Depression is common in older adults and associated with poor medical and mental health outcomes, including increased risk for suicide. Homeless older adults are at increased risk for developing depression. The clinical presentation of depression in older adults and younger adults often differs. Having an appreciation for these differences allows clinicians to better diagnose and treat this vulnerable population. This chapter provides case example highlighting the common themes of the presentation, diagnosis, and treatment of depression in the homeless older adult population. Research and advocacy are warranted to ensure that older homeless individuals with a major depressive disorder receive optimal assessment and treatment of their depression. The chapter discusses barriers to adequate detection and treatment of depression in older homeless adults, as well as assessment and treatment strategies. It covers identification and treatment of grief. The chapter reviews promising directions for future strategies to decrease depression among older homeless adults.
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Neurocognitive disorders are life-disrupting disorders that complicate the lives of those who have them, as well as those who care for them. Speaking about neurocognitive disorders among the geriatric homeless populations is further complicated by the fact that not only is the existing research inconsistent, research on this topic in general is relatively sparse. Much of the research that exists in this area examines homeless populations in general, rather than geriatric homeless populations specifically, but examining this research is still useful for the purposes of better understanding this issue within the geriatric homeless population. This chapter endeavors to do so in order to highlight relevant research and clinical issues. It provides case example illustrating the complex nature of caring for an older homeless adult with probable cognitive deficits, the barriers to fully assessing neurocognitive deficits, and the difficult interactions this can create for staff.
Diabetes mellitus (DM) is one of the most common chronic conditions in older, homeless adults. This chapter provides brief description on DM and prediabetes, and discusses post-hospital admission and clinical manifestations of DM. Careful and deliberate data gathering must take place to understand current health behaviors. Importantly, the patient’s health literacy, memory, and performance of activities of daily living and instrumental activities of daily living will help assess functional status. The chapter covers topics such as nutrition status and food security, fall risk assessment, depression, cognitive impairment, vision, social history, and polypharmacy. It discusses physical exam, diagnostic tests, further work-up, patient education and self-management, prevention, and treatment of DM. The chapter finally provides description on noninsulin versus insulin and oral versus injection, oral noninsulin medications, and strategies to reduce common diabetic complications.
Cardiovascular disease (CVD) remains the leading cause of death in older homeless people. Traditional CV risk factors, such as hypertension, diabetes, smoking, and hyperlipidemia, and nontraditional CV risk factors, such as substance abuse, psychological stress, and lack of diagnostic and preventative medical care, contribute to CVD in this population. Barriers to CV prevention and treatment in homeless individuals include their environment, lack of access to care, substance dependence, mental illness, food insecurity, and medication non-adherence. Healthcare models that provide Housing First and just-in-time care by non-judgmental multidisciplinary teams have been shown to improve the CV health of people who are homeless. CV health requires prevention, as well as prompt intervention, and close follow-up. CV healthcare practice adaptations for homeless clients include ascertaining living conditions, improvising the physical exam, scheduling longer clinic appointments with frequent follow-up, prioritization of the plan of care, and simplification of the medication regimen.
Perhaps end-of-life considerations for homeless elderly could be considered a topic of fictional creation, a sociomedical unicorn. Because, depending on one’s perspective, the curse or blessing of homelessness is the failure to even reach an age that is generally acknowledged as “geriatric”. Advance care planning is the process by which one decides what types of treatment one prefers at the end of life, but also who can speak on his or her behalf should the person become unable to speak for himself or herself. This chapter discusses advance care planning with aging homeless at end of life. It provides brief description on challenges in accessing healthcare for homeless aging, perceptions of dying of the aging homeless, and spiritual and religious consideration at end of life. The chapter then discusses palliative and hospice care delivery for the geriatric homeless. It also discusses innovative palliative care delivery models.
This chapter revisits the issues constituting the main causes of homelessness among the geriatric population, with special attention to people who became homeless due to economic factors, substance abuse, mental illness, or all of these reasons. It begins with a description of a general distinction within the geriatric homeless population followed by an overview of housing, shelter, and community programs that are available in most major cities. Not every region or city will have all cited resources available, and some might be called a different name. The chapter ends with a series of case studies. Each one demonstrates a different social issue facing a geriatric homeless person and how it impacts an older adult in locating housing and/or social services. During the discussion, examples of services and cases from several cities are cited.
The population of geriatric homeless individuals diagnosed with serious mental illness is a largely underrepresented subpopulation in the research literature despite the notion that this population is one of the most vulnerable to negative outcomes due to physical, mental, and psychosocial factors. This chapter briefly summarizes the separate impact of each of these three factors: being homeless, being in the geriatric population, and being diagnosed with a serious mental illness (SMI). In addition, the chapter illustrates how these three factors combined impact overall subjective quality of life and poor outcomes for mental health through the use of a case vignette of a homeless, geriatric individual with a severe mental illness. It also provides case example illustrating that high comorbid substance abuse along with an SMI (i.e., dual diagnosis) associated with complex medical conditions create seemingly insurmountable challenges for the interdisciplinary care team.
Skin problems are one of the most common presenting complaints of homeless persons to emergency departments and community clinics, estimated at 20% of such visits. Adult homeless suffer the usual skin diseases common to nonhomeless adults, but in addition can suffer more frequent infections, dermatitis, and wounds related to their compromised living status. This chapter focuses on the diagnosis, treatment, and triage of common skin complaints in homeless adults. Hospital admission should be considered whenever fever, chills, tachycardia, hypotension, or severe or rapidly progressing infection or other admission criteria are present. Additionally, if outpatient treatment is unrealistic given limited social or logistical challenges, admission may be appropriate even without the aforementioned standards, in order to ensure appropriate critical treatments and resolution. The chapter provides case example for infestations, bites and infections, wounds, neoplasms, and rashes.
Homelessness is a rising healthcare problem. Secondary to poor living situations and limited access to healthcare services, homeless people are at increased risk for exposure to various communicable diseases. The diseases found in the homeless population include viral infections, hepatitis A, hepatitis B, hepatitis C, HIV/AIDS, and influenza. Homelessness, on one hand, increases the prevalence of infectious diseases, and aging, on the other hand, makes the elderly more vulnerable to infections. Homelessness is associated with numerous behavioral, social, and environmental risks that expose persons to many communicable diseases, including viral infections, which may spread among the homeless, and aside from posing a threat to individuals’ health can lead to outbreaks that can become serious public health concerns. Homeless populations may be at higher risk for West Nile virus and other mosquito-borne diseases due to their increased exposure to the outdoors and their limited access to preventive measures.
This book serves as the pillar for clinical care teams to improve health equity among homeless older adults. Interdisciplinary care teams are essential in complex homeless older population clinical practice, as all disciplines must work together to address medical, surgical, behavioral, nutritional, and social determinants of health. All clinicians who treat older adults, from the independent to the frail, should approach problem solving via an inclusive approach that includes social work, pharmacy, nursing, rehabilitation, administrative, and medicine inputs. The social determinants of health that contribute to the complexities of clinical care outcomes cannot be addressed within silos. The book reflects a holistic care model to assist clinicians in the complicated homeless population that is continuing to change in the instability of the homeless environment. The book is divided into 14 chapters. The chapters in are organized by problems most commonly faced by clinicians in servicing homeless populations: mental, social, medical, and surgical challenges. Chapter one presents definition and background of geriatric homelessness. Chapter two discusses chronic mental health issues (psychosis) in the geriatric homeless. Chapters three and four describe neurocognitive disorders, depression, and grief in the geriatric homeless population. The next two chapters explore ethical, legal, housing and social issues in the geriatric homeless. Chapters seven and eight discuss infectious diseases in homeless geriatrics population. Chapter nine is on cardiovascular disease in homeless older adults. Chapter 10 describes care of geriatric diabetic homeless patients. Chapter 11 discusses geriatric nutrition and homelessness. Chapter 12 presents barriers and applications of medication therapy management in the homeless population. Chapter 13 describes dermatologic conditions in the homeless population. Finally, the book addresses end-of-life considerations in homelessness and aging.