Delirium, also known as acute confusional state, organic brain syndrome, brain failure, and encephalopathy, is a common occurrence among medical and surgical patients and causes extensive morbidity and mortality. This chapter provides an updated review of delirium, including pathophysiological correlates, clinical features, diagnostic considerations, and contemporary treatment options. The defining features of delirium include an acute change in mental status characterized by altered consciousness, cognition, and fluctuations. The chapter explores the risk factors for delirium. These can be divided into two categories: predisposing factors and precipitating factors. Imbalances in the synthesis, release, and degradation in gamma-aminobutyric acid (GABA), glutamate, acetylcholine, and the monoamines have also been hypothesized to have roles in delirium. GABA is the primary inhibitory neurotransmitter in the central nervous system (CNS) and medications such as benzodiazepines and propofol have known actions at GABA receptors and have been associated with delirium.

Primary progressive aphasia (PPA) is the term applied to a clinical syndrome characterized by insidious progressive language impairment that is initially unaccompanied by other cognitive deficits. This chapter describes several variants of PPA and more than one etiology. It explains three main variants of PPA, namely, semantic Variant of PPA (svPPA), nonfluent/agrammatic variant of PPA (nfvPPA) and logopenic variant of PPA (lvPPA), and also describes criteria for their diagnoses. The defining symptom of PPA is the presence of a language impairment for at least 2 years in the absence of any other significant cognitive problem. Assessment of other cognitive domains is challenging because many tests of memory, attention, executive functioning, and visual-spatial skills rely on language processes in some manner. There are no drug therapies proven to arrest progression of signs and symptoms of PPA due to frontotemporal lobar dementia (FTLD) or Alzheimer’s disease (AD) pathologies.

Dementia is an umbrella term for conditions such as Alzheimer’s disease (AD), dementia with Lewy bodies (DLB), vascular dementia (VaD), and frontotemporal dementia (FTD). Under that umbrella, FTD, also known as frontotemporal lobar degeneration (FTLD), can be further categorized to define a group of neurodegenerative disorders resulting from a progressive deterioration of the cells in the anterior temporal and/or frontal lobes of the brain. More specifically, ventromedial-frontopolar cortex is identified with metabolic impairment in FTD. This chapter elaborates on the history, epidemiology, pathophysiology, clinical features, treatment, and outcomes of FTD. The history and background section of each of the FTD categories highlights the evolution of the disease conceptualization. The FTD subtypes are conceptualized in three categories: neurobehavioral variant, motor variant, and language variant. The chapter illustrates the features of all three categories of FTD.

The concept of Mild cognitive impairment (MCI) makes a lot of sense in that individuals are typically not “normal” one day and “demented” the next. In theory, especially for progressive neurodegenerative conditions, such as Alzheimer’s disease (AD), frontotemporal dementia (FTD), the development of dementia may take months or years. The clinical syndrome of MCI due to AD can be identified via a neuropsychological evaluation or less-sensitive cognitive screening measures. Much of what we are learning about MCI, and therefore refining its diagnostic criteria, is coming from two large-scale studies of cognition and aging: Alzheimer’s Disease Neuroimaging Initiative (ADNI) and Australian Imaging, Biomarkers and Lifestyle (AIBL). According to the most recent research diagnostic criteria for MCI due to AD, evidence of beta-amyloid deposition, neuronal injury, and/or other biochemical changes needs to be seen to increase confidence of the etiology of MCI. Cholinesterase inhibitors remain the primary pharmacological treatment for AD.

This chapter suggests that the dysexecutive syndrome associated with vascular dementia (VaD) is caused by impairment in separate but related cognitive concepts; that is, pathological inertia, mental bradyphrenia, disengagement, and temporal reordering. During the late 19th and early 20th centuries, cerebrovascular dementia was a well-established clinical syndrome. Multi-infarct dementia (MID) generally became associated with all types of vascular syndromes. Recent research suggests the presence of considerable overlap between the neuropathology underlying Alzheimer’s disease (AD) and VaD. Patients diagnosed with VaD tend to produce hyperkinetic/interminable perseverations, suggesting an inability to appropriately terminate a motor response. Other aspects of the dysexecutive syndrome associated with VaD revolve around constructs related to interference inhibition, flexibility of response selection, and sustained attention. From the view point of diagnosis, the neuropathology of VaD often differentially impacts the frontal lobes, whereas the neuropathology associated with AD revolves more around circumscribed temporal lobe involvement.

Dementia pugilistica (DP) is a form of chronic traumatic encephalopathy (CTE) that involves gross impairment of cognitive and motor functioning due to repetitive blows to the head from boxing. Rapidly increasing in popularity among fight fans and fighters is mixed martial arts (MMA). In the area of sport-related concussion, there are two other frequently used terms that are necessary to distinguish from DP and CTE: postconcussion syndrome (PCS) and second impact syndrome (SIS). The classical clinical signs and symptoms of DP include combinations of dysarthria, incoordination, gait disturbance, pyramidal and extrapyramidal dysfunction, and cognitive impairment. Some media reports about concussion and the potential link between repetitive concussions and long-term problems include eye-catching and emotionally provocative titles. This chapter has provided an overview of the many complex issues surrounding the effects of repeat concussive trauma, particularly in sports.

The Transmissible spongiform encephalopathies (TSEs) form a group of illnesses, characterized by a pathological form of the native prion protein, which results in a rapidly progressive neurodegenerative illness. They also are responsible for Gerstmann-Strâussler-Scheinker (GSS) syndrome and fatal familial insomnia (FFI), and they have been produced experimentally in several other animals. Creutzfeldt-Jakob disease (CJD) is the most common TSE in humans. Human prion diseases have three etiologies: (a) sporadic, (b) genetic, and (c) acquired. Human prion diseases are important to understand because of their underlying pathophysiology, public health implications, and clinical features that often result in misdiagnosis. This chapter reviews the historical discovery of prion diseases and the formulation of the prion hypothesis. It explores prion hypothesis and the neuropathogenesis of prion diseases. The chapter ends with a description of the diagnosis, prognosis, and experimental treatment of human prion diseases.

Dementia with Lewy bodies (DLB) is a clinical syndrome characterized by progressive dementia, cognitive fluctuations, visual hallucinations (VH), and parkinsonism. In 1961, Okazaki, Lipkin, and Aronson reported two patients with dementia and parkinsonism with cortical neuronal inclusions similar to the brain-stem Lewy bodies (LB) seen in Parkinson’s disease (PD). LBs are intra-cytoplasmic neuronal inclusions containing α-synuclein and ubiquitin. There are other associated pathological features in DLB such as spongiform change neuronal loss, and Alzheimer’s disease (AD) pathology includes amyloid plaques and neurofibrillary tangles (NFTs). DLB and other entities such as PD and multiple system atrophy (MSA) have been grouped under the term synucleinopathies due to the existence of &#945-synuclein inclusions in the brain. The central feature required for a diagnosis of DLB is the presence of dementia: a progressive cognitive decline of sufficient magnitude to interfere with normal social or occupational function.

This chapter describes an overview of the procedures that a neuropsychologist may apply to a range of similar referrals in the area of civil capacities. It explores the presentation of a framework developed by the American Bar Association/American Psychological Association (ABA/APA) working group on capacity issues and provides more specific guidance regarding assessment tools. Decision making is a complex cognitive process that involves multiple brain regions and brain systems. Injuries to the prefrontal cortex are common in dementia and are often linked to changes in decision-making abilities. Key differences between clinical assessments and those for capacity evaluations include knowledge of relevant legal and ethical issues, a functional assessment, and an ability to present neuropsychological data to lay readers. Research on medical consent capacity and financial capacity highlight the importance of the assessment of calculation, executive function, and verbal memory as part of any test battery.

Chronic alcohol use has been related to various linked disorders when used in excess, particularly when this excessive use becomes chronic. It is important for clinicians to clarify the amount and type of alcohol being consumed and the frequency of this consumption when considering its potential role in any neuropsychological profile. The most commonly reported terms found in the literature include alcohol-induced persisting dementia (APA), alcohol-related dementia, and Korsakoff’s syndrome (KS). This chapter provides some synthesis of this literature to offer some clarity on cognitive dysfunction as it relates to alcohol and the manifestation of dementia as a result of chronic use, including discussion of the classic KS and related presentations. Alcohol dependency is commonly associated with a number of neurological impairments including deficits in abstract problem solving, visuospatial and verbal learning, memory function, perceptual-motor skills, and even motor function.

Frontotemporal dementia (FTD) is the third leading cause of dementia in large pathological series but tends to have an earlier age of onset than Alzheimer’s disease (AD) and Lewy body dementia, the most frequent and second most frequent forms of dementia. Semantic dementia (SD) includes impairment in the understanding of the meanings of words and difficulty in identifying objects. Semantic primary progressive aphasia, also known as SD, includes difficulties with naming and single-word comprehension although grammar and fluency are often spared. SD is a disorder that involves loss of semantic memory, anomia, receptive aphasia, and an actual loss of word meaning. The chapter presents some assessment tools that are those conducted by a psychologist or a neuropsychologist. Such an evaluation should include a clinical interview and neuropsychological examination. SD has been associated with ubiquitin-positive, TAR-DNA-binding protein-43 (TDP-43)-positive, tau-negative inclusions.

Alzheimer’s disease (AD) and related cortical dementias are a major health problem. Patients with AD and related dementia have more hospital stays, have more skilled nursing home stays, and utilize more home health care visits compared to older adults without dementia. This chapter discusses the role of family caregivers and how they interact with in-home assistance, day care, assisted living, and nursing homes in the care of an individual with dementia. It also discuss important transitions in the trajectory of dementia care, including diagnosis, treatment decision making, home and day care issues, long-term care placement, and death. It highlights the importance of caregiver assessment, education, and intervention as part of the care process. Dementia caregivers are at risk of a variety of negative mental health consequences. Another important moderating variable for dementia caregiver distress is self-efficacy.

Vascular dementia (VaD) is an umbrella term representing a clinical grouping with inherent heterogeneity in its clinical manifestations reflecting a variability in its underlying etiology. This chapter discusses specific presentations that can fall under the VaD heading. It includes discussion of multi-infarct dementia (MID) and dementia associated with lacunar states (LSs), as well as Binswanger’s disease (BD), which remains embroiled in controversy. The chapter discusses cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) and moyomoya disease due to their clinical overlap. The etiology of MID is in many ways the same as the etiology of cerebrovascular disease (CVD) in general and even late-life dementia. The term MID itself is used to describe a disorder characterized by a stepwise deterioration of cognitive functioning associated with strokes or accumulated transient ischemic attacks (TIAs).

With the elderly population rapidly increasing worldwide, neuropsychologists are often called upon to conduct assessments of possible neurodegenerative disorders. This chapter provides an overview of the differential diagnostics via neuropsychological methods of cortical dementia syndromes. Over the last several decades, clinicians have seen significant changes with regard to daily practice in interprofessional settings, which are becoming more commonplace for practicing neuropsychologists. The chapter provides guidance/input/assistance for practitioners working in such settings. Mini-Mental State Examination (MMSE) is the most commonly administered psychometric screening assessment of global cognitive functioning. The Clinical Dementia Rating scale (CDR) is a widely used rating scale for measuring dementia severity. Alzheimer’s disease (AD) is characteristic of a progressive decline in memory, executive functioning, visuospatial abilities, language, and behaviors as a result of neurodegeneration in the brain. Progressive supranuclear palsy (PSP) is a neurodegenerative akinetic rigid disorder.

Dementia is a syndrome in which impairment of cortical or subcortical brain function leads to deterioration of cognitive processes or intellectual abilities, including memory, judgment, language, communication, and abstract thinking. The treatment of dementia can be broadly divided into two domains: those interventions used to improve or preserve cognitive function and those interventions used to control disturbed behavior of individuals with dementia. Dementia can result from many conditions, some of which are potentially reversible, but the most common and clinically relevant forms include Alzheimer’s disease (AD), vascular dementia (VaD), dementia with Lewy bodies (DLB), Parkinson’s disease dementia (PDD), and frontotemporal dementia (FTD). The Acetylcholinesterase inhibitor (AChI) drugs donepezil, rivastigmine, galantamine, and the N-methyl-D-aspartate (NMDA)-receptor antagonist memantine have produced modest and persistent improvements on measures of cognition, activities of daily living (ADL), and behavior in patients with disease severity ranging from mild to severe.

Old age brings with it unique challenges in diagnosis, treatment, and care; dementia complicates these issues even more. Improving the management and care of persons with dementia has positive implications for patients, caregivers, and physicians alike. Two types of secondary complications can be analyzed in relation to dementia: conditions that arise outside of the dementia and then conditions that appear to develop due to the neurological degeneration inherent in dementia. Examples of psychiatric complications include depression, anxiety, and psychosis. Medical problems consist of issues such as stroke, cardiovascular problems, cancer, infections, orthopedic issues, diabetes, nutritional disorders, vision and hearing problems, as well as general pain. The high comorbidity of dementias with other psychiatric and medical issues can complicate the diagnosis and treatment of patients with dementia. Issues in the central nervous system (CNS) have long been looked at as possible predictors of dementia.

This chapter provides a brief guide to the main brain imaging techniques from the point of view of their usefulness in differentiating the principal forms of cortical dementias, that is, Alzheimer’s disease (AD), posterior cortical atrophy (PCA), frontotemporal lobar degeneration (FTLD), and dementia with Lewy bodies (DLB), which have relatively specific imaging findings. It considers mild cognitive impairment (MCI) because it is a clinical condition that is often prodromal to cortical dementias, in particular AD. The chapter discusses in detail other dementias associated with movement disorders, that is, the corticobasal degeneration (CBD) and progressive supranuclear palsy (PSP), because they belong to the FTLD spectrum, and vascular dementia (VaD), which is frequently considered in differential diagnosis of cortical dementias. It also offers a quick look at future directions in neuroimaging, which will most likely be based on the combination of different techniques of structural, molecular, and functional imaging.

Dementia is chronic and causes widespread dysfunction in multiple neuropsychological domains. While cognitive symptoms vary across different types of dementia based on their underlying neuropathology, impairments in attention, memory, and comprehension predominate. This chapter briefly discusses the research on the efficacy of various cognitive and behavioral interventions aimed to improve the neuropsychological symptoms in patients with dementia. Cognitive reserve has been shown to be influenced by various premorbid factors. Cognitive training refers to nonpharmacological interventions aimed to improve a patient’s cognitive function and is specifically designed to improve the patient’s functional capacity. Cognitive training generally includes a combination of cognitive stimulation, memory rehabilitation, reality orientation, and neuropsychological rehabilitation. Cognitive interventions have been shown to improve global cognitive functioning and abilities of daily living, reduce behavioral disturbances, and have positive effects on quality of life in patients with dementia.

Alzheimer’s disease (AD) presents one of the most urgent health care issues of our time. AD is a disease of the brain and mind, and as such, neuropsychology has an essential and evolving role to play in addressing this growing public health concern. Measurement of key cognitive functions, such as delayed recall of recently presented information, is crucial in the diagnosis and monitoring of the disease. In addition to the importance of advancing scientifically informed disease-specific measurement of cognition, neuropsychology has a growing role to play in the design and implementation of nonpharmacological interventions for AD. The neuropathological hallmarks of AD are senile plaques (SP), neurofibrillary tangles (NFTs), and cell and synapse loss in multiple brain areas. Granulovacuolar degeneration (GVD) has long been recognized to be present in the brains of AD patients.

Dementia is a clinical syndrome characterized by the impairment of multiple cognitive domains that is severe enough to interfere with one’s usual social and occupational functioning. The impairment must represent a decline from a previously higher level of functioning and not occur exclusively during the course of delirium. Knowledge of the functional link between neuroanatomy and neurophysiology of neurodegenerative processes and neuropsychological outcomes is critical for clinical practice. This chapter describes the neuropsychological, neuroanatomical, and neurophysiological features of several of the more common “cortical dementias”. It reviews Alzheimer’s disease (AD), the most common form of dementia, and then compares and contrasts the features of AD with those of other disorders that involve significant cortical pathology including dementia with Lewy bodies (DLB), frontotem-poral dementia (FTD), and cortical vascular dementia (VaD). The chapter provides shorthand descriptions of the typical disease onset, course, neuropsychology, neuroimaging, and neuropathology associated with each cortical dementia syndrome.

This chapter shows how the United States and the world are experiencing an aging evolution we are growing older. America is going through a revolution. As a whole, Americans are becoming older, and there are many more older people among people than ever before in our history. Obviously all cohorts of the population youth, young adults, middle-aged, young-old, oldest-old are heterogeneous. When some people think about the elderly as a whole, they picture frail, weak, dependent persons, some in nursing homes and many confined to their homes. The chapter demonstrates the differences the various age categories have in relation to selected chronic health conditions that cause limitations of activity. Widowhood is much more common for elderly American women than for older men. The aging of Baby Boomers will solidify the shift America is experiencing with the aging of its population. Centenarians make up a small percentage of the total U.S. population.

Geriatric homelessness (GH) is a significant and growing social, political, economic, and humanistic issue throughout the United States. This chapter presents case studies that will highlight the GH in four urban areas and among veterans. It defines geriatric homelessness, outlines its general dimensions, explicates its two primary etiologies (loss of employment and the lack of affordable housing in the areas where most homeless persons are located), and gives examples of the diversity of the problem and attempts at solutions in four cities and among veterans. The case examples show that the solution to the medical and psychological issues in the GHP involves much more than traditional medical practices and therapies. The solutions, involving among others politics, economics, and housing, are those of communities and localities acting to positively affect the lives of individuals and families of all ages, particularly the growing population of GHPs in the United States.

This chapter provides brief description on malnutrition and aging, and nutrition and homelessness. It discusses nutritional impact of substance abuse, and nutrition assessment and intervention. The chapter explores the impact that homelessness and food insecurity has on the nutritional status of older adults. Interventions must be tailored to accommodate the patient’s financial resources, medical conditions, and ultimately his or her own personal goals in order to be effective. Patients may be completely disengaged from nutrition education and focused on other priorities, which are essential for survival, that is, shelter and safety, thus making nutrition education the least effective intervention for that patient at that moment in time. Ideally, the homeless geriatric person would be monitored and re-evaluated; however, follow-up may be unrealistic. What does nutrition assessment look like in action? The chapter provides a case study to describe this question.

The ethical and legal issues that arise in the care of the geriatric homeless population are complex not only because they involve nuances unique to either population, but because the combination of being undomiciled and aged leads to significant unique vulnerability. The usual dilemmas in geriatrics of creating an acceptable process for informed consent, judging adequate decision-making capacity for treatment acceptance and refusal, determining appropriate substitute decision makers, preserving privacy and confidentiality, promoting advance care planning, and allocating healthcare resources are made more challenging in the homeless. Complicating factors include ongoing psychiatric comorbidities and serious medical illnesses, which change a patient’s mentation and cognitive capacities. Therefore, appropriate assessment and treatment in these complex cases no doubt requires input from an interprofessional team. This chapter presents a case with changing psychiatric, ethical, and legal issues to illustrate how such complex tensions arise and may be resolved in a homeless geriatric patient.

Medication therapy management (MTM) remains a challenging endeavor to optimally implement in the homeless population. Working in various settings in collaboration with other health professionals, pharmacists are spearheading patient-centered efforts to optimize MTM and assist the homeless with attaining health insurance and continuity of care. In the case of MTM, homeless persons may face significant hardship in not only procuring and using effective drug therapy, but also in following-up with their providers and establishing provider–patient relationships that will help them to meet their target therapeutic goals. This chapter enumerates a review of the more common barriers to MTM in the homeless population, followed by a number of practical applications of MTM in optimizing the health of the homeless. In order to appreciate the value and role that stable MTM can offer the homeless, the chapter briefly discusses perspectives on homeless health and the concept of MTM.

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, including viral and bacterial infections, tuberculosis, and arthropod carried diseases. This chapter briefly discusses infectious diseases such as bacterial infections, tuberculosis, and arthropods infestation in homeless geriatrics population. The bacterial infections covered in the chapter are urinary tract infections, bacterial pneumonia, and foot infections. The arthropods infestations include lice, scabies mites, bed bugs, delusional parasitosis. There are other causes of bites and lesions aside from lice, scabies mites, and bed bugs. Spiders, mosquitoes, ticks, fleas, and ants also pose risks for homeless people, particularly those who live outdoors. Homeless people can have a difficult time avoiding bites from mosquitoes and ticks, which can carry diseases.

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.

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.

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.

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.

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.

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.

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.

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.

This chapter shows the importance, for older persons, of support groups. In spite of the changes that have occurred in the American family, and all the negative things that fill the popular press concerning family relationships, the family is still the backbone of support for most older people. To some extent, the type of family support older people obtain depends on whether they are living in the community or in an institutional setting such as a group home, retirement village, or nursing facility. Whether a person is married, has great impact on that person’s support within a family setting including emotional, financial, and physical support, particularly in times of illness or infirmity. The success of a second marriage depends to a considerable extent on the reaction of the adult children of the elderly couple. Older grandparents, no matter how motivated, can find caring for grandchildren to be very tiring.