Clinical Factors Associated with Cognitive Impairment and Dementia Among Patients Experiencing Homelessness

Abstract

AbstractBackgroundThe population of people experiencing homelessness (PEH) is aging; Half of PEH are now 50 years old or older. Cognitive impairment among PEH is thought to occur earlier, at higher prevalence, and progress faster than in the general population. Homelessness and associated marginalized conditions pose substantial barriers to care of people with cognitive impairment or dementia.MethodWe examined the prevalence of cognitive impairment, dementia, and clinical factors associated with these diagnoses among PEH seen between 7/1/2019‐5/31/2022 in a San Francisco safety net clinic. Medical record data for those who accessed services targeting homeless adults was retained for analysis. We analyzed the data using chi‐squared, T‐tests, and adjusted regression on select variables.ResultAmong 8,387 adults who experienced homelessness, 326 (3.9%) had a diagnosis indicating cognitive impairment or dementia. Of these, the majority (303, 92.9%) had non‐specific diagnoses, such as “cognitive impairment” (207, 2.5%), problems with “cognitive function” (19, 0.2%), or “memory issues” (77, 0.9%). 114 had specific diagnoses such as dementia (74, 0.9%), Alzheimer’s (6, 0.1%), or neurocognitive disorder (34, 0.4%). Some diagnoses overlapped (e.g. “cognitive impairment” and “dementia” were coded for one patient.) More of those with dementia or cognitive impairment had HIV, diabetes, hypertension, depression and/or anxiety, alcohol‐use disorder, and prior TBI. Those with dementia/cognitive impairment were more likely to be male and older (Table 1). More of those with dementia/cognitive impairment were white, Black, or Asian/Pacific Islander, and fewer were Latinx. Since their last clinical encounter, more of those with dementia/cognitive impairment died. In adjusted regression, the difference in hypertension, depression/anxiety, alcohol use disorder, TBI, gender, and mortality remained significant (p<0.05).ConclusionPrevalence of dementia and cognitive impairment in this patient cohort is lower than has been previously estimated in PEH (4% vs up to 25%). Non‐specific diagnoses were more commonly recorded, suggesting under‐identification and under‐diagnosis in non‐research conditions. Those with dementia or cognitive impairment diagnoses had more chronic disease and psychiatric illness, and higher mortality than those without any diagnosis. Better identification of those with cognitive impairment and dementia among PEH can help define areas of focus in the care of these marginalized individuals.