Physical Health Needs

Older adults experiencing homelessness have significantly shorter life spans than housed older adults, though they die from similar chronic conditions.

Studies consistently document a shorter life span of older adults experiencing homelessness despite the range of sub-populations studied, including individuals staying in shelters in New York City (Metraux et al., 2011); veterans in transitional homeless programs (Schinka et al., 2017; Schinka & Byrne, 2018); and individuals experiencing homelessness in Oakland, California (Brown et al., 2016; Kushel, 2020). For example, Metraux and colleagues (2011) matched administrative records for adults staying in the New York City shelter system with death records from the Social Security Administration. They found that older adults experiencing homelessness have a life expectancy of approximately 64 years for men and 69 years for women (Metraux et al., 2011), compared to national life expectancies of 76 years for men and 81 years for women (Xu et al., 2020). Further, Hwang and colleagues (1997; 2008) found that both older adults experiencing chronic homelessness and those who first became homeless later in life had elevated mortality rates. Finally, although the most common causes of death among older homeless adults are similar to housed older adults, for example, cancer and cardiovascular disease, these illnesses occur approximately 20 years earlier (Kushel, 2020).

Older adults experiencing homelessness have health challenges similar to older adults who are housed but who are of more advanced ages.

Adults experiencing homelessness between ages 50 and 62 often have health conditions that are more severe than housed individuals their own age, but similar to those of housed people who are 10-20 years older (Cohen, 1999; Gelberg et al., 1990; HPRI, 2019; Brown et al., 2016). Compared to their housed counterparts, older adults experiencing homelessness have a higher prevalence and severity of physical and geriatric conditions including memory loss, falls, difficulty performing ADLs, and cognitive impairment (Brown et al., 2011; Brown et al., 2017; Hahn et al., 2006; Hwang et al., 1997). Moreover, comorbid conditions among older adults experiencing homelessness are common, including hypertension, arthritis, cognitive impairment, frailty, hearing difficulty, and urinary incontinence (Kushel, 2020; Brown et al., 2011, Brown et al., 2016; Brown, 2017; Gelberg et al., 1990). Additionally, in discussions, experts and providers noted that sleep deprivation resulting from sleeping in unsheltered locations such as tents or cars or in shelters that were crowded or offered limited hours of access exacerbated older adults’ physical and mental health challenges and accelerated cognitive decline.

Older adults have different health conditions than younger adults who are homeless, though adults of all ages experiencing homelessness have poorer health status than those who are housed.

Among those experiencing homelessness, older adults compared to younger adults have higher rates of chronic illnesses such as high blood pressure; geriatric conditions, including arthritis, and functional disability; and cognitive impairments (Garibaldi et al., 2005; Gelberg et al., 1990). To illustrate, in a cross-sectional, community-based survey of homeless adults in two United States cities, older adults were 3.6 times as likely to have a chronic medical condition as those under age 50 (Garibaldi et al., 2005). Older adults also were more likely to report two or more medical conditions (59 percent vs 28 percent) compared to the younger adults experiencing homelessness (Garibaldi et al., 2005). A five-year study of 28,000 adults who received care at the Boston Health Care for the Homeless Program reported death rates of almost 2.5 times higher for those ages 45-64 compared to those ages 25-44 (Baggett et al., 2013). When compared to the general housed population of the same ages, people 25-44 years old experiencing homelessness had mortality rates 9 times higher, while people 45-64 years old experiencing homelessness had mortality rates 4.5 times higher (Baggett et al., 2013).

Older adults experiencing homelessness utilize acute health care services at high rates and significantly more than the general population of older adults.

Older adults experiencing homelessness use acute health care services at high rates, with rates across studies ranging from 43 percent to 70 percent for emergency department visits and 10-43 percent for inpatient hospitalizations (Brown et al., 2010; Brown et al., 2011; Raven et al., 2017). Very few studies have compared national rates of acute health care services utilization between older adults experiencing homelessness to those of their housed counterparts. In a study comparing older adults experiencing homelessness in Boston to three nationally representative samples of older adults, 43 percent of the older homeless adults had been admitted to the hospital more than once in the prior year compared to 11 percent of the nationally representative sample. Moreover, whereas 70 percent of the older adults experiencing homelessness had more than one emergency department visit in the prior year, only 19 percent of the nationally representative sample of older adults did (Brown et al., 2011). Further, most older adults experiencing homelessness in the sample had received ambulatory care (87 percent) within the previous 12 months (Brown et al., 2011). A study using a similar sample of older adults experiencing homelessness found a small proportion of the sample accounted for half of all emergency departments and inpatient visits; those who spent the majority of the past six months homeless, either unsheltered or staying in shelters, had significantly higher rates of emergency department visits than those who had spent most of their time housed (Brown et al., 2010).

Older adults experiencing homelessness use the emergency department most frequently for injuries and exposure to violence; complications resulting from substance use, including alcohol and tobacco; and treatment of mental health disorders (Raven et al., 2017). Among people experiencing homelessness, emergency departments remain a low-barrier access point to seek pain management and medical treatment for chronic medical conditions and pain that could be managed in outpatient settings. Although over two-thirds of the sample of adults 50 and older experiencing homelessness in the study reported having a regular non-emergency place for routine care, it was not associated with reduced use of the emergency department (Raven et al., 2017).

Older adults and younger adults experiencing homelessness use acute health care services at similar rates, despite differences in having health insurance and a regular health care place or provider.

In Brown’s 2010 study of health care utilization by people experiencing homelessness, adults aged 50 and older were more likely to have health insurance, a regular place for health care, and a regular health care provider (e.g., medical doctor, nurse practitioner, or registered nurse) than those under 50. However, both groups had similar rates of acute health care utilization in the prior year, including emergency department visits (43 percent of older adults vs. 49 percent of younger adults) and inpatient hospitalizations (32 percent of older adults vs. 40 percent of younger adults) (Brown et al., 2010). This study showed no significant differences between age groups in the type of visit; most visits were for physical ailments (85 percent for older adults vs. 88 percent for younger adults) as opposed to emotional problems (19.5 percent for both age groups) (Brown et al., 2010).

Behavioral Health Needs

Older adults experiencing homelessness, especially women, are more likely to have mental health conditions than older housed adults.

In studies with samples of older adults experiencing homelessness (Brown et al., 2011; Kaplan et al., 2019), older adults in permanent supportive housing (Henwood et al., 2018), and veterans (Schinka et al., 2012), between 40 percent and 58 percent either screened for or reported mental health conditions. For example, 56 percent of older adults in permanent supportive housing reported at least two chronic mental health conditions (Henwood et al., 2018). Depression was the most common condition identified; other conditions include schizophrenia and post-traumatic stress disorder. These rates of mental health conditions are higher among older adults experiencing homelessness than older housed adults (which range from 18 percent to 34 percent), measured both by diagnoses and symptomology (Brown et al., 2011; U.S. CDC, 2008).

Some studies find evidence of gender differences in rates of mental health conditions among older adults experiencing homelessness. Compared to older homeless men, older homeless women were two and one-half times more likely to have any chronic mental health condition and more likely to be diagnosed with more mental health conditions (Winetrobe et al., 2017; Dickins et al., 2021).

Findings from the Health and Retirement Study indicate race and ethnic differences in the behavioral health conditions of older adults experiencing homelessness. Compared to their White counterparts, Black and African American older adults experiencing homelessness are significantly more likely to report a history of illicit drug use and less likely to report a history of mental illness or domestic violence than White older adults experiencing homelessness (Chekuri et al., 2016).

Older adults experiencing homelessness also have more substance use disorders than the general population.

Although there are no studies that directly compare older homeless adults to their housed counterparts on substance use, a few studies have compared older homeless adults to population-based samples and to other samples. Studies generally find that a higher percentage of older adults experiencing homelessness report alcohol and/or drug use than population-based samples (e.g., CDC, 2008). In the HOPE HOME cohort of older adults experiencing homelessness, for example, rates of binge drinking were significantly higher in older homeless adults than in three large-scale studies of older adults using population-based samples (30 percent vs. 1 percent, 7 percent, and 3 percent) and a greater percentage of the older adults experiencing homelessness reported moderate or greater severity of alcohol use (26 percent) than housed adults of all ages (5 percent) served in a U.S. Department of Veterans Affairs (VA) primary care clinic (Brown et al., 2019). This sample also had a higher rate of current illicit substance use (63 percent) than a national community-based sample of adults of all ages experiencing homelessness (23 percent) (Spinelli et al., 2017).

Studies to date yield inconsistent findings on the differences in mental health conditions and substance use between older and younger adults experiencing homelessness.

It is unclear whether there are age differences in the prevalence of behavioral health conditions among individuals experiencing homelessness. Whereas some studies have found a higher prevalence of mental health conditions such as anxiety, depression, and post-traumatic stress disorder (Garibaldi et al., 2005; Tompsett et al., 2009) among older adults experiencing homelessness than among their younger counterparts, other studies have found either no significant differences in the rates of these conditions (DeMallie et al., 1997; Gelberg et al., 1990) or the opposite finding (Gordon et al., 2012).

Similarly, the limited studies that contrast rates of substance use between older and younger adults experiencing homelessness yield mixed findings. Some studies suggest that, among people experiencing homelessness, younger adults are more likely to use drugs than older adults while older adults may be more likely to use alcohol (DeMallie et al., 1997; Gordon et al., 2012). Yet other studies fail to find such differences (Hecht & Coyle, 2001; Gelberg et al., 1990) or find that there is a lower prevalence of substance use disorders for older versus younger adults experiencing homelessness (Burt et al., 1999; Dietz et al., 2009).

Preliminary evidence suggests older adults who first experienced homelessness earlier in life are more likely to have behavioral health conditions than those who first experienced homelessness after age 50.

In the only study to compare differences between newly and chronically homeless older adults, Brown and colleagues (2016) found that participant characteristics and life course experiences differed by age at first homelessness. Compared to individuals whose first homelessness occurred at age 50 or older, individuals with first homelessness before age 50 showed a greater prevalence of behavioral health disorders at different stages in life. For example, this group had higher rates of drug use in childhood and mental health problems in young and middle adulthood, as well as a higher prevalence of current mental health issues, including depressive symptoms and post-traumatic stress disorder, and drug use, and higher rates of hospitalizations for mental health problems in adulthood (Brown et al., 2016).

Individuals who had experienced homelessness as older adults reported high rates of physical and behavioral health problems, echoing findings from the literature.

All of the older individuals with lived experience of homelessness with whom we spoke discussed suffering from physical and behavioral health problems, including diabetes, HIV, traumatic brain injury, glaucoma, arthritis, bipolar disorder, post-traumatic stress disorder, and substance use disorder. A few people also reported having experienced strokes or cancer in the past. Many of the interviewees, including all of those who were homeless at the time of our interview, reported physical pain and mobility issues, often attributed to being unsheltered. For example, one individual reported they had lost several toes due to frostbite contracted while being outside in bad weather.

Basic Needs

Older adults experiencing homelessness have high rates of food insecurity.

Food insecurity coupled with insufficient nourishment complicates chronic disease management and presents a major challenge for older homeless adults who have a high prevalence of chronic disease and limited mobility (Brown et al., 2011; Patanwala et al., 2018). Food insufficiency among older adults is associated with significantly greater odds of hospitalization for any reason, psychiatric hospitalization, and high emergency department utilization (Baggett et al., 2011). Individuals who are food insecure -- having limited access to adequate food due to lack of resources -- have poorer health and are more likely to consume foods deficient in nutrients (Robaina & Martin, 2013). Also, severely cost-burdened older adults who are in the bottom income quartile reduce their spending on food by 30 percent more than those who are not cost-burdened (National Association of Area Agencies on Aging [n4a], n.d. b). Among participants in the HOPE HOME study, over half reported food insecurity, with one-third reporting low food security and one-quarter reporting very low food security (Tong et al., 2018), consistent with food insecurity estimates among other homeless populations (e.g., Parpouchi et al., 2016) and nearly two times higher than national estimates among the United States population living in poverty (Coleman-Jensen et al., 2016).

Lack of transportation poses a significant barrier for older adults experiencing homelessness.

Adults experiencing homelessness commonly indicate their most used modes of transportation include public transit and walking (Chan et al., 2014; North et al., 2017; Murphy, 2019), which are more difficult for older individuals with mobility challenges. Lack of transportation has been cited as a barrier for adults experiencing homelessness, as it reduces access to shelter and housing, medical and behavioral health care, social engagement, food, and other supportive services (Greysen et al., 2012; Hui & Habib, 2014, ²⁰¹⁷; Niño, Loya, & Cuevas, 2009; Murphy, 2019; Turnbull, Muckle, & Masters, 2007). Among studies of older adults experiencing homelessness, mobility challenges (i.e., difficulty walking without help) and challenges with instrumental ADLs such as using public transportation are common (Henwood et al., 2018). Thus, it is reasonable to conclude that older adults experiencing homelessness face transportation barriers even beyond those of younger adults experiencing homelessness. However, there is little available research focused on transportation issues specifically among older adults experiencing homelessness.

Older adults experiencing homelessness, including those who are newly placed into housing, experience loss of community.

Many of the experts and providers with whom we spoke noted that mobility limitations, frequent address changes, receipt of housing assistance in a new neighborhood, and the death of family and friends contribute to formerly homeless older adults having limited social networks. Multiple interviewees noted that social and physical isolation among this population can contribute to further cognitive and physical declines. One housing provider noted that formerly homeless older residents in her organization’s properties often struggle to identify someone who can serve as their medical power of attorney following years of social isolation.