People experiencing homelessness develop geriatric syndromes and medical conditions that occur more commonly with older age, including cognitive and functional impairment, at younger ages than their counterparts who have not experienced homelessness.
The proportion of people 50 years and older using shelters is increasing, but most shelters in Canada are not adequately designed and resourced to meet the needs of older adults.
Older adults experiencing homelessness, who have often have a history of injustice and trauma, require individualized and integrated approaches to meet their needs; these approaches require collaborations between health and long-term care, public health, housing, and other community agencies.
Many older adults experience homelessness in Canada, yet current shelters and temporary housing are not designed or resourced for them. We outline the magnitude of this large and growing public health and social challenge, describe the social and health care needs of older adults experiencing homelessness, and suggest potential solutions.
How many older adults are experiencing homelessness?
People experiencing homelessness are considered older adults at age 50 years and older, given that phenotypic aging occurs at younger ages in this population.1 According to Canada’s National Shelter Study, the estimated proportion of adults aged 50 years and older among people staying in shelters rose from 13.5% (n = 19 179) in 2005 to 24.2% (n = 33 011) in 2014, with those aged 65 years and older doubling from 1.6% (n = 2244) to 3.2% (n = 4332).2 People older than 50 years were the only age group to have increased shelter use over this time.3 In 2021, 32% of people using shelters were aged 50 years and older.4 These statistics do not include the many older adults who were unsheltered, living outdoors, and experiencing hidden homelessness in provisional accommodations, such as living temporarily with friends or family.2
What puts older adults at risk of homelessness?
Some older adults experiencing homelessness were homeless earlier in life, while others experience homelessness for the first time in later life. Those with homelessness first occurring before the age of 50 years are more likely to have a history of earlier adverse experiences such as trauma and abuse, lower attainment of typical milestones (e.g., stable employment, stable relationships, high school education), and mental health conditions and substance use.5 Some circumstances that occur with advancing age can lead to first homelessness in later life, such as physical health problems, relationship changes (e.g., breakdown of a cohabitation relationship, death of a relative), and lower, fixed income because of the transition to retirement or employment loss.6 However, qualitative and observational research conducted in the last 2 decades in several countries points to insufficient income and a shortage of affordable and suitable housing as core drivers of the rise in late-life homelessness.6,7
In-depth interviews have revealed that interrelated disadvantages experienced throughout all life stages contribute to homelessness and perpetuate health disparities in later life.5,6 Economic disadvantages starting earlier in life contribute to lower income and fewer financial reserves in later life, which can amplify the impacts of high living costs and lack of housing.6,7 Black older adults are overrepresented in shelters, compared with their White counterparts, which highlights how lifelong overt and structural racism affects income, employment, and other opportunities.8 Gender differences in income and career trajectories contribute to a greater proportion of women than men with core housing needs (21% and 9%, respectively).9
Complex health states that occur more commonly in older age — such as dementia, frailty and falls, and chronic health conditions — also contribute to the risk of homelessness.10 Dementia and other causes of cognitive impairment make it harder to navigate health care, social services, and housing systems, especially in the context of breakdowns in personal relationships or social networks. 6 Missed rental payments and hoarding because of cognitive impairment can result in eviction.11 Shortages of appropriate housing options, health and social services to support older adults’ ability to age in place, and vacancies in long-term care (LTC) homes further increase the risk of homelessness among older adults.10
How do older adults experience homelessness?
Evidence suggests that people experiencing homelessness develop manifestations of advanced age and are considered “seniors” at younger ages than those who are housed. Follow-up interviews with participants recruited into a large cohort of people experiencing homelessness during midlife in 1 urban centre in the US found that older adults experiencing homelessness (median age of 58 yr) had geriatric syndromes at higher rates than their housed counterparts (median age 79 yr), including cognitive impairment (25.8% v. 12.0%), difficulties with activities of daily living (38.9% v. 22.6%), visual impairment (45.1% v. 13.8%), and urinary incontinence (48% v. 41.1%).1 A systematic review found that the mean prevalence of cognitive impairment was 25.4% among people experiencing homelessness (mean age 46 yr), which was 5–8 times greater than the average of adults aged 70 years and older.12
A large cohort study found that older adults experiencing homelessness have more chronic health conditions — including cardiovascular disease, mental health diagnoses, and dependency on alcohol, tobacco, and criminalized drugs — than their housed counterparts.5 Moreover, their risk of premature death was recently shown to be 3.5 times higher, with those experiencing homelessness for the first time in late life having the highest risk, possibly because they had a health crisis or a worsening chronic condition, were less resilient to the effects of homelessness than those with previous experiences of it, or both.13
People experiencing homelessness may have prolonged hospital stays.14 When they no longer require acute medical care, they are often discharged to an environment, such as a shelter, where their complex needs cannot be met (e.g., some shelters require residents to vacate during the day).14 Older adults in shelters are more likely than younger people to experience adverse events, including falls, hospital admissions, and being victims of crimes.7
How should older adults at risk of and experiencing homelessness be supported?
A recent Canadian guideline suggested that care of homeless and vulnerably housed people should be tailored to a person’s gender, age, Indigenous heritage, ethnicity, and history of trauma.15 Although few studies have evaluated strategies to prevent first homelessness among older adults, age-related vulnerabilities to homelessness should guide potential interventions.
Social and medical supports
To prevent homelessness, strategies should identify and offer intervention to older adults at highest risk. Service coordinators can review subsidized housing wait-lists to identify and coordinate resources for older adults at highest risk of losing their current housing. 16 Tenancy monitoring programs can identify older adults who are missing rent payments consistently and determine and address the causes, such as cognitive impairment and insufficient income. Financial subsidies may help older adults on fixed incomes to pay rent or mortgages so that they do not forgo basic needs such as food, or lose their housing.16 Other prevention strategies identified by older adults and service providers include addressing isolation (e.g., reuniting with family, matching with roommates), alleviating food insecurity, providing in-home support with activities of daily living, providing transportation, and supporting home modifications.17
Older adults experiencing homelessness deserve shelter policies and government strategies that consider their care needs, and age-friendly shelters that have adequate physical environments, appropriate staffing, and access to required medical services. 7,16 Older adults experiencing homelessness may have faced substantial marginalization, dehumanization, and structural violence, and care models should prioritize trust, rapport building, and ensuring personal safety.18 Trauma-informed approaches are critical to care for those who have experienced abuse and adverse life experiences.15
The Canadian guideline for homeless and vulnerably housed people recommends case management and access to comprehensive primary care.15 Although existing systematic reviews are not specific to older adults experiencing homelessness, these recommendations are likely still appropriate. Primary care, geriatric medicine, and psychiatry services provided within shelters can detect undiagnosed mental health conditions and dementia among older adults experiencing homelessness. Low-barrier, specialized geriatric services may enhance care of older adults experiencing homelessness in shelters.
We developed and implemented a geriatric outreach program for older adults residing in 2 shelters in downtown Toronto, in which a geriatrician provides comprehensive assessments and a geriatric counsellor helps to implement plans, links residents to resources, educates residents and staff, and liaises between the geriatrician, shelter staff, and health care team members, including primary care providers. A preliminary program evaluation involving shelter staff and health care workers found that the program helped to identify undiagnosed and undertreated issues, optimize care for older adults experiencing homelessness, assist in care transitions, and build capacity among clinicians and site staff. Respondents reported that the outreach counsellor with specialized geriatric training and experience was essential to the program.19
Housing
Housing is an important health intervention for older adults experiencing homelessness. Older adults who had formerly experienced homelessness and were then housed had lower mortality than their counterparts who remained homeless or who were institutionalized.13 However, homelessness among older adults can be cyclical if they are not supported by programs that increase the likelihood of successful relocations.20 Housing interventions should provide support for those with decreased mobility, functional decline, and cognitive impairment.10
For older adults experiencing homelessness, urgent development and expansion of housing models that support aging in the right place is needed.10 The models should promote person-centred care that integrates mental and physical health care with housing and social support.10 Important program elements include case management or care navigation, on-site harm-reduction and addiction support, assistance with activities of daily living while promoting life skills and independence, social and recreational programming, relationship building and fostering community, adaptable physical spaces, and staff that are available and empowered to care for older adults.10 Canham and colleagues10 identified and categorized shelter or housing models for older adults experiencing homelessness based on the level of support needed and the intended length of stay. These models included emergency, transitional, or temporary shelter or housing with support; permanent supportive housing; LTC; and palliative care and hospice for end-of-life care.
Permanent supportive housing is a promising model for older adults experiencing homelessness that provides permanent, subsidized housing with on-site or closely linked supportive services for those who do not require continuous supervised care.10 In Ottawa, The Oaks offers harm reduction in permanent supportive housing designed to adapt to the needs of residents as they age.21 The residence provides a medically regulated managed alcohol program, on-site medical and mental health services, case management, assistance with personal care, scheduled activities, meals, and life-skills training. In San Francisco, a permanent supportive housing building — tailored to older adults who have previously experienced homelessness — offers on-site case managers, assistance with activities of daily living, and an adult health program that provides activities and socialization, nursing care, physical therapy, occupational therapy, and meals. An evaluation showed reductions in hospital-based care expenditures after relocation to the building.22 Some older adults who had previously experienced homelessness and had initially moved to skilled nursing facilities, similar to LTC homes in Canada, were successfully transitioned to a level of greater independence in permanent supportive housing. The Program of All-Inclusive Care for the Elderly (PACE) model integrates health and social services within low-income, supportive housing for older adults. Although not specific to older adults who had previously experienced homelessness, this model may reduce hospital use and admissions.23
How should long-term care adjust to better serve older adults experiencing homelessness?
Long-term care may be the most appropriate environment for some older adults experiencing homelessness who require continuous supervised care and higher levels of support with activities of daily living than provided in supportive housing models.10 In Canada, LTC homes have a shortage of vacancies and long wait-lists. However, access to LTC for older adults experiencing homelessness may be disproportionately difficult since they have no fixed address, do not have a consistent health care provider to complete and update the required health assessments, and lack established communication pathways with LTC admission coordinators, which hampers assessment.1,10,20 They are also less likely than housed people to have a stable partner or caregiver to help with advocacy and navigation of the LTC process.1 Since most LTC homes do not support substance use or harmreduction approaches, most decline admission to older adults experiencing homelessness who use substances.10 Concerns that the other LTC residents could be harmed by being exposed to people with a background of homelessness may also trigger application rejection.
Achieving equitable access to LTC for older adults experiencing homelessness will require redesigning LTC assessment and admission processes, including direct admissions from hospitals to LTC. Capacity building in LTC homes and new models of care, co-created with older adults experiencing homelessness, are needed, especially in applying trauma-informed care, accommodating people with substance use disorders, adopting harm-reduction approaches, and expanding managed alcohol programs to LTC.24 Admission to LTC homes should not depend on the financial ability to pay.
A purpose-built LTC model in Australia serves adults at risk of or experiencing homelessness, with different wards for different patient groups, including one for women and one for those with higher physical or cognitive care needs.25 It prioritizes trust-building and uses a trauma-informed lens. A case study reported that participants (median age 76 yr), had significant improvements in personal well-being scores and improvements in healthrelated quality of life; use of the model also resulted in cost savings, driven mainly by reduced hospital admissions.25 When such new models are developed and implemented in Canada, their effectiveness and cost-effectiveness should be evaluated.
Conclusion
Caring for the growing population of older adults experiencing homelessness in Canada will require intersectoral collaborations between health, LTC, public health, housing, and other community agencies. Without urgent action, older adults experiencing homelessness will remain marginalized, undergo early aging, and continue to be at risk for deterioration and death in shelters and other temporary accommodations that are neither equipped nor designed to meet their needs.
Footnotes
Competing interests: Jillian Alston reports funding from the Canadian Institutes of Health Research. Stefan Baral is funded by the Inner City Health Associates. Aaron Orkin is supported by the University of Toronto Department of Family and Community Medicine and the Dalla Lana School of Public Health,, outside the submitted work. Sharon Straus is funded by a Tier 1 Canada Research Chair in Knowledge Translation. The Slaight Family Foundation provides funding to the geriatric shelter outreach initiative and its program evaluation mentioned in this manuscript; Jillian Alston and Sharon Straus are involved with this initiative. No other competing interests were declared.
This article has been peer reviewed.
Contributors: All authors made substantial contributions to the conception or design of the manuscript, with Jillian Alston leading the drafting of the manuscript. All authors made specific contributions to writing the manuscript, revised it critically for important intellectual content, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work.
Disclaimer: Sharon Straus is a member of the CMAJ Governance Council and was not involved in the editorial decision-making process for this article.
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