NOTE: The following report can be downloaded here.
Literature Review: Aging and Homelessness
conducted as part of the SSHRC project:
“Homelessness in late life: growing old on the streets, in shelters and long-term care” (project no 435-2012-1197)
Authors: Amanda Grenier, Rachel Barken, Tamara Sussman, David Rothwell, and Jean-Pierre Lavoie
With thanks to: Victoria Burns, Laura Henderson, Sebastien Mott, and Malorie Moore
Co-Investigators: Amanda Grenier (PI), Tamara Sussman, David Rothwell, and Jean-Pierre Lavoie
Aging and Homelessness (Phase I Literature Review)
This report reviews the state of literature on aging and homelessness. A substantial literature spanning several decades explores homelessness and the programs designed to address this issue (Lee, Tyler, & Wright, 2010; Shlay & Rossi, 1992; Toro, 2007; Trypuc & Robinson, 2009). However, present knowledge and practices about homelessness tend to focus on youth, younger adults, and young families, with far less attention to older people (Beynon, 2009; Burns, Grenier, Lavoie, Rothwell, & Sussman, 2012; Cohen, 1999; Crane & Warnes, 2001; Gonyea, Mills-Dick, & Bachman, 2010; McDonald, Dergal, & Cleghorn, 2004). Older people who are homeless are depicted as an ‘invisible population’ (Gonyea et al., 2010), but with demographic shifts the numbers of older people experiencing homelessness can be expected to rise (Edmonston & Fong, 2011). Population aging calls for research and policy attention to aging and homelessness.
This report focuses on the intersections of aging and homelessness. We draw on international and Canadian research to provide an overview of the circumstances, statistics, and programs that exist in this area and a general understanding of what homelessness means, specifically for older people.
This report is organised according to four relevant areas that contribute to current understandings of homelessness among older people:
- The first section reviews the terminology, definitions, and distinctions that exist in the field, including the age at which homeless people are considered to be ‘old’;
- The second section reviews the available statistics and estimated prevalence of homelessness, and in particular older homelessness, in Canada and Quebec;
- The third section reviews the major pathways into homelessness across the life course, including distinctions between ‘aging on the streets’ and becoming homeless for the first time in later life;
- The fourth section reviews variations that exist between subsets of the homeless population or according to diverse social locations. Gender, immigration status and geographic location, health status, substance use, and violence/abuse are considered to differentially impact experiences of homelessness, both across the life course and in later life. We finish by addressing the unique needs older homeless adults.
The purpose of this research was to compile the literature on aging and homelessness, with a focus on prevalence, pathways to homelessness, and variations according to diverse social locations. We began by locating relevant literature reviews and identifying key sources. A formal literature search was conducted through Web of Science and AgeLine database (1978 – 2004), followed by a search on Google Scholar. Search terms included: ‘elder’, ‘elderly’, ‘older adult’, ‘senior’, ‘homelessness’, ‘programming’, ‘support’, ‘shelter’, ‘Quebec’, and ‘Canada’. We discuss homelessness broadly in this report, but pay special attention to research on older homelessness, on differences between younger and older homeless populations, and on the Canadian context. We also drew on grey literature, which was found using Google and the same keywords listed above.
Summarizing the existing literature, and arriving at more general understandings of homelessness and aging, is challenging due to variations in methodologies and samples. Studies have different research populations and foci and refer to different locations; making it difficult to separate the impacts of geography, service availability, and individual differences. Results are also constrained by challenges in accessing homeless people. The transitional and unstable nature of homelessness makes it difficult to maintain contact with these individuals (Greenwood, Schaefer-McDaniel, Winkel, & Tsemberis, 2005), and some of them are less likely to be participants in research studies because they are cautious of authority and bureaucracy (O’Connell et al., 2004). Despite limitations in research data and access, this report is a best attempt to compile what is known about homelessness in later life, with the aim of creating a research agenda and developing best practices for care.
The State of the Literature on Aging and Homelessness
Section One: Defining Aging and Homelessness
What is ‘homelessness’?
Definitions and categories of homelessness vary among sources and between programs. The Canadian Homelessness Research Network (2012) provides a comprehensive definition, describing homelessness as “the situation of an individual or family without stable, permanent, appropriate housing, or the immediate prospect, means and ability or acquiring it” (1). They identify four living circumstances that fall under the umbrella of homelessness:
1) Unsheltered, or absolutely homeless and living on the streets or in places not intended for human habitation;
2) Emergency sheltered, including those staying in overnight shelters for people who are homeless, as well as shelters for those impacted by family violence;
3) Provisionally accommodated, referring to those whose accommodation is temporary or lack security of tenure, and finally,
4) At risk of homelessness, referring to people who are not homeless, but whose current economic and/or housing situation is precarious or does not meet public health and safety standards
(Canadian Homelessness Research Network, 2012,1).
Although people who are provisionally accommodated or at-risk fall under the umbrella of homelessness, the typical image of a homeless person is someone who lives on the streets or in shelters. It may be particularly challenging to identify the provisionally accommodated and the at-risk because they may not use services, such as shelters, which are typically associated with homelessness (Mott, Moore, & Rothwell, 2012).
In the literature there are distinctions between types of homelessness, including transitional or temporary, episodic or cyclical, and chronic homelessness (Culhane & Metraux, 2008; Echenberg & Jensen, 2008; Kuhn & Culhane, 1998). Some researchers write that individuals who are homeless for three full months fall into the chronic category (Trypuc & Robinson, 2009) while others explain that people who are repeatedly homeless for more than a year are chronically homeless (McDonald et al., 2004). People who are chronically homeless often use shelters as a means of housing, rather than an emergency service (Mott, 2012). Chronically homeless people tend to be older, persistently unemployed, and are more likely to be disabled or experience substance use problems. By contrast, cyclically and episodically homeless people are typically younger (Mott, 2012). A less frequently used category is ‘rough sleepers’, which refers to homeless people who tend to avoid shelters and outreach services (Crane & Warnes, 2000; Johnsen, Cloke, & May, 2005; O’Connell et al., 2004). Research suggests that a small proportion of the homeless population, referred to as ‘heavy shelters users,’ accounts for over 50% of overall shelter use (Mental Health Commission of Canada, 2012).
What is ‘older homelessness’?
There is an acceptance that homelessness among older people is on the rise, but differences in life trajectories and health status make it difficult to determine what constitutes the older homeless population. While 65 —the dominant age of retirement — is the most widely accepted marker of old age, it is deficient where later life homelessness is concerned. Older adults living on the street tend to exhibit mental and physical health issues that are more consistent with non-homeless people who are approximately ten years older than them (Cohen, 1999; Gonyea et al., 2010; Hibbs et al., 1994; Hwang et al., 1998; Morrison, 2009; Ploeg, Hayward, Woodward, & Johnston; 2008). People who live on the streets also have higher rates of early mortality than the general population (Cohen, 1999; Hibbs et al., 1994; Hwang et al. 1998; Morrison 2009), with the average age of death for a homeless person in Canada cited as 39 years (Trypuc & Robinson, 2009).
Attempting to find an appropriate marker for later life among homeless people is not as simple as subtracting ten years from the general age classification of 65. Aging is a process that takes place across the life course and in relation to institutional structures, practices and experiences (Grenier, 2012). For example a study of older homeless people in Toronto finds that those over 50 subjectively consider themselves “old” (McDonald et al., 2004). As a result, the general trend in research is to consider persons who are above 50 or 55 years as “older” (Cohen, 1999; Garibaldi, Conde-Martel, and O’Toole, 2005; Gonyea et al., 2010; McDonald, Dergal, & Cleghorn, 2007; Ploeg et al. 2008; Shinn et al., 2007). For this reason, we suggest that 50 is an appropriate and inclusive threshold for considerations of homelessness and aging. We recognise, though, that health and personal trajectories across the life course—not just chronological age—define the experience of aging.
Section Two: Statistics and Estimated Prevalence
How many homeless people are there in Canada?
Homelessness is a global issue, with an estimated 100 million people considered homeless worldwide(United Nations Organization, 2005). Canada does not gather comprehensive data on homeless individuals (Trypuc & Robinson 2009). The information collected by Statistics Canada is based on the number of persons living in shelters, with a category that includes “persons lacking a fixed address, shelters for abused women and children, and other shelters or lodging with assistance” (Statistics Canada, 2012). This, combined with the realities that homeless people live in transition and often lack a fixed address, means that it is difficult to gather general estimates of the homeless population (Mott et al., 2012). Different understandings of the living circumstances that constitute homelessness, and different counting methods, further complicate this issue. Some studies use a point prevalence count to estimate the number of homeless people at a specific time. They do this by conducting a survey of shelter users and counting the number of individuals in ‘homeless hotspots’ on one night. Other studies use a period prevalence count to estimate the homeless population over a given duration (Hulchanski, 2000). Using administrative data, such as the recorded number of people using a shelter over a given length of time, is an example of the period prevalence method
Estimates suggest that Canada’s homeless population ranges from 150,000 to 300,000 (Laird, 2007; Mental Health Commission of Canada, 2012). The lower number is a conservative estimate government sources give, and the higher number, proposed by advocates and non-governmental sources, accounts for the rapid growth in municipal homeless counts and persons who may not use homeless services (Laird, 2007). Approximately 20,170 individuals (.05% to .06% of the population) lived in shelters between 2001 and 2011 (Statistics Canada, 2012) and in 2008 there were 1,128 shelters in Canada (Echenberg & Jensen, 2008). Data on shelters and shelter users gives some information on homelessness, but it does not accurately capture the entire homeless population. Discrepancies in estimates of Canada’s homeless population are indicative of insufficient data on this issue.
While national data is sparse, some urban centres collect information on homelessness. Toronto has the largest number of homeless people in the country, but cities in Alberta seem to have significant homeless problems (Gaetz, Donaldon, Richter, & Gulliver, 2013). Available information collected by point prevalence methods outlines that there were approximately 5,086 homeless people on a single night in Toronto in 2008 (representing 0.19% of the city population); 1,602 on one night in Vancouver in 2012 (representing 0.27% of the city population); and 3,190 on one night in Calgary in 2012 (representing 0.29% of the city population) (Gaetz et al., 2013). Comparable data for Montreal is not available, but a survey conducted in 1996-1997 found that approximately 28,214 people in Montreal used shelters, soup kitchens, and day centers for homeless people over a one-year period. Of survey respondents, 12,666 lacked a fixed address in the previous year (Chevalier & Fournier, 2009). Although a reliable estimate of homeless prevalence has not been produced since then, Montreal’s homeless services have seen an increase in the number of users (RAPSIM, 2010). From 2008 to 2009, the Old Brewery Mission (OBM), a service for homeless men and women in Montreal, witnessed a 34% increase in admissions to its transition services, from 708 to 1,077 people (Old Brewery Mission, 2009-2010).
Age is similarly difficult to assess with available data. Research suggests that 75% of Canada’s homeless population is between the ages of 25 and 55 (Social Planning and Research Council of BC, 2005). A 2001 reports finds that families with young children and youth are the most quickly growing group of homeless people in Toronto and Ottawa (Eberle, Kraus, & Serge, 2001). Approximately 6% of the visible homeless population in Canada is considered to be over the age of 65 (Stuart & Arboleda-Flórez, 2000) and 9% are over the age of 55 (Social Planning & Research Council of BC, 2005). Older adults are a minority among homeless people—perhaps due to higher mortality rates in this population—but a Vancouver-based study found that older people spends more time in shelters than their younger homeless counterparts (Serge & Gnaedinger, 2003). Adults over the age of 55 represent 14%-28% of shelter users in Canada (Stergiopoulos & Herrmann, 2003). With a lack of viable housing alternatives for older adults and over-crowding in acute hospitals, there is pressure on shelters to fill the gap in convalescent care by accepting elderly and unwell patients who can no longer care for themselves (Serge & Gnaedinger, 2003). The number of older adults who are homeless is increasing, and they are considered to be particularly vulnerable (Stergiopoulos & Herrmann, 2003).
Section Three: Pathways into Homelessness
What are the major pathways into homelessness?
Pathways into homelessness among youth are more clearly articulated than those of later life. Research finds that homelessness often occurs when cumulative difficult circumstances and triggers events, rather than a single incident, make homelessness the only (or the preferable) option. Psychological disorders, connected with traumatic events in childhood or adolescence (Martijn & Sharpe, 2006), as well as family breakdown and/or the death of a parent (Padgett, Smith, Henwood, & Tiderington, 2012), are associated with homelessness in earlier parts of the life course. As such, the literature on the accumulation of events points to the importance of treatment such as psychological counselling for trauma experienced in childhood (Padgett et al., 2012) and the importance of teaching youth coping and resilience skills to prevent breakdowns and decrease the risk of homelessness (Kennedy, Agbenyiga, Kasiborski, & Gladden, 2010; Padgett et al., 2012).
The literature on pathways into homelessness in adulthood and later life is less definitive. Research indicates that gradual declines and/or trigger events (Shinn et al., 2007; Gonyea et al., 2010), as well as various individual and structural factors, contribute to later life homelessness. While there are complex interconnections between these pathways, in this section we try to untangle structural conditions, cumulative circumstances and risk factors, and trigger events. Our goal is to give readers a better sense of diverse conditions, operating at different levels, associated with later life homelessness.
Macro-level forces that disadvantage particular groups of older adults may increase risks of homelessness. A report comparing 21 OECD countries suggests that Canada’s social policy expenditures are relatively equally distributed among people under and over 65 (Lynch, 2001). Still, structural issues associated with homelessness include inadequate affordable housing; fewer available jobs, leading to competition for employment and poverty among some older adults; and policies that limit certain individuals’ access to health, disability and pension benefits (Gaetz et al., 2013; Lee et al., 2010; Tully & Jacobson, 1994). Since the 1990s, the rising cost of housing in Canada has also resulted in increasing numbers of citizens living below the low-income cut-off in both urban and rural areas (Skaburskis, 2004). Asset poverty research shows that 28% of adults 66 and older do not have sufficient financial assets to survive at the low-income threshold for three months (Rothwell & Haveman, 2013).
In this context, individuals may experience a gradual decline into homelessness. Conditions associated with a gradual decline include precarious employment and/or diminishing finances leading to poverty, poor mental and/or physical health, decreasing social connections (Morris, Judd, & Kavanagh, 2005; Shinn et al., 2007), psychiatric conditions (Barak & Cohen, 2003), and alcoholism (Crane, 1999; Dietz, 2009). Education, work history, and incarceration are also associated with homelessness. People with lower levels of education are at greater risk (Rank & Williams, 2010), and persons released from prison are more likely to be homeless than those who have never been incarcerated (Kushel, Evans, Perry, Robertson, & Moss, 2003; Metraux & Culhane, 2006). Other findings indicate that those who experience higher levels of victimization and poverty when younger are more likely to be homeless later in life (Browne & Bassuk, 1997; Koegel, Melamid, & Burnam, 1995; North, Smith, & Spitznagel, 1994; Stein, Leslie, & Nyamathi, 2002; Toro, 2007), as were those who experience traumatic life changes if they have limited social and family networks (Morris et al., 2005).
People who experience these vulnerabilities may lack the skills or resources to cope with emergency situations. In turn, these situations may trigger homelessness (Crane & Warnes, 2005). Trigger events include loss of accommodation; death of a spouse, relative, or close friend who may have provided care; domestic violence, and/or family breakdown (Crane & Warnes, 2005; Gonyea et al., 2010). For example, a Toronto study found that 70% of people over 50 became homeless between the ages of 41 and 60 as a result of family breakdown, eviction, and/or a loss of employment (McDonald et al., 2004).
There is no single pathway into homelessness, but older adults typically experience one of two types of homelessness: they are either chronically homeless throughout their lives and continue this pattern as they age, or they become homelessness for the first time in later life. The literature suggests that the second pathway is increasingly common. Research conducted with older homeless individuals in the United States, England, and Australia found that two thirds had not experienced homelessness earlier in life, while the other third had been homeless before (Crane et al., 2005). Similarly a New York City study of 79 homeless adults over 55 finds that half of the participants lead what they considered ‘conventional lives’ prior to becoming homeless. The other half was more likely to have experienced homelessness throughout their lives (Shinn et al., 2007). In addition to representing a new population, the duration of time an individual spends homeless is typically longer for older adults than younger people because they are less likely to reintegrate into the workforce (Caton et al., 2005). Evidence of new homelessness in late life underscores the urgent need to understand later life pathways to homelessness.
It is difficult to reach conclusions about the ways older people become homeless because studies in this area are often qualitative with small sample sizes. The literature suggests, though, that accounting for life course trajectories can lead to better understandings of pathways and potential solutions to homelessness. Understanding the pathways in and out of homelessness throughout the life course also can assist when developing treatment plans for older homeless individuals. This is especially the case where questions of decades of impoverishment and victimization may be concerned. An approach that balances income security and affordable housing in late life with counselling and psychological services may be a way to address the complex factors contributing to later life homelessness.
Section Four: Variations Among Subsets of the Homeless Population
This section addresses noteworthy variations in the homeless population. Although not meant to be comprehensive, the following section outlines major trends that exist regarding diverse locations including gender, immigration status and geographic location, health, and substance use. The section ends with a discussion of the unique needs of older homeless people.
Gender. Research on gender and homelessness suggests that men outnumber women about 4 to 1 among all homeless adults (Cohen, 1999), with the gender gap narrower among older people (McDonald et al., 2007). These numbers reflect that men are more likely to use shelter services and are thus more visible in the homeless population (Rich & Clark, 2005). Homeless women’s invisibility makes it difficult to provide precise information on gender differences. The number of older homeless women is likely under-reported, particularly among those who are leaving abusive situations (Kosor & Kendal-Wilson, 2002). The research that does exist, however, points to differences in the pathways and experiences of men and women. Men are more likely to be homeless and/or precariously housed throughout their lives (Hecht & Coyle, 2001). Where men’s homelessness is often connected to loss of employment (McDonald et al., 2004), mental health problems, or addiction (Peressini, 2007), older women’s homelessness is often associated with a trigger event leading to homeless for the first time in later life (Hecht & Coyle 2001; Shinn et al., 2007; Toro, 2007). Two issues regarding older women’s pathways to and experiences of homelessness stand out in the literature: (1) poverty as a result of family circumstances and the structure of the pension system (Rahder, 2006); and (2) experiences of abuse (Kosor & Kendal-Wilson, 2002; Toro, 2007).
Women experience financial disadvantages throughout their lives (McDonald et al., 2004; Rahder, 2006) and this increases their risks of homelessness in later life. Women’s disproportionate involvement in unpaid care work may disrupt or take the place of labour force participation (Denton & Boos, 2007). Unpaid care work is uncompensated in Canada’s pension system; increasing women’s chances of poverty in later life (Wakabayashi & Donato, 2006). Women are also more likely to work for lower pay or on a part-time basis, and this limits their access to pension and health benefits. Women’s poverty can increase with age, when sexism and ageism in the labour market make it difficult for older women to find employment. Women are also more likely to become homeless due to family circumstance, such as becoming a widow or marital breakdown (McDonald et al., 2004). In these situations women may lose support from a spouse’s income or pension benefits (Denton & Boos, 2007). Eviction or loss of accommodation may result when women lack sufficient finances (Hecht & Coyle, 2001).
There are specific concerns regarding older homeless women’s experiences of abuse and violence. Kosor and Kendal-Wilson (2002) find that spousal abuse, family violence, and disputes with family and friends are major pathways to homelessness among older women in one American city. Other studies suggest that the number of women over 55 who are forced to leave their homes as a result of physical and/or sexual violence is increasing (Grossman & Lundy, 2003). There is a service gap between domestic and elder abuse; leaving few to no services for older women who are abused (Straka & Montminy, 2006). Older women leaving abusive situations are often forced to stay with family or friends or live on the streets. In the latter case, older women’s risks of abuse and victimization are significantly higher than men’s (Dietz & Wright, 2005; Grossman & Lundy, 2003; Wenzel, Leake, & Gelberg, 2001). There is a national shortage of shelters for abused women, and changes in funding for social housing has resulted in even fewer units available for them (Rahder, 2006).
Immigration status and race/ethnicity. Older adults belonging to minority racial/ethnic groups face unique challenges that impact their pathways to and experiences of homelessness. There are a disproportionate number of First Nations people in Canada’s homeless population (Canadian Institute for Health Information, 2007), with one study reporting that they are over-represented by a factor of 10 (Hwang, 2001). Immigrants are also over-represented in the homeless population. A study in Toronto (McDonald et al., 2007) finds that 55% of the recent older homeless population was born outside of Canada, compared with 29% of the long-term homeless. The high representation of immigrants among recently homeless older adults may be connected to Canada’s pension structure. Someone who moves to the country during his or her adult life has significantly less time to build a pension. This results in a much lower retirement income and greater risks of poverty and homelessness in later life. Most people in McDonald et al.’s (2007) study were receiving some amount of provincial benefits, but social assistance is often inadequate given the high cost of rent in urban centres like Toronto. Gaps between services and benefits may hinder older homeless people’s access to housing (McDonald et al., 2007). Language is also significant barrier for older adults who cannot communicate well in English or French because speaking the dominant language is often necessary to access housing and support services (McDonald et al., 2007). Non-first language speakers often feel marginalized and isolated; particularly in institutional settings such as residential homes or hospitals (Saldov & Chow, 1994).
Geographic location. Geographic location is also implicated in experiences of homelessness and must be accounted for when considering the diverse needs of older adults across Canada. The majority of homeless people live in large cities (Statistics Canada, 2001), where services, such as shelters, are located. Shelter use is reportedly higher in Quebec, Alberta, Ontario, British Columbia, and Manitoba than in other provinces and territories (Statistics Canada, 2001). Homelessness is typically considered an urban problem, but homeless people who live outside urban areas face additional challenges accessing services and support (North et al., 1994). Here the intersections of poverty, new homelessness, and Northern or rural locations need further investigation.
Health and safety issues. Health problems experienced across the life course are both a risk factor for homelessness and an outcome of homelessness. People with mental health and/or addiction problems are more likely to become homeless (Mott et al., 2012). At the same time, people who lack stable housing face threats to their mental and physical health (Bhui, Shanahan, & Harding, 2006; Power & Hunter, 2001; Schanzer, Dominguez, Shrout, & Caton, 2007). Common health problems in the general homeless population include tuberculosis, HIV, arthritis, hypertension, diabetes, fungal infections, and parasites (Hwang, 2001). Traumatic brain injury is also relatively common among homeless people. A survey finds that 53% of people using homeless services in Toronto have experienced a traumatic brain injury (Hwang et al., 2008). Rape and assault are also health and safety risks associated with homelessness. Studies on violence and homelessness find that 40% of homeless men were assaulted, and 20% of women were raped, in the year prior to study (Crowe & Hardill, 1993; Kushel et al., 2003).
The literature on homelessness in later life suggests that older people face greater disadvantages than younger groups regarding physical and mental health (Bhui et al., 2006; Cohen, 1999; Dennis, McCallion, & Ferretti, 2012; Garibaldi et al., 2005; Gonyea et al., 2010; Kim, Ford, Howard, & Bradford, 2010; Lipmann, 2009; Martins, 2008; Ploeg et al., 2008; Quine, Kendig, Russell, & Touchard, 2004). Garibaldi et al. (2005) find that those over 50 were 3.6 times more likely than the younger homeless population to suffer from a chronic medical problem, while Kim et al. (2010) find that the likelihood of having mental health problems doubles for homeless people over the age of forty-two.
Specific health issues among older homeless adults have also been documented. In a Toronto study, the most frequently reported ailments among this population were vision, arthritis, dental problems, and back problems (McDonald et al., 2004). There are gender differences, with women reporting greater difficulties with arthritis and bladder control while men are more likely to suffer from back and skin problems (McDonald et al., 2004). Older homeless men—particularly those who lose their jobs between the ages of 60 and 65—are also at a high risk of suicide associated with mental illness (Greater Vancouver Shelter Strategy, 2013). In some circumstances, health conditions are already present when one becomes homeless. In other cases, they manifest or become worse during periods of homelessness (Horn, 2008; Hwang et al., 1998). Canadian data on the health status of older homeless people is inadequate, with more accurate information needed to account for the discrepancies in conditions and services across the country (At Home/Chez Soi Interim Report, 2012).
Substance use. Drug and alcohol use is often associated with homelessness. In the general homeless population, substance use is reported to affect 49% of those who are transitionally homeless, 66% of those who are episodically homeless, and 83% of those who are chronically homeless (Kuhn & Culhane, 1998). Homeless people use a range of substances, but alcohol is used most often. Between 53% and 73% of homeless people reportedly use alcohol (Frankish, Hwang, & Quantz, 2005; Podymow, Turnbull, Coyle, Yetisir, & Wells, 2006). That said, a Toronto study finds that others substances are also used frequently: 60% use marijuana, 52% use cocaine, 49% use crack, 25% use oxycontin, 18% use morphine, 14% use heroin, and 25% use other opiates (Khandor & Mason, 2008). Some differences in substance use among members of the homeless population are noted. Men are more likely than women to use drugs, and those with mental illnesses are more likely to use alcohol or drugs than those without documented mental illnesses (Blazer & Wu, 2009; Dietz, 2009).
There is little information on older people’s use of substances, and less on the impacts of drugs and alcohol as one ages. The literature on substance use among older homeless people presents mixed results that are challenging to interpret. Some research reports that substance use patterns are considered to differ between age cohorts and are thought to decrease with age (Blazer & Wu, 2009; Cohen, 1999). Other studies highlight that where younger and older groups of homeless people are equally as likely to report alcohol abuse (Dennis et al., 2012; Dietz, 2009; Hecht & Coyle, 2001), older adults are less likely to report drug use (Hecht & Coyle, 2001). Conversely, there is a literature suggesting that drug use among the elderly has been increasing and is expected to continue on this upward trajectory (Beynon, 2009; Proehl, 2007). For example, Garbibaldi et al.’s (2005) study of homeless people in two American cities finds that those over the age of 50 are 2.4 more likely to be dependent on heroine than those who are under 50. The reported increased rates of drug use among older people are likely a cohort effect: people tend to maintain drug habits throughout their lives, and the cohort of people entering their senior years reports higher rates of drug use than previous generations (Beynon, 2009). Research suggests that older people who have used substances across the life course will have co-morbidity issues as a result of prolonged use of drugs or alcohol (Beynon, 2009), but the paucity of relevant information and services leaves an already vulnerable population at risk (Blazer & Wu, 2009; Proehl, 2007).
The unique needs of older homeless people. The research on homelessness among older people identifies a number of needs unique to this population. Needs that parallel those of younger homeless groups include stable housing, income, food, and health care. Needs specific to younger groups, such as job training and employment assistance, are often considered irrelevant for the older population (Garibaldi et al., 2005). This may need to be reconsidered where gender or immigration status limits older adults’ access to pension benefits. These individuals may also need assistance finding employment, especially in the years prior to qualifying for public pension and/or in cases where benefits are insufficient. Greater attention to employment may be necessary in the future. Aside from housing needs across the life course and in late life, which requires a separate review (see Crane & Warnes, 2007: McGhie, Barken, & Grenier, 2013; Serge & Gnaedinger, 2003), two of the more prevalent issues outlined in the literature are: (1) access to health and social services and (2) safety.
Older homeless adults often experience challenges accessing health and social services. Because they are more likely than their younger counterparts to have mental and physical health concerns, they may require access to specialized medical care beyond that which is available in shelters (Power & Hunter, 2001). Living without a home can be especially challenging in later life; making older adults’ needs to access housing particularly urgent (Abbott & Sapsford, 2005). Interviews with health care providers address how mental health conditions present challenges to generating continued engagement with older homeless people (Cohen, Onserud, & Monaco, 1992; Horn, 2008; Proehl, 2007). Due to memory problems, they sometimes forget to attend scheduled appointments and are unable to complete programs. Older homeless people have also reported discriminatory treatment and stigmatization in health care settings, demonstrating a need for medical staff to become more sensitive in the way they treat this population (Martins, 2008; Lipmann, 2009; Quine et al., 2004).
Difficulties navigating government services, not just financial restrictions, can be a barrier to accessing government assistance and health services. Most older homeless people do not receive the full amount of government assistance for which they qualify (Ploeg et al., 2008). There are also concerns regarding the appropriateness of services available for older homeless adults. One Canadian research project found that there is a gap in services for homeless people aged 50-65 (McDonald et al., 2006). In this study clients reported frustration because neither the services offered, nor the programs created for the general homeless population, suited their needs (McDonald et al., 2006).
Older homeless adults have unique needs regarding safety. They encounter violence on the streets and in shelters (Cohen et al., 1992; Lee, 2005; North et al., 1994). Older adults face higher threats to safety than their younger counterparts because they are more likely to be in poor health and because they are seen as easy targets (Dietz & Wright, 2005). Older women and transgendered people face higher risks of victimization, but homeless men still experience high risks of physical abuse (Cohen, 1999; Dietz & Wright, 2005; Gonyea et al., 2010; Grossman & Lundy, 2003; Lee, 2005; North et al., 1994; Tully & Jacobson, 2008). The literature is unanimous in pointing to older homeless adults’ unique challenges.
Conclusion: Knowledge Gaps
This report has reviewed extant research on aging and homelessness in four key areas. There are notable knowledge gaps in each of these areas. First, with regard to definitions and distinctions in research on homelessness, it is necessary to reach a consensus regarding the age at which homeless people reach ‘later life.’ Based on research on physical and mental health in homeless populations as well as homeless people’s subjective perceptions of old age, we suggest that 50 is an appropriate threshold for considerations of homelessness and aging. Second, better estimates of the number of homeless people and their age distribution in the Canadian population are necessary. Third, we suggest that a life course perspective could be fruitfully applied to understand major pathways leading to homelessness, particularly risk factors and trigger events, and their prevalence across the life course. Fourth, greater attention to intersecting inequalities when exploring locations of risk is necessary (Brotman, 2003; Klodawsky, 2009). Some studies focus on gender and others on ethnicity, but research considering the impact of multiple marginalized categories on older homeless adults’ experiences is necessary. Another notable gap in the literature is the impact of sexual orientation on older adults’ life courses and risks of homelessness. Future studies should be designed to fill these knowledge gaps and to generate a more comprehensive understanding of aging and homelessness.
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