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The homeless population is aging; older homeless adults may be at high risk of experiencing violent victimization. To examine whether homelessness is independently associated with experiencing physical and sexual abuse, we recruited 350 adults, aged 50 and older in Oakland, California, who met criteria for homelessness between July 2013 and June 2014. We interviewed participants at 6-month intervals for 3 years in Oakland about key variables, including housing status. Using generalized estimating equations, we examined whether persistent homelessness in each follow-up period was independently associated with having experienced physical or sexual victimization, after adjusting for known risk factors. The majority of the cohort was men (77.4%) and Black American (79.7%). At baseline, 10.6% had experienced either physical or sexual victimization in the prior 6 months. At 18-month follow-up, 42% of the cohort remained homeless. In adjusted models, persistent homelessness was associated with twice the odds of victimization (adjusted odds ratio [AOR] = 2.01; 95% confidence interval [CI]: [1.41, 2.87]). Older homeless adults experience high rates of victimization. Re-entering housing reduces this risk. Policymakers should recognize exposure to victimization as a negative consequence of homelessness that may be preventable by housing.

Background/Objectives: Older homeless-experienced adults have low rates of advance care planning (ACP) engagement despite high rates of morbidity and mortality. To inform intervention development, we examined potential barriers and solutions to ACP engagement. Design: Cross-sectional qualitative study. Setting: We recruited adults who were homeless in the prior three years and ≥50 years of age in the San Francisco Bay Area, and recruited clinical stakeholders from a national meeting of homeless providers. We analyzed qualitative data using thematic analysis. Measurements: We conducted semistructured interviews with homeless-experienced older adults (n = 20) and focus groups with clinical stakeholders (n = 24) about perceived barriers and solutions to ACP engagement. Results: Participants considered ACP important, reflecting on deaths of people in their networks who had died. Participant-identified barriers to ACP included poor ACP knowledge, lack of familial ties and social isolation, competing priorities, avoidance and lack of readiness, fatalism and mistrust, and lack of ACP training for clinical and nonclinical staff. They identified solutions that included framing ACP as a way to provide meaning and assert choice, providing easy-to-read written documents focused on the populations' unique needs, tailoring content and delivery, initiating ACP in nonclinical settings, such as permanent supportive housing, and providing incentives. Conclusions: Both older homeless-experienced adults and clinical stakeholders believe that ACP is important, but acknowledge multiple barriers that impede engagement. By focusing on potential solutions, including capitalizing on opportunities outside of health care settings, focusing on the period after housing, and tailoring content, there are opportunities to improve ACP uptake.

ObjectivesTo describe the prevalence of and factors associated with oral health measures in a sample of older homeless adults in Oakland, CA.MethodsWe conducted a cross-sectional analysis of data from a population-based study of 350 homeless adults aged ≥50 in which trained researchers conducted structured interviews using validated questions regarding sociodemographics, health-related behaviors, healthcare utilization, and health status. We assessed self-reported tooth loss, oral pain, and unmet need for dental care. We used multivariable logistic regression to examine factors associated with missing half or more teeth.ResultsOver half 201/350 (57.4 percent) of participants were missing at least half of their teeth. Half 191/350 (54.6 percent) reported oral pain in the past 6 months; 101/350 (28.9 percent) reported that oral pain prevented them from eating and 73/350 (20.9 percent) reported that pain prevented sleeping. Almost half, 141/350 (40.3 percent), had not seen a dentist in over 5 years, and over half 190/350 (54.3 percent) reported being unable to obtain needed dental care. In multivariate models, increased age (AOR = 1.09, 95 percent CI 1.04-1.14), moderate-to-high risk alcohol use (AOR = 2.17, CI = 1.23-3.84), moderate-to-high risk cocaine use (AOR = 1.72, CI = 1.03-2.88), and ever smoking (AOR = 2.87, CI = 1.59-5.18) were associated with an increased odds of having lost half or more teeth.ConclusionsTooth loss and oral pain are highly prevalent in older homeless adults. Increasing age, alcohol, drug, and tobacco use are associated with tooth loss.

AimsTo examine the prevalence of and factors associated with unmet need for mental health and substance use treatment in older homeless adults.MethodsAmong 350 homeless adults aged ≥50, we examined prevalence of mental health and substance use problems and treatment. Using logistic regression, we examined factors associated with unmet treatment need.ResultsAmong those with a mental health problem, being aged ≥65 was associated with an increased odds, while having a regular healthcare provider and case manager were associated with a decreased odds of having unmet need for mental health treatment. A first homelessness episode at age ≥50 was associated with increased, while spending time in jail/prison or having a case manager was associated with decreased odds of unmet needs for substance use treatment.ConclusionOlder homeless adults have a high prevalence of unmet behavioral health treatment need. There is a need for targeted services for this population.

Difficulty performing activities of daily living ("functional impairment") is common in homeless adults aged 50 and older. However, little is known about the trajectory of these impairments, nor the extent to which these trajectories are similar to those of older adults in the general population. We identified trajectories of functional impairment in homeless adults aged 50 and older, and risk factors for differing trajectories. We conducted a prospective cohort study of 350 homeless adults, aged 50 and older, recruited via population-based sampling in Oakland, California and interviewed at 6-month intervals for up to 3 years. We assessed functional trajectories based on self-reported difficulty performing 5 activities of daily living. We used multivariable multinomial logistic regression to identify baseline risk factors for each trajectory. At baseline, participants' mean age was 58 years (SD, 5.3), 24.1% were women, 80.9% were African American, and 38.6% had difficulty performing 1 or more activities of daily living. We identified 4 distinct functional trajectories: minimal impairment in 136 participants (41.1%); persistent impairment in 81 (25.4%); partial improvement in 74 (23.5%); and decline in 28 (10.0%). Risk factors for persistent impairment included falls in the 6 months before baseline, depressive symptoms, and low physical performance. Although functional impairment improved in some homeless adults, it persisted or worsened in many others. These findings suggest that, similar to older adults in the general population, functional impairment among older homeless persons is not a transient phenomenon, but instead a chronic issue requiring long-term solutions.

ContextThe homeless population is aging. Older homeless adults experience premature development of age-related conditions and an elevated symptom burden. Little is known about symptom experience among older homeless adults.ObjectivesTo characterize the experience, understanding, and management of physical, psychological, social (e.g., loneliness), and existential (e.g., regret, loss of dignity) symptoms among older homeless adults.MethodsWe conducted semistructured interviews from June 2016 to March 2017 with a purposive sample of participants from the Health Outcomes of People Experiencing Homelessness in Older Middle Age cohort, a longitudinal study of homeless adults aged 50 and older. We analyzed data between June 2016 and December 2017 using thematic analysis.ResultsWe found four main themes: 1) nonphysical symptoms are interwoven with, and as distressing as, physical symptoms; 2) individuals attribute symptoms to childhood abuse, manual labor, the conditions of homelessness, and aging; 3) symptoms interfere with daily functioning, causing negative changes in personality, energy, and motivation; and 4) individuals cope with symptoms through religion, social support, and substance use.ConclusionHomelessness causes and exacerbates physical and psychological distress. Interventions should address multiple interconnected dimensions of suffering. Health systems that care for homeless patients should adapt palliative care practices using a stepwise approach. Homeless shelters should adopt policies and modifications that increase privacy and autonomy while promoting community building. Housing interventions should promote community building. All who work with people experiencing homelessness should avoid stigmatizing language and recognize homeless individuals' sources of strength and coping.

Older homeless-experienced adults have low engagement in advance care planning (ACP) despite high morbidity and mortality. We conducted a cross-sectional analysis of a cohort of 350 homeless-experienced adults aged 50 and older in Oakland, California. We assessed the prevalence of potential surrogate decision-makers, ACP contemplation, discussions, and ACP documentation (surrogate designation, advance directives). We used multivariable logistic regression to examine factors associated with ACP discussions and documentation. The median age of the cohort was 59 (range 52-82), 75.2% were male, and 82.1% were black. Sixty-one percent reported a potential surrogate, 21.5% had discussed ACP, and 19.0% reported ACP documentation. In multivariable models, having 1 to 5 confidants versus none (adjusted odds ratio (aOR)=5.8, 95% confidence interval (CI)=1.7-20.0), 3 or more chronic conditions versus none (aOR=2.3, 95% CI=0.9-5.6), and a recent primary care visit (aOR=2.1, 95% CI=1.0-4.4) were associated with higher odds of ACP discussions and each additional 5 years of homelessness (aOR=0.7, 95% CI=0.5-0.9) with lower odds. Having 1 to 5 confidants (aOR=5.0, 95% CI=1.4-17.5), being black (aOR=5.5, 95% CI=1.5-19.5), and having adequate versus limited literacy (aOR=7.0, 95% CI=1.5-32.4) were associated with higher odds of ACP documentation and illicit drug use (aOR=0.3, 95% CI=0.1-0.9) with lower odds. Although the majority of older homeless-experienced adults have a potential surrogate, few have discussed or documented their ACP wishes; the odds of both were greater with larger social networks. Future interventions must be customized for individuals with limited social networks and address the instability of homelessness, health literacy, and the constraints of safety-net healthcare settings.