As the first study to rigorously characterize the presence of geriatric syndromes in older homeless adults, this report increases our understanding of age-related syndromes in this population. Our findings demonstrate that older homeless adults commonly experience geriatric syndromes that may be amenable to intervention. Even after multivariate adjustment, syndromes including functional and mobility impairment, frailty, depression, visual impairment and urinary incontinence were significantly more common in the homeless compared to population-based cohorts.
Our cohort was similar to large representative cohorts of homeless adults, with respect to gender, race/ethnicity, marital32
and health status.33
The cohort differs from other homeless cohorts in several respects. In comparison to homeless adults aged ≥50 in one study of self-reported comorbidities, subjects in our cohort reported higher comorbidity rates, including hypertension (59.0% vs. 43.2%) and arthritis (44.9% vs. 27.0%).3
Subjects also reported higher insurance rates than other studies. In a nationally-representative homeless cohort, 56.6% of adult subjects were insured32
; homeless adults aged ≥50 have reported similar insurance rates.3
As in other studies, the majority of subjects in our study had Medicaid.34
The high insurance rate in our cohort reflects both Massachusetts’ history of insuring the homeless population and recent health care reform, which provides subsidized insurance for residents earning ≤300% of the federal poverty level.
Health insurance is associated with better ambulatory care access and fewer barriers to obtaining care in both homeless and housed adults.35
Consistent with this finding, our cohort had high rates of ambulatory care. However, our cohort also had more ED visits and hospitalizations relative to the comparison cohorts, suggesting that in older homeless adults, high insurance rates may still be associated with high rates of acute care utilization.
This study corroborates research reporting high rates of geriatric syndromes in homeless adults, but extends earlier work by providing a more comprehensive assessment of these syndromes and by comparison with population-based cohorts. Prior studies of older homeless adults have reported high rates of functional impairment,4
and visual impairment.38
A recent systematic review of cognitive impairment in homeless adults found that 0-21% (weighted mean, 4.2%) of subjects scored <24 on the MMSE.36
While the proportion of subjects in our cohort scoring <24 (24.4%) is higher than the upper range of reviewed studies, the review included adults aged ≥18, while our subjects were aged ≥50.
The prevalence of most geriatric syndromes was significantly higher compared to the population-based cohorts. Even when compared to MBS, with an average age >20 years older, the homeless cohort had a higher prevalence of most geriatric syndromes. While differences between the cohorts including demographics, alcohol use, and comorbidities might be hypothesized to account for the higher prevalence of syndromes, differences in prevalences persisted after adjustment for these factors, with the exception of selected measures of cognitive impairment, falls in MBS, and self-reported visual impairment in NHANES. Higher rates of drug use among the homeless cohort may explain some of the observed differences in rates of syndromes. Because measurement of drug use differed between the cohorts, we did not adjust for this variable.
The study has several limitations. Inter-rater reliability was not tested for RTB’s measurements. However, RTB was trained in administration of cognitive measures by the Hebrew SeniorLife Clinical Studies Manager. All other instruments were administered according to published guidelines, using a written script to ensure consistent administration. While the questionnaire data are based on self-report, homeless adults’ self-reports are as accurate as the general population.39
Limited power may account for our inability to detect a significant difference between the cohorts in prevalence of cognitive impairment defined by MMSE <24. Recruitment of subjects was limited to shelters, and therefore does not capture individuals who do not access these organizations. This could either overestimate geriatric syndromes (if more functional individuals do not access shelters) or underestimate (if frailer individuals are unable to seek shelter). However, <6% of single homeless adults in Boston stay on the street during the winter.9
Finally, because we only included Massachusetts shelters, the findings may not be generalizable to other areas. However, the subjects’ demographic characteristics are similar to a nationally representative homeless sample.32
The average age of the homeless population is expected to continue to increase.1
Our study shows that older homeless adults have higher rates of most geriatric syndromes compared to the general population. Many geriatric syndromes are potentially amenable to intervention, and, if addressed proactively, may reduce adverse outcomes and acute care utilization. While delivering health care services to homeless elders is challenging, screening and standard treatment for geriatric syndromes is warranted for homeless adults aged ≥50 who access health care.