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EFFECTS OF HOMELESSNESS ON THE ELDERLY

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Effects of Homelessness on the Elderly
Logan Geren, Taru Nikkinen, Diana Matei, and Piper Smith

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Effects of Homelessness on the Elderly
Whenever examining the effect of homelessness on the elderly population, it is necessary
to examine how nurses, and the population served, view health. The World Health Organization
(WHO) defines health in a holistic sense: health is a state of complete physical, mental, and
social well-being and not merely the absence of disease or infirmity (World Health
Organization, 2015). As representatives of the nursing community, this group examined nurses
opinions of health and well-being. Health, as viewed by this aggregate, is holistic--it
encompasses physical, mental, spiritual, and social well-being. However, health has a unique
meaning to the individual.
Regarding the homeless, elderly population, healthcare concerns are not viewed as
immediate needs (i.e. food or shelter) (Kushel, Vittinghoff, & Haas, 2001). Typically, homeless
elderly are the most vulnerable to healthcare needs, and yet " ...multiple studies have
documented that the elderly homeless seek medical care at about the same rates if not less
than their younger counterparts" (Ng, Rizvi, & Kunik, 2013). Despite their reluctance to seek
treatment, homeless [populations] do show a concern for physical illness, mental health,
addictions, and stress (Daiski, 2007). The homeless elderly population is growing, in 2003, it
was estimated that 23% of homeless people were over the age of 50 compared to 11% in 1990.
Today, it is estimated that as much as 50% of the homeless population is over the age of 50
(Brown et al., 2015). With a growing population, it is necessary to examine the effects of
homelessness on the elderly and understand how to address this populations healthcare
concerns.

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Vulnerable Population
In order to understand rehabilitation, health promotion, and methods to address
healthcare needs of the homeless elderly population, we must first understand the health risks
and dynamics of this group. Homeless elderly live in emergency and temporary accommodation
and, without permanent and stable housing, they are at increased risk for health complications.
Homeless people have an increased incidence of morbidity when compared with the general
population. Healthcare needs of the general homeless community include: treatment for trauma,
adverse effects and complications of drug use, infection, and mental health needs (Wright &
Tompkins, 2006). Homeless older adults have additional health-related impairments that the
younger generation does not face. Specific healthcare concerns of the homeless elderly include:
functional impairment, frailty, depression, visual impairment, and urinary incontinence (Brown,
Kiely, Bharel, & Mitchell, 2012). With increased healthcare concerns, there is an added pressure
on healthcare personnel to address this population.
By 2050, the elderly homeless population is expected to double to approximately 95,000
elderly without stable housing (National Healthcare for the Homeless Council, 2013). The rate of
homeless elderly is expected to increase for two reasons: expanded life expectancy and the rate
of deep poverty is expected to remain constant (National Alliance to End Homelessness, 2010).
The prevalence of this population requires healthcare providers to address the needs and
concerns of this population through rehabilitation programs, health promotion, government
organizations.
In Finland, homelessness cannot be specified by a certain age because the homeless
population is very small and homelessness is not a widely recognized phenomenon. Homeless
people are defined as those that sleep outside, stay in makeshift shelters or night shelters, lodge

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in nursing homes or institutions, or those that temporarily lodge with relatives or friends
(Turvallinen kaupunki, 2015). In Finland, homelessness is concentrated in big cities, especially
in the metropolitan area. According to a survey, there were 7,850 homeless people in Finland in
2012 (Asumisen rahoitus- ja kehittmiskeskus, 2015). Homelessness has increased in eight EU
member states, however, the rate of homelessness in Finland has declined (Juupaluoma, 2015).
Most of the homeless people are men, but there is an increasing incidence of homeless
women, young adults, and immigrants (Turvallinen kaupunki, 2015). Long-term-homelessness is
typically confined to elderly, alcoholic man (Hankonen 2013). Homelessness is usually due to a
lack of inexpensive rental apartments, however, it may also be related to exclusion and substance
abuse (Turvallinen kaupunki, 2015). Many specialists believe that the best method to prevent
homelessness is to provide reasonably priced apartments (Nyknen, 2014).
Homelessness is mentally and physically difficult. Homeless people often exhibit alcohol
abuse and mental diseases (i.e. anxiety, depression), injuries, different contagious diseases,
infections, musculoskeletal disorders, and somatic diseases. Alcohol abuse causes neurological
problems, such as, intermittent claudication. If homelessness is long-term, there is an increased
incidence of psychiatric disorders, alcohol abuse, and use of illicit drugs (Koski, 2013;
Hankonen, 2013). Homeless elderly have a diet that is lacking in appropriate calories and
nutrients. This population may resort to dumpster diving, however, some may be able to access
food from a breadline (Pyyvaara & Timonen, 2012, 26-27.) Winter months also increase the risk
for health complications as homeless people are at risk for frostbite and hypothermia (Hankonen,
2013).
Rehabilitation

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According to WHO, rehabilitation of any population can be described as ...a process
aimed at enabling [patients] to reach and maintainoptimal physical, sensory, intellectual,
psychological and social functional levels. Rehabilitation providesthe tools [necessary] to
attain independence and self-determination (World Health Organization, 2015). This special
facet of healthcare does not necessarily aim to cure an ailment or disability, but rather to equip
the individual with the care, equipment, and support that is needed to achieve the highest level of
health possible.
The need for rehabilitation has grown overtime due to longer life expectancy. If there is
adequate access to healthcare, numerous services are available. Today's rehabilitation
professional provides a broad scope of services involving medical, vocational, psychological,
and advocacy interventions, all across various settings (Chan, Rosenthal, & Pruett, 2008).
Rehabilitation includes physical therapy for new injuries and old physical disabilities,
occupational therapy, counseling and health coaching, nutritional guidance, and several other
services. Rehabilitation empowers the patient and directs them towards better health. Healthcare
personnel emphasize holistic care and address each patients individual needs and help
provideintegrated medical and therapeutic treatments [that are] individually tailored
(Marionjoy Rehabilitation Hospital, 2014).
Rehabilitation for the older individual requires additional resources as they typically have
a longer recovery period. Strokes, hip fractures, and dementia are just a few conditions that the
elderly are more susceptible to. An interdisciplinary team, patient advocates, and resources are
needed to ensure that the person meets his or her optimal state. A subgroup of older adults that is
consistently overlooked is the homeless. Older homeless individuals very rarely seek
rehabilitation services themselves. Homeless individuals often learn to cope with their situation

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and become acclimated to their way of life andonly after a serious trigger occurs will they
realize the need to change their lives (Philipps, 2012, p. 32). Like many older adults, this
subgroup usually suffers from co-morbidities and chronic illnesses. These health conditions are
rarely kept under control due to a lack of resources. This population is usually in desperate need
of medical care and rehabilitationespecially in the area of mental and cognitive health. Mental
illness, nonadherence to medications, and substance abuse contributes to the increased
proportion of homeless people suffering from psychiatric disorders (Nieto, Gittleman, & Abad,
2008).
There is a unique challenge in providing rehabilitation services to homeless older adults.
Public policy and programs currently used to help homeless individuals have proven to be
severely lacking in their ability to make positive change in the lives of those they are supposed to
be helping (Philips, 2012, p.32). It takes more than money allocated by the government into
subsequent housing or detox centers (Philips, 2012, p.32). It takes outreach into the community,
kindness, and therapeutic communication to reach out to homeless older adults. While there is a
severe shortage of rehabilitation services for the elderly and homeless, this problem has not gone
completely unnoticed. The concept of community-based rehabilitation has been introduced and
continues to bring about positive change. Community-based rehabilitation (CBR) is a resource
aimed at improving quality of life, meeting basic needs, and empowering individuals and
familiesspecifically those of low and middle income (WHO, 2015). The best resource to
encourage rehabilitation for the homeless elderly is to provide adequate housing. Numerous
organizations such as the Salvation Army and the Department of Veteran Affairs (for homeless
Veterans) aim to help the homeless move toward a better life. The Salvation Army in particular
can provide a place to stay as well as skills training and drug and alcohol rehabilitation if needed.

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One of the biggest challenges that nurses have is connecting homeless clients with these types of
services.
Rehabilitation for the homeless population in Finland focuses on providing more access
to housing. There are numerous homeless shelters and temporary resident homes available to
address housing needs. However, the number of shelter places has declined significantly in the
last four decades. For example, in 1970, there were 3,665 shelters in Helsinki; this has reduced to
558 by 2008 (Fredriksson 2009). This downward trend in shelter provision, combined with the
lack of substitute housing solutions, has meant that there is often an unmet need for such
provision, especially during harsh winters (Housing First, 2015). Finland recognizes these
challenges and appears to be proactive in addressing this problem. For example, the Ministry of
the Environmenta key governmental entity in Finlandstresses that supported and sheltered
housing will improve community conditions and provide more opportunities for rehabilitation.
Furthermore, a shift towards tailored and rehabilitative housing willreduce the costs
generated by inpatient care associated with solving problems frequently linked to homelessness
(Ministry of Environment, 2014). Along with long-term projects, there are also organizations to
meet immediate needs and crises such as the Salvation Army in Finland and the Helsinki
Deaconess Institute.
In Helsinki, Finland, there are service centers that offer continuous care for the homeless
population. From these service centers, homeless individuals can receive temporary boarding and
does not refuse service to anyone. The goals of service centers are to improve living conditions
and assist with rehabilitation of the homeless. In the center, homeless individuals can receive
food, have access to showers, receive guidance and assistance for affording permanent residence,
and meet with social workers, nurses, or physicians (Asunto ensin, 2015). Service centers

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promote health and well-being of the homeless population (Hankonen, 2013). In Helsinki there
are also street patrols that consist of two nurses. Their target is to locate homeless people that
have been missed by society. These nurses provide disinfectants and plasters to assist with minor
treatment (Hankonen, 2013).
One of the biggest challenges for rehabilitation in both Finland and America is acting as
the case manager and patient advocate. It is difficult to refer homeless individuals to
rehabilitative services. In both countries, progress must be made in the areas of rehabilitation.
Issues of financial funding, remodeling rehabilitation practices and services, and raising
governmental and community support of these projects are potential obstacles.
Health Promotion and Disease Prevention
Health promotion and disease prevention is difficult to achieve in the homeless elderly
population for several reasons: primary care must be adapted to the specific needs of this
population, health needs vary, and this population places greater importance on immediate care
(i.e. food, shelter, acute care), rather than long-term prevention. Homeless, elderly are more
likely to receive care at a later stage, so health promotion needs to address the healthcare mindset
of homeless elderly. Additionally, homeless people often feel alienated and have low
expectations that prevent engagement with community resources (Wright & Tompkins, 2006).
Health promotion needs to adapt to the specific health risks of the homeless population.
Prevention that is applicable to this population includes vaccinations, needle exchange programs,
sexual health promotion, washing and laundry facilities, smoking cessation, and insecticide
application. When designing promotion programs, it is necessary to consider less traditional
approaches to disease prevention. Medically supervised injection centers are an example of a
unique approach to health promotion. At these centers, homeless people are able to use injectable

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drugs in a safe, controlled environment. These types of centers have been found to reduce the
incidence of drug-related death, decrease reports of hepatitis B or C infection, and increase
likelihood of starting necessary treatment for dependence (Wright & Tompkins, 2006). While
these types of centers are not a traditional approach to health promotion, they address the
immediate issue of safety and health regarding injectable drugs. Without these centers, there is an
increased risk for fatalities related to injecting alone, combination of drugs, and decreased
tolerance after abstinence.
Health promotion should be focused on practical and easily accessible assistance. Mobile
screening clinics offer this population an opportunity to receive screening in their environment.
This promotes accessibility as well as provides education in a neutral location. Information
regarding health promotion may be more readily accepted whenever it is combined with practical
help (i.e. providing clean socks while discussing foot care). If homeless elderly are given
educational materials in combination with items targeted towards immediate care, there may be
increased compliance (Weinstein, LaNoue, Plumb, King, Stein, & Tsemberis, 2013). In
summation, health promotion techniques that are applicable to the general population may not be
successful in this specific subgroup. Nurses, and other healthcare personnel, must work to tailor
promotion techniques to the unique needs of the homeless elderly.
Government and NGOs that address Community Health Concerns
Providing health care for the elderly homeless population is an important issue faced in
many countries. The United States Department of Human Health Services (USDHHS) is a
governmental agency that deals with health problems in the United States. The Centers for
Disease Control and Prevention, the State Department of Health, Social Services, and Local
Health Departments all branch from the USDHHS. At a national level, one governmental

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organization concerned with homelessness is the National Health Care for the Homeless Council
agency (NHCHC). This agency is a network of over 10,000 healthcare professionals who
collaborate to bring the best healthcare to the homeless population and provides support to over
200 state and local organizations that deal with homelessness (National Health Care for the
Homeless Council [NHCHC], 2015).
Many non-governmental organizations also provide support to the homeless population,
such as the St. Louis City Continuum of Care, the Homeless Services Coalition of Greater
Kansas City, and Missouri 2-1-1, although each state has its own organizations (Naroth, Pardo,
Liu, Zhaxynbek, & Osayi, 2013; Substance Abuse and Mental Health Services Administration,
2015; The City of Saint Louis, 2015). In the United States, Health Care for the Homeless (HCH),
a federally funded program, is designed to provide primary health care, substance abuse services,
emergency care, outreach, and assistance in qualifying for housing. Some HCH programs
provide additional services such as dental care or mental health care services (Health Care and
Homelessness, 2009).
According to the Homelessness Among Elderly Persons (2009) article, the elderly
homeless population is entitled to Social Security benefits. Although qualifiers receive
Supplemental Security Income (SSI) this does not cover housing costs. An affordable cost for
housing is no more than 30% of a persons income according to the National Low Income
Housing Coalition (Homelessness, 2009). To meet this challenge, each elderly homeless person
should be given a SSI that can cover the expenses of housing as well as other living expenses. As
nurses, it is important to be educated and understand each organization and what is provided for
the homeless elderly population. Advocating for the patients and making sure they are receiving

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the health care they need for the cost they can afford is also an important role the nurse can play
in helping this population.
The World Health Organization (WHO), the National Health Service (NHS), and the
Organization for Economic Co-operation and Development (OECD) are all part of the healthcare
system in Finland. The Ministry of the Environment is an organization that specifically targets
homelessness in Finland (Tainio & Fredriksson, 2009). Both countries have multiple local
organizations, or departments of health, which operate under a larger, national organization
(Kokko, 2009). In Finland, each local or municipal health organization provides universal public
healthcare for their permanent residents. Private insurance is also available. According to Stuart
Allt (2015), primary healthcare that is provided locally includes consultations with physicians,
health counseling and screenings, oral health services, school and student health care services as
well as mental health care, emergency services, and home care services.
Nursing Theory Related to Homelessness in Elderly Population
Although many nursing theories can serve as a model when applied to homeless elderly
populations, Betty Neumans Systems Theory serves as a great tool in primary, secondary, and
tertiary prevention strategies when working with this specific group. This system focuses on
prevention of disease, screening for the disease, and nursing care for clients in a later stage of the
disease process.
Those who are homeless are at an increased risk for skin and dental problems, nutritional
disorders, higher rates of respiratory disorders, sexually transmitted diseases, accidents and
violence, and injuries due to environmental exposure, along with many other health related
conditions (Bharel, 2011). To implement primary prevention of diseases, nurses can make sure
the elderly are up to date with their vaccinations. Vaccinations that are applicable to this

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population include, tetanus, influenza, pneumococcus, and diphtheria (Wright & Tompkins,
2006). Hepatitis A and B are also important because drug usage and needle sharing is a common
practice among this population. Educational programs about needle exchanges could also be a
great way to prevent spread of disease. Washing and laundry facilities, podiatry interventions,
and applying insecticides to the beddings in the shelters could all be part of primary prevention
(Wright & Tompkins, 2006).
Secondary prevention includes screenings that are relevant to the homeless population.
For cardiovascular risks, it is important to have routine high blood pressure screening,
hyperlipidemia screening, and type 2 diabetes screening in asymptomatic patients with a
sustained blood pressure greater than 135/80 mmHg. It is also important to screen for depression,
intimate partner violence, hepatitis C, HIV, tuberculosis, sexually transmitted diseases, alcohol
misuse, and drug and tobacco abuse (Bharel et al., 2011). Screenings are important in secondary
prevention because they can detect possible diseases or problems. If diseases are discovered
early, interventions can be implemented to keep them from progressing. If the health issues are
more advanced, tertiary preventions can be used.
Tertiary preventions occur after a disease is present and attempt to prevent possible
complications (Bharel, 2011). Once diseases have progressed or are chronic, it is important to
provide the elderly homeless patients with any resources and rehabilitation facilities. When
nurses deal with individuals in this phase of their life, making them comfortable and providing
palliative care is the most important aspect of tertiary prevention. Whether in the primary,
secondary, or tertiary stage of prevention, Neumans Systems Theory can be a beneficial model
for nurses to use in preventing illnesses and health issues in the elderly homeless population as
well as dealing with issues once they are already present.

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Conclusion
Elderly homeless individuals make up a unique population with distinct characteristics
and needs. Although there have been efforts in both Finland and the United States to combat the
issue of homelessness in the elderly population, it is clear that more work needs to be done.
Raising awareness of this issue, finding ways to adequately fund projects, and providing
adequate housing options for elders are necessary tasks to decrease homelessness in Finland, the
United States, and around the globe. These tasks will not be easy to accomplish, but the future
looks promising. Homelessness may never be completely eradicated, but by viewing and treating
this unique population as valued members of the community and by being vocal about this
widespread problem, progress can be made.

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