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People Experiencing Homelessness at Higher Risk of Dementia
People experiencing homelessness experience a higher burden of dementia compared to housed populations, according to recent population-based, cross-sectional, comparative analysis results published in The Lancet Public Health.
“Efforts to enhance dementia screening among people experiencing homelessness, particularly at younger ages, the development of coordinated care approaches, and improved access to supportive housing arrangements could have far-reaching impacts,” authors said in the study.
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Researchers used linked health care administrative data from Ontario, Canada, including individuals aged 45 or older on January 1, 2019, who visited hospital-based ambulatory care, were hospitalized, or visited a community health center. Authors identified people experiencing homelessness through health care records indicating homelessness or unstable housing and ascertained dementia prevalence as of December 31, 2019, using a validated case definition for Alzheimer disease and related dementia that was modified to include diagnoses made at a community health center. Poisson models compared dementia prevalence among this group to the general population and a low-income group accessing the same health care services.
The study included 12,863 people experiencing homelessness—475,544 in the low-income comparator group, and 2,273,068 in the general population comparator group. Dementia prevalence was 68.7 per 1000 among people experiencing homelessness, 62.6 per 1000 in the low-income group, and 51.0 per 1000 in the general population. Prevalence ratios for homelessness versus comparators were highest in the 55 to 64 and 65 to 74 age groups, ranging from 2.98 to 5.00. Adjusted for age, sex, geographical location, and health conditions, the dementia prevalence ratio was 1.71 for people experiencing homelessness compared to the low-income group and 1.90 compared to the general population.
The authors noted several study limitations. Researchers only included individuals interacting with Ontario's health care system, excluding some subgroups like Indigenous people on reserves and certain refugee claimants. Additionally, people experiencing homelessness might avoid formal health care due to stigma, potentially limiting the data's generalizability. The case definition for identifying homelessness required at least 1 health care encounter, possibly missing some individuals. Routine health data lacked variables like ethnicity and gender, and diagnosing dementia among the homeless is challenging, likely leading to underestimation. Finally, authors recognized that the results may not be fully generalizable to homeless populations outside Canada.
Researchers hope their study leads to improved screening in the studied populations. “An immediate implication arising from this study is the need to re-examine screening guidelines for people experiencing homelessness. Cognitive screening for dementia is suggested by some guidelines for individuals older than 65 years, if there are concerns noted by family members,” authors concluded. “Our findings suggest that more specific screening might be warranted at a younger age for people experiencing homelessness, especially given that obtaining a history of concern might be difficult if there is a lack of sources for collateral history.”
