Old, alone and on the streets

With their numbers rising, elderly homeless people need you
more than ever

By Wendy Banks

OLD BEFORE THEIR TIME
Defining the perimeters of the term 'elderly' gets complicated when it comes to homeless persons. Many researchers argue that homeless lifestyle and exposure to the elements renders such people old before their time. As a result, old age is often set at 55+ years for the homeless.

"There are relatively few homeless people over the age of 65 or 70, but there are many people in their 50s who are effectively elderly, who have suffered the biological effects of disease and aging," explains Dr Stephen Hwang, a general internist and homeless healthcare expert at St Michael's Hospital in Toronto and staff physician at Seaton House, the largest homeless shelter in Canada.

Research on the health status of older homeless people in Canada is scant. Although they make up a relatively small percentage of the overall homeless population as a whole, according to a study by Toronto psychiatrists Dr Vicky Stergiopoulos and Dr Nathan Herrmann, in the July 2003 issue of the Canadian Journal of Psychiatry, their numbers appear to be on the rise. Data from homeless hostels indicates that 2% of adult hostel users in Toronto are over 65, and 9% in Alberta are over 55. The Mission, an emergency shelter in Ottawa, reports that about 10% of its visitors were over 55; Montreal elderly homeless day centre Le PAS de la rue reports an attendance of about 120 people a day.

SPECIAL HEALTHCARE NEEDS
Dr Stergiopoulos and Dr Herrmann set out to find out how older homeless people's health needs differ from the majority of people living on the streets and in shelters. They found that this group presents a host of medical challenges that aren't even on the radar for younger homeless people.

The researchers asked staff at 11 Toronto hostels to fill in a questionnaire about their elderly clients. They reported that, like younger clients, substance abuse and mental illness are common among elderly shelter visitors. Older people are less likely to abuse illicit drugs and no more likely to be alcoholics than younger people. As for mental illness, depression seems to be more common among older homeless people. The main difference — a higher rate of cognitive impairment and dementia — is probably due to advanced age.

"Those over age 65 years are more likely to have memory difficulties, a concurrent physical illness, restricted mobility, difficulty with self-care, and difficulty planning daytime activities," write Dr Stergiopoulos and Dr Herrmann. A recent housing report for the Canadian Mortgage and Housing Corporation counts stroke, heart conditions and incontinence among the health problems that plague older homeless people.

STABILITY IS KEY
All this means their needs for care are different, too. Dr Hwang says elderly homeless people tend to remain in the system longer. And although a fear of violence from younger homeless people can sometimes drive them to the streets, many older people end up using one shelter for years on end. That's almost an advantage, at least in terms of access to health care.

"In my experience, they're more willing to accept assistance than the younger homeless people," says Dr Hwang. "So, whereas a 30-year-old might go their own way and ignore advice, 70-year-olds are much more likely to allow the shelter staff to help them with their medications."

Unlike younger homeless people, who often rely on the emergency room and outreach workers as their main source of care, most elderly homeless people have a much closer relationship with the medical mainstream of clinics, specialists and family doctors.

So what's an inner city GP to do when they start treating an elderly homeless patient? "One key thing is to think of shelter staff as the patient's surrogate family," Dr Hwang advises. "Often they'll have a certain sense of protectiveness towards their elderly patients. To coordinate office visits, transportation, laboratory testing, even monitoring of patients' well-being, it's critical to be in communication with them."

Dr Stergiopoulos and Dr Herrmann found that older homeless people end up in stable housing far less often than expected, which "may be owing to lack of supportive housing, strict nursing-home admission criteria, and their fear of institutionalization."

But even when they do find housing, it may be a mixed blessing: "Because some of these people qualify for pension benefits," says Dr Hwang, "they're more able to move out of the shelter system and into some kind of housing, and paradoxically sometimes that's when you get lost to follow-up. In the shelter system, at least there's someone there who you see every day. When you're on your own in a basement apartment, there's often no one."