Study Finds 2 Main Factors Associated With Death Among Older Homeless Adults

Rebecca T. Brown, MD, MPH

The 2 factors associated with death for homeless adults aged ≥50 were later in life episodes of homelessness and ongoing homelessness, according to recent research.

More than one-third of single homeless adults are currently over 50 years old compared to just 1 in 10 in 1990, with homeless people commonly struggling with the premature onset of functional and cognitive issues, chronic medical conditions, and premature mortality.

Those experiencing homelessness also often suffer from comorbidities associated with premature death and their experiences in this state may be contributors, including stress, lack of accessible healthcare, and different kinds of exposures, explained investigators from a recent study led by Rebecca T. Brown, MD, MPH, for the Division of Geriatrics in the University of California, San Francisco Department of Medicine.

However, there is little research on mortality in homeless populations, with most of what exists being gathered from medical records without a standardized assessment of time-related factors such as changing status of housing, Brown and colleagues wrote in their latest analysis.

“Understanding how time-varying factors affect mortality risk in homeless older adults is necessary to identify high-risk individuals, inform interventions to prevent premature mortality, and target resources,” the researchers wrote. Researchers conducted their assessment to address this lack of widespread knowledge of premature mortality for homeless persons.

Research and Methods

Brown and colleagues set up the prospective cohort Health Outcomes in People Experiencing Homelessness in Older Middle Age (HOPE HOME)  study with 450 homeless adults aged ≥50 years found through a venue-based sampling in Oakland, California. They sampled for the study by accessing low-cost meal programs, overnight shelters, places where unsheltered individuals stayed, and a recycling center.

The researchers used an eligibility screen for participants during an enrollment interview. Study participants were interviewed every 6 months, with participants providing written informed consent. For the initial cohort, participants were aged ≥50 years, and the second cohort was aged ≥53 years. In addition to age, eligibility criteria included:

• English-speaking.
• Currently homeless, defined in the study as lacking a regular nighttime residence and including emergency shelter habitation.
• If not currently homeless under the above definition, not having somewhere to stay due to the following reasons: having lost housing within 14 days, staying temporarily in an institution, or fleeing interpersonal violence.
• The ability to provide informed consent.

The study used 2 periods for enrollment: July 2013 to June 2014 (n = 350) and from August 2017 to July 2018 (n = 100). Cash incentives were offered for enrollment interviews, 6-month follow-ups, and monthly check-ups.

Research staff held interviews in several Oakland nonprofit field sites, guided by a community advisory board, or the place in which the participants were living; subjects were not excluded from the study if they found a form of housing later on.

Several sources were used to assess participants’ mortality and ensure that outcomes were not missed during the research. The measures that were assessed at baseline for participants included sociodemographics, substance use, housing status, mental health, and incarceration status.

Investigators used Cox regression models to analyze associations of participant factors with mortality, using variables associated with deaths in the general population and those variables present in homeless populations. After mortality rates were assessed through various methods, including state records, these rates were compared with the mortality rate of the general population from 2014 - 2019 by age-specific standardized mortality ratios, with 95% CIs.

Study Results

Investigators observed 117 older adults (26%) from the cohort died over a median follow-up time of 55 months, with a median age of death being 64.6 years. A majority of the deaths (n = 93) occurred among men, and 24 among women.

The leading causes of death analyzed by researchers were heart disease (n = 17 [14.5%]), cancer (n = 17 [14.5%]), and drug overdose (n = 14 [12.0%]), which is consistent with prior research. Out of the 46 participants who died following March 2020, 3 listed COVID-19 as the cause of death. For those who participated in the study from 2013 through 2014, the age-standardized mortality ratio over a 4-year follow-up was 3.5-fold higher (95% CI, 2.5-4.4) than that of the general population, investigators wrote.

The study’s multivariable analysis concluded that the 2 factors associated with death included a first episode of homelessness in late life and homelessness or institutionalization at any follow-up compared with being housed.

Brown and colleagues concluded their findings with a note on their beliefs about endorsing the use of permanent supportive housing for homeless adults, adding that mortality risk for homeless adults can be mitigated with both outreach programs and tailored, end-of-life medical care.

The rates among Black adults were also noted as higher, with 80% of study participants being Black. The disparity highlights investigators' concerns over systemic racism and other associated problems contributing to high mortality rates among homeless adults.

“Newly homeless individuals may not have access to resources, or resilience, from prior lived experiences of homelessness,” they wrote. “Individuals with late-life homelessness are more likely to have a crisis leading to homelessness; serious illness is a common precipitant. In these cases, illness leads to job loss, eviction, and homelessness. Illness may then lead to death while homeless.”

This premature mortality risk among older homeless adults demonstrated to the researchers the timely need for future policy approaches designed to end homelessness, especially among the older population.

The study, “Factors Associated With Mortality Among Homeless Older Adults in California,” was published online in JAMA Internal Medicine.