Introduction

Tobacco-attributable deaths contribute significantly to the increased mortality observed among homeless adults aged 50 years or more. Little is known about the epidemiology of tobacco use among older homeless individuals. This longitudinal cohort study examines smoking behaviors and factors associated with smoking cessation among homeless individuals aged 50 years or more.

Methods

We recruited a prospective cohort of 350 homeless individuals sampled from the community in Oakland, California. At 6 months follow-up, participants reported their cigarette quit attempts and 30-day abstinence. We used multivariable logistic regression to examine factors associated with making a quit attempt at follow-up, hypothesizing that heavier smokers would be less likely to make a quit attempt.

Results

Of the 272 ever-smokers, 229 (84.2%) were current smokers (quit ratio 15.8). Among current smokers at enrollment who had a follow-up interview at 6 months, 43.6% (n = 71) reported making a quit attempt during the follow-up. Of those who reported making a quit attempt, 14.3% (n = 10) reported 30-day abstinence at follow-up. Among those who had reported making a quit attempt at follow-up, 22.5% had used nicotine replacement therapy (NRT). Staying in shelters (adjusted odds ratio [AOR] = 2.5, 95% confidence interval [CI] = 1.0-5.8) was associated with higher odds of making a quit attempt at follow-up. Higher cigarette consumption was associated with lower odds of making a quit attempt (AOR = 0.9, 95% CI = 0.8-0.9).

Conclusions

In this study of tobacco use in older homeless adults, rates of quit attempts were similar to that observed in the general population, but successful quitting was lower.

Implications

The current study is among the first studies to focus specifically on tobacco use and cessation behaviors among older homeless adults. The high prevalence of smoking and the low rates of successful quitting highlight numerous opportunities to intervene to increase quitting rates among this population. Among these, increasing access to smoke-free living environments and identifying effective cessation therapies will be critical to reducing tobacco-related disease burden among older homeless adults.

Objectives

To describe the prevalence of and factors associated with oral health measures in a sample of older homeless adults in Oakland, CA.

Methods

We 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.

Results

Over 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.

Conclusions

Tooth loss and oral pain are highly prevalent in older homeless adults. Increasing age, alcohol, drug, and tobacco use are associated with tooth loss.

Purpose

To examine attitudes toward tobacco control policies among older African American homeless-experienced smokers.

Approach

A qualitative study.

Setting

Oakland, California.

Participants

Twenty-two African American older homeless-experienced smokers who were part of a longitudinal study on health and health-related outcomes (Health Outcomes of People Experiencing Homelessness in Older Middle Age Study).

Method

We conducted in-depth, semistructured interviews with each participant to explore beliefs and attitudes toward tobacco use and cessation, barriers to smoking cessation, and attitudes toward current tobacco control strategies including raising cigarette prices, smoke-free policies, and graphic warning labels. We used a grounded theory approach to analyze the transcripts.

Results

Community social norms supportive of cigarette smoking and co-use of tobacco with other illicit substances were strong motivators of initiation and maintenance of tobacco use. Self-reported barriers to cessation included nicotine dependence, the experience of being homeless, fatalistic attitudes toward smoking cessation, substance use, and exposure to tobacco industry marketing. While participants were cognizant of current tobacco control policies and interventions for cessation, they felt that they were not specific enough for African Americans experiencing homelessness. Participants expressed strong support for strategies that de-normalized tobacco use and advertised the harmful effects of tobacco.

Conclusion

Older African American homeless-experienced smokers face significant barriers to smoking cessation. Interventions that advertise the harmful effects of tobacco may be effective in stimulating smoking cessation among this population.

Aims

To examine the prevalence of and factors associated with unmet need for mental health and substance use treatment in older homeless adults.

Methods

Among 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.

Results

Among 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.

Conclusion

Older homeless adults have a high prevalence of unmet behavioral health treatment need. There is a need for targeted services for this population.

Objective

To examine whether childhood adversity is associated with depressive symptoms, suicide attempts, or psychiatric hospitalization.

Methods

History of seven childhood adversities (physical neglect, verbal abuse, physical abuse, sexual abuse, parental death, parental incarceration, and child welfare system placement) was gathered through in-person interviews. Multivariate models examined associations between history of childhood adversities and moderate to severe depressive symptoms, lifetime history of suicide attempt, or lifetime history of psychiatric hospitalization. The study enrolled 350 homeless adults, aged 50 and older, in Oakland, California, using population-based sampling methods. Moderate to severe depressive symptoms were measured on a Center for Epidemiologic Studies-Depression Scale (≥22), self-reported lifetime history of suicide attempt, and self-reported lifetime history of psychiatric hospitalization.

Results

Participants with exposure to one childhood adversity had elevated odds of reporting moderate to severe depressive symptoms (adjusted odds ratio [AOR]: 2.0; 95% confidence interval [CI]: 1.1-3.7) and lifetime history of suicide attempt (AOR: 4.6; 95% CI: 1.0-21.6) when compared with those who had none; the odds of these two outcomes increased with exposure to additional childhood adversities. Participants with four or more childhood adversities had higher odds of having a lifetime history of psychiatric hospitalization (AOR: 7.1; 95% CI: 2.8-18.0); no increase with fewer adversities was found.

Conclusion

Childhood adversities are associated with poor mental health outcomes among older homeless adults. Clinicians should collect information about childhood adversities among this high-risk population to inform risk assessment and treatment recommendations.

Individuals experiencing homelessness in the United States are aging; little is known about chronic pain in this population. In a cross-sectional, population-based study, we interviewed 350 homeless individuals aged 50 years and older to describe pain experienced by older persons experiencing homelessness and to assess factors associated with chronic moderate to severe pain, defined as pain lasting ≥3 months, with a past week average severity score of 5 to 10 (scale 0-10). The median age of participants was 58 years. Participants were predominantly African American (79.6%) and male (77.3%). Overall, 46.8% reported chronic moderate to severe pain. Almost half of participants reported a diagnosis of arthritis (44.3%) and one-third reported symptoms consistent with post-traumatic stress disorder (PTSD; 32.8%). Three-quarters (75.3%) endorsed a personal history of abuse. In multivariate analyses, PTSD (adjusted odds ratio [AOR]: 2.2, 95% confidence interval [CI], 1.4-3.7), arthritis (AOR: 4.8, 95% CI, 3.0-7.8), and history of experiencing abuse (AOR: 2.4, 95% CI, 1.3-4.3) were associated with chronic moderate to severe pain. HIV status, diabetes, depressive symptoms, and substance use were not associated with pain. Clinicians should consider the management of associated mental health conditions and the sequelae of experiencing abuse in the treatment of chronic pain in older adults experiencing homelessness.

Perspective

This article describes the prevalence and factors associated with chronic pain in older homeless adults. Almost half report chronic pain, which was associated with PTSD, arthritis, and personal history of abuse. Clinicians should address chronic pain, trauma, and the associated mental health conditions in this high-risk population.

Little is known about pathways to homelessness among older adults. We identified life course experiences associated with earlier versus later onset of homelessness in older homeless adults and examined current health and functional status by age at first homelessness. We interviewed 350 homeless adults, aged 50 and older, recruited via population-based sampling. Participants reported age at first episode of adult homelessness and their life experiences during 3 time periods: childhood (<18 years), young adulthood (ages 18-25), and middle adulthood (ages 26-49). We used a structured modeling approach to identify experiences associated with first adult homelessness before age 50 versus at age 50 or older. Participants reported current health and functional status, including recent mental health and substance use problems. Older homeless adults who first became homeless before 50 had more adverse life experiences (i.e., mental health and substance use problems, imprisonment) and lower attainment of adult milestones (i.e., marriage, full-time employment) compared to individuals with later onset. After multivariable adjustment, adverse experiences were independently associated with experiencing a first episode of homelessness before age 50. Individuals who first became homeless before age 50 had higher prevalence of recent mental health and substance use problems and more difficulty performing instrumental activities of daily living. Life course experiences and current vulnerabilities of older homeless adults with first homelessness before age 50 differed from those with later onset of homelessness. Prevention and service interventions should be adapted to meet different needs.

Adults aged 50 and older make up half of individuals experiencing homelessness and have high rates of morbidity and mortality. They may have different life trajectories and reside in different environments than do younger homeless adults. Although the environmental risks associated with homelessness are substantial, the environments in which older homeless individuals live have not been well characterized. We classified living environments and identified associated factors in a sample of older homeless adults. From July 2013 to June 2014, we recruited a community-based sample of 350 homeless men and women aged fifty and older in Oakland, California. We administered structured interviews including assessments of health, history of homelessness, social support, and life course. Participants used a recall procedure to describe where they stayed in the prior six months. We performed cluster analysis to classify residential venues and used multinomial logistic regression to identify individual factors prior to the onset of homelessness as well as the duration of unstable housing associated with living in them. We generated four residential groups describing those who were unsheltered (n = 162), cohabited unstably with friends and family (n = 57), resided in multiple institutional settings (shelters, jails, transitional housing) (n = 88), or lived primarily in rental housing (recently homeless) (n = 43). Compared to those who were unsheltered, having social support when last stably housed was significantly associated with cohabiting and institution use. Cohabiters and renters were significantly more likely to be women and have experienced a shorter duration of homelessness. Cohabiters were significantly more likely than unsheltered participants to have experienced abuse prior to losing stable housing. Pre-homeless social support appears to protect against street homelessness while low levels of social support may increase the risk for becoming homeless immediately after losing rental housing. Our findings may enable targeted interventions for those with different manifestations of homelessness.

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.

Objective

The median age of single homeless adults is over 50, yet little is known about their emergency department (ED) use. We describe use of and factors associated with ED use in a sample of homeless adults 50 and older.

Methods

We recruited 350 participants who were homeless and 50 or older in Oakland, California. We interviewed participants about residential history in the prior 6 months, health status, health-related behaviors, and health services use and assessed cognition and mobility. Our primary outcome was the number of ED visits in the prior 6 months based on medical record review. We used negative binomial regression to examine factors associated with ED use.

Results

In the 6 months prior to enrollment, 46.3% of participants spent the majority of their time unsheltered; 25.1% cycled through multiple institutions including shelters, hospitals, and jails; 16.3% primarily stayed with family or friends; and 12.3% had become homeless recently after spending much of the prior 6 months housed. Half (49.7%) of participants made at least one ED visit in the past 6 months; 6.6% of participants accounted for 49.9% of all visits. Most (71.8%) identified a regular non-ED source of healthcare; 7.3% of visits resulted in hospitalization. In multivariate models, study participants who used multiple institutions (incidence rate ratio [IRR] = 2.27; 95% confidence interval [CI] = 1.08 to 4.77) and who were unsheltered (IRR = 2.29; 95% CI = 1.17 to 4.48) had higher ED use rates than participants who had been housed for most of the prior 6 months. In addition, having health insurance/coverage (IRR = 2.6; CI = 1.5 to 4.4), a history of psychiatric hospitalization (IRR = 1.80; 95% CI = 1.09 to 2.99), and severe pain (IRR = 1.72; 95% CI = 1.07 to 2.76) were associated with higher ED visit rates.

Conclusions

A sample of adults aged 50 and older who were homeless at study entry had higher rates of ED use in the prior 6 months than the general U.S. age-matched population. Within the sample, ED use rates varied based on individuals' residential histories, suggesting that individuals' ED use is related to exposure to homelessness.