Trajectories of functional impairment in homeless older adults: Results from the HOPE HOME study

Social isolation and loneliness among people living with experience of homelessness: a scoping review

Social isolation and loneliness (SIL) are public health challenges that disproportionally affect individuals who experience structural and socio-economic exclusion. The social and health outcomes of SIL for people with experiences of being unhoused have largely remained unexplored. Yet, there is limited synthesis of literature focused on SIL to appropriately inform policy and targeted social interventions for people with homelessness experience. The aim of this scoping review is to synthesize evidence on SIL among people with lived experience of homelessness and explore how it negatively impacts their wellbeing. We carried out a comprehensive literature search from Medline, Embase, Cochrane Library, PsycINFO, CINAHL, Sociological Abstracts, and Web of Science's Social Sciences Citation Index and Science Citation Index for peer-reviewed studies published between January 1st, 2000 to January 3rd, 2023. Studies went through title, abstract and full-text screening conducted independently by at least two reviewers. Included studies were then analyzed and synthesized to identify the conceptualizations of SIL, measurement tools and approaches, prevalence characterization, and relationship with social and health outcomes. The literature search yielded 5,294 papers after removing duplicate records. Following screening, we retained 27 qualitative studies, 23 quantitative studies and two mixed method studies. SIL was not the primary objective of most of the included articles. The prevalence of SIL among people with homelessness experience varied from 25 to 90% across studies. A range of measurement tools were used to measure SIL making it difficult to compare results across studies. Though the studies reported associations between SIL, health, wellbeing, and substance use, we found substantial gaps in the literature. Most of the quantitative studies were cross-sectional, and only one study used health administrative data to ascertain health outcomes. More studies are needed to better understand SIL among this population and to build evidence for actionable strategies and policies to address its social and health impacts.

Exploring the Role of Rehabilitation Medicine within an Inclusion Health Context: Examining a Population at Risk from Homelessness and Brain Injury in Edinburgh

People experiencing homelessness are at risk from a number of comorbidities, including traumatic brain injury, mental health disorders, and various infections. Little is known about the rehabilitation needs of this population. This study took advantage of unique access to a specialist access GP practice for people experiencing homelessness and a local inclusion health initiative to explore the five-year period prevalence of these conditions in a population of people experiencing homelessness through electronic case record searches and to identify barriers and facilitators to healthcare provision for this population in the context of an interdisciplinary and multispecialist inclusion health team through semi-structured interviews with staff working in primary and secondary care who interact with this population. The five-year period prevalence of TBI, infections, and mental health disorders was 9.5%, 4%, and 22.8%, respectively. Of those who had suffered a brain injury, only three had accessed rehabilitation services. Themes from thematic analysis of interviews included the impact of psychological trauma, under-recognition of the needs of people experiencing homelessness, resource scarcity, and the need for collaborative and adaptive approaches. The combination of quantitative and qualitative data suggests a potential role for rehabilitation medicine in inclusion health initiatives.

Memory, fluid reasoning, and functional capacity in adults experiencing homelessness

BACKGROUND AND OBJECTIVE

In individuals experiencing homelessness, determinants of functional capacity (i.e. the ability to perform activities of daily living) are poorly understood. Identifying potentially modifiable correlates of functional capacity, such as cognitive abilities, may inform treatment targets to address independence and housing stability. This study aimed to identify the strongest neuropsychological predictors of variance in functional performance in 100 adults living in a homeless shelter.

METHODS

Participants completed a brief cognitive screening test, from which four composite scores were derived, as well as tests of processing speed, fluid reasoning, premorbid intellectual function, and performance-based functional capacity. We conducted a hierarchical linear regression to predict variance in functional capacity.

RESULTS

Beyond the impact of education and premorbid intellectual function, better memory and fluid reasoning predicted better functional performance.

CONCLUSIONS

Although our cross-sectional design does not permit causal inference, it is possible that interventions targeting memory and fluid reasoning may improve functional ability in individuals experiencing homelessness.

A qualitative exploration of older people's lived experiences of homelessness and memory problems - stakeholder perspectives

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.

Quality of Depression Care for Veterans Affairs Primary Care Patients with Experiences of Homelessness

BACKGROUND

Persons who experience homelessness (PEH) have high rates of depression and incur challenges accessing high-quality health care. Some Veterans Affairs (VA) facilities offer homeless-tailored primary care clinics, although such tailoring is not required, within or outside VA. Whether services tailoring enhances care for depression is unstudied.

OBJECTIVE

To determine whether PEH in homeless-tailored primary care settings receive higher quality of depression care, compared to PEH in usual VA primary care.

DESIGN

Retrospective cohort study of depression treatment among a regional cohort of VA primary care patients (2016-2019).

PARTICIPANTS

PEH diagnosed or treated for a depressive disorder.

MAIN MEASURES

The quality measures were timely follow-up care (3 + completed visits with a primary care or mental health specialist provider, or 3 + psychotherapy sessions) within 84 days of a positive PHQ-2 screen result, timely follow-up care within 180 days, and minimally appropriate treatment (4 + mental health visits, 3 + psychotherapy visits, 60 + days antidepressant) within 365 days. We applied multivariable mixed-effect logistic regressions to model differences in care quality for PEH in homeless-tailored versus usual primary care settings.

KEY RESULTS

Thirteen percent of PEH with depressive disorders received homeless-tailored primary care (n = 374), compared to usual VA primary care (n = 2469). Tailored clinics served more PEH who were Black, who were non-married, and who had low income, serious mental illness, and substance use disorders. Among all PEH, 48% received timely follow-up care within 84 days of depression screening, 67% within 180 days, and 83% received minimally appropriate treatment. Quality metric attainment was higher for PEH in homeless-tailored clinics, compared to PEH in usual VA primary care: follow-up within 84 days (63% versus 46%; adjusted odds ratio [AOR] = 1.61, p = .001), follow-up within 180 days (78% versus 66%; AOR = 1.51, p = .003), and minimally appropriate treatment (89% versus 82%; AOR = 1.58, p = .004).

CONCLUSIONS

Homeless-tailored primary care approaches may improve depression care for PEH.

Cognitive determinants of community functioning and quality of life in homeless adults with mental illness: 6-year follow-up from the At Home/Chez Soi Study Toronto site

BACKGROUND

High rates of physical and mental health comorbidities are associated with functional impairment among persons who are homeless. Cognitive dysfunction is common, but how it contributes to various functional outcomes in this population has not been well investigated. This study examines how cognition covaries with community functioning and subjective quality of life over a 6-year period while accounting for the effects of risk and protective factors.

METHODS

Participants were 349 homeless adults (mean age = 39.8) recruited from the Toronto site of the At Home/Chez Soi study, a large Canadian randomized control trial of Housing First. Participants completed up to four clinical evaluations over 6 years. Factor scores were created to index verbal learning and memory (vLM) and processing speed-cognitive flexibility (PSCF). The primary outcomes were community functioning and subjective quality of life. Risk factors included lifetime homelessness, mental health diagnoses, medical comorbidity, and childhood adversity. Linear mixed-effects models were conducted to examine cognition-functional outcome associations over time, with resilience as a moderator.

RESULTS

Better vLM (b = 0.787, p = 0.010) and PSCF (b = 1.66, p < 0.001) were associated with better community functioning, but not with quality of life. Resilience conferred a protective effect on subjective quality of life (b = 1.45, p = 0.011) but did not moderate outcomes.

CONCLUSIONS

Our findings suggest a need to consider the unique determinants of community functioning and quality of life among homeless adults. Cognition should be prioritized as a key intervention target within existing service delivery models to optimize long-term functional outcomes.

Understanding the Ephemeral Moment of COVID Avoidance Hotels: Lessons Learned from Acknowledging Housing as Central to Dignified Later Life

Place and health are intricately bound. COVID has amplified system burdens and health risks within the housing care continuum, in which older adults with chronic illnesses are disproportionately represented. The paper identifies the health experiences of older adults with severe conditions living in and moving through temporary avoidance hotels during the COVID-19 pandemic. An interpretive descriptive approach was taken with qualitative chart data and provider observation to represent the experiences of 14 older avoidance hotel residents living with serious illnesses. Through provider documentation, we illustrate trends pre-pandemic, in the first nine months of the pandemic, and the second nine months. Such trends include strengths and opportunities such as the health-affirming nature of avoidance hotels, their potential in generating continuity of care and permanent housing, and synergy between harm reduction approaches and palliative care. Challenges were also identified in catering to the diverse medical, behavioral, and psychosocial-spiritual needs of older and seriously ill residents and the consequences of geographic dispersion on health care, health behaviors, and informal care networks. Through these strengths and challenges, avoidance hotels present essential lessons in considering future housing and healthcare intervention and implementation that addresses the needs of older seriously ill people facing homelessness and housing precarity.

Caregiving Needs Are Unmet for Many Older Homeless Adults: Findings from the HOPE HOME Study

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.

COVID-19 Testing and Vaccine Acceptability Among Homeless-Experienced Adults: Qualitative Data from Two Samples

BACKGROUND

Homeless-experienced populations are at increased risk of exposure to SARS-CoV-2 due to their living environments and face an increased risk of severe COVID-19 disease due to underlying health conditions. Little is known about COVID-19 testing and vaccination acceptability among homeless-experienced populations.

OBJECTIVE

To understand the facilitators and barriers to COVID-19 testing and vaccine acceptability among homeless-experienced adults.

DESIGN

We conducted in-depth interviews with participants from July to October 2020. We purposively recruited participants from (1) a longitudinal cohort of homeless-experienced older adults in Oakland, CA (n=37) and (2) a convenience sample of people (n=57) during a mobile outreach COVID-19 testing event in San Francisco.

PARTICIPANTS

Adults with current or past experience of homelessness.

APPROACH

We asked participants about their experiences with and attitudes towards COVID-19 testing and their perceptions of COVID-19 vaccinations. We used participant observation techniques to document the interactions between testing teams and those approached for testing. We audio-recorded, transcribed, and content analyzed all interviews and identified major themes and subthemes.

KEY RESULTS

Participants found incentivized COVID-19 testing administered in unsheltered settings and supported by community health outreach workers (CHOWs) to be acceptable. The majority of participants expressed a positive inclination toward vaccine acceptability, citing a desire to return to routine life and civic responsibility. Those who expressed hesitancy cited a desire to see trial data, concerns that vaccines included infectious materials, and mistrust of the government.

CONCLUSIONS

Participants expressed positive evaluations of the incentivized, mobile COVID-19 testing supported by CHOWs in unsheltered settings. The majority of participants expressed a positive inclination toward vaccination. Vaccine hesitancy concerns must be addressed when designing vaccine delivery strategies that overcome access challenges. Based on the successful implementation of COVID-19 testing, we recommend mobile delivery of vaccines using trusted CHOWs to address concerns and facilitate wider access to and uptake of the COVID vaccine.

Multi-trajectory group profiles of well-being and associated predictors among adults experiencing homelessness and mental illness: findings from the At Home/Chez Soi study, Toronto site

PURPOSE

To conduct a multi-dimensional and time-patterned analysis to identify distinct well-being trajectory profiles over a 6-year follow-up period among adults experiencing homelessness and mental illness.

METHODS

Data from 543 participants of the At Home Chez Soi study's Toronto site were examined over a 6-year follow-up period, including measures of quality of life, community functioning, housing stability, and substance use. Well-being trajectories were identified using Group-Based Trajectory Modelling. Multinomial regression was used to identify predictor variables that were associated with each well-being trajectory profile.

RESULTS

Four well-being profiles were identified: low well-being, moderate well-being, good well-being, and high well-being. Factors associated with a greater likelihood of following a better well-being profile included receiving Housing First, reporting female gender and non-white ethnicity, having post-secondary studies, and reporting a high resilience level. Concurrently, factors associated with a lower likelihood of better well-being profiles were having a history of chronic homelessness, experiences of discrimination in the healthcare setting, having comorbid mental disorders and a high level of symptom severity, and reporting a history of traumatic brain injury and childhood adversity.

CONCLUSIONS

Individuals experiencing homelessness follow distinct well-being profiles associated with their socio-demographic characteristics, health status, trauma history, resilience capabilities, and access to housing and support services. This work can inform integrated housing and support services to enhance the well-being trajectories of individuals experiencing homelessness.

TRIAL REGISTRATION

At Home/Chez Soi trial was registered with ISRCTN, ISRCTN42520374, http://www.isrctn.com/ISRCTN42520374 .

"Without my medication, I'm a wreck": Photo-elicitation to explore medication use among people experiencing homelessness

BACKGROUND

People experiencing homelessness (PEH) live with a high burden of chronic illness, functional and cognitive impairments, and serious mental illness. Many PEH are prescribed complex medication regimens to manage symptoms and improve health and functioning. However, medication use within the context of homelessness is complicated, and adherence is often suboptimal.

OBJECTIVE

To document medication use within the context of homelessness and explore experiences of medication use among people experiencing homelessness (PEH).

METHODS

This study used mixed methods including photo-elicitation interviews. Participants were given a digital camera and asked to take pictures of people, places, things, and situations that represented every day medication use. Participants were also asked to write down reasons for taking the pictures. After two weeks, participants returned the camera and notes. At a subsequent interview, the photographs and notes were reviewed and discussed. Demographic and health-related information was also collected for each participant. An interpretive description approach was used for qualitative data analysis. Quantitative data were analyzed using descriptive statistics in order to describe the sample.

RESULTS

Seven PEH completed this study. Mean age was 45 years (SD = 11.3) and length of homelessness was 6.1 years (SD = 11.3). All reported multiple chronic conditions (≥2) and reported taking 6.6 (SD = 2.6) medications. Participants reported medication adherence barriers with mean score of 37 (SD = 5.5) on the ASK-12, a 12-item scale with a range of 12-60 (higher scores indicate more barriers). Qualitative analysis identified four categories: medication-related burdens, medication-related beliefs, connectedness, and stigmatizing encounters.

CONCLUSIONS

Medication use among PEH is complex and cannot be considered separately from daily life or from struggles to meet basic needs. Multi-level interventions are needed to optimize medication use among PEH, and healthcare professionals including community pharmacists should reinforce beliefs that medication-related benefits outweigh the burdens and then tailor services to the context of homelessness.

Homelessness and rates of physical dysfunctions characteristic of premature geriatric syndromes: systematic review and meta-analysis

BACKGROUND

Homeless adults may experience accelerated aging, presenting earlier with geriatric syndromes such as falls and functional limitations. Though homelessness is surging in United States, data are scarce regarding rates of physical dysfunctions characteristic of geriatric syndromes experienced in this underserved population.

PURPOSE

Examine associations between homelessness, premature geriatric syndromes, and functional limitations.

METHODS

Two reviewers independently searched PubMed, CINAHL, and PEDro databases for prognostic studies reporting rates of geriatric syndromes in homeless adults aged 40 years and older. Two reviewers independently performed study selection. Data were extracted for homeless adults and community-dwelling controls regarding age, demographic information, limitations of activities of daily living (ADL) and instrumental ADL (IADL), frailty, and falls the past year. Risk ratio (RR) and 95% confidence interval (CI) were calculated across studies to compare groups.

RESULTS

Five studies met predetermined criteria. Meta-analysis revealed greater rates in homeless adults (average age 56) compared to housed adults (average age 78) for ADL limitation (RR = 1.50, 95% CI = 1.37-1.64) and IADL limitation (RR = 1.36, 95% CI = 1.28-1.45). Falls were three times more prevalent in homeless individuals (RR = 3.42, 95% CI = 3.16-3.70). Heterogeneous frailty data did not reach significance (RR = 2.59, 95% CI = 0.90-7.46).

CONCLUSION

Homeless adults have increased risk of premature geriatric syndromes. Limitations in ADL and IADL rates were 30-50% higher than adults with stable housing averaging 20 years older, and fall rates were three times higher than controls averaging 4.5 years older. These results underscore the need for healthcare providers such as physical therapists to address physical dysfunction in homeless adults.