Frailty among the homeless population comparable to that of 89-year-olds in the general population


Paper: Rogans-Watson, R., Shulman, C., Lewer, D., Armstrong, M., Hudson, B.F  

Premature frailty, geriatric conditions and multimorbidity among people experiencing homelessness: a cross-sectional observational study in a London hostel. Housing care and support.

 

People experiencing homelessness are some of the most disadvantaged within our society. Homelessness is associated with extremely poor health outcomes with mortality rates 3–6 times those of the general population. Homelessness in the UK has been steadily rising throughout the past decade – having more than doubled since 2010.

When in their 30s, 40s, and 50s people who are homeless often experience health problems similar to much older people. Hostels and health services are not set up to deal with this.

This research, conducted in partnership with Pathway and researchers at the Marie Curie Palliative Care Research Department and Institute of Epidemiology & Health Care at UCL, involved the first exploration of premature aging among people experiencing homelessness in the UK. It involved a detailed geriatric health assessment of residents at a hostel in London.

Though the average age of participants was 56 (ranging from 38-74), the levels of frailty were comparable to 89-year-olds in the general population. Conditions usually associated with old age were common, with more than half experiencing falls, visual impairment, low grip strength, and mobility impairment. Cognitive impairment was also found to be prevalent but under recognised and rarely diagnosed. In addition, all participants had more than one long-term health condition, with an average of 7 long-term conditions identified per person. This is greater by far than even the oldest people in the general population.

These results might feel less unexpected among residents of a nursing home rather than a homeless hostel.

However, hostel staff are not healthcare workers. Their role is to support people to recover and move out of homelessness. This particular hostel had some support from specialist homeless nurses and a GP (most hostels in the UK do not have such services) but in spite of this, many health needs were unmet. Over a third reported difficulty managing medications, but functional assistance and care packages were rarely provided. Non-clinical hostel staff were the main source of support for residents.

The study demonstrates the need to assess frailty and consider geriatric conditions in people experiencing homelessness. A needs-based rather than age-based approach is essential, and would help reduce profound health inequities seen in this population. Good practice might include frailty screening by hostel staff, followed by comprehensive assessment in selected residents by a clinician. Selected patients should have care coordinators, as is recommended for frail older people, with cases reviewed in wider multi-agency meetings that include housing and social care services. There is a need for improved access to Care Act 2014 assessments in hostels and increased availability of appropriate stable sheltered housing and residential placements for older people who have experienced homelessness.

The degree of frailty and physical vulnerability also highlights the potentially devastating risk of COVID-19 to many homeless hostels, the need for vigilance to support social distancing, screening to detect outbreaks at an early stage, and self-isolation of people who are symptomatic. Without these interventions, outbreaks like those already seen in care homes could lead to a high number of preventable deaths among hostel residents.