Factors associated with cognitive impairment in a cohort of older homeless adults: Results from the HOPE HOME study

Abstract

Background We evaluated cognitive function and factors associated with cognitive impairment in a cohort of older homeless adults. We hypothesized that substance use and a history of traumatic brain injury would be associated with cognitive impairment. Methods We recruited 350 homeless individuals aged ≥50 years using population-based sampling and conducted structured interviews and neuropsychological testing. We evaluated alcohol use with the Alcohol Use Disorder Identification Test, defining high-severity alcohol use as a total score ≥16 or ≥4 on the alcohol dependency sub-scale. We assessed global cognition with the Modified Mini-Mental State Test (3MS) and processing speed and executive function with the Trail Making Test (TMTB), defining impairment as performing 1.5 standard deviations below the standardized mean. We used multivariable logistic regression to examine the association between alcohol use and cognition. Results Participants had a median age of 58 years [IQR 54–61], 76.7% were men, and 79.9% were African American. A quarter (25.1%) of participants met criteria for impairment on the 3MS; 32.9% met criteria for impairment on TMTB. In models adjusted for sociodemographic variables and health conditions, high-severity alcohol use was associated with global cognitive impairment (AOR 2.39, CI 1.19–4.79) and executive dysfunction (AOR 3.09, CI 1.61–5.92). Conclusions Older homeless adults displayed a prevalence of cognitive impairment 3–4 times higher than has been observed in general population adults aged 70 and older. Impaired cognition in older homeless adults could impact access to housing programs and the treatment of health conditions, including the treatment of alcohol use disorders.

Cognitive impairment and homelessness: A scoping review

“…Empirical studies mostly ( n = 29) recruited from homeless populations, with definitions of homelessness ranging from absolute homelessness to recently rehoused, or in unsecure or unsuitable accommodation. Additional sample criterion included veteran status (Barnes et al, ; Brenner et al, ) and older age (Brown et al, ; Brown, Kiely, Bharel, & Mitchell, ; Hurstak et al, ; Joyce & Limbos, ; Okamura et al, ). Of studies which did not sample from homeless populations, two recruited from prisons (Hennessey, Stein, Rosengard, Rose, & Clarke, ; McCarthy et al, ), and other sampling frames included professionals who worked with the homeless (Colman, Hebblethwaite, Hames, Forsyth, & Donkin, ), mental health service clients (Keyser & Mathiesen, ), and records of hospital admissions (McMillan et al, ).…”

“…Some papers reported on the same project or sample. These papers are at times reported on independently due to differences in sample type (Colman et al, ; Hebblethwaite, Colman, Hames, Forsyth, & Donkin, ) and measures or methodology employed (Barnes et al, ; Brenner et al, ; Brown et al, ; Hurstak et al, ; Pluck et al, ; Van Straaten et al, ).…”

“…Two papers directly investigated the link between mental health problems or substance abuse and CI. Using a subset of Brown et al’s, sample of older homeless adults, Hurstak et al () found high‐severity alcohol use was strongly associated with cognitive impairment. Furthermore, in a sample of 1,500 homeless adults with mental health problems, Stergiopoulos et al () recorded 72% CI, noting around half of their sample met criteria for psychosis, major depressive disorder, and alcohol or substance use disorder.…”

“…Furthermore, in a sample of 1,500 homeless adults with mental health problems, Stergiopoulos et al () recorded 72% CI, noting around half of their sample met criteria for psychosis, major depressive disorder, and alcohol or substance use disorder. Despite these correlations, both studies note that their cross‐sectional design limits implications of causality (Hurstak et al, ; Stergiopoulos et al, ). Stergiopolous et al () also acknowledge that much of the variation in their sample was unaccounted for, and other variables of interest, such as the presence of learning disability, were not tested for.…”

“…Low levels of educational attainment and inconsistent employment were also suggested as leading to poverty and subsequent homelessness (Hennessey et al, ). Many prevalence studies found that within homeless populations levels of educational attainment were lower for those with CI (Hurstak et al, ; Patterson et al, ; Rogoz & Burke, ; Stergiopoulos et al, ; Van Straaten et al, ). CI was also linked to contact with the Criminal Justice System.…”