Cognitive Impairments and the Prevention of Homelessness: Research and Practice Review

Screening for Autism Spectrum Condition Through Inner City Homeless Services in the Republic of Ireland

Homeless service users were screened for autism spectrum disorder through one of Ireland's leading not for profit service providers. Keyworkers acted as proxy informants; their caseloads were screened using the DSM-5-Autistic Traits in the Homeless Interview (DATHI). Client current and historical health and behaviour data was collated. A representative sample of 106 eligible keyworkers caseloads were screened, identifying 3% "present" and 9% "possibly present" for autistic traits with the DATHI. These findings suggest a high estimate of autism prevalence and support emerging evidence that, people with autism are overrepresented in the homeless population, compared to housed populations. Autism may be a risk factor for entry into homelessness and a challenge to exiting homeless and engaging with relevant services.

The Impact of COVID-19 on Access to Resources among Individuals Experiencing Homelessness and Traumatic Brain Injury

The rates of traumatic brain injury (TBI) are higher among individuals experiencing homelessness compared with the general population. Individuals experiencing homelessness and a TBI may experience barriers to care. COVID-19 may have further impacted access to basic resources, such as food, shelter, and transportation for individuals experiencing homelessness. This study aimed to answer the following research question: What is the impact of COVID-19 on access to resources among individuals experiencing homelessness and TBI? A cross-sectional study design and purposive sampling were utilized to interview 38 English-speaking adults experiencing homelessness and who had sustained a TBI (ages 21–73) in one Colorado city. Qualitative questions related to the impact of COVID-19 were asked and qualitative analysis was used to analyze the responses. Three primary themes emerged regarding the types of resources that were restricted by COVID-19: basic/biological needs, financial needs, and a lack of connection. COVID-19 has shown the social work field the need for continued innovation and better practice standards for individuals who are not housed. For those living with a reported TBI history and experiencing homelessness, COVID-19 made it difficult to access basic services for survival.

Exploring and Mapping Screening Tools for Cognitive Impairment and Traumatic Brain Injury in the Homelessness Context: A Scoping Review

Cognitive impairment is common amongst people experiencing homelessness, yet cognitive screening and the collection of history of brain injury rarely features in homelessness service delivery practice. The purpose of this research was to scope and map strategies for screening for the potential presence of cognitive impairment or brain injury amongst people experiencing homelessness and identify instruments that could be administered by homelessness service staff to facilitate referral for formal diagnosis and appropriate support. A search was conducted across five databases, followed by a hand search from relevant systematic reviews. A total of 108 publications were included for analysis. Described in the literature were 151 instruments for measuring cognitive function and 8 instruments screening for history of brain injury. Tools that were described in more than two publications, screening for the potential presence of cognitive impairment or history of brain injury, were included for analysis. Of those regularly described, only three instruments measuring cognitive function and three measuring history of brain injury (all of which focused on traumatic brain injury (TBI)) may be administered by non-specialist assessors. The Trail Making Test (TMT) and the Ohio State University Traumatic Brain Injury Identification Method (OSU TBI-ID) are both potentially viable tools for supporting the identification of a likely cognitive impairment or TBI history in the homelessness service context. Further population-specific research and implementation science research is required to maximise the potential for practice application success.

Cognitive determinants of community functioning and quality of life in homeless adults with mental illness: 6-year follow-up from the At Home/Chez Soi Study Toronto site

BACKGROUND

High rates of physical and mental health comorbidities are associated with functional impairment among persons who are homeless. Cognitive dysfunction is common, but how it contributes to various functional outcomes in this population has not been well investigated. This study examines how cognition covaries with community functioning and subjective quality of life over a 6-year period while accounting for the effects of risk and protective factors.

METHODS

Participants were 349 homeless adults (mean age = 39.8) recruited from the Toronto site of the At Home/Chez Soi study, a large Canadian randomized control trial of Housing First. Participants completed up to four clinical evaluations over 6 years. Factor scores were created to index verbal learning and memory (vLM) and processing speed-cognitive flexibility (PSCF). The primary outcomes were community functioning and subjective quality of life. Risk factors included lifetime homelessness, mental health diagnoses, medical comorbidity, and childhood adversity. Linear mixed-effects models were conducted to examine cognition-functional outcome associations over time, with resilience as a moderator.

RESULTS

Better vLM (b = 0.787, p = 0.010) and PSCF (b = 1.66, p < 0.001) were associated with better community functioning, but not with quality of life. Resilience conferred a protective effect on subjective quality of life (b = 1.45, p = 0.011) but did not moderate outcomes.

CONCLUSIONS

Our findings suggest a need to consider the unique determinants of community functioning and quality of life among homeless adults. Cognition should be prioritized as a key intervention target within existing service delivery models to optimize long-term functional outcomes.

Schizophrenia: a disorder of broken brain bioenergetics

A substantial and diverse body of literature suggests that the pathophysiology of schizophrenia is related to deficits of bioenergetic function. While antipsychotics are an effective therapy for the management of positive psychotic symptoms, they are not efficacious for the complete schizophrenia symptom profile, such as the negative and cognitive symptoms. In this review, we discuss the relationship between dysfunction of various metabolic pathways across different brain regions in relation to schizophrenia. We contend that several bioenergetic subprocesses are affected across the brain and such deficits are a core feature of the illness. We provide an overview of central perturbations of insulin signaling, glycolysis, pentose-phosphate pathway, tricarboxylic acid cycle, and oxidative phosphorylation in schizophrenia. Importantly, we discuss pharmacologic and nonpharmacologic interventions that target these pathways and how such interventions may be exploited to improve the symptoms of schizophrenia.

Homelessness and Research: Methodological Obstacles and Lessons Learned from a Psychological Study in Parisian Homeless Services

Homelessness, defined as a lack of appropriate, stable, and permanent housing, is a common issue in many societies and is linked to both structural and individual factors. These factors include psychological mechanisms and disorders which can trigger or worsen already precarious situations. In order for these factors to be taken into account in social rehabilitation programs, they need to be precisely described. However, at present, studies in this field are lacking in France. Despite homelessness being an issue across the country, few studies have evaluated the underlying psychological or neuropsychological mechanisms. More data are needed, not only to provide an accurate description of the situation in France, but also to ensure that foreign observations and interventions are relevant for application to the homeless population. In order to achieve this, more quantitative and qualitative data and investigative methodologies and studies are needed. Sharing experience and methods within the scientific community is one way to support further research, particularly in complex domains such as homelessness. At the moment, only a few such papers have been published. In this paper, we share our experiences from a research project that started in 2020 (currently unpublished) on the prevalence of cognitive disorders among homeless service users in Paris. We describe the exploratory phase of our project, obstacles encountered during the implementation of the study, including how we dealt with ethical issues, and data collection. We end the paper with recommendations for future psychological studies on homelessness.

Community Rehabilitation Outcomes for Different Stroke Diagnoses: An Observational Cohort Study

Objective

To determine the differences in functional and cognitive rehabilitation gains made in community-based rehabilitation following a stroke based on stroke diagnosis (left or right hemisphere, hemorrhagic, or ischemic).

Design

A 12-month follow-up observational retrospective cohort study.

Setting

Staged community-based brain injury rehabilitation.

Participants

Clients (N=61) with hemorrhagic left brain stroke (n=10), hemorrhagic right brain stroke (n=8), ischemic left brain stroke (n=27), or ischemic right brain stroke (n=16) participating in rehabilitation for at least 12 months.

Intervention

Not applicable.

Main Outcome Measures

The Mayo-Portland Adaptability Inventory-4 (MPAI-4) was completed at admission and 12 months post admission to staged community-based brain injury rehabilitation by consensus of a multidisciplinary team.

Results

After 12 months in staged community-based brain injury rehabilitation, the study population made significant gains in Total (P<.001) and across Ability (P<.001) and Participation (P<.001) subscales of the MPAI-4. All diagnostic groups made significant gains in Participation T-scores, and no groups made significant gains in Adjustment. The ischemic left and right hemisphere stroke groups also made significant gains in Ability and Total T-scores from admission to 12 months. Clients with ischemic left hemisphere stroke had more severe limitations in motor speech (P<.05) than clients with right hemisphere stroke at admission and/or review and were also more impaired in verbal communication (P<.01) than the hemorrhagic right hemisphere group at admission.

Conclusions

There are some differences in outcomes on presentation to rehabilitation based on type of stroke; there are also differences in rehabilitation gains. Improvement in physical ability does not always translate to improvement in social participation and independence; those with right brain stroke need further assistance to translate physical gains into participatory outcomes.

Integrated Care: Provider referrer perceptions of occupational therapy services for homeless adults in an integrated primary care setting

BACKGROUND

Occupational therapists have a long history of addressing community performance and participation challenges faced by individuals with complex, chronic conditions, including those with serious mental illnesses (SMI) and cognitive issues that present with a traumatic brain injury (TBI). Healthcare reform has shifted incentives to support practices that promote successful community life for people with complex medical conditions. Community based care models emphasizing integrated primary care, such as Federally Qualified Health Centers (FQHC) are emerging, and a generalist role for occupational therapy is being defined. Those with complex comorbid conditions such as mental illness, substance abuse and traumatic brain injury are at risk for negative health outcomes that are further compounded by homelessness. There is a critical need to understand effective treatment options for this population to reduce the negative effects of chronic health conditions. As occupational therapists further define a role serving traditional clients in less traditional settings, such as the FQHC, it is helpful to explore the perceptions of the utility of OT services on the part of provider referrers.

OBJECTIVE

This study explored provider referrer perceptions of a new occupational therapy service for homeless adults in an FQHC to assist effective allocation of scarce resources.

METHODS

Twelve provider referrers at an FQHC were interviewed regarding their perception of the role and utility of occupational therapy in this setting. Interviews were then coded for themes.

RESULTS

Providers identified the unique value of occupational therapy, emphasizing critical information gleaned from the performance-based assessment of functional cognition, and the positive impact on team interactions and subsequent care decisions.

CONCLUSION

Occupational therapy provides a distinct perspective on client performance in FQHC settings indicating benefit for inclusion of services.

Addressing brain injury in health care for the homeless settings: A pilot model for provider training

BACKGROUND

Brain injury has been recently understood to be a common occurrence among adults experiencing homelessness, resulting in the need for modifications to clinical practice in agencies serving this population.

OBJECTIVE

A health care agency for adults experiencing homelessness initiated a pilot training for mental health providers to address the issues of brain injury.

METHODS

Providers attended eight training sessions which focused on: screening for a history of brain injury, treatment planning, and specific strategies to implement with individuals with a history of brain injury. Strategies taught were based on current literature and therapeutic methods, adapted specifically for the clinic's population of adults experiencing homelessness.

RESULTS

Screening for a history of brain injury at the clinic indicated a high prevalence of a history of brain injury that was previously unidentified, indicating need for provider training. Providers reported increased ability to screen for and address the needs of individuals with brain injury within their clinical setting. Providers reported benefit from sessions tailored to address various cognitive functions which incorporated evidence-based practice and familiar therapeutic methods.

CONCLUSION

Providers who engage individuals experiencing homelessness benefit from structured training in order to increase ability to screen for and modify interventions for a history of brain injury to better address their clients' needs.

Housing Stability and Neurocognitive Functioning in Homeless Adults With Mental Illness: A Subgroup Analysis of the At Home/Chez Soi Study

Objective: This study examined the association of housing stability with neurocognitive outcomes of a well-characterized sample of homeless adults with mental illness over 18 months and sought to identify demographic and clinical variables associated with changes in neurocognitive functioning. Method: A total of 902 participants in the At Home/Chez Soi study completed neuropsychological measures 6 and 24 months after study enrollment to assess neurocognitive functioning, specifically verbal learning and memory, cognitive flexibility, and complex processing speed. Multivariable linear regression was performed to assess the association of housing stability with changes in neurocognitive functioning between 6 and 24 months and to examine the effect of demographic and clinical variables on changes in neurocognitive functioning. Results: Overall neurocognitive impairment remained high over the study period (70% at 6 months and 67% at 24 months) with a small but significant improvement in the proportion of those experiencing more severe impairment (54% vs. 49% p < 0.002). Housing stability was not associated with any of the neuropsychological measures or domains examined; improvement in neurocognitive functioning was associated with younger age, and bipolar affective disorder at baseline. Conclusions: The high prevalence and persistence of overall neurocognitive impairment in our sample suggests targeted approaches to improve neurocognitive functioning merit consideration as part of health interventions to improve everyday functioning and outcomes for this population. Further efforts are needed to identify potential modifiable factors that contribute to improvement in cognitive functioning in homeless adults with mental illness.

Cognitive Impairment in Marginally Housed Youth: Prevalence and Risk Factors

Objective: Homeless and marginally housed youth are particularly vulnerable members of society, and are known to experience numerous health problems, including psychiatric illness, substance use, and viral infection. Despite the presence of these risk factors for cognitive compromise, there is limited research on the cognitive functioning of homeless and marginally housed youth. The present study examines the degree and pattern of cognitive impairment and associations with key risk factors in a sample of marginally housed young adults. Method: Participants (N = 101) aged 20-29 years old were recruited from single-room occupancy hotels, and underwent cognitive, psychiatric, neurological, and serological assessments. Results: Forty percent of participants were identified as mildly cognitively impaired across multiple domains, and 16% were moderately-severely impaired. Deficits in memory and attention were most prevalent, while impairments in inhibitory control/processing speed and cognitive flexibility were also present but tended to be less severe. Developmental and historical factors (premorbid intellectual functioning, neurological soft signs, earlier exposure to and longer duration of homelessness or marginal housing), as well as current health risks (stimulant dependence and hepatitis C exposure), were associated with cognitive impairment. Conclusions: The strikingly high rate of cognitive impairment in marginally housed young adults represents a major public health concern and is likely to pose a significant barrier to treatment and rehabilitation. These results suggest that the pathway to cognitive impairment involves both developmental vulnerability and modifiable risk factors. This study highlights the need for early interventions that address cognitive impairment and risk factors in marginalized young people.

[One homeless person out of ten suffers from cognitive disorders: What do we know about these impairments? A systematic review of homeless people's cognition]

OBJECTIVES

Homelessness is associated with several issues (psychiatric and neurological disorders, neurodevelopmental difficulties, malnutrition…) which are also risk factors for cognitive disorders. However, little is known about the relationship between the cognition of homeless people and these eventual explicative etiologies. The aim of this work is to complete the results of Depp et al. about cognition in homelessness by proposing a systematic review of the neuropsychological disorders of homeless people associated with an analysis of the etiologies likely to explain these disorders.

METHODS

We followed the PRISMA recommendations to build up this work. We analyzed the abstracts of 385 papers found on databases PSYCINFO and PubMed. Twenty-two studies have been selected for respecting our criteria (at least one valid neuropsychological test ; general group of homeless people and not a sub-group of this population ; study published in English). The prevalence quality has been evaluated through the criteria of Loney et al. Cognitive scores and etiological factors have been compared between studies.

RESULTS

The 22 studies represent only nine countries. More than half of them are considered as having a poor prevalence quality. In total, 4,256 participants have been evaluated. Their mean age was around 40 years, and 85 % of the participants were men. The results show a prevalence of cognitive disorders (MMSE) in 8.77 % of the sample. The mean IQ was 87.47 and the premorbid IQ 94.59. We also notice possible disorders affecting the episodic memory and the executive functions. Mean scores for short-term memory, speech and visuo-spatial functions are relatively low. None of the studies evaluated the praxia, the gnosia or the social cognition. The heterogeneity of studies and the lack of data did not allow us to give general conclusions about the etiology of these disorders. However, we see that around 40 % of the time subjects had histories of brain injuries and 89 % of childhood trauma. Intellectual disability is found in 49 % of the sample of a single study. Also, 70 % of the homeless population have been diagnosed with substance-related disorders and 65 % with psychiatric disorders. It appears that the only factors correlated with cognitive disorders would be the history of brain injuries and childhood traumas.

CONCLUSIONS

We confirm that homeless people often suffer from cognitive difficulties, and some of these difficulties (memory, executive functioning) are severe. Yet the etiology of these disorders remain relatively unknown: even if we observe a high prevalence of psychiatric, substance-related, neurodevelopmental and neurological issues by the homeless population, only a few of them (brain injury history and childhood trauma) seem to be correlated with cognition in homelessness. The potential explicative factors have been too rarely explored to bring a powerful explanation of cognitive disorders in homeless people. Further research needs to be done in order to give a more precise neuropsychological profile of the homeless population and to better understand what the disorders are rooted in. Last but not least, all this research and knowledge should be applied more to the care of homeless people by providing neuropsychological assessment and rehabilitation and by training the team to detect cognitive disorders and to support the person with a cognitive disability.

Exploring the experiences and needs of homeless aboriginal and torres strait islander peoples with neurocognitive disability

Objective:

The current study explored the experiences and aspirations of a cohort of Aboriginal and Torres Strait Islander adults with neurocognitive disability residing in a homeless shelter in regional Queensland, Australia. Neurocognitive disability (NCD) refers to any acquired disorder or injury to the brain where the primary clinical deficit is in cognitive function.

Method:

The data reported on in this paper emerged from a broader study that aimed to understand the extent and nature of neurocognitive disability amongst homeless Aboriginal and Torres Strait Islander people. The broader study found high levels of NCD which impacted on people’s ability to participate in society. As part of the study, qualitative information was sought regarding participant life experiences. A culturally safe and acceptable structure of “past, present and future” was applied to open-ended questions.

Results:

Thematic analysis of the data identified four broad themes of i) normalisation of illness and disability; ii) trauma and loss; iii) socioeconomic disadvantage; and iv) hope and disempowerment. This paper reports on these themes and experiences, which occurred across the life span, intersected with NCD, and contributed to what we have termed ‘complex disablement’ amongst this cohort.

Conclusions:

While causal links between life experience, disability and disablement are not always clear, our findings suggest that attempts to address homelessness must engage with this complexity. The application of holistic, intersectoral supports, which encompass culturally informed, community driven approaches are needed. Understanding the impacts of individual and intergenerational trauma is crucial to safe and effective service provision for this cohort.

Cognitive impairment and homelessness: A scoping review

This paper reports the findings of a scoping review designed to identify research which has explored the relationship between cognitive impairment and homelessness. A systematic search of databases for articles published between 2007 and 2017 was conducted using keywords relating to cognitive impairments and homelessness. Sources were expanded using manual searches of citations and grey literature. Forty studies represented in 45 papers were selected for review using predefined inclusion criteria. Sources were subject to quality appraisal and data were extracted in line with review questions. Prevalence studies were over-represented in the review, while qualitative data were lacking. Aetiology of impairments was delineated by acquired and developmental causes. A variety of measures were employed by studies which were not validated in homeless populations. Studies did not give sufficient consideration to co-occurring disorders and overlapping symptoms between aetiologies. Because of these factors, it was difficult to conclude that all studies had accurately measured what they set out to; however, the evidence suggested that cognitive impairment was disproportionately over-represented in homeless populations. Cognitive impairment was found to be both a risk factor to and perpetuator of homelessness. Risk factors for homelessness were similar to those of the general population, though exaggerated by sequelae of certain cognitive impairments. The results of this review suggest that more attention needs to be paid to the underlying socioeconomic disadvantages, persons with cognitive impairments face which may lead to homelessness. Further research should prioritise the voice of homeless persons with cognitive impairments, to better understand both causes of homelessness and effective methods of rehabilitation.

Identifying Social Skills That Support Housing Attainment and Retention Among Homeless Persons With Serious Mental Illness

OBJECTIVE

By combining supportive services with independent housing, permanent supportive housing (PSH) programs effectively address homelessness. Yet, many persons with serious mental illness struggle to attain and retain housing in these programs. Social skills-which facilitate social interactions and instrumental tasks-predict premature exit from PSH. This project aimed to build consensus on a set of social skills that supports independent housing attainment and retention among homeless persons with serious mental illness, with a clinical focus on PSH programs.

METHODS

Guided by the RAND/University of California, Los Angeles, appropriateness method, the set of social skills was developed by using literature review; key informant interviews (N=12), a national consensus panel of experts in psychosocial rehabilitation and homelessness (N=11), and two focus groups with homeless persons with serious mental illness (N=17).

RESULTS

These methods identified 24 social skills in seven domains: finding and renting an apartment, using one's time well, getting closer to people, managing finances, avoiding problems with drugs and alcohol, solving interpersonal problems, and managing one's health. Expert panelists and focus group participants agreed that these social skills were feasible for inclusion in social skills training and could strongly affect housing outcomes in PSH settings.

CONCLUSIONS

Consensus was reached about a set of social skills relevant to housing attainment and retention for persons with serious mental illness engaged in PSH. Next steps include modifying social skills training interventions to this skill set, making contextual modifications relevant to the setting and context of PSH, and studying the effectiveness and implementation of the adapted intervention in PSH.

Service provision for older homeless people with memory problems: a mixed-methods study

Background

Early or timely recognition of dementia is a key policy goal of the National Dementia Strategy. However, older people who are homeless are not considered in this policy and practice imperative, despite their high risk of developing dementia.

Objectives and study design

This 24-month study was designed to (1) determine the prevalence of memory problems among hostel-dwelling homeless older people and the extent to which staff are aware of these problems; (2) identify help and support received, current care and support pathways; (3) explore quality of life among older homeless people with memory problems; (4) investigate service costs for older homeless people with memory problems, compared with services costs for those without; and (5) identify unmet needs or gaps in services.

Participants

Following two literature reviews to help study development, we recruited eight hostels – four in London and four in North England. From these, we first interviewed 62 older homeless people, exploring current health, lifestyle and memory. Memory assessment was also conducted with these participants. Of these participants, 47 were included in the case study groups – 23 had ‘memory problems’, 17 had ‘no memory problems’ and 7 were ‘borderline’. We interviewed 43 hostel staff who were participants’ key workers. We went back 3 and 6 months later to ask further about residents’ support, service costs and any unmet needs.

Findings

Overall, the general system of memory assessment for this group was found to be difficult to access and not patient-centred. Older people living in hostels are likely to have several long-term conditions including mental health needs, which remain largely unacknowledged. Participants frequently reported experiences of declining abilities and hostel staff were often undertaking substantial care for residents.

Limitations

The hostels that were accessed were mainly in urban areas, and the needs of homeless people in rural areas were not specifically captured. For many residents, we were unable to access NHS data. Many hostel staff referred to this study as ‘dementia’ focused when introducing it to residents, which may have deterred recruitment.

Conclusions

To the best of our knowledge, no other study and no policy acknowledges hostels as ‘dementia communities’ or questions the appropriateness of hostel accommodation for people with dementia. Given the declining number of hostels in England, the limits of NHS engagement with this sector and growing homelessness, this group of people with dementia are under-recognised and excluded from other initiatives.

Future work

A longitudinal study could follow hostel dwellers and outcomes. Ways of improving clinical assessment, record-keeping and treatment could be investigated. A dementia diagnosis could trigger sustained care co-ordination for this vulnerable group.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

On the Margins of Death: A Scoping Review on Palliative Care and Schizophrenia

Schizophrenia is a serious chronic mental illness that results in marginalization and stigma for sufferers. It is the seventh leading cause for disability worldwide. The symptoms of the illness, including hallucinations, delusions, and extremely disordered thinking and behavior, may also introduce barriers to accessing treatment, education, housing, and employment. Little is known about end-of-life care for individuals with schizophrenia. To address this gap, a scoping review was conducted to enhance understanding of hospice and palliative care for patients with schizophrenia. From this scoping review, 342 unique titles and abstracts were identified through a search of 20 databases, including 11 social science databases, 6 medical databases, and 3 gray literature databases. A total of 32 articles met the inclusion criteria and the following 4 themes were identified: Stigma affecting quality of care and access to care; Issues related to consent and capacity for the patient's end-of-life care decisions and to appoint substitute decision makers; Best practices for psychosocial interventions, pharmacology, family and health-care collaborations, goals of care, setting, and smoking; and Barriers to care, including setting, communication, provider education, and access to care. The review suggests the importance of mandatory interdisciplinary training practices and policy standards outlining cooperative communication across health-care providers. It highlights gaps in evidence-based research on psychosocial interventions and collaborative frameworks to enable the provision of quality end-of-life care for individuals with schizophrenia.

Problem solving skills and deficits among homeless veterans with serious mental illness

Few interventions train homeless consumers in housing-related independent living skills. To inform the development of such interventions for the Department of Veterans Affairs' Supported Housing consumers with serious mental illness, we examined these consumers' problem-solving skills and deficits. We performed semistructured interviews and cognitive tests with 20 consumers who retained housing for ≥1 year ("stayers") and 20 consumers who lost housing in <1 year ("exiters"). Salient types of problems were identified in the qualitative data; we categorized problem-solving approaches by complexity level and identified differences in problem-solving complexity by consumers' housing outcomes. Instrumental (e.g., money management), interpersonal, and health-related problems were prominent in consumers' narratives. Cognition was poor among stayers and exiters. Problem-solving approaches were highly relevant to day-to-day functioning in supported housing. There was a trend toward greater problem-solving complexity in stayers versus exiters. These data explore potential challenges faced in supported housing and help inform the development of a Veterans Affairs-based housing-focused skills training intervention. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Clinical and cognitive correlates of unsheltered status in homeless persons with psychotic disorders

Homeless persons with psychosis are particularly susceptible to unsheltered homelessness, which includes living on the streets, in cars, and other places not meant for human habitation. Homeless persons with psychosis have distinct barriers to accessing care and comprise a high-need and hard-to-serve homeless subpopulation. Therefore, this study sought to understand unsheltered homelessness in persons with psychosis and its relationship to cognitive impairment, clinical symptoms, and community functioning, examined both categorically and dimensionally. This study included 76 homeless participants with a history of a psychotic diagnosis who were enrolled in a supported housing program but had not yet received housing. This study used two different housing stability thresholds (literally homeless at any point vs. literally homeless >20% of days) for comparing homeless Veterans with psychosis living in sheltered versus unsheltered situations on cognition, clinical symptoms, and community integration. Dimensional analyses also examined the relationship between percentage of days spent in unsheltered locations and cognition, clinical symptoms, and community integration. Sheltered and unsheltered Veterans with psychosis did not differ on clinical symptoms or community integration, but there was an inconsistent group difference on cognition depending on the threshold used for determining housing stability. In the unsheltered group, cognitive deficits in overall cognition, visual learning, and social cognition were related to more days spent in unsheltered locations. Rehabilitation efforts targeting specific cognitive deficits may be useful to facilitate greater access to care and successful interventions in this population.

Interventions for preventing or treating malnutrition in homeless problem-drinkers: a systematic review

BACKGROUND

Excessive drinking leads to poor absorption of nutrients and homeless problem-drinkers often have nutritionally inadequate diets. Depletion of nutrients such as vitamin B1 can lead to cognitive impairment, which can hinder efforts to reduce drinking or engage with services. This review aimed to assess effectiveness of interventions designed to prevent or treat malnutrition in homeless problem-drinkers.

METHODS

We systematically searched nine electronic databases and 13 grey literature sources for studies evaluating interventions to improve nutrition in homeless populations, without regional or language restrictions. Screening for inclusion was done in duplicate. One reviewer extracted data and assessed risk of bias, and another checked the extractions. Primary outcomes were nutrition status/deficiency, liver damage, and cognitive function. Secondary outcomes included abstinence, comorbidities, resource use, acceptability and engagement with intervention. Results were synthesised narratively.

RESULTS

We included 25 studies (2 Randomised Controlled Trials; 15 uncontrolled before and after; 7 surveys; 1 case-control). Nine studies evaluated educational and support interventions, five food provision, and three supplement provision. Eight studies evaluated a combination of these interventions. No two interventions were the same, and all studies were at high risk of bias. Nutritional status (intake/ deficiency) were reported in 11 studies and liver function in one. Fruit and vegetable intake improved with some education and support interventions (n = 4 studies) but not others (n = 2). Vitamin supplements appeared to improve vitamin deficiency levels in the blood (n = 2). Free or subsidised meals (n = 4) and food packs (n = 1) did not always fulfil dietary needs, but were usually considered acceptable by users. Some multicomponent interventions improved nutrition (n = 3) but acceptability varied (n = 3). No study reported cost effectiveness.

CONCLUSIONS

The evidence for any one intervention for improving malnutrition in homeless problem-drinkers was based on single studies at high risk of bias. Various food and supplement provision interventions appear effective in changing nutritional status in single studies. Educational and multicomponent interventions show improved nutritional behaviour in some studies but not others. Further better quality evidence is required before these interventions can be recommended for implementation. Any future studies should seek the end user input in their design and conduct.

TRIAL REGISTRATION

Registered with PROSPERO: CRD42015024247 .

The Effect of Housing First on Housing Stability for People with Mental Illness and Low Intellectual Functioning

OBJECTIVE

Housing First (HF) has been linked to increased tenure in housing for homeless people with mental illness, but the effect of HF on housing stability for people with borderline or lower intellectual functioning has not been examined. This study of homeless adults with mental illness in Toronto, Ontario assessed whether the association between housing stability and HF differed for adults with borderline or lower intellectual functioning, compared to adults with above borderline intellectual functioning.

METHOD

This study included 172 homeless adults with mental illness from the Toronto site of the At Home-Chez Soi randomized trial that compared receiving HF relative to treatment as usual. This sample was divided into two intellectual functioning groups: 1) adults with borderline or lower intellectual functioning (IQ < 85, 16%), and 2) adults with above borderline intellectual functioning (IQ ≥ 85, 84%). We compared these groups by modelling the percentage of days stably housed using a linear multivariable generalized estimating equation and included interaction between treatment and intellectual functioning. An interaction between treatment and time was also included.

RESULTS

There were no overall differences in housing stability for individuals with borderline or lower intellectual functioning compared to people with higher than borderline intellectual functioning in either the HF or the treatment as usual groups.

CONCLUSION

This study is the first to demonstrate that for homeless adults with mental illness, borderline or lower intellectual functioning did not significantly affect housing stability. This accentuates the need for more research and potentially wider consideration of their inclusion in housing interventions, such as HF.

Cognitive Skills Training for Homeless Transition-Age Youth: Feasibility and Pilot Efficacy of a Community Based Randomized Controlled Trial

Cognitive impairments are common in homeless youth and negatively impact academic and vocational outcomes. We examined the feasibility and efficacy of cognitive interventions provided to 18- to 22-year-old homeless youth living in urban supportive housing. Ninety-one homeless youth were randomized to receive either targeted cognitive training (cognitive remediation) or general cognitive activation (computer skills training). Cognitive and psychological outcomes were assessed at baseline, after 13 and 26 sessions, and 1 month postintervention. A high dropout rate highlighted the feasibility challenges of treating this population. Intent-to-treat analysis found significant improvements across groups in specific and global measures of cognition and psychological distress, with no significant group differences. Transition-age homeless youth show improvements in cognitive and psychological functioning when engaged in interventions that address their cognitive development. This speaks to the malleability of cognitive skills in this cohort and lays the groundwork for future research to address their cognitive health.

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

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.

Prevalence of Mental Illness among Homeless People in Hong Kong

Metholodogy

This study examined the prevalence and correlates of mental illness in homeless people in Hong Kong and explored the barriers preventing their access to health care. Ninety-seven Cantonese-speaking Chinese who were homeless during the study period were selected at random from the records of the three organisations serving the homeless population. The response rate was 69%. Seventeen subjects could not give valid consent due to their poor mental state, so their responses were excluded from the data analysis. A psychiatrist administered the Structured Clinical Interview for DSM-IV Axis-I disorders (SCID-I) and the Mini -Mental State Examination. Consensus diagnoses for subjects who could not complete the SCID-I were established by three independent psychiatrists.

Findings

The point prevalence of mental illness was 56%. Seventy-one percent of the subjects had a lifetime history of mental illness, 30% had a mood disorder, 25% had an alcohol use disorder, 25% had a substance use disorder, 10% had a psychotic disorder, 10% had an anxiety disorder and 6% had dementia. Forty-one percent of the subjects with mental illness had undergone a previous psychiatric assessment. Only 13% of the subjects with mental illness were receiving psychiatric care at the time of interview. The prevalence of psychotic disorders, dementia and the rate of under treatment are hugely underestimated, as a significant proportion (18%) of the subjects initially selected were too ill to give consent to join the study.

Conclusion

The low treatment rate and the presence of this severely ill and unreached group of homeless people reflect the fact that the current mode of service delivery is failing to support the most severely ill homeless individuals.

Neurocognitive impairment in a large sample of homeless adults with mental illness

OBJECTIVE

This study examines neurocognitive functioning in a large, well-characterized sample of homeless adults with mental illness and assesses demographic and clinical factors associated with neurocognitive performance.

METHOD

A total of 1500 homeless adults with mental illness enrolled in the At Home Chez Soi study completed neuropsychological measures assessing speed of information processing, memory, and executive functioning. Sociodemographic and clinical data were also collected. Linear regression analyses were conducted to examine factors associated with neurocognitive performance.

RESULTS

Approximately half of our sample met criteria for psychosis, major depressive disorder, and alcohol or substance use disorder, and nearly half had experienced severe traumatic brain injury. Overall, 72% of participants demonstrated cognitive impairment, including deficits in processing speed (48%), verbal learning (71%) and recall (67%), and executive functioning (38%). The overall statistical model explained 19.8% of the variance in the neurocognitive summary score, with reduced neurocognitive performance associated with older age, lower education, first language other than English or French, Black or Other ethnicity, and the presence of psychosis.

CONCLUSION

Homeless adults with mental illness experience impairment in multiple neuropsychological domains. Much of the variance in our sample's cognitive performance remains unexplained, highlighting the need for further research in the mechanisms underlying cognitive impairment in this population.

A quantitative review of cognitive functioning in homeless adults

Homeless people experience elevated rates of risk factors for cognitive impairment. We reviewed available peer-reviewed studies reporting data from objective measures of cognition in samples identified as homeless. Pooled sample-weighted estimates of global cognitive screening measures, full-scale intelligence quotient (IQ), and premorbid IQ were calculated, in addition to pooled sample characteristics, to understand the representativeness of available studies. A total of 24 unique studies were identified, with 2969 subjects. The pooled estimate for the frequency of cognitive impairment was 25%, and the mean full-scale IQ score was 85, 1 standard deviation below the mean of the normal population. Cognitive impairment was found to be common among homeless adults and may be a transdiagnostic problem that impedes rehabilitative efforts in this population. Comparatively little data are available about cognition in homeless women and unsheltered persons.

Adverse outcomes among homeless adolescents and young adults who report a history of traumatic brain injury

OBJECTIVES

We examined the prevalence of self-reported traumatic brain injury (TBI) among homeless young people and explored whether sociodemographic characteristics, mental health diagnoses, substance use, exposure to violence, or difficulties with activities of daily living (ADLs) were associated with TBI.

METHODS

We analyzed data from the Wilder Homelessness Study, in which participants were recruited in 2006 and 2009 from streets, shelters, and locations in Minnesota that provide services to homeless individuals. Participants completed 30-minute interviews to collect information about history of TBI, homelessness, health status, exposure to violence (e.g., childhood abuse, assault), and other aspects of functioning.

RESULTS

Of the 2732 participating adolescents and young adults, 43% reported a history of TBI. Participants with TBI became homeless at a younger age and were more likely to report mental health diagnoses, substance use, suicidality, victimization, and difficulties with ADLs. The majority of participants (51%) reported sustaining their first injury prior to becoming homeless or at the same age of their first homeless episode (10%).

CONCLUSIONS

TBI occurs frequently among homeless young people and is a marker of adverse outcomes such as mental health difficulties, suicidal behavior, substance use, and victimization.

Humanistic burden in schizophrenia: a literature review

OBJECTIVES OF THE STUDY AND BACKGROUND

Schizophrenia is a complex disease that affects 1% of the population. This disease has a considerable impact not only on patients' health and well-being but also on their surrounding environment. The costs of the disease's management remain large for individuals and society. While literature on the economic impact of schizophrenia is abundant, few studies have focused on its humanistic burden. This does not only concern patients, but also caregivers, relatives, neighbours and others in a patient's daily life. This burden appears through several dimensions, including treatment side effects and the impact on caregivers and features of the patient's environment. The aim of this review is to consider, compile and describe the humanistic burden of schizophrenia as documented in the literature.

MATERIALS AND METHODS

We conducted a literature review assessing the worldwide disease burden of schizophrenia, taking into account all humanistic burden topics. The search considered several databases, including Embase, Medline, Cochrane Library, The German Institute of Medical Documentation and Information (DIMDI) and the ISPOR conference websites.

RESULTS

The search identified 200 literature reviews, covering several dimensions of humanistic burden and documenting many issues. Main findings included the high death rates that may be explained by long-lasting negative health habits, disease- and treatment-related metabolic disorders, and consequent increased frequencies of cardiovascular diseases. Co-existing depression was found to have adverse consequence on the course of schizophrenia progression, morbidity and mortality. Cognitive impairment also adds to the burden of schizophrenia. Social impairment is worsened by underestimated stigmatisation and lack of corresponding awareness within the professional and social spheres. Finally, caregiver burden was found to be considerable.

DISCUSSION

Humanistic burden among patients with schizophrenia is substantial potentially impacted by co-morbid depressive symptoms, caregiver burden and cognitive impairment. Effects of treatment on humanistic burden in addition to economic burden need to be explored in future trials.

Cognitive deficit and mental health in homeless transition-age youth

BACKGROUND AND OBJECTIVES

There is increasing recognition of the cognitive consequences of socioeconomic adversity during childhood, which can impair learning and negatively affect social and emotional development. However, there is a paucity of research on cognitive functioning and mental health among transition-age homeless youth. This study aimed to address this knowledge gap by examining the prevalence and functional significance of cognitive impairment and mental health disorders in a sample of 18- to 22-year-old homeless youth.

METHODS

Participants (N = 73) were recruited from a vocational support program at Covenant House New York, a care agency for homeless youth. Assessments included diagnostic assessment for mental health disorders and evaluation of neurocognition and vocational outcomes.

RESULTS

Youth demonstrated histories of academic instability, academic achievement below expectation, and high rates of untreated psychiatric disorders, the most prominent of which were anxiety, substance use, and mood disorders. Of those who had a mental health diagnosis, more than half demonstrated cognitive deficits. Performance on measures of working memory and verbal memory was <70% of that of the age-matched normative population. Cognitive impairment was associated with a significant risk for making a wage insufficient for independent living.

CONCLUSIONS

These data confirm the need to focus on cognitive as well as emotional and physical health in transition-age youth. Comprehensive intervention at this later developmental stage has the potential to facilitate the acquisition of skills needed for academic, vocational, and independent living success in adulthood.

Traumatic brain injury among men in an urban homeless shelter: observational study of rates and mechanisms of injury

BACKGROUND

Little empiric research has investigated the interrelationship between homelessness and traumatic brain injury. The objectives of this study were to determine the rate, mechanisms and associated outcomes of traumatic brain injury among men in an urban homeless shelter.

METHODS

We recruited participants from an urban men's shelter in Toronto, Ontario. Researchers administered the Brain Injury Screening Questionnaire, a semistructured interview screening tool for brain injury. Demographic information and detailed histories of brain injuries were obtained. Participants with positive and negative screening results were compared, and the rates and mechanisms of injury were analyzed by age group.

RESULTS

A total of 111 men (mean age 54.2 ± standard deviation 11.5 yr; range 27-81 yr) participated. Nearly half (50 [45%]) of the respondents had a positive screening result for traumatic brain injury. Of these, 73% (35/48) reported experiencing their first injury before adulthood (< 18 yr), and 87% (40/46) reported a first injury before the onset of homelessness. Among those with a positive screening result, 33 (66%) reported sustaining at least one traumatic brain injury by assault, 22 (44%) by sports or another recreational activity, 21 (42%) by motor vehicle collision and 21 (42%) by a fall. A positive screening result was significantly associated with a lifetime history of arrest or mental illness and a parental history of substance abuse.

INTERPRETATION

Multiple mechanisms contributed to high rates of traumatic brain injury within a sample of homeless men. Assault was the most common mechanism, with sports and recreation, motor vehicle collisions and falls also being reported frequently by the participants. Injury commonly predated the onset of homelessness, with most participants experiencing their first injury in childhood. Additional research is needed to understand the complex interactions among homelessness, traumatic brain injury, mental illness and substance use.

Traumatic brain injury among people who are homeless: a systematic review

Background

Homelessness and poverty are important social problems, and reducing the prevalence of homelessness and the incidence of injury and illness among people who are homeless would have significant financial, societal, and individual implications. Recent research has identified high rates of traumatic brain injury (TBI) among this population, but to date there has not been a review of the literature on this topic. The objective of this systematic review was to review the current state of the literature on TBI and homelessness in order to identify knowledge gaps and direct future research.

Methods

A systematic literature search was conducted in PsycINFO (1887–2012), Embase (1947–2012), and MEDLINE/Pubmed (1966–2012) to identify all published research studies on TBI and homelessness. Data on setting, sampling, outcome measures, and rate of TBI were extracted from these studies.

Results

Eight research studies were identified. The rate of TBI among samples of persons who were homeless varied across studies, ranging from 8%-53%. Across the studies there was generally little information to adequately describe the research setting, sample sizes were small and consisted mainly of adult males, demographic information was not well described, and validated screening tools were rarely used. The methodological quality of the studies included was generally moderate and there was little information to illustrate that the studies were adequately powered or that study samples were representative of the source population. There was also an absence of qualitative studies in the literature.

Conclusions

The rate of TBI is higher among persons who are homeless as compared to the general population. Both descriptive and interventional studies of individuals who are homeless should include a psychometrically sound measure of history of TBI and related disability. Education of caregivers of persons who are at risk of becoming, or are homeless, should involve training on TBI. Dissemination of knowledge to key stakeholders such as people who are homeless, their families, and public policy makers is also advocated.

Housing status as an independent predictor of functional capacity in patients with schizophrenia

This study compared the functional capacity and neurocognitive status of homeless and housed adults with schizophrenia or schizoaffective disorder and examined whether housing status is an independent predictor of functional capacity. We examined 30 homeless individuals and 21 housed controls and matched for diagnosis, sex, and age. The participants, recruited from an acute psychiatric inpatient unit, completed a measure of psychiatric symptom severity, a neuropsychological test battery, and a measure of functional capacity, the University of California-San Diego performance-based skills assessment (UPSA). There were no significant differences in performance on the neuropsychological test battery or the UPSA between housed and homeless participants. In a multivariate model, however, cognitive status and housing status were independent predictors of functional capacity, and homelessness was associated with an approximately 9-point lower score on the UPSA. This finding highlights the importance of neuropsychological screening and interventions that promote housing stability for patients with schizophrenia.

Smoking cessation among sheltered homeless: a pilot

OBJECTIVE

To test the feasibility and effect of a smoking cessation intervention among sheltered homeless.

METHODS

Homeless smokers were enrolled in a 12-week group counseling program plus pharmacotherapy (n = 58).

RESULTS

The mean number of sessions attended was 7.2; most participants used at least one type of medication (67%); and 75% completed 12-week end-of-treatment surveys. Carbon-monoxide-verified abstinence rates at 12 and 24 weeks were 15.5% and 13.6% respectively.

CONCLUSION

Results support the feasibility of enrolling and retaining sheltered homeless in a smoking cessation program. Counseling plus pharmacotherapy options may be effective in helping sheltered homeless smokers quit.

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

OBJECTIVE

The primary goals of this systematic review were to assess studies of homeless adults and cognitive functioning, and to explore the clinical implications and potential impacts on social functioning of these cognitive deficits.

METHOD

The MEDLINE, CINAHL, EMBASE, PsycINFO, Applied Social Sciences Index and Abstracts, ERIC, Social Sciences Abstracts, Social Sciences Citation Index, Social Services Abstracts, and Sociological Abstracts databases were searched from 1970 (or their inception) to October 2007. Abstracts from 582 studies were screened and 22 studies were found to meet inclusion criteria (published in the English language, reported results of neuropsychological tests, or screening tests for cognitive dysfunction in homeless people aged 18 years or older). Two investigators independently reviewed each study and rated its quality based on well-defined criteria.

RESULTS

Ten studies were of good or fair quality. Studies that administered the Mini Mental State Examination indicate about 4% to 7% of homeless people exhibit global cognitive deficits. Focal deficits in verbal and visual memory, attention, speed of cognitive processing, and executive function were also apparent. No studies of the functional implications of cognitive deficits were found.

CONCLUSIONS

Cognitive deficits in homeless people likely have a significant mediating impact on the effectiveness of skills training and rehabilitation programs. Clinicians should be cognizant that cognitive deficits probably impair homeless patients' ability to maintain housing stability and follow treatment recommendations. Implications for housing options and health service delivery should also be considered. Research is lacking on interventions to improve cognitive functioning in the homeless.

The role of effective discharge planning in preventing homelessness

Effective discharge planning can contribute significantly to preventing homelessness. As part of a larger continuum of care, this process can help people reach goals of stable housing, recovery, and increased quality of life in the community. Discharge planning identifies and organizes services a person with mental illness, substance abuse, and other vulnerabilities needs when leaving an institutional or custodial setting and returning to the community. A three-component model is presented, relating discharge planning to institutional assessment and treatment, and to community services. Service challenges, innovative programs (based on a state-by-state analysis), and recommendations for enhancing discharge planning also are discussed.