Elsevier

Drug and Alcohol Dependence

Volume 178, 1 September 2017, Pages 562-570
Drug and Alcohol Dependence

Full length article
Factors associated with cognitive impairment in a cohort of older homeless adults: Results from the HOPE HOME study

https://doi.org/10.1016/j.drugalcdep.2017.06.002Get rights and content

Highlights

  • Cognitive impairment occurs at younger ages than expected among homeless adults.

  • Alcohol misuse, more than other risk factors, is strongly associated with impairment.

  • Impaired cognition may impede the treatment of substance use disorders in homeless adults.

Abstract

Background

We evaluated cognitive function and factors associated with cognitive impairment in a cohort of older homeless adults. We hypothesized that substance use and a history of traumatic brain injury would be associated with cognitive impairment.

Methods

We recruited 350 homeless individuals aged ≥50 years using population-based sampling and conducted structured interviews and neuropsychological testing. We evaluated alcohol use with the Alcohol Use Disorder Identification Test, defining high-severity alcohol use as a total score ≥16 or ≥4 on the alcohol dependency sub-scale. We assessed global cognition with the Modified Mini-Mental State Test (3MS) and processing speed and executive function with the Trail Making Test (TMTB), defining impairment as performing 1.5 standard deviations below the standardized mean. We used multivariable logistic regression to examine the association between alcohol use and cognition.

Results

Participants had a median age of 58 years [IQR 54–61], 76.7% were men, and 79.9% were African American. A quarter (25.1%) of participants met criteria for impairment on the 3MS; 32.9% met criteria for impairment on TMTB. In models adjusted for sociodemographic variables and health conditions, high-severity alcohol use was associated with global cognitive impairment (AOR 2.39, CI 1.19–4.79) and executive dysfunction (AOR 3.09, CI 1.61–5.92).

Conclusions

Older homeless adults displayed a prevalence of cognitive impairment 3–4 times higher than has been observed in general population adults aged 70 and older. Impaired cognition in older homeless adults could impact access to housing programs and the treatment of health conditions, including the treatment of alcohol use disorders.

Introduction

The median age of single homeless adults in the United States is rising, and now approaches 50 (Culhane et al., 2013; Hahn et al., 2006). Those born in the latter half of the baby boom (1954–1963) have had an elevated risk of homelessness throughout their lives (Culhane et al., 2013). For older homeless adults, chronic medical conditions, including geriatric syndromes, are causally linked to healthcare utilization and mortality (Brown et al., 2016b, Brown et al., 2012, Garibaldi et al., 2005, Gelberg et al., 1990).

Prior studies have found a high prevalence of cognitive impairment among homeless adults (point estimates range from 4 to 40%) and impairment occurring at an earlier age than in the general population (Brown et al., 2012, Buhrich et al., 2000, Burra et al., 2009, Depp et al., 2015, Gonzalez et al., 2001, Nishio et al., 2015, Pluck et al., 2011, Spence et al., 2004). However, the majority of these studies relied on samples either recruited from shelter environments, which may not be representative of the homeless population overall, (Burra et al., 2009, Spence et al., 2004) or from specific populations (e.g., persons with mental health conditions) (Bousman et al., 2010, Seidman et al., 1997, Stergiopoulos et al., 2015). Most studies of cognitive function in homeless adults have used global tests of cognition (e.g., Modified Mini Mental Status Exam [MMSE]) (Burra et al., 2009, Depp et al., 2015). Few studies have examined specific domains, such as memory and executive function (Bousman et al., 2010, Brown et al., 2012, Ennis et al., 2014). Executive function is defined as high-level cognitive processing involved in the control and regulation of goal-directed behaviors (Alvarez and Emory, 2006). Studies of homeless adults recruited from shelters identified a high prevalence of executive dysfunction (Brown et al., 2012, Gonzalez et al., 2001, Seidman et al., 1997, Seidman et al., 2003). Preserved executive function is essential to making plans, prioritizing, and completing tasks and thus may be of particular importance to homeless adults attempting to navigate complex social services to address their basic needs (Burra et al., 2009).

There is a poor understanding of the risk factors associated with cognitive impairment in homeless adults. Potential explanations include comorbid conditions such as vascular disease, substance use, traumatic brain injury (TBI), neurodevelopmental disorders, and psychiatric disease (Backer and Howard, 2007). Alcohol misuse and TBI are known causes of cognitive impairment in the general population (Brandt et al., 1983, Gardner et al., 2017), but few studies have explored these risk factors among homeless adults (Seidman et al., 2003, Topolovec-Vranic et al., 2012). We evaluated global cognitive function and executive function in a population-based sample of homeless adults aged ≥50. We chose this age range because of the high prevalence of geriatric conditions occurring in homeless adults 50 and older (Brown et al., 2012, Brown et al., 2013). We examined the relationship between substance use, TBI, and cognitive impairment, hypothesizing that high-risk substance use and a history of traumatic brain injury (TBI) are associated with cognitive impairment.

Section snippets

Participants

During July 2013–June 2014, we enrolled a population-based sample of 350 homeless adults from overnight shelters, homeless encampments, meal programs, and recycling centers in Oakland, California for the Health Outcomes in People Experiencing Homelessness in Older Middle agE (HOPE HOME) study. This outreach approach expanded on prior methods (Burnam and Koegel, 1988) to include homeless encampments and recycling centers to ensure inclusion of unsheltered adults. We recruited individuals from

Sample description

Of 350 participants enrolled in the HOPE HOME study, we included data from 343 participants. We excluded one participant who had visual impairment, three participants who were intoxicated during the assessment, two participants who could not read or write, and one participant with limited English fluency. Six individuals declined to complete the TMTB assessment and we excluded TMTB data for an additional participant due to a stopwatch malfunction (n = 336 for TMTB outcome) (Fig. 1).

Participants

Discussion

In a population-based sample of older homeless adults with a median age of 58, we found a prevalence of impairment in global cognitive function (25.1%) and executive function (32.9%) three to four times higher than the reported prevalence in populations more than 10 years older. In a national sample of adults 70 years and older in 2002, 9% demonstrated cognitive impairment on a telephone interview cognitive scale (Langa et al., 2008). Early age of onset of cognitive impairment, defined as the

Conclusions

We found a high prevalence of global cognitive and executive function impairment in our population-based sample of older homeless adults. Cognitive impairment was associated with high-severity alcohol use. Our results have several implications. First, policy-makers should consider cognitive impairment when designing supportive housing, intensive case management programming, substance use treatment, and healthcare delivery for older homeless adults. Second, clinicians should screen homeless

Role of funding source

This study was funded by grants from the National Institute on Aging (NIA): R01AG041860 [Kushel, Ponath, Guzman], K24AG046372 [Kushel, Guzman and Tieu], P30AG15272 [Johnson], and P30AG044281 [Kushel]. These funding sources had no role in the preparation, review, or approval of the manuscript and do not necessarily represent the official views of the NIH or AHRQ.

Dr. Hurstak receives fellowship support from National Institute of HealthT32HP19025.

Contributors

Drs. Hurstak and Kushel had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Kushel, Ponath.

Acquisition of data: Kushel, Ponath, Weyer-Jamora.

Statistical analysis: Hurstak, Guzman.

Analysis and interpretation of data: Hurstak, Johnson, Kushel, Lee, Weyer Jamora.

Drafting of the manuscript: Hurstak, Kushel, Johnson, Tieu.

Critical revision of the manuscript for important intellectual

Conflict of interest

Dr. Kushel is a member of the leadership board of Everyone Home, which seeks to end homelessness in Alameda County, CA. No other conflicts of interest were reported.

Acknowledgements

The authors gratefully acknowledge their colleagues Angela Allen, Pamela Olsen, Nina Fiellin, Tauni Marin, and Kenneth Perez for their invaluable contributions to the HOPE HOME study. The authors also thank the staff at St. Mary’s Center and the HOPE HOME Community Advisory Board for their guidance and partnership.

References (87)

  • B.J. Yarborough et al.

    Understanding opioid overdose characteristics involving prescription and illicit opioids: a mixed methods analysis

    Drug Alcohol Depend.

    (2016)
  • A. Zeki Al Hazzouri et al.

    Sustained economic hardship and cognitive function: the coronary artery risk development in young adults study

    Am. J. Prev. Med.

    (2017)
  • J.A. Alvarez et al.

    Executive function and the frontal lobes: a meta-analytic review

    Neuropsychol. Rev.

    (2006)
  • J. Andersen et al.

    Traumatic brain injury and cognitive impairment in men who are homeless

    Disabil. Rehabil.

    (2014)
  • T.F. Babor et al.

    The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care

    (2001)
  • T.E. Backer et al.

    Cognitive impairments and the prevention of homelessness: research and practice review

    J. Prim. Prev.

    (2007)
  • M.E. Bates et al.

    Short-term neuropsychological recovery in clients with substance use disorders

    Alcohol. Clin. Exp. Res.

    (2005)
  • R.C. Bland et al.

    Mild dementia or cognitive impairment: the modified mini-mental state examination (3MS) as a screen for dementia

    Can. J. Psychiatry

    (2001)
  • C.A. Bousman et al.

    Homelessness and neuropsychological impairment: preliminary analysis of adults entering outpatient psychiatric treatment

    J. Nerv. Ment Dis.

    (2010)
  • J. Brandt et al.

    Cognitive loss and recovery in long-term alcohol abusers

    Arch. Gen. Psychiatry

    (1983)
  • G. Bravo et al.

    Age- and education-specific reference values for the mini-mental and modified mini-mental state examinations derived from a non-demented elderly population

    Int. J. Geriatr. Psychiatry

    (1997)
  • R.T. Brown et al.

    Geriatric syndromes in older homeless adults

    J. Gen. Intern. Med.

    (2012)
  • R.T. Brown et al.

    Factors associated with geriatric syndromes in older homeless adults

    J. Health Care Poor Underserved

    (2013)
  • R.T. Brown et al.

    Pathways to homelessness among older homeless adults: results from the HOPE HOME Study

    PLoS One

    (2016)
  • R.T. Brown et al.

    Geriatric conditions in a population-based sample of older homeless adults

    Gerontologist

    (2016)
  • N. Buhrich et al.

    Prevalence of cognitive impairment among homeless people in inner Sydney

    Psychiatr. Serv.

    (2000)
  • M.A. Burnam et al.

    Methodology for obtaining a representative sample of homeless persons – the Los angeles skid row study

    Eval. Rev.

    (1988)
  • T.A. Burra et al.

    A systematic review of cognitive deficits in homeless adults: implications for service delivery

    Can. J. Psychiatry

    (2009)
  • M.R. Burt

    U.S. department of housing and urban development, interagency council on the homeless

    Homelessness: Programs and the People They Serve: Findings of the National Survey of Homeless Assistance Providers and Clients: Summary

    (1999)
  • J. Cantor et al.

    Evaluation of the short-term executive plus intervention for executive dysfunction after traumatic brain injury: a randomized controlled trial with minimization

    Arch. Phys. Med. Rehabil.

    (2014)
  • W.T. Carpenter et al.

    Decisional capacity for informed consent in schizophrenia research

    Arch. Gen. Psychiatry

    (2000)
  • Y. Chen et al.

    Progression from normal cognition to mild cognitive impairment in a diverse clinic-based and community-based elderly cohort

    Alzheimers Dement.

    (2016)
  • T. Cimino et al.

    The course of functional impairment in older homeless adults: disabled on the street

    JAMA Intern. Med.

    (2015)
  • K.M. Conigrave et al.

    Predictive capacity of the AUDIT questionnaire for alcohol-related harm

    Addiction

    (1995)
  • R. Connelly et al.

    A review of educational attainment measures for social survey research

    Method Innov.

    (2016)
  • F.T. Crews et al.

    Alcoholic neurobiology: changes in dependence and recovery

    Alcohol. Clin. Exp. Res.

    (2005)
  • D. Culhane et al.

    The age structure of contemporary homelessness: evidence and implications for public policy

    Anal. Soc. Issues Public Policy

    (2013)
  • S. Darke et al.

    Cognitive impairment among methadone maintenance patients

    Addiction

    (2000)
  • Department of Housing and Urban Development

    Homeless Emergency Assistance and Rapid Transition to Housing: Defining Homeless. CFR Parts 91, 581, and 283

    (2011)
  • C.A. Depp et al.

    A quantitative review of cognitive functioning in homeless adults

    J. Nerv. Ment. Dis.

    (2015)
  • N. Ennis et al.

    Memory impairment among people who are homeless: a systematic review

    Memory

    (2014)
  • K.D. Ersche et al.

    Profile of executive and memory function associated with amphetamine and opiate dependence

    Neuropsychopharmacology

    (2006)
  • S. Gabrielian et al.

    Factors affecting exits from homelessness among persons with serious mental illness and substance use disorders

    J. Clin. Psychiatry

    (2015)
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