Homelessness

Carl Cohen has proposed a model of homelessness in which various biographical and individual risk factors accumulate over a lifetime. Except in the case of extremely vulnerable individuals, homelessness is not likely to occur unless several of these factors coexist. In most instances, however, the ultimate determinants are the unavailability of low-cost housing and insufficient income to pay for housing. Finally, the length and patterns of homelessness reflect a person's ability to adapt to the street or shelter, along with individual and system factors that may prolong homelessness. The principal risk factors that have been found to increase vulnerability to homelessness among older individuals are described below.

Race. While the proportionate representation of Caucasians is higher among older than younger homeless persons, African Americans are still over-represented among older homeless persons in the United States.

Age 50–64. Because of the entitlements available to persons at age sixty-five (e.g., Social Security), their proportion among the homeless is roughly one-fourth of their representation in the general population. Conversely, persons between fifty and fifty-nine years old are disproportionately represented among the homeless, compared with their representation in the general population (about one and one-half to two times).

Extremely low income (current and lifetime). Older homeless persons are likely to come from poor or impoverished backgrounds and to spend their lives in a similar economic condition. More than three-fifths work in unskilled or semiskilled occupations, with current income roughly one-half the poverty level.

Disruptive events in youth. Consistent with reports of high prevalence of childhood disruptive events among younger homeless persons, about one-fifth of older homeless persons have had disruptive events such as death of parents or placement in foster care.

Prior imprisonment. Roughly half of older homeless men and one-fourth of older homeless women report prior imprisonment.

Chemical abuse. Although prevalence rates of alcoholism vary, the levels are about three to four times higher among older men than among older women, and levels are higher among homeless men and women than among their age peers. Illicit drug abuse falls off sharply in homeless persons over fifty, but this may increase with the aging of the younger generation of heavy drug users.

Psychiatric disorders. The rates of psychiatric illness among older homeless persons have been biased by the difficulty that such persons encounter in attempts to be rehoused. Levels of mental illness have been found to be consistently higher among women than men, with psychosis more common among women and depression slightly more prevalent among men. Studies of homeless people in New York City have found that 9 percent of older men and 42 percent of older women displayed psychotic symptoms, whereas 37 percent of older men and 30 percent of older women exhibited clinical depression. Levels of cognitive impairment range from 10 to 25 percent, but severe impairment occurred in only 5 percent of older homeless persons, which is roughly comparable to the general population.

Physical health. Older homeless persons suffer a level of physical symptoms roughly one and one-half to two times the level of their age peers in the general population, although their functional impairment is not worse than their age peers.

Victimization. Both younger and older homeless persons report high rates of victimization. Studies have found that nearly half of older persons had been robbed and one-fourth to one-third had been assaulted in the previous year. More than one-fourth of women reported having been raped during their lifetime.

Social supports. Compared to their age peers, social networks of older homeless persons are smaller (about three-fourths the size), more concentrated on staff members from agencies or institutions, more likely to involve material exchanges (e.g., food, money, or health assistance) and reciprocity. Older homeless persons also have fewer intimate ties than their age peers. Although not utterly isolated, older homeless persons lack the diverse family ties that characterize older adults in the general population. Only 1 to 7 percent are currently married, versus 54 percent in the general population. Nevertheless, various studies have found that about one-third to three-fifths of older homeless persons believed that they could count on family members for support.

Prior history of homelessness. One of the key predictors of prolonged and subsequent homeless episodes is a prior history of homelessness. Lengths of homelessness are higher among older men than older women.

Once a person is homeless, evolution into long-term homelessness involves a process in which the individual learns to adapt and survive in the world of shelters or streets. Furthermore, certain persons (e.g., men, the mentally ill, those with prior homeless episodes) are more apt to remain homeless for extended periods, most likely reflecting impediments at the personal and systems levels.

The two principal systemic factors that create homelessness are lack of income and lack of affordable housing. In cities where there may be adequate housing supplies, high levels of poor-quality jobs, unemployment, and low incomes make most housing unavailable to the poor. Conversely, in cities where incomes may be higher and jobs are more plentiful, tight rental markets stemming from middle-class pressure and escalating living costs also makes housing less available to lower-income persons. Both these conditions can push some people over the edge into homelessness.

Although it is now recognized that a majority of homeless persons do not suffer from severe mental illness, the closing of mental hospitals (deinstitutionalization) has been often cited as playing a critical role in causing homelessness. There is strong evidence that deinstitutionalization does not exert a direct effect on homelessness, as there is usually a time lag between a person's discharge from a psychiatric hospital and subsequent homelessness, and many homeless people with mental illness have never been hospitalized for psychiatric illness. Thus, whereas mental illness may at times lead to homelessness, it is also apparent that the disproportionately large numbers of homeless mentally ill persons also reflect systemic factors such as the unavailability of appropriate housing and inadequate entitlements for this population.

At the service level, there has been a paucity of programs for homeless and marginally housed older persons. Age-segregated drop-in/social centers, coupled with outreach programs, have been shown to be useful with this population. Unfortunately, while many agencies proclaim an official goal of rehabilitating the homeless person and reintegrating them into conventional society, the bulk of their energies go into providing accommodative services that help the person survive from day to day.

Another potentially useful modality is a mobile unit, of the type developed by Project Help in New York City, to involuntarily hospitalize persons. Used judiciously, and being mindful of civil rights, such units can assist those elderly homeless who are suffering from moderate or severe organic mental disorders or from mental illness that is endangering their lives. Advocacy is also important. For example, in Boston, the Committee to End Elder Homelessness consists of a coalition of public and private agencies working to eliminate elder homelessness and to provide options for this population.

Based on the model of aging and homelessness described above, it is likely that the imminent burgeoning of the aging population will result in a substantial rise in at-risk persons. Prevention of homelessness among older persons will depend primarily on altering systemic and programmatic factors. In some geographic areas, where income supports and employment opportunities are greater, it will mean ensuring that there is adequate low-income housing stock. Conversely, in areas where cheaper housing may be available, it will be necessary to boost entitlements to levels sufficient to make existing housing affordable. Finally, for people who become homeless, there must be an expansion of programs targeted to the needs of older persons that work seriously towards reintegrating these persons into the community.