Older homeless adults must cope with high rates of chronic conditions in the chaotic setting of homeless shelters or the street. Living in a shelter or on the street is hazardous at any age, but poses special hazards for older adults (see Table 70–3). Most shelters are group living spaces, with bunk beds and shared bathing facilities. These features may increase the risk of falling. Older adults also encounter risks outside of the shelter. Many shelters require occupants to vacate each morning and return in the evening to wait in line for a bed. On the street during the day, homeless adults are exposed to the elements and at risk for victimization. They must navigate a complex web of social services to obtain meals or shelter. Older homeless adults with impaired function, mobility, or cognition may be unable to safely perform these activities, resulting in falls, injuries, or inability to obtain food or shelter. Other hazards include difficulty toileting because of limited public bathroom facilities, and inability to safely store personal items, leading to lost or stolen medications, canes, and glasses.
Although clinicians face many challenges in caring for older homeless adults, several measures may improve care for these vulnerable older patients. These measures include screening for geriatric syndromes, mental health problems, and substance use disorders. As noted above, clinicians should work with other members of the health care team to determine eligibility for benefits and to refer to available community resources.
Most screening tools for geriatric syndromes are not validated in homeless adults, and there are no evidence-based guidelines for when to screen homeless patients for geriatric syndromes. The American Geriatrics Society recommends comprehensive assessment for geriatric syndromes (Chapter 6, “Geriatric Assessment”) in frail, older patients who are at risk for functional decline, hospitalization, or nursing home placement. Because older homeless adults have rates of geriatric syndromes and hospitalizations similar to housed adults 15–20 years older, we recommend assessing homeless adults age 50 years and older for geriatric syndromes, as most screening instruments have been validated in these age groups, despite the lack of specific evidence in the homeless population. Based on the pattern of geriatric syndromes among older homeless adults, we recommend screening for functional and mobility impairment, falls, cognitive impairment, and urinary incontinence.
Although the Katz ADL Scale has not been validated in homeless adults, it has been widely used in younger patients with a range of chronic conditions. One-third of older homeless adults have difficulty performing ADLs, yet treatment options are limited because of the difficulty of modifying the environment of the shelter or street. Public or shared bathing facilities may lack modifications like grab bars and raised toilet seats. Informal caregiving by partners or friends is often not possible in the shelter, because shelters are segregated by sex, which may separate individuals from their caregivers. In addition, many adults experiencing homelessness are socially isolated. Furthermore, referrals for formal caregiving services such as home health aides are impractical in a shelter. A physical therapist may be able to recommend portable adaptive equipment for use in the shelter, such as canes, walkers, and dressing aids, but these materials are often stolen or lost.
Standard IADL scales include items that do not apply to homeless adults living in shelters or on the street, such as food preparation and housekeeping. The Brief Instrumental Functioning Scale (BIFS) was developed and validated for homeless adults, and asks about ability to perform the following activities independently or with help: fill out an application for benefits, budget money, use public transportation, set up a job interview, find an attorney to help with a legal problem, and take medications as prescribed by a physician. Homeless patients who are unable to perform these activities independently should be referred to social work and/or case managers.
Taking medications as prescribed poses special challenges in the shelter or on the street, where loss and theft of medications is common. Clinicians should ask if patients have a secure location to store medication, such as a storage locker at a shelter. If they do not, consider other strategies, such as dispensing medications 1 week at a time. Standard measures that improve medication adherence in older adults may also be helpful (Chapter 53, “Addressing Polypharmacy & Improving Medication Adherence in Older Adults”).
The American Geriatrics Society recommends screening for falls beginning at age 65 years. However, homeless adults age 50 years and older fall at rates higher than the general older population and may benefit from earlier screening. A combination of factors may contribute to high rates of falls among older homeless adults, including environmental hazards (Table 70–4), functional and mobility impairment, and substance use disorders. Clinicians may be able to decrease the risk of falls among older homeless patients by ensuring that patients have a pass to sleep on the lower bunk, referring patients with impaired function or mobility to physical therapy, and providing counseling for substance use disorders.
Table 70–4.Environmental hazards for older homeless adults. ||Download (.pdf) Table 70–4. Environmental hazards for older homeless adults.
|Environmental Hazard ||Associated Risk |
|Homeless Shelter |
|Bunk beds ||Falls, injuries |
|Lack of refrigeration ||Inability to properly store medications (eg, insulin) |
|Lack of secure storage || |
|Noisy environment ||Disrupted sleep |
|Group living environment ||Victimization, lack of privacy, falls, injuries |
|Group showers ||Victimization, lack of privacy, falls, injuries |
|Bathing and toileting facilities without adaptive equipment (ie, raised toilet seats, grab bars) ||Falls, injuries |
|Institutional meals, often with high starch and salt content ||Limited ability to modify diet to accommodate health conditions |
|Lack of public toilet facilities ||Urinary incontinence, inability to maintain hygiene |
|Need to walk long distances between services, requiring higher functional status ||Falls, injuries |
|Need to navigate complex web of social services to obtain food and shelter, requiring intact cognition and executive function ||Food insecurity |
|Exposure to elements ||Falls, injuries |
Although screening tests for cognitive impairment have not been validated among homeless adults, most have been widely used in younger patients. Patients who screen positive for cognitive impairment should undergo standard medical assessment for reversible causes (Chapter 22, “Cognitive Impairment & Dementia”). Assess patients with cognitive impairment for decision-making capacity, and refer patients who lack decision-making capacity to social work.
Most screening tests for urinary incontinence have been validated in younger patients, such as the International Consultation on Incontinence Questionnaire (ICIQ). Managing urinary incontinence in shelters and on the street is challenging because of limited access to public toilets and use of shared toileting facilities. Where feasible, consider a trial of standard behavioral interventions, such as bladder training and pelvic muscle exercises.
To screen for depression in older homeless adults, we recommend using a screening tool validated in patients younger than age 65 years, such as the Patient Health Questionnaire 9. Although little is known about the prevalence of other mental health conditions among older homeless adults, consider screening for anxiety and posttraumatic stress disorder, given the high rates of mental health conditions in the general homeless population.
Substance use disorders are often underrecognized in older adults. However, screening for substance use disorders in older adults is particularly important because older adults are at higher risk for adverse effects of substance use as a result of changes in body composition with aging, higher rates of prescription medication use, and impairments in function, gait, and balance, among other factors (Chapter 58, “Managing Misuse of Alcohol & Psychoactive Prescription Medications in Older Adults”). The risk for adverse effects of substance use may be even more acute in older homeless adults, who have higher rates of substance use disorders and geriatric syndromes compared to the general older population.
Clinicians caring for older homeless patients should be aware of several resources for homeless individuals, including rapid rehousing, permanent supportive housing, medical respite, and intensive case management. Rapid rehousing provides rental assistance and services, and is most appropriate for individuals who experience barriers to housing but have the potential to sustain housing after the rental subsidy ends. Permanent supportive housing is defined as permanent, subsidized housing with onsite or closely linked supportive services (eg, medical, psychiatric, case management, vocational, and substance use services) for chronically homeless individuals. Because permanent supportive housing programs help chronically homeless adults maintain housing and may decrease use of acute health services, the federal government has identified such programs as a priority intervention for people experiencing chronic homelessness. Permanent supportive housing units are available in an increasing number of communities, funded by a combination of resident income, rent subsidies, tax credits, grants, and service-linked funding, such as Department of Mental Health benefits.
Medical respite is also recognized by the federal government as a strategy to decrease the negative impacts of homelessness on health. Medical respite programs provide temporary post-hospitalization care with medically oriented supportive services to homeless people discharged from acute care hospitals, but who are not medically ready to return to a shelter or the street. These services may be less costly compared to longer-term hospitalizations or stays in skilled nursing facilities or nursing homes. Moreover, patients discharged to medical respite instead of directly to shelters or to the street have fewer hospital readmissions. Medical respite services exist in a growing number of cities.
Intensive case management refers to a set of wraparound services delivered by highly trained case managers whose low case load allows for intensive follow-up with clients. Intensive case management programs were originally developed for patients with severe mental illness, and were later adapted to support individuals who used health services frequently, many of whom were homeless. Intensive case management differs from case management, a general term used to describe a range of programs, from peer support to medically oriented services. Many shelters and homeless assistance programs offer case management programs to help individuals experiencing homelessness to identify and access appropriate services.
As in general geriatric medicine, interprofessional teams may help improve care for older homeless adults (Chapter 5, “The Interprofessional Team”). An interprofessional team for an older homeless patient might include a case manager working to obtain permanent supportive housing, clinicians providing medical and psychiatric care, a social worker, and a substance abuse counselor.