Addressing issues related to geropsychiatry and the well-being of older adults
The homeless population in America is growing increasingly old. Today, older adults are at greater risk for homelessness than at any time in recent history (Goldberg, Lang, & Barrington, 2016). Baby Boomers born between 1955 and 1965 are aging into poverty at the same time as housing is becoming more unaffordable and health care costs are rising. In the early 1990s, only 11% of the adult homeless population was 50 or older. Today, approximately one half of homeless individuals in America are older than 50 (Cimino et al., 2015; Kushel, 2016). This significant shift in demographics has created serious challenges for how cities, governments, and health care providers care for homeless populations.
The Path to Homelessness for Older Adults
It is important to consider that “the homeless,” as this population is often referred to in the literature, is not an amorphous mass, but individuals with diverse backgrounds who share the common problem of striving for quality of life while living without a home. For older adults, there are two main routes into homelessness: (a) the aging of the chronically homeless and (b) older adults who experience homelessness for the first time (Seegert, 2016). In the first scenario, adults who have been homeless for many years age into their 50s and 60s, unable to secure stable housing. In the second scenario, older adults previously had stable housing, working throughout their lives, but ended up homeless after such problems as losing jobs in the recessions of the late 1970s and early 1980s, illness or disability, the death of a loved one, or spending time in jail. Others were unable to stretch a fixed income to cover the cost of high rent in many large cities such as Los Angeles, New York, Honolulu, and San Francisco and had to choose between housing and basic needs such as food and medical care. Older adults of color are disproportionately represented in this population (Kushel, 2016). The 2013 estimate by the National Low Income Housing Coalition noted that the amount needed for housing exceeded the $14.32 hourly wage earned by the average renter by approximately $4.50 per hour and greatly exceeded wages earned by low income renter households (National Coalition for the Homeless, n.d.). Compounding this problem is a lack of affordable housing, with an average wait time of 3 to 5 years (Seegert, 2016).
The sad circumstances of homeless older adults often spill over into the lives of their family members, who may not even know where their mothers, fathers, sisters, or brothers are, or whether they are even alive. One young woman, a talented artist, talked of hearing that her mother was on Skid Row in Los Angeles, but she was unable to find her (personal communication, 2015). Some homeless older adults state that they do not contact family because they do not want to interfere with their children's lives (Nagourney, 2016).
Other individuals are rejected by their families. One man described his path to homelessness after being evicted when his wife had a stroke and his daughter revoked her promise to let them stay with her:
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…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.
Unique Challenges for Homeless Older Adults
The perception that homelessness affects mainly those with mental health or substance abuse problems does not fit the experiences of homeless older adults, especially those who became homeless late in life (Kushel, 2016). Once homeless, older adults' health often decreases rapidly.
Individuals living in poverty often experience premature aging, also called weathering (Seegert, 2016). Weathering dramatically affects those without stable housing, causing individuals to age prematurely by 10 to 20 years beyond their chronological age. Physical and mental health problems that are seen in older adults in their 70s, 80s, and 90s are found to be common in homeless adults with an average age of 58, especially women (Nagourney, 2016; Seegert, 2016).
With an older homeless population, health care providers have the difficult task of treating chronic illnesses such as diabetes, heart disease, and lung problems. In addition, the older homeless population is often dealing with cognitive and functional impairments and deteriorating hearing and vision. In one study of 360 homeless individuals 50 and older, approximately 40% reported difficulty with one or more activities of daily living, 33% reported that they had fallen in the past 6 months, 25% had cognitive impairment, 45% had impaired vision, and 48% had urinary incontinence (Seegert, 2016). Management of chronic problems often requires repeated visits to health care providers and adherence to complicated medication protocols, specific diets, and therapeutic exercise regimens. Adhering to prescribed treatments may be impossible for older adults who are homeless (Kushel, 2016).
Functional impairment that creates difficulty in performing basic self-care activities that are considered essential for independence occurs in 30% of homeless adults in their 50s and early 60s; this prevalence exceeds that of housed adults who are 20 years older (Cimino et al., 2015). All 350 participants in Kushel's (2016) study faced increased health problems once they lost their home. Loss of strength and mobility can lead to frequent falls. High rates of tobacco, alcohol, and drug use; poor nutrition; high stress from attempting to manage the problems of homelessness; and decreased access to health care are common challenges faced by homeless older adults. They may not have transportation to a clinic or seek health care because of shame at their homelessness or fear of how they will be treated by health care providers (Kushel, 2016).
Difficulty Accessing Benefits
Most homeless older adults have not worked the time required to qualify for Social Security benefits and have not put aside money for retirement (Nagourney, 2016). They often need to rely on Supplemental Security Income (SSI), which pays approximately $733 per month, but this is only for individuals 65 or older. This age may be too late for many, as the average lifespan for a homeless person living on the street is 64 years (Nagourney, 2016).
Public benefits programs can help some homeless older adults obtain the services they need but getting connected to those benefits can be difficult. Older adults may be unaware of their eligibility for public assistance programs, and once they apply, they face the difficult task of navigating complex application processes. In addition, physical impairments, cognitive difficulties, and lack of a permanent address can be serious barriers to applying for and receiving benefits that provide income support and health care (Goldberg et al., 2016).
Risk of Institutionalization
Homeless older adults face a high risk of institutionalization due to lack of sufficient funding for, and availability of, alternative housing solutions (Goldberg et al., 2016). Because of health problems and needed support for activities of daily living, the only permanent shelter available may be a nursing home, as Medicaid funding pays for these residences. Worse, they may be placed in jail or a psychiatric hospital. Homeless older adults may find themselves in an “institutionalization circuit,” cycling between living on the street or in a shelter and living in an institution (Goldberg et al., 2016, p. 5).
Dying on the Street
Homeless older adults live with the threat of violence daily. In 2006, 27% of homeless victims of violent crimes were 50 or older (Goldberg et al., 2016). As a result, these individuals may avoid shelters and other services due to distrust and be more likely to live on the street.
Older homeless individuals die at a rate three to five times what would be expected in the general population, and they die of different causes than younger homeless individuals (Corporation for Supportive Housing, 2011; Ko, Kwak, & Nelson-Becker, 2015). They often die from the same causes as older adults in the general population (e.g., heart disease, cancer), but die 20 to 30 years sooner (Kushel, 2016).
Ko et al. (2015) performed a qualitative research study to explore 21 homeless older adults' perspectives of a good or bad death and their concerns about care at the end of life. Themes identified for a good death were dying peacefully, not suffering, experiencing spiritual connection, and making amends with significant others. Themes from participants' descriptions of a bad death were experiencing death by accident or violence, prolonging dying with life supports, becoming dependent during the dying process, and dying alone. Dying alone on the street was seen as the most un-dignified death and confirmed rejection, marginalization, and negligence by society.
Because so many older homeless adults are estranged from their families, their fear of dying alone is poignant. Participants in Ko et al.'s (2015) study talked of wanting opportunities to express their affection and emotions such as thankfulness and forgiveness to family members and friends, highlighting the importance of social support at the end of life. A need to make amends with those they had hurt, and the difficulty of doing this, may be greater among homeless older adults than non-homeless individuals (Ko et al., 2015). One participant expressed these emotions: “I'd tell them how much I love them, you know…tell them if I did…forgive me if I did something wrong…Express my feeling and say I love them” (Ko et al., 2015, p. 426).
What Needs to Bbe Done?
The problem of homeless older adults has presented new challenges for government and community agencies. Systems established in the 1980s were not designed to address problems of aging (Kushel, 2016; Nagourney, 2016). Housing with bunk beds is not appropriate for older adults who are at risk for falls. Bathrooms in homeless shelters often lack grab bars or slip-resistant floors. Providers of shelters are grappling with the need to provide personal care assistants for older homeless clients who cannot independently handle activities of daily living. Clients with cognitive impairments may not be able to understand or follow rules for living in the shelter (Kushel, 2016).
Kushel (2016) noted that the solution to the problem of homeless older adults is not one-size-fits-all. An individual who has become homeless for the first time after having steady employment for many years requires different services than someone who has spent years cycling between institutional care and living on the streets. Goldberg et al. (2016) have suggested the following:
- Increase income support. Because homelessness is primarily a poverty problem, increasing income supports can make an important difference for low-income older adults and individuals with disabilities. Safety net programs such as Social Security and SSI should be expanded so that they provide sufficient basic income and are accessible to those who qualify—even those without a permanent address.
- Make health care affordable and accessible. Medicare and Medicaid benefits should be expanded so that older adults' out-of-pocket costs do not threaten their economic security. Simplifying and expanding Medicare Savings Programs, such as the Qualified Medicare Beneficiary Program, which pays for Medicare premiums and co-insurance for low-income older adults, would allow more individuals to access affordable health care.
- Create more affordable and accessible housing. Research has demonstrated that homeless older adults who obtained housing experienced improved depressive symptoms and reduced use of acute care services (Brown et al., 2015). A critical need exists to increase the availability of affordable housing for older adults and to fund/develop permanent supportive housing for homeless older adults. Supportive housing is a combination of affordable housing with deep subsidies and helpful landlords/property management. Supportive services include care management, such as client-centered counseling, goal setting, and services planning; services coordination; connection to mainstream services; and evidence-based services models that reflect cognitive behavioral and family systems approaches (Goldberg et al., 2016). Research has demonstrated that permanent supportive housing is essential to address the complex medical needs of homeless older adults and help them avoid emergency department (ED) visits and institutionalization.
- Target programs to unique needs of homeless older adults. Targeted programs are needed to provide preventive health care and help ensure less reliance on ED visits. Medical respite programs and hospice for homeless older adults should be provided for those who need these services and the Medicaid program should be expanded to provide housing-related services to homeless older adults who need long-term supports. There is also a need to enhance health care coordination to help homeless individuals find and retain housing and connect with social services.
- Increase access to low-cost legal services for older adults. Homeless older adults need access to affordable legal services that prevent evictions, foreclosures, and elder financial abuse. Expanded legal services can also help older adults access crucial safety net programs, such as SSI and Medicaid. Increased funding for legal services could be obtained through Title IIIB of the Older Americans Act and Legal Services Corporation (Goldberg et al., 2016).
Homeless older adults may be invisible to many nurses unless they appear in the ED or hospital with an illness that needs immediate treatment. When caring for homeless patients, nurses may feel frustrated and powerless to find ways to help with such vast problems in the face of poor adherence to discharge instructions and frequent cycling through EDs (Gerber, 2013). It is important to know this population's unique needs to improve their health care.
Although the prevalence of health risk factors such as smoking, alcohol use, and poor nutrition is high among homeless older adults, their desire to change these modifiable risk factors is also high (Taylor, Kendzor, Reitzel, & Businelle, 2016). Homeless older adults may welcome practical interventions that target smoking cessation, weight reduction, increased fruit and vegetable consumption, and increased physical activity.
When communicating with homeless older adults, it is important to ensure enough time and patience to develop a trusting, nonjudgmental relationship that conveys respect, dignity, and value (Gerber, 2013). Communicating in a calm manner will help allay anxiety. Encouraging patients' stories can help nurses understand what it is like for them to live as homeless older adults. Simple open-ended questions can help patients feel welcomed and comfortable. An interesting way to encourage meaningful conversation might be, “What would make your day better right now?” (Gerber, 2013, p. 35).
It is important to coordinate care by obtaining previous records and identify any support persons in the patient's life. Follow up with an assigned case manager can be helpful. Services should be linked together whenever possible to avoid fragmentation. Electronic medical records can facilitate sharing information with all providers within Health Insurance Portability and Accountability Act guidelines. The U.S. Department of Housing and Urban Development's software program, Homeless Management Information System, can be an effective tool for recording and storing information about homeless individuals (Gerber, 2013).
Nurses working in any public, private, or Veterans hospital are responsible for providing homeless individuals with realistic discharge plans for follow up and appropriate referrals (Gerber, 2013). Nurses working in prisons are key personnel in developing discharge plans before inmate release that include referrals for housing and health care. Research indicates that coordinated discharge planning can form the foundation for a comprehensive community homelessness prevention strategy (Corporation for Supportive Housing, 2011). It is important for nurses to become knowledgeable about community services for homeless older adults, including educational opportunities; job training programs; free legal services; and emergency, transitional, or permanent housing programs. The Table lists websites with helpful information for nurses to learn more about unique needs and resources for homeless older adults.
Resources for Information about Caring for Homeless Older Adults
Nursing research is needed to identify and evaluate creative solutions to the problem of homeless older adults. In a review of nursing literature from the past decade, there were few research studies that addressed this problem. Nursing interventions to enhance self-confidence of homeless older adults have been found to be successful. Washington, Moxley, and Taylor (2009) implemented a 6-week life management enhancement group intervention for older minority homeless women. Findings from the study showed that after the intervention women showed significantly greater personal control and self-confidence than women in the control group. These attributes can help women increase and sustain appropriate coping mechanisms needed to overcome homelessness.
As the Baby Boomer cohort continues to age and the rates of poverty do not diminish significantly, the problem of homeless older adults will continue to grow. It is critical that nurses and all health professionals have a better understanding of the unique needs and concerns of homeless older adults to support the dignity of their care. Nurses can be an important part of the solution, not only through direct patient care, but by advocating for improvements in care for this vulnerable population.
- Brown, R.T., Miao, Y., Mitchell, S.L., Bharel, M., Patel, M., Ard, K.L. & Steinman, M.A. (2015). Health outcomes of obtaining housing among older homeless adults. American Journal of Public Health, 105, 1482–1488. doi:10.2105/AJPH.2014.302539 [CrossRef]
- Cimino, T., Steinman, M.A., Mitchell, S.L., Miao, Y., Bharel, M., Barnhart, C.E. & Brown, R.T. (2015). Disabled on the street: The course of functional impairment in older homeless adults. JAMA Internal Medicine, 175, 1237–1239. doi:10.1001/jamainternmed.2015.1562 [CrossRef]
- Corporation for Supportive Housing. (2011). Ending homelessness among older adults and elders through permanent supportive housing. Revised Policy Paper prepared for the National Leadership Initiative to End Elder Homelessness. Retrieved from http://www.csh.org/wp-content/uploads/2012/01/Report_EndingHomelessnessAmongOlderAdultsandSeniorsThroughSupportive-Housing_112.pdf
- Gerber, L. (2013). Bringing home effective nursing care for the homeless. Retrieved from http://journals.lww.com/nursing/Fulltext/2013/03000/Bringing_home_effective_nursing_care_for_the.12.aspx
- Goldberg, J., Lang, K. & Barrington, V. (2016). How to prevent and end homelessness among older adults. Retrieved from http://www.justiceinaging.org/wp-content/uploads/2016/04/Homelessness-Older-Adults.pdf
- Ko, E., Kwak, J. & Nelson-Becker, H. (2015). What constitutes a good and bad death? Perspectives of homeless older adults. Death Studies, 39, 422–432. doi:10.1080/07481187.2014.958629 [CrossRef]
- Kushel, M. (2016, January8). How the homeless population is changing: It's older and sicker. Retrieved from https://theconversation.com/how-the-homeless-population-is-changing-its-older-and-sicker-50632
- Nagourney, A. (2016, May31). Old and on the street: The graying of America's homeless. Retrieved from http://www.nytimes.com/2016/05/31/us/americas-aging-homeless-old-and-on-the-street.html?_r=1
- National Coalition for the Homeless. (n.d.). Homeless in America. Retrieved from http://nationalhomeless.org/about-homelessness
- Seegert, L. (2016, April1). Homeless get “older” at younger ages than their peers, research says. Retrieved from http://healthjournalism.org/blog/2016/04/homeless-get-older-at-younger-ages-than-their-peers-research-says
- Taylor, E.M., Kendzor, D.E., Reitzel, L.R. & Businelle, M.S. (2016). Health risk factors and desire to change among homeless adults. American Journal of Health Behavior, 40, 455–460. doi:10.5993/AJHB.40.4.7 [CrossRef]
- Washington, O.G.M., Moxley, D.P. & Taylor, J.Y. (2009). Enabling older homeless minority women to overcome homelessness by using a life management enhancement group intervention. Issues in Mental Health Nursing, 30, 86–97. doi:10.1080/01612840802597580 [CrossRef]
Resources for Information about Caring for Homeless Older Adults
|Corporation for Supportive Housing||http://www.csh.org|
|National Alliance to End Homelessness||http://www.endhomelessness.org|
|National Coalition for the Homeless||http://nationalhomeless.org/issues/elderly|
|National Health Care for the Homeless Council||http://nhchc.org|
|U.S. Department of Housing and Urban Development||http://portal.hud.gov|