration of homelessness and quality of life. We measured the effect of the presence and quality of formal (professional) and informal (family or friend) advocates on these outcomes. Our team interviewed 67 adults experiencing homelessness at tiny house villages and self-organized encampments in Seattle/King County, Washington in 2018-2019. The duration of homelessness was 19.6 months shorter for those with a high-quality informal advocate, compared to those without, while controlling for race, age, gender, and sexuality. However, this difference did not reach statistical significance at the alpha 0.05 level (p = .069). Additionally, those with high-quality informal advocates had 5.3 times the odds (p = .010) of reporting high quality of life compared to those without. The effect of at least one high-quality, professional advocate was insignificant in our model. Our results suggest social workers and other professional advocates integrate methods that strengthen clients' informal relationships into their practice.
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Affiliation(s)
- Margaret Babayan
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington, USA
| | - Marvin Futrell
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington, USA
| | - Bert Stover
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington, USA
| | - Amy Hagopian
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington, USA
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15
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Dickins KA, Philpotts LL, Flanagan J, Bartels SJ, Baggett TP, Looby SE. Physical and Behavioral Health Characteristics of Aging Homeless Women in the United States: An Integrative Review. J Womens Health (Larchmt) 2020; 30:1493-1507. [PMID: 33290147 DOI: 10.1089/jwh.2020.8557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The average age of the homeless population is and will continue to rise. Although women comprise a significant and growing percentage of this vulnerable population, their age- and sex-specific health characteristics are poorly understood. Materials and Methods: This integrative review appraises published research addressing the physical and behavioral health characteristics of aging homeless women (≥50 years) in the United States (2000-2019). The authors searched six electronic databases to identify eligible studies. Studies were screened for methodological quality by using the Johns Hopkins Nursing Evidence-Based Practice model. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Results: Ten primary studies met the review eligibility criteria. All were level III (non-experimental); nine appraised as "good" quality (level B), and one as "lower" quality (level C). Aging homeless women demonstrate elevated rates of physical health conditions, related to suboptimal nutrition, lower than expected preventive health screening uptake, and geriatric concerns. Disproportionate rates of mental health conditions are compounded by substance use and interpersonal trauma. Familial and social dynamics and socioeconomic disadvantage contribute to social health concerns. Spiritual health is a critically important yet underexplored protective factor. Conclusions: Studies are limited, though collective findings suggest that aging homeless women endure a disproportionate physical, behavioral, and social health burden compared with aging non-homeless women and aging homeless men. Implications for research on early aging, preventative health strategies, and homelessness among women, and clinical practice in the context of geriatric and women's health are described.
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Affiliation(s)
- Kirsten A Dickins
- Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lisa L Philpotts
- Treadwell Library, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jane Flanagan
- Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, Massachusetts, USA
- William F. Connell School of Nursing, Boston College, Boston, Massachusetts, USA
| | - Stephen J Bartels
- Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Travis P Baggett
- Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Boston Health Care for the Homeless Program, Boston, Massachusetts, USA
| | - Sara E Looby
- Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, Massachusetts, USA
- Metabolism Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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16
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Change in Housing Status among Homeless and Formerly Homeless Individuals in Quebec, Canada: A Profile Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176254. [PMID: 32867382 PMCID: PMC7504688 DOI: 10.3390/ijerph17176254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 12/29/2022]
Abstract
Housing stability is a key outcome in studies evaluating housing services for the homeless population. Housing stability has typically been defined dichotomously and based on a fixed duration of maintenance in housing accommodations, which does not fully capture change in housing status among homeless individuals. Moreover, few typologies have examined housing trajectories across different housing types. Cluster analysis was used to develop a typology of housing status change for 270 currently or formerly homeless individuals in Quebec (Canada) residing in shelters and temporary and permanent housing. Participants were interviewed at baseline (T0) and 12 months later (T1). The Gelberg–Andersen Model was used to organize housing-related variables into predisposing, needs and enabling factors. Comparison analyses were conducted to assess group differences. Three groups (Groups 1, 3 and 4) had more favorable and two (Groups 2 and 5) less favorable, housing status at T1. Findings suggest that maintenance or improvement of housing status requires suitable types and frequencies of service use (enabling factors) that are well adapted to the nature and complexity of health problems (needs factors) among homeless individuals. Specific interventions, such as outreach programs and case management, should be prioritized for individuals at higher risk for returning to homelessness.
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17
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Sussman T, Barken R, Grenier A. Supporting Older Homeless Persons' Positive Relocations to Long-Term Care: Service Provider Views. THE GERONTOLOGIST 2020; 60:1149-1158. [PMID: 31895408 DOI: 10.1093/geront/gnz171] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES This study sought to explore the challenges and opportunities associated with supporting older homeless persons' relocations to long-term care (LTC) from the perspective of service providers. It aims to inform how to improve relocation processes for this vulnerable and growing subpopulation of older persons. RESEARCH DESIGN AND METHODS This cross-sectional qualitative study employed semistructured face-to-face interviews with service providers from two Health and Social Service Centres in Montreal, Quebec. All interviews were audio-recorded, transcribed verbatim, and thematically analyzed in five stages. RESULTS A total of eight service providers reported on their experiences supporting over 40 relocations of older homeless persons (50+) in the last year. According to participants, older homeless persons' trajectories into LTC typically included a series of neglected medical issues followed by hospitalization and eventual relocation to LTC. Systemic barriers such as limited-time for proper planning, insufficient housing options for persons with minor functional limitations, disregard for preferred geographic location, multiple moves, and staff prejudices worked together to expedite premature relocation and challenge relocation processes. DISCUSSION AND IMPLICATIONS Older homeless persons appear to be at heightened risk of premature and challenging relocation processes. Expanding housing stock for persons with functional limitations, strengthening intersectoral collaborations, providing education and training to staff, and ensuring flexibility around rules and regulations in receiving LTC homes would both improve access to aging in place for this marginalized group of older persons and ensure conditions are in place to support positive relocations to LTC for those who require it.
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Affiliation(s)
- Tamara Sussman
- School of Social Work, McGill University, Montreal, Quebec, Canada
| | - Rachel Barken
- Department of Sociology, York University, Toronto, Ontario, Canada
| | - Amanda Grenier
- Factor-Inwentash Faculty of Social Work, University of Toronto and Baycrest Hospital, Ontario, Canada
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18
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Abbs E, Brown R, Guzman D, Kaplan L, Kushel M. Risk Factors for Falls in Older Adults Experiencing Homelessness: Results from the HOPE HOME Cohort Study. J Gen Intern Med 2020; 35:1813-1820. [PMID: 31965522 PMCID: PMC7280424 DOI: 10.1007/s11606-020-05637-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/13/2019] [Accepted: 01/03/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND More than half of homeless adults are of age ≥ 50 years. Falls are a common cause of morbidity in older adults in the general population. Risk factors for falls in the general population include poor health, alcohol use, and exposure to unsafe environments. Homeless adults aged ≥ 50 have a high prevalence of known risk factors and face additional potential risks. OBJECTIVES To examine the prevalence of and risk of falling in a cohort of older homeless adults. DESIGN Longitudinal cohort study with participant interviews every 6 months for 3 years; data were analyzed using generalized estimating equations (GEEs). PARTICIPANTS Three hundred fifty adults aged ≥ 50, homeless at study entry, recruited via population-based sampling. MEASURES The dependent variable is any falls in prior 6 months; independent variables include individual (i.e., illness, behaviors) and social/environmental (i.e., social support, experiencing violence, living unsheltered) factors. RESULTS Over three quarters of participants were men (77.1%) and Black (79.7%). The median age was 58 (IQR 54, 61). At baseline, one third (33.7%) reported a fall in the prior 6 months. At follow-up visits, 23.1% to 31.2% of participants reported having fallen. In GEE models, individual risk factors (non-Black race, being a women, older age, functional impairment, urinary incontinence, history of stroke, and use of assistive devices, opioid, and marijuana) were associated with increased odds of falls. Environmental and social factors (spending any nights unsheltered (adjusted odds ratio (AOR) = 1.42, CI = 1.10-1.83) and experiencing physical assault (AOR = 1.67, CI = 1.18-2.37) were also associated. CONCLUSIONS Older homeless adults fall frequently. Likely contributors include having a high prevalence of conditions that increase the risk of falls, compounded by heightened exposure to unsafe environments. Fall prevention in this population should target those at highest risk and address modifiable environmental conditions. Providing shelter or housing and addressing substance use could reduce morbidity from falls in homeless older adults.
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Affiliation(s)
- Elizabeth Abbs
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Rebecca Brown
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA, USA.,Division of Geriatric Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Corporal Michael J. Crescenz Veterans Affairs Medical Center, San Francisco, CA, USA
| | - David Guzman
- UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.,Center for Vulnerable Populations, University of California, San Francisco, UCSF Box 1364, San Francisco, CA, 94143, USA
| | - Lauren Kaplan
- UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.,Center for Vulnerable Populations, University of California, San Francisco, UCSF Box 1364, San Francisco, CA, 94143, USA
| | - Margot Kushel
- UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA. .,Center for Vulnerable Populations, University of California, San Francisco, UCSF Box 1364, San Francisco, CA, 94143, USA.
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19
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Kaplan LM, Sudore RL, Arellano Cuervo I, Bainto D, Olsen P, Kushel M. Barriers and Solutions to Advance Care Planning among Homeless-Experienced Older Adults. J Palliat Med 2020; 23:1300-1306. [PMID: 32182155 DOI: 10.1089/jpm.2019.0550] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background/Objectives: Older homeless-experienced adults have low rates of advance care planning (ACP) engagement despite high rates of morbidity and mortality. To inform intervention development, we examined potential barriers and solutions to ACP engagement. Design: Cross-sectional qualitative study. Setting: We recruited adults who were homeless in the prior three years and ≥50 years of age in the San Francisco Bay Area, and recruited clinical stakeholders from a national meeting of homeless providers. We analyzed qualitative data using thematic analysis. Measurements: We conducted semistructured interviews with homeless-experienced older adults (n = 20) and focus groups with clinical stakeholders (n = 24) about perceived barriers and solutions to ACP engagement. Results: Participants considered ACP important, reflecting on deaths of people in their networks who had died. Participant-identified barriers to ACP included poor ACP knowledge, lack of familial ties and social isolation, competing priorities, avoidance and lack of readiness, fatalism and mistrust, and lack of ACP training for clinical and nonclinical staff. They identified solutions that included framing ACP as a way to provide meaning and assert choice, providing easy-to-read written documents focused on the populations' unique needs, tailoring content and delivery, initiating ACP in nonclinical settings, such as permanent supportive housing, and providing incentives. Conclusions: Both older homeless-experienced adults and clinical stakeholders believe that ACP is important, but acknowledge multiple barriers that impede engagement. By focusing on potential solutions, including capitalizing on opportunities outside of health care settings, focusing on the period after housing, and tailoring content, there are opportunities to improve ACP uptake.
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Affiliation(s)
- Lauren M Kaplan
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, USA.,Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | | | - Dustin Bainto
- UC Berkeley-University of California, San Francisco Joint Medical Program, UC Berkeley School of Public Health, University of California, Berkeley, Berkeley, California, USA.,School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Pamela Olsen
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, USA.,Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California, USA
| | - Margot Kushel
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, USA.,Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California, USA
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20
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Rosenwohl-Mack S, Kushel M, Ramsey C, Handley M, Knight KR. "We Really Help, Taking Care of Each Other": Older Homeless Adults as Caregivers. Gerontol Geriatr Med 2019; 5:2333721419894765. [PMID: 31903411 PMCID: PMC6926971 DOI: 10.1177/2333721419894765] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/08/2019] [Accepted: 11/21/2019] [Indexed: 12/24/2022] Open
Abstract
Objectives: Many older homeless adults maintain contact with family. We conducted a qualitative study examining the role of family caregiving for older homeless adults. Method: We conducted semi-structured qualitative interviews with a sample of 46 homeless participants who reported spending at least one night with a housed family member in the prior 6 months. Results: A total of 13 of 46 older adult participants provided caregiving. Themes included (a) the death of the care recipient led to the participant’s homelessness; (b) feeling a duty to act as caregivers; (c) providing care in exchange for housing; (d) caregivers’ ability to stay was tenuous; (e) providing care conflicted with the caregiver’s needs; and (f) resentment when family was ungrateful. Discussion: In a sample of older homeless adults in contact with family, many provided caregiving for housed family. For some, caregiving precipitated homelessness; for others, caregiving provided temporary respite from homelessness, and for others, caregiving continued during homelessness.
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Affiliation(s)
| | - Margot Kushel
- Zuckerberg San Francisco General Hospital and Trauma Center, CA, USA
| | | | - Margaret Handley
- Zuckerberg San Francisco General Hospital and Trauma Center, CA, USA.,University of California, San Francisco, USA
| | - Kelly R Knight
- Zuckerberg San Francisco General Hospital and Trauma Center, CA, USA.,University of California, San Francisco, USA
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21
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Magee C, Norena M, Hubley AM, Palepu A, Hwang SW, Nisenbaum R, Karim ME, Gadermann A. Longitudinal Associations between Perceived Quality of Living Spaces and Health-Related Quality of Life among Homeless and Vulnerably Housed Individuals Living in Three Canadian Cities. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16234808. [PMID: 31795464 PMCID: PMC6926800 DOI: 10.3390/ijerph16234808] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 11/15/2019] [Accepted: 11/27/2019] [Indexed: 01/09/2023]
Abstract
The objective of this study was to examine longitudinal associations between perceived quality of living spaces and mental and physical health-related quality of life (HRQoL) among homeless and vulnerably housed individuals living in three Canadian cities. The Health and Housing in Transition (HHiT) study was a prospective cohort study conducted between 2009 and 2013 of N = 1190 individuals who were homeless and vulnerably housed at baseline. Perceived quality of living spaces (based on rated comfort, safety, spaciousness, privacy, friendliness and overall quality) and both mental and physical HRQoL were assessed at baseline and at four annual follow up points. Generalized estimating equation (GEE) analyses were used to examine associations between perceived quality of living spaces and both mental and physical HRQoL over the four-year study period, controlling for time-varying housing status, health and socio-demographic variables. The results showed that higher perceived quality of living spaces was positively associated with mental (b = 0.42; 95% CI 0.38—0.47) and physical (b = 0.11; 95% CI 0.07—0.15) HRQoL over the four-year study period. Findings indicate that policies aimed at increasing HRQoL in this population should prioritize improving their experienced quality of living spaces.
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Affiliation(s)
- Carly Magee
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (M.E.K.); (A.G.)
- Human Early Learning Partnership, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
- Correspondence:
| | - Monica Norena
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, BC V6T 1Z3, Canada; (M.N.); (A.P.)
| | - Anita M. Hubley
- Department of Educational and Counselling Psychology, and Special Education, University of British Columbia, Vancouver, BC V6T 1Z4, Canada;
| | - Anita Palepu
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, BC V6T 1Z3, Canada; (M.N.); (A.P.)
- Division of General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - Stephen W. Hwang
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, ON M5B 1A6, Canada; (S.W.H.); (R.N.)
| | - Rosane Nisenbaum
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, ON M5B 1A6, Canada; (S.W.H.); (R.N.)
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, ON M5B 1A6, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
| | - Mohammad Ehsanul Karim
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (M.E.K.); (A.G.)
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, BC V6T 1Z3, Canada; (M.N.); (A.P.)
| | - Anne Gadermann
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (M.E.K.); (A.G.)
- Human Early Learning Partnership, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital, Vancouver, BC V6T 1Z3, Canada; (M.N.); (A.P.)
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Kaplan LM, Vella L, Cabral E, Tieu L, Ponath C, Guzman D, Kushel MB. Unmet mental health and substance use treatment needs among older homeless adults: Results from the HOPE HOME Study. JOURNAL OF COMMUNITY PSYCHOLOGY 2019; 47:1893-1908. [PMID: 31424102 PMCID: PMC7046319 DOI: 10.1002/jcop.22233] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/19/2019] [Accepted: 07/25/2019] [Indexed: 05/04/2023]
Abstract
AIMS To examine the prevalence of and factors associated with unmet need for mental health and substance use treatment in older homeless adults. METHODS Among 350 homeless adults aged ≥50, we examined prevalence of mental health and substance use problems and treatment. Using logistic regression, we examined factors associated with unmet treatment need. RESULTS Among those with a mental health problem, being aged ≥65 was associated with an increased odds, while having a regular healthcare provider and case manager were associated with a decreased odds of having unmet need for mental health treatment. A first homelessness episode at age ≥50 was associated with increased, while spending time in jail/prison or having a case manager was associated with decreased odds of unmet needs for substance use treatment. CONCLUSION Older homeless adults have a high prevalence of unmet behavioral health treatment need. There is a need for targeted services for this population.
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Affiliation(s)
- Lauren M Kaplan
- Division of General Internal Medicine, University of California, San Francisco, CA Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California
| | - Lea Vella
- San Francisco Veteran Affairs Medical Center, San Francisco, California and Division of Geriatrics, University of California, San Francisco, California
- Department of Quality, University of California San Francisco Medical Center, San Francisco, California
| | - Elise Cabral
- Department of Medicine, School of Medicine, University of California, San Francisco, California
| | - Lina Tieu
- Division of General Internal Medicine, University of California, San Francisco, CA Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California
| | - Claudia Ponath
- Division of General Internal Medicine, University of California, San Francisco, CA Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California
| | - David Guzman
- Division of General Internal Medicine, University of California, San Francisco, CA Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California
| | - Margot B Kushel
- Division of General Internal Medicine, University of California, San Francisco, CA Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
- UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California
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Brown RT, Guzman D, Kaplan LM, Ponath C, Lee CT, Kushel MB. Trajectories of functional impairment in homeless older adults: Results from the HOPE HOME study. PLoS One 2019; 14:e0221020. [PMID: 31408488 PMCID: PMC6692032 DOI: 10.1371/journal.pone.0221020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 07/30/2019] [Indexed: 01/18/2023] Open
Abstract
Difficulty performing activities of daily living ("functional impairment") is common in homeless adults aged 50 and older. However, little is known about the trajectory of these impairments, nor the extent to which these trajectories are similar to those of older adults in the general population. We identified trajectories of functional impairment in homeless adults aged 50 and older, and risk factors for differing trajectories. We conducted a prospective cohort study of 350 homeless adults, aged 50 and older, recruited via population-based sampling in Oakland, California and interviewed at 6-month intervals for up to 3 years. We assessed functional trajectories based on self-reported difficulty performing 5 activities of daily living. We used multivariable multinomial logistic regression to identify baseline risk factors for each trajectory. At baseline, participants' mean age was 58 years (SD, 5.3), 24.1% were women, 80.9% were African American, and 38.6% had difficulty performing 1 or more activities of daily living. We identified 4 distinct functional trajectories: minimal impairment in 136 participants (41.1%); persistent impairment in 81 (25.4%); partial improvement in 74 (23.5%); and decline in 28 (10.0%). Risk factors for persistent impairment included falls in the 6 months before baseline, depressive symptoms, and low physical performance. Although functional impairment improved in some homeless adults, it persisted or worsened in many others. These findings suggest that, similar to older adults in the general population, functional impairment among older homeless persons is not a transient phenomenon, but instead a chronic issue requiring long-term solutions.
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Affiliation(s)
- Rebecca T. Brown
- Division of Geriatrics, University of California San Francisco, San Francisco, California, United States of America
- Division of Geriatric Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, United States of America
| | - David Guzman
- Division of General Internal Medicine, University of California San Francisco, San Francisco, California, United States of America
- Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
- UCSF Center for Vulnerable Populations, San Francisco, California, United States of America
| | - Lauren M. Kaplan
- Division of General Internal Medicine, University of California San Francisco, San Francisco, California, United States of America
- Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
- UCSF Center for Vulnerable Populations, San Francisco, California, United States of America
| | - Claudia Ponath
- Division of General Internal Medicine, University of California San Francisco, San Francisco, California, United States of America
- Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
- UCSF Center for Vulnerable Populations, San Francisco, California, United States of America
| | | | - Margot B. Kushel
- Division of General Internal Medicine, University of California San Francisco, San Francisco, California, United States of America
- Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America
- UCSF Center for Vulnerable Populations, San Francisco, California, United States of America
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24
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Tong M, Tieu L, Lee CT, Ponath C, Guzman D, Kushel M. Factors associated with food insecurity among older homeless adults: results from the HOPE HOME study. J Public Health (Oxf) 2019; 41:240-249. [PMID: 29617886 PMCID: PMC6636692 DOI: 10.1093/pubmed/fdy063] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 02/09/2018] [Accepted: 03/15/2018] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The US homeless population is aging. Older adults and those living in poverty are at a high risk of food insecurity. METHODS We conducted a cross-sectional analysis of baseline data from a population-based study of 350 homeless adults aged ≥50. We assessed food security and receipt of food assistance. We used multivariable logistic regression to examine factors associated with very low food security. RESULTS The majority of the cohort was male and African American. Over half (55.4%) met criteria for food insecurity, 24.3% reported very low food security. Half (51.7%) reported receiving monetary food assistance. In the multivariable model, those who were primarily sheltered in the prior 6 months, (multi-institution users [AOR = 0.44, 95% CI: 0.22-0.86]) had less than half the odds of very low food security compared with those who were unsheltered. Depressive symptoms (AOR = 3.01, 1.69-5.38), oral pain (AOR = 2.15, 1.24-3.74) and cognitive impairment (AOR = 2.21, 1.12-4.35) were associated with increased odds of very low food security. CONCLUSIONS Older homeless adults experience a high prevalence of food insecurity. To alleviate food insecurity in this population, targeted interventions must address specific risk groups.
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Affiliation(s)
- M Tong
- School of Public Health, University of California, Berkeley, USA
| | - L Tieu
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, UCSF Box 1364, San Francisco, CA, USA
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, USA
| | - C T Lee
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, UCSF Box 1364, San Francisco, CA, USA
| | - C Ponath
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, UCSF Box 1364, San Francisco, CA, USA
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, USA
| | - D Guzman
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, UCSF Box 1364, San Francisco, CA, USA
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, USA
| | - M Kushel
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, UCSF Box 1364, San Francisco, CA, USA
- Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, USA
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25
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Raven MC, Kaplan LM, Rosenberg M, Tieu L, Guzman D, Kushel M. Mobile Phone, Computer, and Internet Use Among Older Homeless Adults: Results from the HOPE HOME Cohort Study. JMIR Mhealth Uhealth 2018; 6:e10049. [PMID: 30530464 PMCID: PMC6305882 DOI: 10.2196/10049] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 09/20/2018] [Accepted: 09/25/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The median age of single homeless adults is approximately 50 years. Older homeless adults have poor social support and experience a high prevalence of chronic disease, depression, and substance use disorders. Access to mobile phones and the internet could help lower the barriers to social support, social services, and medical care; however, little is known about access to and use of these by older homeless adults. OBJECTIVE This study aimed to describe the access to and use of mobile phones, computers, and internet among a cohort of 350 homeless adults over the age of 50 years. METHODS We recruited 350 participants who were homeless and older than 50 years in Oakland, California. We interviewed participants at 6-month intervals about their health status, residential history, social support, substance use, depressive symptomology, and activities of daily living (ADLs) using validated tools. We performed clinical assessments of cognitive function. During the 6-month follow-up interview, study staff administered questions about internet and mobile technology use. We assessed participants' comfort with and use of multiple functions associated with these technologies. RESULTS Of the 343 participants alive at the 6-month follow-up, 87.5% (300/343) completed the mobile phone and internet questionnaire. The median age of participants was 57.5 years (interquartile range 54-61). Of these, 74.7% (224/300) were male, and 81.0% (243/300) were black. Approximately one-fourth (24.3%, 73/300) of the participants had cognitive impairment and slightly over one-third (33.6%, 100/300) had impairments in executive function. Most (72.3%, 217/300) participants currently owned or had access to a mobile phone. Of those, most had feature phones, rather than smartphones (89, 32.1%), and did not hold annual contracts (261, 94.2%). Just over half (164, 55%) had ever accessed the internet. Participants used phones and internet to communicate with medical personnel (179, 64.6%), search for housing and employment (85, 30.7%), and to contact their families (228, 82.3%). Those who regained housing were significantly more likely to have mobile phone access (adjusted odds ratio [AOR] 3.81, 95% CI 1.77-8.21). Those with ADL (AOR 0.53, 95% CI 0.31-0.92) and executive function impairment (AOR 0.49; 95% CI 0.28-0.86) were significantly less likely to have mobile phones. Moderate to high risk amphetamine use was associated with reduced access to mobile phones (AOR 0.27, 95% CI 0.10-0.72). CONCLUSIONS Older homeless adults could benefit from portable internet and phone access. However, participants had a lower prevalence of smartphone and internet access than adults aged over 65 years in the general public or low-income adults. Participants faced barriers to mobile phone and internet use, including financial barriers and functional and cognitive impairments. Expanding access to these basic technologies could result in improved outcomes.
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Affiliation(s)
- Maria C Raven
- Department of Emergency Medicine, School of Medicine, University of California, San Francisco, San Francisco, CA, United States.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, United States
| | - Lauren M Kaplan
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, United States.,Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, United States
| | - Marina Rosenberg
- School of Public Health, University of California, Berkeley, Berkeley, CA, United States
| | - Lina Tieu
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, United States.,Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, United States
| | - David Guzman
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, United States.,Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, United States
| | - Margot Kushel
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, United States.,Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, United States.,Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, United States
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26
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Bazari A, Patanwala M, Kaplan LM, Auerswald CL, Kushel MB. 'The Thing that Really Gets Me Is the Future': Symptomatology in Older Homeless Adults in the HOPE HOME Study. J Pain Symptom Manage 2018; 56:195-204. [PMID: 29783004 PMCID: PMC6050110 DOI: 10.1016/j.jpainsymman.2018.05.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 05/10/2018] [Accepted: 05/11/2018] [Indexed: 01/23/2023]
Abstract
CONTEXT The homeless population is aging. Older homeless adults experience premature development of age-related conditions and an elevated symptom burden. Little is known about symptom experience among older homeless adults. OBJECTIVES To characterize the experience, understanding, and management of physical, psychological, social (e.g., loneliness), and existential (e.g., regret, loss of dignity) symptoms among older homeless adults. METHODS We conducted semistructured interviews from June 2016 to March 2017 with a purposive sample of participants from the Health Outcomes of People Experiencing Homelessness in Older Middle Age cohort, a longitudinal study of homeless adults aged 50 and older. We analyzed data between June 2016 and December 2017 using thematic analysis. RESULTS We found four main themes: 1) nonphysical symptoms are interwoven with, and as distressing as, physical symptoms; 2) individuals attribute symptoms to childhood abuse, manual labor, the conditions of homelessness, and aging; 3) symptoms interfere with daily functioning, causing negative changes in personality, energy, and motivation; and 4) individuals cope with symptoms through religion, social support, and substance use. CONCLUSION Homelessness causes and exacerbates physical and psychological distress. Interventions should address multiple interconnected dimensions of suffering. Health systems that care for homeless patients should adapt palliative care practices using a stepwise approach. Homeless shelters should adopt policies and modifications that increase privacy and autonomy while promoting community building. Housing interventions should promote community building. All who work with people experiencing homelessness should avoid stigmatizing language and recognize homeless individuals' sources of strength and coping.
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Affiliation(s)
- Adam Bazari
- University of California Berkeley - University of California San Francisco Joint Medical Program, Berkeley, California, USA
| | - Maria Patanwala
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Lauren M Kaplan
- General Division of General Internal Medicine, University of California San Francisco/Zuckerberg San Francisco, San Francisco, California, USA; University of California San Francisco Center for Vulnerable Populations, San Francisco, California, USA
| | - Colette L Auerswald
- University of California Berkeley - University of California San Francisco Joint Medical Program, Berkeley, California, USA; University of California Berkeley School of Public Health, Berkeley, California, USA
| | - Margot B Kushel
- General Division of General Internal Medicine, University of California San Francisco/Zuckerberg San Francisco, San Francisco, California, USA; University of California San Francisco Center for Vulnerable Populations, San Francisco, California, USA.
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27
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Sudore RL, Cuervo IA, Tieu L, Guzman D, Kaplan LM, Kushel M. Advance Care Planning for Older Homeless-Experienced Adults: Results from the Health Outcomes of People Experiencing Homelessness in Older Middle Age Study. J Am Geriatr Soc 2018; 66:1068-1074. [PMID: 29741765 PMCID: PMC6105505 DOI: 10.1111/jgs.15417] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Older homeless-experienced adults have low engagement in advance care planning (ACP) despite high morbidity and mortality. We conducted a cross-sectional analysis of a cohort of 350 homeless-experienced adults aged 50 and older in Oakland, California. We assessed the prevalence of potential surrogate decision-makers, ACP contemplation, discussions, and ACP documentation (surrogate designation, advance directives). We used multivariable logistic regression to examine factors associated with ACP discussions and documentation. The median age of the cohort was 59 (range 52-82), 75.2% were male, and 82.1% were black. Sixty-one percent reported a potential surrogate, 21.5% had discussed ACP, and 19.0% reported ACP documentation. In multivariable models, having 1 to 5 confidants versus none (adjusted odds ratio (aOR)=5.8, 95% confidence interval (CI)=1.7-20.0), 3 or more chronic conditions versus none (aOR=2.3, 95% CI=0.9-5.6), and a recent primary care visit (aOR=2.1, 95% CI=1.0-4.4) were associated with higher odds of ACP discussions and each additional 5 years of homelessness (aOR=0.7, 95% CI=0.5-0.9) with lower odds. Having 1 to 5 confidants (aOR=5.0, 95% CI=1.4-17.5), being black (aOR=5.5, 95% CI=1.5-19.5), and having adequate versus limited literacy (aOR=7.0, 95% CI=1.5-32.4) were associated with higher odds of ACP documentation and illicit drug use (aOR=0.3, 95% CI=0.1-0.9) with lower odds. Although the majority of older homeless-experienced adults have a potential surrogate, few have discussed or documented their ACP wishes; the odds of both were greater with larger social networks. Future interventions must be customized for individuals with limited social networks and address the instability of homelessness, health literacy, and the constraints of safety-net healthcare settings.
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Affiliation(s)
- Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | | | - Lina Tieu
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California
- Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General, San Francisco, California
| | - David Guzman
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California
- Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General, San Francisco, California
| | - Lauren M Kaplan
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California
- Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General, San Francisco, California
| | - Margot Kushel
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California
- Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General, San Francisco, California
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28
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Seng JJB, Kwan YH, Goh H, Thumboo J, Low LL. Public rental housing and its association with mortality - a retrospective, cohort study. BMC Public Health 2018; 18:665. [PMID: 29843652 PMCID: PMC5975624 DOI: 10.1186/s12889-018-5583-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 05/22/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Socioeconomic status (SES) is a well-established determinant of health status and home ownership is a commonly used composite indicator of SES. Patients in low-income households often stay in public rental housing. The association between public rental housing and mortality has not been examined in Singapore. METHODS A retrospective, cohort study was conducted involving all patients who utilized the healthcare facilities under SingHealth Regional Health (SHRS) Services in Year 2012. Each patient was followed up for 5 years. Patients who were non-citizens or residing in a non-SHRS area were excluded from the study. RESULTS A total of 147,004 patients were included in the study, of which 7252 (4.9%) patients died during the study period. The mean age of patients was 50.2 ± 17.2 years old and 7.1% (n = 10,400) of patients stayed in public rental housing. Patients who passed away had higher utilization of healthcare resources in the past 1 year and a higher proportion stayed in public rental housing (p < 0.001). They also had higher rates of co-morbidities such as hypertension, hyperlipidaemia and diabetes. (p < 0.001) After adjustment for demographic and clinical covariates, residence in public rental housing was associated with increased risk of all-cause mortality (Adjusted hazard ratio: 1.568, 95% CI: 1.469-1.673). CONCLUSION Public rental housing was an independent risk factor for all-cause mortality. More studies should be conducted to understand health-seeking behavior and needs of public rental housing patients, to aid policymakers in formulating better plans for improving their health outcomes.
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Affiliation(s)
| | - Yu Heng Kwan
- Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore
| | - Hendra Goh
- Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Julian Thumboo
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore
- SingHealth Regional Health System, Singapore Health Services, Singapore, Singapore
| | - Lian Leng Low
- SingHealth Regional Health System, Singapore Health Services, Singapore, Singapore
- Department of Family Medicine and Continuing Care, Singapore General Hospital, Outram Road, Singapore, 169608 Singapore
- SingHealth Duke-NUS Family Medicine Academic Clinical Program, Singapore, Singapore
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29
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Brown RT, Hemati K, Riley ED, Lee CT, Ponath C, Tieu L, Guzman D, Kushel MB. Geriatric Conditions in a Population-Based Sample of Older Homeless Adults. THE GERONTOLOGIST 2018; 57:757-766. [PMID: 26920935 DOI: 10.1093/geront/gnw011] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 11/17/2015] [Indexed: 01/23/2023] Open
Abstract
Purpose of the Study Older homeless adults living in shelters have high rates of geriatric conditions, which may increase their risk for acute care use and nursing home placement. However, a minority of homeless adults stay in shelters and the prevalence of geriatric conditions among homeless adults living in other environments is unknown. We determined the prevalence of common geriatric conditions in a cohort of older homeless adults, and whether the prevalence of these conditions differs across living environments. Design and Methods We interviewed 350 homeless adults, aged 50 and older, recruited via population-based sampling in Oakland, CA. We evaluated participants for common geriatric conditions. We assessed living environment using a 6-month follow-back residential calendar, and used cluster analysis to identify participants' primary living environment over the prior 6 months. Results Participants stayed in 4 primary environments: unsheltered locations (n = 162), multiple locations including shelters and hotels (n = 88), intermittently with family/friends (n = 57), and, in a recently homeless group, rental housing (n = 43). Overall, 38.9% of participants reported difficulty performing 1 or more activities of daily living, 33.7% reported any falls in the past 6 months, 25.8% had cognitive impairment, 45.1% had vision impairment, and 48.0% screened positive for urinary incontinence. The prevalence of geriatric conditions did not differ significantly across living environments. Implications Geriatric conditions were common among older homeless adults living in diverse environments, and the prevalence of these conditions was higher than that seen in housed adults 20 years older. Services that address geriatric conditions are needed for older homeless adults living across varied environments.
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Affiliation(s)
- Rebecca T Brown
- Division of Geriatrics, University of California, San Francisco.,San Francisco VA Medical Center, California
| | - Kaveh Hemati
- School of Medicine, Stony Brook University, New York
| | - Elise D Riley
- Division of HIV/AIDS, San Francisco General Hospital, University of California
| | - Christopher T Lee
- Division of General Internal Medicine, San Francisco General Hospital, University of California
| | - Claudia Ponath
- Division of General Internal Medicine, San Francisco General Hospital, University of California
| | - Lina Tieu
- Division of General Internal Medicine, San Francisco General Hospital, University of California
| | - David Guzman
- Division of General Internal Medicine, San Francisco General Hospital, University of California
| | - Margot B Kushel
- Division of General Internal Medicine, San Francisco General Hospital, University of California
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Patanwala M, Tieu L, Ponath C, Guzman D, Ritchie CS, Kushel M. Physical, Psychological, Social, and Existential Symptoms in Older Homeless-Experienced Adults: An Observational Study of the Hope Home Cohort. J Gen Intern Med 2018; 33:635-643. [PMID: 29185174 PMCID: PMC5910332 DOI: 10.1007/s11606-017-4229-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 09/14/2017] [Accepted: 11/03/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND The homeless population in the United States is aging. Aging-associated comorbidities are associated with increased symptoms. OBJECTIVE To describe the prevalence of symptoms among older homeless-experienced adults, analyze factors associated with moderate-high physical symptom burden, and identify symptom clusters. DESIGN Cross-sectional analysis within longitudinal cohort study. PARTICIPANTS Using population-based sampling from shelters, meal programs, encampments, and a recycling center in Oakland, CA, we recruited homeless adults aged ≥ 50 for a longitudinal cohort. This study includes participants who participated in the 18-month follow-up visit. MAIN MEASURES We assessed physical symptoms using the Patient Health Questionnaire-15 (PHQ-15); psychological symptoms using the Center for Epidemiologic Studies Depression Scale (CES-D), Primary Care PTSD Screen (PC-PTSD), and psychiatric section of the Addiction Severity Index (ASI); loneliness using the Three-Item Loneliness Scale; and regret using a six-item regret scale. KEY RESULTS Two hundred eighty-three participants (75.6% men and 82.3% African-Americans) completed symptoms interviews. Over a third (34.0%) had moderate-high physical symptom burden. The most prevalent physical symptoms were joint pain, fatigue, back pain, and sleep trouble. Over half (57.6%) had psychological symptoms; 39.6% exhibited loneliness and 26.5% had high regret. In a multivariate model, being a woman (AOR 2.54, 95% CI 1.28-5.03), childhood abuse (AOR 1.88, 95% CI 1.00-3.50), cannabis use (AOR 2.59, 95% CI 1.38-4.89), multimorbidity (AOR 2.50, 95% CI 1.36-4.58), anxiety (AOR 4.30, 95% CI 2.24-8.26), hallucinations (AOR 3.77, 95% CI 1.36-10.43), and loneliness (AOR 2.32, 95% CI 1.26-4.28) were associated with moderate-high physical symptom burden. We identified four symptom clusters: minimal overall (n = 129), moderate overall (n = 68), high physical and high psychological (n = 67), and high physical and low psychological (n = 17). CONCLUSIONS Older homeless-experienced adults exhibit a high prevalence of symptoms across multiple dimensions. To reduce suffering, clinicians should recognize the interaction between symptoms and address multiple symptom dimensions.
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Affiliation(s)
- M Patanwala
- UCSF School of Medicine, San Francisco, CA, USA
| | - L Tieu
- UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
- UCSF Center for Vulnerable Populations, San Francisco, CA, USA
| | - C Ponath
- UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - D Guzman
- UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
- UCSF Center for Vulnerable Populations, San Francisco, CA, USA
| | - C S Ritchie
- UCSF Division of Geriatrics, Department of Medicine, San Francisco, CA, USA
| | - Margot Kushel
- UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.
- UCSF Center for Vulnerable Populations, San Francisco, CA, USA.
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Burns VF, Sussman T. Homeless for the First Time in Later Life: Uncovering More Than One Pathway. THE GERONTOLOGIST 2018; 59:251-259. [DOI: 10.1093/geront/gnx212] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Tamara Sussman
- School of Social Work, McGill University, Montreal, Québec, Canada
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Hurstak E, Johnson JK, Tieu L, Guzman D, Ponath C, Lee CT, Jamora CW, Kushel M. Factors associated with cognitive impairment in a cohort of older homeless adults: Results from the HOPE HOME study. Drug Alcohol Depend 2017; 178:562-570. [PMID: 28738314 PMCID: PMC5568464 DOI: 10.1016/j.drugalcdep.2017.06.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/27/2017] [Accepted: 06/01/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND We evaluated cognitive function and factors associated with cognitive impairment in a cohort of older homeless adults. We hypothesized that substance use and a history of traumatic brain injury would be associated with cognitive impairment. METHODS We recruited 350 homeless individuals aged ≥50 years using population-based sampling and conducted structured interviews and neuropsychological testing. We evaluated alcohol use with the Alcohol Use Disorder Identification Test, defining high-severity alcohol use as a total score ≥16 or ≥4 on the alcohol dependency sub-scale. We assessed global cognition with the Modified Mini-Mental State Test (3MS) and processing speed and executive function with the Trail Making Test (TMTB), defining impairment as performing 1.5 standard deviations below the standardized mean. We used multivariable logistic regression to examine the association between alcohol use and cognition. RESULTS Participants had a median age of 58 years [IQR 54-61], 76.7% were men, and 79.9% were African American. A quarter (25.1%) of participants met criteria for impairment on the 3MS; 32.9% met criteria for impairment on TMTB. In models adjusted for sociodemographic variables and health conditions, high-severity alcohol use was associated with global cognitive impairment (AOR 2.39, CI 1.19-4.79) and executive dysfunction (AOR 3.09, CI 1.61-5.92). CONCLUSIONS Older homeless adults displayed a prevalence of cognitive impairment 3-4 times higher than has been observed in general population adults aged 70 and older. Impaired cognition in older homeless adults could impact access to housing programs and the treatment of health conditions, including the treatment of alcohol use disorders.
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Affiliation(s)
- Emily Hurstak
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.
| | - Julene K Johnson
- Institute for Health and Aging, University of California, San Francisco, San Francisco, CA, USA; Center for Aging in Diverse Communities, University of California, San Francisco, San Francisco, CA, USA
| | - Lina Tieu
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA; Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
| | - David Guzman
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA; Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
| | - Claudia Ponath
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
| | - Christopher T Lee
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA; Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
| | - Christina Weyer Jamora
- Center for Aging in Diverse Communities, University of California, San Francisco, San Francisco, CA, USA; Department of Psychiatry, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
| | - Margot Kushel
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA; Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA.
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Landefeld JC, Miaskowski C, Tieu L, Ponath C, Lee CT, Guzman D, Kushel M. Characteristics and Factors Associated With Pain in Older Homeless Individuals: Results From the Health Outcomes in People Experiencing Homelessness in Older Middle Age (HOPE HOME) Study. THE JOURNAL OF PAIN 2017; 18:1036-1045. [PMID: 28412229 PMCID: PMC5581208 DOI: 10.1016/j.jpain.2017.03.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 03/16/2017] [Accepted: 03/28/2017] [Indexed: 12/22/2022]
Abstract
Individuals experiencing homelessness in the United States are aging; little is known about chronic pain in this population. In a cross-sectional, population-based study, we interviewed 350 homeless individuals aged 50 years and older to describe pain experienced by older persons experiencing homelessness and to assess factors associated with chronic moderate to severe pain, defined as pain lasting ≥3 months, with a past week average severity score of 5 to 10 (scale 0-10). The median age of participants was 58 years. Participants were predominantly African American (79.6%) and male (77.3%). Overall, 46.8% reported chronic moderate to severe pain. Almost half of participants reported a diagnosis of arthritis (44.3%) and one-third reported symptoms consistent with post-traumatic stress disorder (PTSD; 32.8%). Three-quarters (75.3%) endorsed a personal history of abuse. In multivariate analyses, PTSD (adjusted odds ratio [AOR]: 2.2, 95% confidence interval [CI], 1.4-3.7), arthritis (AOR: 4.8, 95% CI, 3.0-7.8), and history of experiencing abuse (AOR: 2.4, 95% CI, 1.3-4.3) were associated with chronic moderate to severe pain. HIV status, diabetes, depressive symptoms, and substance use were not associated with pain. Clinicians should consider the management of associated mental health conditions and the sequelae of experiencing abuse in the treatment of chronic pain in older adults experiencing homelessness. PERSPECTIVE This article describes the prevalence and factors associated with chronic pain in older homeless adults. Almost half report chronic pain, which was associated with PTSD, arthritis, and personal history of abuse. Clinicians should address chronic pain, trauma, and the associated mental health conditions in this high-risk population.
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Affiliation(s)
- John C Landefeld
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Christine Miaskowski
- Department of Physiological Nursing, University of California, San Francisco, California
| | - Lina Tieu
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Claudia Ponath
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Christopher T Lee
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - David Guzman
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Margot Kushel
- Division of General Internal Medicine, University of California, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California.
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Raven MC, Tieu L, Lee CT, Ponath C, Guzman D, Kushel M. Emergency Department Use in a Cohort of Older Homeless Adults: Results From the HOPE HOME Study. Acad Emerg Med 2017; 24:63-74. [PMID: 27520382 DOI: 10.1111/acem.13070] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/27/2016] [Accepted: 07/29/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The median age of single homeless adults is over 50, yet little is known about their emergency department (ED) use. We describe use of and factors associated with ED use in a sample of homeless adults 50 and older. METHODS We recruited 350 participants who were homeless and 50 or older in Oakland, California. We interviewed participants about residential history in the prior 6 months, health status, health-related behaviors, and health services use and assessed cognition and mobility. Our primary outcome was the number of ED visits in the prior 6 months based on medical record review. We used negative binomial regression to examine factors associated with ED use. RESULTS In the 6 months prior to enrollment, 46.3% of participants spent the majority of their time unsheltered; 25.1% cycled through multiple institutions including shelters, hospitals, and jails; 16.3% primarily stayed with family or friends; and 12.3% had become homeless recently after spending much of the prior 6 months housed. Half (49.7%) of participants made at least one ED visit in the past 6 months; 6.6% of participants accounted for 49.9% of all visits. Most (71.8%) identified a regular non-ED source of healthcare; 7.3% of visits resulted in hospitalization. In multivariate models, study participants who used multiple institutions (incidence rate ratio [IRR] = 2.27; 95% confidence interval [CI] = 1.08 to 4.77) and who were unsheltered (IRR = 2.29; 95% CI = 1.17 to 4.48) had higher ED use rates than participants who had been housed for most of the prior 6 months. In addition, having health insurance/coverage (IRR = 2.6; CI = 1.5 to 4.4), a history of psychiatric hospitalization (IRR = 1.80; 95% CI = 1.09 to 2.99), and severe pain (IRR = 1.72; 95% CI = 1.07 to 2.76) were associated with higher ED visit rates. CONCLUSIONS A sample of adults aged 50 and older who were homeless at study entry had higher rates of ED use in the prior 6 months than the general U.S. age-matched population. Within the sample, ED use rates varied based on individuals' residential histories, suggesting that individuals' ED use is related to exposure to homelessness.
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Affiliation(s)
- Maria C. Raven
- Department of Emergency Medicine University of California at San Francisco San Francisco CA
- Philip R. Lee Institute for Health Policy Studies University of California at San Francisco San Francisco CA
| | - Lina Tieu
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
- Center for Vulnerable Populations University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - Christopher T. Lee
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - Claudia Ponath
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - David Guzman
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
- Center for Vulnerable Populations University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - Margot Kushel
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
- Center for Vulnerable Populations University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
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Spinelli MA, Ponath C, Tieu L, Hurstak EE, Guzman D, Kushel M. Factors associated with substance use in older homeless adults: Results from the HOPE HOME study. Subst Abus 2016; 38:88-94. [PMID: 27897965 DOI: 10.1080/08897077.2016.1264534] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The median age of the single adult homeless population is 50 and rising. Although the prevalence of substance use decreases as individuals age, older adults now have a higher prevalence of substance use than older adults did 10 years ago. Homeless individuals have a higher prevalence of substance use disorders than the general population. However, little is known about substance use in older homeless adults. METHODS The objective of the study was to examine prevalence of and factors associated with substance use in a population-based sample (N = 350) of homeless individuals aged 50 and older in Oakland, California. Dependent variables included moderate or greater severity illicit drug symptoms (Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) score >3) and moderate or greater alcohol symptoms (Alcohol Use Disorders Identification Test (AUDIT) score >7). Independent variables included demographics, mental health problems, and negative life course events such as physical and sexual abuse, school expulsion, and onset of homelessness. RESULTS Almost two thirds of participants, 64.6%, had moderate or greater severity symptoms for at least 1 illicit drug; 25.8% had moderate or greater severity alcohol symptoms. History of psychiatric hospitalization was associated with moderate or greater illicit drug symptoms (adjusted odds ratio [AOR] = 1.9, 1.0-3.6). The presence of major depressive symptoms was associated with moderate or greater severity alcohol symptoms (AOR = 1.8, 1.1-3.0). CONCLUSIONS In this sample of older homeless adults, substance use is common. There is a need for substance use treatment programs, integrated with mental health services, which are targeted towards the needs of older homeless adults.
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Affiliation(s)
- Matthew A Spinelli
- a Division of General Internal Medicine , University of California, San Francisco, San Francisco General Hospital , San Francisco , California , USA
| | - Claudia Ponath
- a Division of General Internal Medicine , University of California, San Francisco, San Francisco General Hospital , San Francisco , California , USA
| | - Lina Tieu
- a Division of General Internal Medicine , University of California, San Francisco, San Francisco General Hospital , San Francisco , California , USA
| | - Emily E Hurstak
- a Division of General Internal Medicine , University of California, San Francisco, San Francisco General Hospital , San Francisco , California , USA
| | - David Guzman
- a Division of General Internal Medicine , University of California, San Francisco, San Francisco General Hospital , San Francisco , California , USA
| | - Margot Kushel
- a Division of General Internal Medicine , University of California, San Francisco, San Francisco General Hospital , San Francisco , California , USA
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