Neurodegenerative Disease and the Experience of Homelessness

Abstract

Introduction: Today, half of the American homeless population is older than 50 years of age. This shift in age distribution among people experiencing homelessness has challenged our long-held views of the causes of homelessness. Age-related neurological diseases, especially neurodegenerative diseases of the brain (NDDB), may play a role eliciting homelessness in a significant proportion of vulnerable older adults. This article aims to explore relationships between homelessness and NDDB in a cohort of research participants enrolled in observational studies on NDDB at an academic center.Methods: We reviewed charts of the Memory and Aging Center (MAC) of the University of California, San Francisco's database searching for research participants with NDDB that had direct relationship to homelessness. We reviewed all research visits conducted between 2004 and 2018 (N = 5,300). Research participants who had any relationship to homelessness were included in this analysis. NDDB was diagnosed via comprehensive neurological, functional, neuropsychological, and biomarker assessments. Non-parametric tests were used for analysis. Thirteen participants were found to have a direct relationship with homelessness. Seven were female and the median of education was 16 (IR: 12.0–19.5) years. Participants were divided into two groups: Those who experienced homelessness while symptomatic from a NDDB but before formal diagnosis (n = 5, Group 1); and participants with formally diagnosed NDDB who exhibited a new propensity toward homelessness (n = 8, Group 2). Compared to Group 2, participants in Group 1 were younger (p = 0.021) and showed similar results in the neuropsychological evaluation. In both groups, the most prevalent diagnosis was frontotemporal dementia. In Group 1, the majority of participants became homeless in the setting of a fragile socioeconomic situation and informants believed that NDDB contributed or caused their homeless state. In Group 2, a new propensity toward homelessness became manifest in different ways and it stood out that all of these participants were well-supported by family and friends during their illness.Conclusions and Relevance: This case series highlights the role that NDDB may have in precipitating homelessness among vulnerable older adults, particularly in the setting of challenging socioeconomic circumstances and unsupportive living environments. Social ramifications of these findings, particularly pertaining to challenges around rehousing these individuals is discussed.

Neurocognitive health of older adults experiencing homelessness in Oakland, California

“…We found a high prevalence of socioemotional processing deficits, as well as signs of executive dysfunction and associative memory dysfunction. These deficits provide evidence for frontotemporal lobar dysfunction, in agreement with findings from our retrospective study on homelessness among persons with NDDB (8). Moreover, our study results also suggest a relative sparing of parieto-occipital lobe functions, based on both history and neuropsychological testing.…”

“…Although lack of longitudinal data, including reliable informants, and lack of brain health biomarkers greatly limited our ability to characterize these individuals more precisely, we found that the signs and symptoms elicited from our participants based on detailed history and neuropsychological testing conformed mostly to AD and FTLD syndromes, whereas other neurodegenerative syndromes such as PD, progressive supranuclear palsy, corticobasal syndrome, and primary progressive aphasia, were less common in our study. These findings support our prior study results (8) and our overarching hypothesis that frontotemporal neurocognitive syndromes are prevalent in older adults experiencing homelessness.…”

“…Persons affected by NDDB often engage in behaviors that are harmful to their personal and social lives, intimate relationships, and work responsibilities (5,6). We hypothesize that early changes in cognition caused by NDDB, particularly changes in social cognition, could precipitate homelessness in selected individuals, especially those who live alone, are minimally supported, or are socioeconomically vulnerable (7,8). Second, most of the non-communicable health conditions that are disproportionately prevalent in homeless older adults are known risk factors for NDDB (9).…”

“…To study the intersection between NDDB and the experience of homelessness among older adults, we previously investigated relationships between homelessness and NDDB among an existing cohort of adult research participants with different forms of NDDB evaluated in the Memory and Aging Center (MAC) of the University of California San Francisco (UCSF) (8). We found that persons with anterior frontal and temporal neurocognitive deficits (i.e., persons with FTLD or the frontal variant of AD, for example) were highly represented among our homeless cohort, and most of these participants had become homeless in the setting of a fragile socioeconomic context.…”

Prevalence of dementia and mild cognitive impairment before incarceration

“…Like mental illness, these conditions are disproportionately higher among incarcerated individuals and linked to increased risk of dementia and neurodegenerative diseases. 13,23,28 Experiencing preincarceration TBI or homelessness may indicate an early-onset clinical phenotype of dementia.…”