The Course of Functional Impairment in Older Homeless Adults: Disabled on the Street

During the past 25 years, the proportion of the homeless population aged 50 years or older has increased, from 11% in 1990¹ to 50% today.² Older homeless adults experience the early onset of age-related conditions compared with the general population, including difficulty performing basic self-care activities that are considered essential for independence, such as bathing and dressing.³ Such functional impairment occurs in 30% of homeless adults in their 50s and early 60s—a prevalence exceeding that of housed adults who are 20 years older.³ However, it is unknown whether functional impairment among older homeless adults is transient or persistent and thus what types of interventions are needed to address these deficits. We examined the persistence of functional impairment in homeless adults aged 50 years or older and identified risk factors for persistent or worsened functional impairment.

We conducted a 12-month prospective study of 250 older homeless adults recruited from 8 homeless shelters in Boston, Massachusetts, from January 25 to June 30, 2010.³ Eligibility criteria included age 50 years or older, current homelessness, and ability to communicate in English. We interviewed participants in person at baseline and at 12 months. The institutional review boards of the participating universities approved the study; all participants provided written informed consent and received financial compensation.

At baseline and 12 months, participants reported whether they had difficulty performing 5 Katz activities of daily living (ADLs)⁴ and 6 instrumental ADLs (IADLs). We assessed IADLs using a validated instrument developed for use in homeless persons.⁵ We defined persistent ADL impairment as difficulty performing the same number of ADLs at baseline and follow-up and worsened ADL impairment as difficulty performing an increased number of ADLs from baseline to follow-up. We defined the IADL impairment categories similarly. We used multivariable regression models to identify risk factors for persistent or worsened functional impairment.

Of the 250 participants enrolled at baseline, 204 completed the 12-month follow-up assessments from January 25 to June 30, 2011. The mean age was 56.0 years, and 37 participants were women (Table).

At baseline, 65 of 204 participants reported impairment in 1 or more ADLs; 51 of these 65 individuals had difficulty performing 1 or 2 ADLs. The most common ADL impairment at baseline was transferring (n = 54), followed by dressing (n = 23) and toileting (n = 17).

In 32 of the 65 participants with ADL difficulty at baseline, these difficulties persisted or worsened at follow-up. The ADL impairment most likely to persist was transferring, followed by bathing and dressing (Figure). Among the 32 participants with persistent or worsened ADL impairment, 11 participants had improvement in the original impairment but onset of 1 or more other impairments.

Of 139 participants who had no ADL impairment at baseline, 21 developed new ADL impairment at follow-up. The most commonly acquired new ADL impairment was transferring (n = 18), followed by dressing (n = 5) and bathing (n = 5). Results for IADLs were similar to those for ADLs. In multivariable analyses, demographics, medical comorbidity, substance use, and health services use were not associated with persistent or worsened ADL impairment or IADL impairment.

Functional impairment improved over time in some older homeless adults but persisted or worsened in many others. These findings suggest that functional impairment in many older homeless adults is a long-term issue in need of long-term solutions. Approaches to managing functional impairment among older homeless adults might include referral to medical respite for individuals with short-term impairments and, for persons with longer-term impairments, promoting access to permanent supportive housing with appropriately tailored environmental adaptations and personal care services. Because few factors measured in standard practice predict whose impairments will persist vs improve, monitoring older homeless individuals over time will be necessary to understand their functional trajectory and identify appropriate services.

Corresponding Author: Rebecca T. Brown, MD, MPH, Geriatrics and Extended Care Service, San Francisco Veterans Affairs Medical Center, UCSF Box VA-181G, 4150 Clement St, San Francisco, CA 94121 (rebecca.brown@ucsf.edu).

Published Online: May 26, 2015. doi:10.1001/jamainternmed.2015.1562.

Author Contributions: Dr Brown had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Cimino, Bharel, Brown.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Cimino, Brown.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Miao, Brown.

Obtained funding: Brown.

Administrative, technical, or material support: Barnhart, Brown.

Study supervision: Steinman, Mitchell, Bharel, Brown.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was funded by a Medical Student in Aging Research Program award from the American Federation for Aging Research and the National Institute on Aging at the National Institutes of Health (Ms Cimino) and by grants K23AG045290 from the National Institute on Aging (NIA) at the National Institutes of Health (NIH) (Dr Brown); KL2TR000143 from the National Center for Advancing Translational Sciences, NIH, through the University of California, San Francisco, Clinical and Translational Science Institute (Dr Brown); P30AG044281 from the NIA at the NIH (Dr Brown); and K23AG030999 from the NIA at the NIH and the American Federation for Aging Research (Dr Steinman).

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Previous Presentation: This study was presented at the Annual Medical Student in Aging Research Program Student Presentations Session; July 31, 2014; Los Angeles, California.