Homelessness Is a ‘Cognitive Impairment Crisis’ in Canada

Reframing homelessness as a “cognitive impairment crisis” is key to developing policies that more effectively address Canada’s homelessness crisis, a new commentary asserts.“This issue has been something I’ve noticed for a few years, but it took a while for me to examine it in depth and understand the degree of compounding issues that affect this population,” commentary author Sumantra Monty Ghosh, MD, MPH, an addiction medicine specialist at the University of Alberta in Edmonton, told Medscape News Canada.Causes of cognitive impairment among people experiencing homelessness (PEH) that exacerbate each other include undiagnosed fetal alcohol spectrum disorder, adverse childhood experiences, traumatic brain injury, mental illness, and substance use, including anoxic brain injury from opioid overdoses or drug poisonings, Ghosh wrote. His commentary was published online on September 21 in CMAJ.“Addressing impaired cognition will not eliminate homelessness, but it offers a realistic and compassionate path to addressing the most complex and visible aspects of the crisis,” he wrote.Death Over Hospitalization“A troubling double standard exists regarding how Canadian society responds to cognitive impairment,” Ghosh wrote. “Housed people with strokes, dementia, or traumatic brain injury are kept in hospital until they can be safely discharged to supportive long-term care settings.”By contrast, PEH with equally severe brain injuries are routinely sent back to the streets and expected to manage medications, finances, and complex social systems, despite profound cognitive limitations.“PEH also face stigma in clinical settings,” Ghosh told Medscape News Canada. “Various qualitative studies have demonstrated concerns about mistreatment of and discrimination against PEH by healthcare providers. I often hear from PEH that they would rather die than go to the hospital because of mistreatment in the past.”Nevertheless, “Our culture in healthcare is changing, and there is greater understanding of how to support PEH. There is also a larger understanding that some in this population are high systems users, and they must be engaged with innovative models of care to reduce this high systems use. This [engagement] can include medical respite, intensive case management, community health hubs, street medicine, and outreach, to name a few.”Patients with cognitive impairment who are experiencing homelessness may need the same level of care that is routinely provided to patients with dementia or severe brain injury who are not homeless, including round-the-clock supervision, medication support, cognitive rehabilitation, and structured routines, Ghosh suggested.An intervention such as Canada’s Housing First, however, which provides permanent stable housing to individuals as quickly as possible, “is insufficient for PEH with cognitive deficits unless paired with robust, ongoing cognitive and medical supports,” he wrote in the commentary. PEH may benefit more from an intensive housing model “that integrates long-term medical management with supportive housing, behavioral care, and substance use treatment.”“Leveraging our occupational therapists in acute care, or in our clinics, can be helpful, as well,” Ghosh told Medscape News Canada. “It’s something we don’t look for enough, and it needs to be a priority so we can understand how best to support the needs of this population.”Reframing chronic homelessness as a cognitive impairment crisis “will require investment in screening, diagnostic services, capacity assessments, guardianship systems, interdisciplinary medical supports, and the construction of intensive housing facilities,” he wrote.The following three next steps could help for the near future, Ghosh told Medscape News Canada: creating a screening tool followed by a more detailed cognitive assessment plan; creating a clearer, more organized pathway to guardianship for people who lack decision-making capacity; and creating intensive housing facilities of different acuity levels tailored to the needs and complexities of the clients.Patient Advocacy, Policy ReformRadek Budin, PhD, a psychologist at the Centre for Addiction and Mental Health in Toronto, told Medscape News Canada that Ghosh’s commentary on chronic homelessness and its relation to cognitive impairment is consistent with his group’s work in this area.Several years ago, Budin and colleagues collected data as part of the Connecting the Dots program in Ontario, with the goal of identifying neurocognitive disorders and serious mental illness among PEH across 25 shelters. Their analysis showed that 60% of 1872 individuals living in the shelter system presented with a neurocognitive disorder or serious mental illness, and 19% had both. These conditions are associated with cognitive impairment, Budin said, and “the majority of affected individuals struggled to carry out basic and instrumental activities of daily living compared with those who were not affected.”He cautioned, however, against framing homelessness as solely a cognitive impairment crisis. “Such a focus could take attention away from the many other factors that contribute to this societal issue and affect PEH, including a lack of affordable housing, funding, and social programs; poverty; inappropriate discharges from institutions; racial disparities; other health issues; stigma; trauma; and abuse,” he said. “Homelessness is a complex issue that requires a multipronged approach.”Stigma remains a significant barrier to care in healthcare settings, Budin affirmed. “Healthcare workers are not immune to believing some of the stereotypes that the public holds about those who are homeless,” which tend to be more pronounced among people who also struggle with substance use and “magnified” for people who are racialized.Highlighting the issue as being related to cognitive impairment, as Ghosh did, “characterizes a large proportion of this population more accurately as individuals facing cognitive challenges who deserve the same supports as those who have traditional homes,” said Budin.Individual clinicians can make a difference in how PEH are treated by advocating for them and pushing for policy change, he said, whether through research, writing to officials, or joining coalitions such as Health Providers Against Poverty, a Canadian alliance that has developed poverty-screening tools for primary care providers.“Healthcare organizations and hospitals also need to speak out and push for policy change in relation to the homelessness crisis,” said Budin. “They can contribute their knowledge and expertise on how various health problems and disability contribute to chronic homelessness, as well as provide guidance on how to intervene when it comes to medical conditions such as cognitive impairment.”Budin pointed to Ontario’s Bridges to Housing program, which uses triage, screening, and assessment to identify homeless individuals with developmental disabilities and connect them to supportive housing as an example of what targeted investment can accomplish.Ghosh and Budin reported having no relevant financial interests.Marilynn Larkin, MA, is an award-winning medical writer and editor based in New York City whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.