Mortality Among Homeless Adults in Boston Shifts in Causes of Death Over a 15-Year Period
ABSTRACT BACKGROUND Homeless persons experience excess mortality, but US-based studies on this topic are outdated or lack information about causes of death. To our knowledge, no studies have examined shifts in causes of death for this population over time. METHODS We assessed all-cause and cause-specific mortality rates in a cohort of 28 033 adults 18 years or older who were seen at Boston Health Care for the Homeless Program from January 1, 2003, through December 31, 2008. Deaths were identified through probabilistic linkage to the Massachusetts death occurrence files. We compared mortality rates in this cohort with rates in the 2003-2008 Massachusetts population and a 1988-1993 cohort of homeless adults in Boston using standardized rate ratios with 95% confidence intervals. RESULTS A total of 1302 deaths occurred during 90 450 person-years of observation. Drug overdose (n = 219), cancer (n = 206), and heart disease (n = 203) were the major causes of death. Drug overdose accounted for one-third of deaths among adults younger than 45 years. Opioids were implicated in 81% of overdose deaths. Mortality rates were higher among whites than nonwhites. Compared with Massachusetts adults, mortality disparities were most pronounced among younger individuals, with rates about 9-fold higher in 25- to 44-year-olds and 4.5-fold higher in 45- to 64-year-olds. In comparison with 1988-1993 rates, reductions in deaths from human immunodeficiency virus (HIV) were offset by 3- and 2-fold increases in deaths owing to drug overdose and psychoactive substance use disorders, resulting in no significant difference in overall mortality. CONCLUSIONS The all-cause mortality rate among homeless adults in Boston remains high and unchanged since 1988 to 1993 despite a major interim expansion in clinical services. Drug overdose has replaced HIV as the emerging epidemic. Interventions to reduce mortality in this population should include behavioral health integration into primary medical care, public health initiatives to prevent and reverse drug overdose, and social policy measures to end homelessness.
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ABSTRACT: This qualitative study explored perspectives toward a good or bad death among twenty-one older homeless adults residing in transitional housing. Using grounded theory approach, the themes for a good death were: 1) dying peacefully; 2) not suffering; 3) experiencing spiritual connection; and 4) making amends with significant others. Themes for a bad death were: 1) experiencing death by accident or violence; 2) prolonging life with life supports; 3) becoming dependent while entering a dying trajectory; and 4) dying alone. Healthcare professionals need to develop a culturally sensitive approach for end-of-life care grounded in understanding unique needs of older homeless adults.Death Studies 02/2015; DOI:10.1080/07481187.2014.958629 · 0.92 Impact Factor
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ABSTRACT: The homeless population is aging faster than the general population in the United States. As this vulnerable population continues to age, addressing complex care and housing needs will become increasingly important. This article reviews the often-overlooked issue of homelessness among older adults, including their poor health status and unique care needs, the factors that contribute to homelessness in this population, and the costs of homelessness to the U.S. health care system. Permanent supportive housing programs are presented as a potential solution to elder homelessness, and Hearth, an outreach and permanent supportive housing model in Boston, is described. Finally, specific policy changes are presented that could promote access to housing among the growing older homeless population.01/2013; 21(1):126-135.
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ABSTRACT: PURPOSE OF REVIEW: Mentally ill homeless persons are among the most neglected or marginalized patient groups. Their needs for mental healthcare are widely unmet. The current economic crisis probably accelerates the social decline and deterioration of physical and mental health in high-risk groups worldwide and increases the need for appropriate treatments, services, and prevention strategies. RECENT FINDINGS: Research on service provision for mentally disordered homeless people (from 2010 to 2012) covers the following issues: epidemiology of mental ill health among homeless persons, service delivery and healthcare utilization, specific treatments, specific high-risk groups among homeless persons, and subjective experience with mental health service provision. SUMMARY: The number of studies published on these issues between 2010 and 2012 may suggest an awareness for the need for adequate service provision of this marginalized clientele. Research evidence is still not sufficient. The majority of studies are from the United States. The methodological quality of the studies is still moderate, being descriptive in nature or applying qualitative approaches to small samples. Included are usually easy to access patients from inner-city regions. There is an encouraging trend to focus on younger age groups that supports the focus on primary or secondary prevention strategies for homelessness and mental disorders.Current opinion in psychiatry 05/2013; 26(4). DOI:10.1097/YCO.0b013e328361e596 · 3.55 Impact Factor