The Aging and Homelessness Project

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An Educational Outreach Project of the Specialized Geriatric Services at The Toronto Rehabilitation Institute and the University Health Network supported by the The Regional Geriatric Program of Toronto with the kind assistance of the CAMH's Psychiatric Assessment,Consultation and Education (PACE)East, the St. Michael's Hospital Crisis Intervention Team, and the administration and staff of the Women's Residence and Seaton House Shelter for Men.

Did you know that as many as 13% of the people using shelters in Toronto may be seniors and it is not uncommon to find homeless people who are 80 even 90 years old.

The Invisible Homeless Older Person

Some facts about the older homeless person
[Cohen,C.,1999, DeMallie, D. et al.1997,Seidman & Caplan et al.,1997]
  1. Homeless people are physiologically "old" at 50.
  2. The rate of functional decline is low given the high rate of physical illness.
  3. The U.S. has 60,000 older homeless people, Canada may have 6000.
  4. Alcohol consumption may be lower among older homeless people.
  5. Some studies find low rates of mental illness.
  6. The rate of diagnosable cognitive impairment among older homeless people
  7. The occurance of dementia is about the same as for the general population of senior i.e. about 6%.
  8. While, the general homeless population may have severe difficulties in executive, conceptual and motor functions, attention and memory.

The Death of Mad Dog

Last year, George Chester, an activist for homeless people in Toronto and a senior citizen of great feeling and humour helped to raise our awareness of the needs of homeless seniors. Lynda Meneely, a nurse from the Women's Residence,a shelter for homeless women lent a hand. Our staff wanted to know whether homeless really was an older person's problem and whether, through the RGP's educational outreach services, there was anything that we could do to help.

George started off by telling us the story of the death of Mad Dog. George was called to a local hospital one night because a homeless person was dying and had asked to speak to him. He went and found Mad Dog. He had only met Mad Dog once, weeks before, and could hardly remember what had happened when they had met. But as Mad Dog died he told George that he had asked to see him because "dying isn't so bad when you know that someone who loves you is nearby".

There were two lessons for George in Mad Dog's death. The first lesson was "you don't have to do much". "Sometimes", George explained, "small things end up being something really big". The second lesson was that "you never know, with each small act, which one might turn into something great".

How Out of the Cold Got Started

George also told us another story. The story of a homeless person whose death initiated a chain of events which produced the Out of the Cold Program that has now spread across the nation.

It seems that there were two young St. Michael's Collegians who would go out behind the arena for a smoke at lunchtime. They found a homeless man holed up in the garbage bins and over the next few months they befriended him and shared their lunch and cigarettes with him. Then one day he wasn't there. He had frozen to death the night before.

His body was laid out at the Anglican Chapel down the street where these two collegians met our friend George. Together they talked the Anglican minister into opening his doors for "just one night". Then they went to a church nearby and asked whether they had heared about the "wonderful thing that the Anglicans are doing" and one by one some 240 churches in Toronto opened their doors for "just one night" for homeless people to come in "out of the cold."

Our team asked whether elderly homeless people who come in out of the cold? "Most certainly", George and Lynda insisted. It was then that we were told that at the Women's Residence, as many as 13% of the clients might be over the age of 65. We were startled to discover during the deep freeze of the previous winter, the residence was the temporary home for a woman of 93 and another who was 87. Octogenerian homeless people. It was hard to imagine.

That afternoon George and Lynda were asked whether education for shelter staff would be helpful. "Absolutely", we were told. "Aren't homeless people often alcoholic or ill with psychiatric problems?", we asked. "About 75% of shelter residents do" but, Lynda pointed out, many elderly people come to the shelters for protection from younger and more aggressive street people. And, when they do come they bring all the problems of frail elders with them: problems like confusion, memory difficulties, falls and fractures, incontinence, competency issues, respiratory problems, skin break down, inadequate walking aids and palliative care needs. "If you could teach us some of what you know about caring for elders it would really help us", said Lynda. "Knowledge that is second nature to you," she said, " like what is the right height for a walking stick, might be just the thing that we need to help a frail bag lady get through the winter without falling.". And so, the dye was cast. A team was formed to see what could be done. As George had said, "you never know which little act might turn into something great."

The Aging & Homelessness Education Project Emerged

The director of the Women's Residence was enthusiatic and saw great value in increasing her staff's skills and knowledge in geriatric care. A focus group confirmed that the complex bio-psychosocial and functional needs that were the focus of the work of Specialized Geriatric Services teams were common amongst homeless seniors. The director also told us that while people aged early "living on the street", the number of homeless elders was increasing. And, it was increasing so rapidly that the Seaton House Shelter for Men was renovating to provide long-term care for elderly homeless men.

Contact was established with the Director of Seaton House. Following an initial meeting, a team of Specialized Geriatric Service clinicians from the Rehabilitation Institute, the University Health Network, and Sunnybrook & Women's College Health Science Center met with the renovation architects to give geriatrics focused advice and an aging simulation to assist in the renovation. Discussions covered issues such as wheelchair access, designs for falls prevention and the maintenance of independence.

The next step was a meeting with the Inner City Health Program to share our willingness to provide education in aging and health to staff working with homeless elders. Our assistance was welcomed and we were encouraged to go on.

Meanwhile, meetings with the shelter directors focused on developing a way of identifying the learning needs of the shelter staff. A learning needs survey was developed which included Objective measures such as Knowledge of Normal Aging, Knowledge of Alzheimer's Disease, Mental Health Caregiving, Knowledge of Depression and Alcohol Use in Older Age, as well as allowing staff to identify their own Subjective Learning Needs. Eighty two percent of the shelter staff, from all  levels of the organization completed the survey and the data is presented below.

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The Results of the Learning Needs Survey

The Learning Needs Identified by Shelter Staff (N=43)
(note that items with the same number shared the same rank)

Cognitive Impairment 1
Mental Health Problems 2
Diseases Like Diabetes & Congestive Heart Failure 3
Competence 5
Medications and Aging 5
Advocacy and Linkage 5
Agitation Management 7.5
Addictions & Aging 7.5
Elder Abuse 9.5
Communication & Support 9.5
Cultural Diversity 12
Managing Pain 12
Promoting Safety 12
Mobility 14.5
Exercise & Diet 14.5
Falls Prevention 16
End of Life Care 17
Managing Continence 18
Personal Care (bathing etc) 19
Income Management 20

Facts On Aging 64% Retirement Centre 63% 
Retirement Centre Volunteers 65% 
Physical Therapy Students 75%
Alzheimers Disease 
51% Retirement Centre 64% 
Retirement Centre Volunteers 45%
Undergraduates 42%
Mental Health
68% Retirement Centre 74% 
Nursing Home Consultants 88% 
Nursing Aides 54%
and Aging Quiz
53% Retirement Centre 80% 
Retirement Centre Volunteers 67% 
Homecare Staff 71%

A Program To Support Learning

The Learning Needs Survey was completed in the spring of 1998 and the results were reviewed by the shelter directors, attending physicians, shelter educational leaders and the training team. A program of workshops was scheduled. It was decided that shelter staff would participate in joint workshops but staffing schedules required that each workshop would be run twice. Four workshops were planned requiring eight training sessions. Shelter directors took responsibility for planning venues and circulating notices while the training team planned and staffed the workshops.

The schedule of workshop training sessions were as follows:

1. Meetings to Introduce the teaching team
                       Review results of the learning needs survey
                       Focus our priorizing of learning needs
                       Edumetric exercise on normal aging using the  Facts On Aging Quiz
                    Participant Feedback

2. Workshops on  Cognitive Impairment and Dementia in the Inner City.
                  Workshop slides
                   Participant Feedback

3.  Workshops on Developing Community Linkages
                      Develop two contextually detailed case studies using Build-A-Case
                     The case of Clarence, The case of Agnes (Please note that these are
                      composite cases built by the group and do not refer to specific
                      Use the cases to identify service linkage needs
                     Participant Feedback

4.  Workshops on Developing Community Linkages
                       Use Build-A-Case linkage profiles
                       Understand the history organizational status of service agencies
                       Clarify linked services information  needs.
                        Develop  a minimal client profile form
                       Participant Feedback

Next Steps

Our next steps are an evaluation of learning outcomes and planning further educational activities including the development of workshops for the annual summer institute for all shelter staff across the region

Some Helpful Print and Online References

Homelessness and health care is the cover story of CMAJ's July 2000 issue

Cohen, C., (1999) Aging and homelessness, The Gerontologist, 99, 5-14.
Cohen develops a structural and testable model explaining homeless for seniors and presents an overview of American aging & homelessness demographics.

DeMallie,D. et al.(1997)Psychiatric disorders among the homeless: A comparison of older and younger groups. The Gerontologist, 37, 61-66.
Suggesting that older and younger indivudals have different vulnerabilities to homelessness.

Keigher, S. & Greenblatt, S. (1992) Housing emergencies and the etiology of homelessness among the urban elderly. The Gerontologist, 32, 457-465.
Homelessness found to be significantly associated with low income, dementia, living alone, and an unstable residential history.

Reilly, F. (1994) An ecological approach to health risk: A case study of urban elderly homeless people. Public Health Nursing, 11, 305-314.
Describes an ecological approach to assessing health risk and applies it to a sample of elderly homeless people with the context of a single day in a single urban setting.

Seidman & Caplan et al., (1997) Neuropsychological function in homeless mentally ill individuals. Journal of Nervous & Mental disorders, 185, 3-12.
Perhaps the largest study of neuropsychological functioning of homeless people revealing a wide range of significant impairment.

Report of the Mayor's Task Force on Homelessness
Faces of Homelessness: Toronto's Homelessness Memorial, 1999, Gallery
International HOMELESS DiscussionList, Archives, and Weblinks - HomePage
The U.S. National Alliance to End Homelessness
U.S. National Survey of Homeless Assistance Providers and Homeless Persons

Images of Homelessness

Nightime at the Mission (linocut by Ely Jacobi) Group of Men (linocut by Julius Weis)
Images from the New Deal Network Library