Homelessness in older adults: an emerging crisis

Margot Kushel, MD Professor of Medicine, UCSF

5/4/17

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“I’m old and I’m tired and I got my disability...I can’t, I can’t do it no more...” -55 year old homeless woman in HOPE HOME Study

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The homeless population is aging

• In 1990, 11% of people experiencing homelessness in SF were over 50

• In 2003, 37% were over 50

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Hahn J, Kushel M et al. The Aging of the Homeless Population JGIM 2006

Generational effect

§ Americans born in the second half of the baby boom (1954-1963) have had elevated risk of homelessness throughout lifetime

§ 30-40% of homeless individuals* born 1954-1963

§ Estimated that about half are aged 50 and over

* Excluding homeless youth and homeless people living in families

Dennis P. Culhane, Stephen Metraux, Thomas Byrne, Magdi Steno, Jay Bainbridge, and National Center on Homelessness among Veterans. "The Age Structure of Contemporary Homelessness: Evidence and Implications for Public Policy" Analyses of Social Issues and Public Policy 13.1 (2013): 1-17.

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Will the trend continue?

§ Housing affordability crisis acute for those 50 and over

§ Among renters age 50 and over, 30% spend more than half their income in rent “severe housing burden”

§ Median age of homeless individuals expected to rise

Baker K, Baldwin P, Donahue K, et al. Housing America’s Older Adults – Meeting the Needs of an Aging Population. Joint Center for Housing Studies of Harvard University. 2014.

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What are the implications of the aging of the homeless population?

§ Different pathways to homelessness

§ High prevalence of chronic and life-limiting diseases

§ High prevalence of functional and cognitive impairment

§ Substance use and mental health problems are prevalent, but may require treatment adjustments due to co-occurring functional and cognitive problems

§ Implications for housing design, service design and service delivery

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HOPE HOME Study

§ Health outcomes of people experiencing homelessness in older middle age

§ Funded by National Institute on Aging § Longitudinal cohort study in Oakland CA § 350 participants enrolled July 2013 to June 2014, following participants every six months § Renewed for another five years

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HOPE HOME Study

§ Study activities take place at St Mary’s Center § Active Community Advisory Board

•  Local experts

•  Two study participants

§ Study includes •  Regular study interviews and exams

•  Qualitative interviews on topics of interest

•  Ability to add new questions/adapt study

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HOPE HOME Study

§ Aged 50 and older § English speaking § Homeless by HEARTH Act definition at time of enrollment •  Living outdoors, places not meant for human

habitation • Emergency shelters •  Losing housing within 14 days (eviction notice) •  Fleeing domestic violence with no place to go

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Two thirds are 60 and under, but 12% are older than 65 years at study entry

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Study population

§ 77% men § 80% African American § 5% currently married/partnered; 11% widowed; 43% divorced or separated § 13% currently work for pay § 28% currently looking for work § 90% income less than $1150/month

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Years since last stable housing Percent

None 3.4 <6 months 14.3

6 mo to <1 yr 15.1 1 yr to <5 yrs 38.6

5 yrs to <10 yrs 13.7 10+ years 14.9

Almost a third of the sample lost stable housing* in the past year

Where did you live when you last had stable housing?

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6% 11%

46%

12%

14%

6% 5%

Hotel or Motel Rented Room Rented apartment or house Lived with friends/fam for free Paid friends/fam to live Owned house/condo/apt Other

Economic challenges and interpersonal conflict are most common reasons to have left last stable housing

Reason % of Sample

Couldn't pay rent/mortgage 28

Rent increased 2

Lost job 7

Became sick/disabled 1

Other bills (not medical) 1

Someone else stopped paying rent/mortgage 15

Family abuse/violence 1

Kicked out (not related to money) 41

Didn’t get along/asked to leave 11

Drinking/doing drugs 4

Evicted 7

Housemates’ substance use/stealing 1

Building condemned/destroyed/foreclosed 6

Other reasons 21

Moved to new city/more desirable place 6

Hospital/treatment program 1

Incarcerated 4

Conditions were poor 4

What proportion first became homeless after age 50?

§ 12%

§ 24%

§ 44%

§ 68%

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44% with first episode of homelessness after age 50

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PATHWAYS TO HOMELESSNESS

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Those with early homeless (<50)

• More adverse life experiences Low income attainment in early adulthood No spouse partner Mental health problems Traumatic brain injury Imprisonment Alcohol use problem

Brown RT, Goodman L, Guzman D, Tieu L, Ponath C, Kushel MB. Pathways to Homelessness among Older Homeless Adults: Results from the HOPE HOME Study. PLoS One. 2016 May 10;11(5)

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I only did like 5-6 months in YA [juvenile justice] when I was 13, but then after that I started getting violations over the years, that’s where the four years [in juvenile justice system] came in at, going back and forth.... Yeah, when I got to be 17 then they took me off.... When I got 21, that’s when I started using drugs...At that time I was doing burglaries and all kind of petty thefts and …I don’t know, back then it was like every ninety days I end up back in San Quentin. It wasn’t like, “Oh, I can’t wait until I go get high,” or nothing like that, but eventually I got high. Then that one time led to one another and a thousand other too many. So I was in that mentality, trapped in that mentality for over forty years.

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§ (My father said): “Next time you, if you runaway, I’ll beat you with a car chain or I’m going to throw you out the window.” Okay, so I, I was, I wouldn’t use the word ‘reasonable’ but I put things in perspective real quick and I would say, “Could I survive a car chain? Probably not.” Then I looked out the window and said, and we lived on the 13th floor, I said, “I ain’t playing with this man.” He went to work, I had whatever I had on me, I was out the door.

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Late onset homelessness

§ Low wage work throughout life

§ Job loss in late life

§ Marital breakdown

§ Illness (participant, spouse)

§ Death (spouse, parent)

§ Lack of advocacy

•  Evictions for reasons other than non-payment of rent

•  Not getting benefits

•  Multiple bureaucratic hurdles

§ Low social support from families/friends

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“It was a lot of different things but basically the new owners took over, we were being evicted. My wife, she had just got out of the hospital, had the stroke and was blind….so, the daughter came up and said, ‘Don’t fight it, y'all can come stay with me for a couple months and save your money.’ So we said, ‘Okay’ ...[and didn’t fight the eviction]. After we moved out of the place, turned in the keys and everything we went over to her house and she said, ‘Y'all can’t stay here.’ And I said, ‘I got $9 in my pocket,’ I said, ‘At least let your mother spend the night because we don’t have enough money to get a motel room.’ She said, ‘No.’ So that was the beginning.”

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…When they bought the company out they cut our hours back and they would bring in temp workers and they would give them all the hours and they weren’t giving us our hours, which caused me to lose my place I was staying in because I couldn’t afford to pay the rent, because, you know, from, you’re going from almost 80-100 (hours) a week down to 20 hours a week, it’s kind of hard to pay bills.

She [participant’s niece, who lived in Section 8 housing] was helping me out, I was getting my little GA [General Assistance], helping her out…Then I had to leave for a while, then come back. That’s the way she was staying on top of the rules.   And what would have happened if you had stayed there longer than a week?  I don’t really know but she didn’t want to break her rules [about not having extra people staying with her] and find out, and so I had, I had to leave. In other words, I had to get kicked out. But she didn’t kick me out, though. And I was staying in the one-night shelters, bouncing around and with her.

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“Yeah, well, you know, I had lost my job and just could not be able to find another one. Yeah, so in that 27 years, you know, I worked, you know, paid bills, and, you know, pretty much tried to enjoy…the things that life gives you when you go out and earn. And, but when I became homeless it was like a little, it was like a little shock at the time…”

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While late onset homeless individuals tend to have fewer vulnerabilities, many had significant health challenges related to their homelessness

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SOCIAL SUPPORT

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What proportion of older homeless adults report having someone to confide in?

§ 10%

§ 33%

§ 50%

§ 67%

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Partnership: § 5% currently married/partnered

§ 41% never married

§ 11% widowed; 43% divorced or separated

Other Sources:

§ 80% of our sample was able to give us a contact

•  60% of time that contact was a family member

§ 67% say that they have “someone to confide in”

§ 54% report attending house of worship or social club

Social Support: few are currently married, but there are other sources of social support

Most participants have a contact; the most common contacts are family

Emergency Contacts Listed by Aging Homeless Participants % of cohort

Any contact 80.6 Family member 61.4

Sibling 28.9 Child 18.6

Parent 10.9 Spouse 5.4

Other Family Member (e.g. aunt, cousin) 11.75/4/17 Homelessness in older adults: an emerging crisis 31

While many have family, loneliness is common

40% of participants meet criteria for “loneliness”

One of the things that gets me is when I say hello to somebody, and they don’t say hello back. That hurts. That’s one of the mix ups of this culture that I am, that level of being untouchable…and that hurts. I mean psychologically is devastating.

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HEALTH

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Poor health in every measure

56% report health as fair or poor

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Self-reported chronic diseases are common: but may be underreported

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What proportion of older homeless adults have a limitation in Activity of Daily Living?

§ 10%

§ 25%

§ 40%

§ 75%

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High Proportion with functional impairments

0%

10%

20%

30%

40%

50%

60%

Actvitivies of Daily Living Independent Activities of Daily Living

2 or more impairments

1 impairment

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High prevalence of cognitive impairment 3MS measures global impairments; Trails B measures executive function

0

5

10

15

20

25

30

35

40

3MS Trails B

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High prevalence of all geriatric conditions

§ Mobility impairment: 27% § One or more falls (6 months) 34% § Visual impairment 45% § Hearing impairment 36% § Urinary incontinence 48%

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. Gerontologist. 2016 Feb 26. pii: gnw011. [Epub ahead of print] PubMed PMID: 26920935.

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Overall poor functional status

§ Median age of sample 57 § Prevalence of geriatric conditions worse than those in general population samples in their 70s and 80s

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“I’m starting to forget stuff. … that day I came down here I had lost a day, …now I write down everything … I used to be an organized person … I thought that I was really down here on a Wednesday and it was a Thursday. And that kind of bothered me.” -HOPE HOME Study participant

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I’m tired, but…I’ll be 79 in a month. I think it’s just old age, but I walk two or three blocks, and sit for five to 15 minutes depending on how tired I am. This is why it takes me seven hours to get about three miles down to the clinic and then back.

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DRUGS AND ALCOHOL

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Illicit drug and alcohol use common

Substance % Alcohol 26%

Any illicit drug past 6 months 63%

Cannabis 39%

Cocaine 43%

Opioid 13%

Amphetamine 8%

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Alcohol and Drug use problems common

§ 65% with moderate or greater severity of drug use symptoms •  15% severe symptoms

•  Cocaine (43%), Cannabis (39%) and opioids (13%) moderate or severe use symptoms

§ 26% moderate or greater severity alcohol use symptoms

•  15% severe symptoms

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Spinelli et al. Factors associated with substance use in older homeless adults: Results from the HOPE HOME study. Substance Abuse 2017; 38(1): 88-94.

Prevalence of illicit drug and alcohol use problems lower than samples of younger homeless adults, but higher than age-matched (and dramatically higher than those of general population ages 70s and 80s)

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“Because I’m more mature and I don’t use drugs and my mind’s not like it was.”

-63 year old man explaining why he no longer uses drugs, which he has used since he was a teenager

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MENTAL HEALTH PROBLEMS

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Mental Health Problems are common

0

5

10

15

20

25

30

35

40

Depression PTSD Psychiatric hospitalization ever

Psychiatric hospitalization last 6

months

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Mental health and Substance use co-morbidity common

§ Among the 38% with moderate to severe depressive symptoms, 78% had moderate to severe substance use problems

§ Among the 15% with both severe PTSD symptoms AND a history of experiencing violence, 77% had co-morbid moderate-severe substance use

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HEALTH CARE UTILIZATION

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High rates of acute healthcare utilization

§ 72% had a non-ED source for care

§ 53% reported a PCP

§ Half of all participants had visited an ED (confirmed) in the prior six months

§ <7% of participants accounted for half of all ED visits

§ 24% of visits for worsening of chronic illness

§ 10% were hospitalized for physical condition in prior six months

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High mortality rate and institutional care

§ 33-45 months after study entry, 26 confirmed deaths

§ Multiple diagnoses of metastatic cancer, strokes, heart attacks, kidney failure, etc.

§ Several under conservatorship

§ Several living in nursing homes

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HOUSING OUTCOMES

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What proportion were housed 2 years after study entry?

§ 10%

§ 30%

§ 55%

§ 80%

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Housing Status at 24 months n=286

38%

55%

7%

Housing Status at 24 months

Homeless n=110

Housed n=157

Institution n=19

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Not included: Deceased n=17 Dropped out or unable to ascertain n=47

Where were individuals housed at 24 months? n=286

37

17

24

40

34

5 0% 2% 4% 6% 8%

10% 12% 14% 16%

Permanent Supportive Housing

Transitional Housing

Subsidized Housing

Housed alone Housed with friends or family

Hotel with tenancy rights

Housing status

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§ At 24 months, approximately half still homeless or living in institutional settings § Of those housed, about half received any institutional support • About half of those within system for

homelessness and half mainstream vouchers

§ Assistance from family and friends crucial

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CONCLUDING THOUGHTS

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What are possible solutions?

§ Preventing new homelessness •  Affordable housing •  Eviction prevention ‒  Legal protection ‒  Short term subsidies

§ For those with new onset homelessness, focus on rehousing quickly •  Rental subsidies •  Focus on family as potential source of support •  Assess eligibility for benefits

§ For those with long-term homelessness and disabling conditions •  Permanent supportive housing ‒  Adapt for needs of older adults

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Implications

§ Homeless population will continue to grow older § High needs population

•  continued behavioral health challenges •  High prevalence of chronic diseases, life limiting diseases,

functional and cognitive deficits

§ Housing interventions will need to be: •  Fully accessible for people with mobility and sensory impairments

•  Accessible to those who require personal care assistance

•  Understanding that older population may have important connections to other family members that need to be supported

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Implications

§ Housing processes and service delivery

•  Need to be usable by individuals with significant cognitive and sensory impairments

‒ Executive function impairments create unique challenges

‒ Behaviors may be result of cognitive deficits

§ Providers need to be ready to support clients and staff through end of life care

•  Helping clients express their preferences

•  Palliative/hospice care outside of hospital settings

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Margot.kushel@ucsf.edu @mkushel

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HOPE HOME Papers currently available

Lee CM, Mangurian C, Tieu L, Ponath C, Guzman D, Kushel M. Childhood Adversities Associated with Poor Adult Mental Health Outcomes in Older Homeless Adults: Results From the HOPE HOME Study. Am J Geriatr Psychiatry. 2017 Feb;25(2):107-117. doi: 10.1016/j.jagp.2016.07.019. Epub 2016 Aug 17. PubMed PMID: 27544890; PubMed Central PMCID: PMC5253307.

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 Jan;24(1):63-74. doi: 10.1111/acem.13070. PubMed PMID: 27520382.

Brown RT, Goodman L, Guzman D, Tieu L, Ponath C, Kushel MB. Pathways to Homelessness among Older Homeless Adults: Results from the HOPE HOME Study. PLoS One. 2016 May 10;11(5):e0155065. doi: 10.1371/journal.pone.0155065. eCollection 2016. PubMed PMID: 27163478; PubMed Central PMCID: PMC4862628.

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. Gerontologist. 2016 Feb 26. pii: gnw011. [PubMed PMID: 26920935.

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HOPE HOME papers currently available Vijayaraghavan M, Tieu L, Ponath C, Guzman D, Kushel M. Tobacco Cessation Behaviors Among Older Homeless Adults: Results From the HOPE HOME Study. Nicotine Tob Res. 2016 Aug;18(8):1733-9. doi: 10.1093/ntr/ntw040. Epub 2016 Feb 26. PubMed PMID: 26920648; PubMed Central PMCID: PMC4941600. Lee CT, Guzman D, Ponath C, Tieu L, Riley E, Kushel M. Residential patterns in older homeless adults: Results of a cluster analysis. Soc Sci Med. 2016 Mar;153:131-40. doi: 10.1016/j.socscimed.2016.02.004. PubMed PMID: 26896877; PubMed Central PMCID: PMC4788540. 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. 2017 Jan-Mar;38(1):88-94. doi: 10.1080/08897077.2016.1264534. PubMed PMID: 27897965. 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 HOPE HOME Study. J Pain. 2017 Apr 12. pii:S1526-5900(17)30535-7. doi: 10.1016/j.jpain.2017.03.011. [Epub ahead of print] PubMed PMID: 28412229.

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