This question came from Glenda L. via our latest website survey: “How will the needs of seniors with dementia who are at risk of becoming homeless be effectively met? These are vulnerable individuals who may need a high level of support to obtain and retain housing.”
Many existing services for people experiencing homelessness do not meet the unique needs of seniors, especially those with dementia or other cognitive impairments. With the number of seniors experiencing homelessness growing over the past few years – doubling in Toronto between 2009 and 2013 - this is a really important question. Like anyone else, the causes of homelessness for seniors are varied and can include:
...lack of finances to pay for housing (low government assistance, insufficient pensions etc), lack of affordable and secure housing (including conversion of apartments into unaffordable condominiums), declining physical health, mental health issues, relationship breakdown, violence and abuse. The risk of homelessness can also be compounded by the death of a spouse, social isolation, discrimination, or lack of knowledge of benefits and services.
In the category of personal factors, however, dementia is important to highlight amongst the risk factors for homelessness. According to the Alzheimer’s Association, dementia describes a series of symptoms of decline in memory or other thinking skills that affect someone’s everyday life. Alzheimer’s disease is 60-80% of cases, while vascular dementia (after a stroke) is the second most common type. Symptoms include memory loss, faulty reasoning, and impaired judgment. Diagnosing dementia among seniors who are isolated and/or experiencing homelessness can be challenging as it requires a series of tests and documented patterns of behaviour. Another area of concern is the premature aging caused by stressful living conditions in poverty and/or homelessness - for example, people who may be biologically 50 years old may be need to be screened as if they were 65.
While the rate of diagnosed dementia amongst seniors experiencing homelessness compared to those who are housed varies by study - a Toronto study placed both at 6%; while a study based in Sydney estimated that 67% of the older homeless population showed evidence of cognitive impairment), declining mental abilities can compound other existing issues (such as limited income, sparse social supports) and put someone at a high risk of homelessness.
Research on the specific relationship between dementia and homelessness is scarce. A 2015 literature review of Australian research found that most studies are, on average, over ten years old. There is a need for more, but existing studies have provided some useful frameworks for how we can approach service provision for seniors with dementia. As the author of the literature review concluded:
…providing access to services including aged care, health and housing for older homeless people with multiple complex problems including mental illness who are hard to reach and do not seek services, is challenging. Therefore a combination of outreach using multidisciplinary teams to initially build trust with older homeless people, make assessments and evaluate the type of care needed, as well as an effective pathway through the aged care system to permanent housing either in the community or in residential aged care, is recommended. [O’Connell, 2004; Yang et al 2006; Crane et al, 2008; Rogoz et al, 2008) Ultimately, the best model for care of older homeless people is a one stop service that provides prevention, outreach, assessment and evaluation, all types of housing including crisis, transitional, community and residential, supportive services such as mental health, addiction etc; assistance with all aspects of daily living and continuity of care. (Green 2005)
Many Canadian studies also recommend moving towards a coordinated system of care that seamlessly provides services. In one Ontario case study, 129 older adults experiencing homelessness “…confirmed the value of a continuous caring relationship with an identified provider and the delivery of a seamless service through coordination, integration and information sharing between different providers.” Similarly, another Canadian study from 2009 examined a community shelter program that gave residents access to primary care physicians, nurses, personal support workers, and housing workers. The writers concluded that such an integrated system helped workers identify mental health and cognitive issues that may not have been otherwise discovered.
Fortunately, the Canadian government has already identified seniors as a priority population and has made progress in helping them age in place. In the Action for Seniors Report (2014), the following initiatives (among others) are highlighted:
- An investment in affordable housing that benefitted almost 184,000 households
- The Homelessness Partnering Strategy, which invests in programs and services to reduce homelessness and advocates for a Housing First approach
- The Home Adaptations for Seniors Independence Program, which assists Aboriginal seniors in making changes to on-reserve homes
While progress is definitely being made, we must continue working towards changing how we help seniors experiencing or at risk of experiencing homelessness. We will also need to:
Plan for the long-term
Hostels and shelters are not appropriate housing for seniors who, in addition to declining cognitive ability, may also have physical mobility issues that make these environments difficult to access. These seniors may also not be able to retain their existing housing and may need to look into long-term care.
Despite there being some funding for coordinated care teams, these teams only address a few of the issues faced by seniors. As such, we will need to look beyond emergency and transitional housing and invest in more long-term housing options. This will involve putting pressure on municipal, provincial and federal governments to go beyond Housing First and affordable housing plans to include more long-term/permanent supportive housing for seniors in our communities.
Start outreach early
Many seniors become socially isolated. Furthermore, some may worry about losing their independence and avoid making contact with healthcare providers until they absolutely have to. As Barrett et al. pointed out (from the Australian literature review):
Unfortunately due to the lack of engagement with services until an acute episode where urgent hospitalisation is required, preventative care delivered within the community poses enormous challenges (Barrett et al, 2011). A number of studies have found that effective models of care include outreach on an ongoing basis. In this way the many acute and chronic conditions that older homeless people suffer can be managed to minimise disability. Acute conditions can be detected in an earlier stage and chronic conditions can be better managed to prevent exacerbation (O’Connell et al, 2004; Green, 2005; Yang et al 2006; Crane et al, 2008; Rogoz et al, 2008).
Even though it requires more financial support and the use of multidisciplinary teams (doctors, housing workers, support workers, etc.), ongoing outreach to seniors at risk of homelessness will be crucial in making early screening for dementia and appropriate care a reality.
Invest in senior-specific programming
We will also need to support dementia-focused, senior-specific programs, as:
There is a strong need for more health care providers who are specialized in the care of seniors with mental health disorders, including those who reside in institutional settings. Current service delivery models do not meet the complex and ever changing mental health needs of seniors. There is a pressing need for best practice guidelines in managing multiple mental illnesses and physical problems in aging Canadians. Family caregivers also need a coordinated range of supports in order to help senior family members with mental disorders and to meet their own needs as the caregiver. The economic value of those support services is enormous.
This last point about caregivers is really important, especially for seniors who cannot afford to live in high-end institutions or who want to stay in their homes. While the Canadian government does offer 6 weeks of Compassionate Care Coverage and the Family Caregiver Tax Credit, this is not enough to support long-term, full-time care of seniors who need it.
Finally, these services will also have to be culturally appropriate. For Indigenous seniors experiencing homelessness, funding for housing both on and off-reserve is important; as well as for Indigenous caregivers.
- What makes good supportive housing?
- How does homelessness affect senior women?
- What are the pathways to homelessness in old age?
This post is part of our Friday "Ask the Hub" blog series. Have a homeless-related question you want answered? E-mail us at firstname.lastname@example.org and we will provide a research-based answer.
Photo credit: Affinity Training (UK)