Abstract
Introduction:
Housing insecure veterans are aging, but the prevalence of Alzheimer’s disease and related dementias (AD/ADRD) in the population is unknown.
Methods:
We calculated the prevalence of AD/ADRD diagnoses in 2018 among veterans that experienced homelessness, were at-risk for homelessness, or were stably housed. We determined acute care (emergency department, hospitalizations, psychiatric hospitalizations), and any long-term care (nursing home, and community-based) use by housing status among veterans with an AD/ADRD diagnosis.
Results:
The overall prevalence of AD/ADRD diagnoses for homeless, at-risk, and stably housed veterans was 3.66%, 13.48%, and 3.04%, respectively. Housing insecure veterans with AD/ADRD used more acute care, and were more likely to have a nursing home admission compared to stably housed veterans. At risk, but not homeless veterans, were more likely to use US Department of Veterans Affairs–paid home and community-based care than stably housed veterans.
Discussion:
The prevalence of AD/ADRD diagnoses is greater among housing insecure veterans than stably housed veterans.
Keywords: Alzheimer’s disease and related dementias, dementia, housing insecurity, veterans
1. INTRODUCTION
An estimated 7% (5.8% to 9.4%) of veterans are living with Alzheimer’s disease (AD) and AD-related dementias (AD/ADRD). Greater rates are reported among veterans with traumatic brain injury and post-traumatic stress disorder.1–4 The prevalence of AD/ADRD in the United States is expected to greatly increase over the next 30 years as the population ages, and growth in the prevalence is predicted to be even greater in the veteran population.5
Housing insecure veterans have either directly experienced homelessness or are at-risk of experiencing homelessness due to extreme poverty, inadequate housing, or failure to make mortgage/rent payments or are uncertain about the ability to make payments. Housing insecure veterans may be particularly vulnerable to developing AD/ADRD. Nearly 60% of veterans experiencing homelessness are >50 years of age, and age is a leading risk factor for AD/ADRD.6 Homeless veterans often have co-occurring substance abuse, medical (e.g., traumatic brain injury), and social needs also associated with a greater risk of AD/ADRD.7–10 Aging, age-related conditions, and premature mortality are also major contemporary concerns among housing policymakers.11
Over time people living with AD/ADRD lose the ability to live independently.12,13 Generally, people living with AD/ADRD receive most of their long-term care from spouses, children, and other family/friends.14 Homeless veterans may not have a family network that is willing to provide long-term care. Although formal community-based long-term care (e.g., skilled home health care) can help people living with AD/ADRD age in the community, many of these services are delivered in the home. Without family/friend caregiving support and stable housing, housing insecure veterans living with AD/ADRD may encounter difficulties living safely in the community. Nursing homes are an alternative to community living, but they are costly and most people want to age in their community.15,16 To successfully enable all people living with AD/ADRD to age in the community requires timely diagnosis and making connections with appropriate community-based services.
The US Department of Veterans Affairs (VA) has many resources to support housing insecure and aging veterans. For example, the VA and Department of Housing and Urban Development partner to provide eligible veterans with housing vouchers, case management, and other wraparound clinical services. The VA has piloted using vouchers to pay for assisted living. The VA also offers multiple home- and community-based services including adult day health care, home based primary care, homemaker and home health aide care, and skilled home health care. These programs may be formative in helping housing insecure veterans living with AD/ADRD age safely in the community.
Although housing insecure veterans are aging, little is known about their prevalence of AD/ADRD, which can help with planning and allocating VA resources to needs of vulnerable veterans. Therefore, in this study, we aimed to: (1) evaluate the prevalence of AD/ADRD diagnoses in 2018 among veterans who experienced homelessness, were at-risk of experiencing homelessness, or were stably housed; and (2) examine the association between housing status and number of emergency department visits, inpatient admissions and psychiatric hospital admissions, and use of any nursing home and community long-term care services among veterans with an AD/ADRD diagnosis. In terms of hypotheses, we expected diagnosed prevalence of AD/ADRD to be higher for housing insecure veterans compared to their stably housed counterparts based on housing insecure veterans having more comorbidities and risk factors for AD/ADRD; and that housing insecure veterans with an AD/ADRD diagnosis used more acute and institutional care, but less community based long-term care services than their stably housed counterparts.
2 |. METHODS
2.1 |. Data
We used the VA Corporate Data Warehouse to identify all veterans between January 1, 2018 and December 31, 2018 who were ≥18 years of age at the beginning of 2018, and who lived the entire year. We also limited our sample to veterans with at least one inpatient or outpatient encounter at a VA facility between 2016 and 2018. If a veteran does not receive care from VA providers, then we will be unable to determine their housing or AD/ADRD status. There were no other study exclusion criteria.
We used International Classification of Diseases 10th Revision (ICD-10) codes to determine whether a Veteran had a diagnosis of experiencing homelessness at any time in 2018 (Z59.0), a diagnosis for being at-risk of homelessness but never homeless at any time in 2018 (Z59.1, Z59.3, Z59.5, Z59.8, Z59.9, Z62.21, and Z74.2), or stably housed (i.e., no ICD-10 code for homelessness or at-risk) throughout 2018 (Table S1 in supporting information describes the ICD-10 codes). The housing status categories are mutually exclusive.
We verified a veteran’s 2018 housing status against four screening health questions collected during the course of outpatient care (lives on the street, lives in a hotel/motel, lives in a shelter, and has unstable housing) and whether a veteran had a healthcare for homeless veteran outreach encounter. The screening questions and encounter data are stored in the VA electronic medical record. We reclassified at-risk and stably housed veterans as homeless if they had a 2018 positive screen for living on the street (0.012%; n = 1330), living in a hotel/motel (0.011%; n = 1221), living in a shelter (0.0029%; n = 309), having unstable housing (0.13%; n = 14,194), or having a healthcare for homeless veteran outreach encounter (0.46%; n = 49,898).
2.2 |. Demographic characteristics, AD/ADRD diagnoses, and VA healthcare use
We determined each veteran’s age, sex, race, degree of service-connected disability (Priority 1 or other), prior combat service, and rural or urban residential area at the beginning of 2018. A veteran’s level of service-connected disability is used to determine eligibility for VA paid long-term care and monthly disability pension. We also determined whether a veteran had a diagnosis for comorbidities associated with AD/ADRD including alcohol dependence, substance abuse, rheumatic disease, kidney disease, liver disease, depression, diabetes, hypertension, congestive heart failure, valvular disease, lung disease, post-traumatic stress disorder, schizophrenia/psychosis, or traumatic brain injury any time between 2017 and 2018. We evaluated whether a veteran ever had an AD/ADRD diagnosis code between 2016 and 2018 using the Medicare Chronic Conditions Data Warehouse algorithm for AD/ADRD (Table S2 in supporting information describes the ICD-9/10 codes).17
Finally, we evaluated the number of emergency department visits, inpatient admissions, psychiatric hospital admissions, and whether a veteran used any (1 = yes; 0 = no) nursing home care and (1 = yes; 0 = no) VA-paid home and community-based care (adult day health care, home based primary care, homemaker and home health aide care, hospice care, palliative care, and skilled home health care) in 2018.
2.3. Statistical analysis
We calculated the overall and age-specific prevalence of AD/ADRD diagnosis in 2018 by dividing the total number of veterans with an AD/ADRD diagnosis within a stratum by the total number of veterans within the stratum. We used logistic regression and calculated the unadjusted (just controls for age) and adjusted (controls for all demographics and comorbidities) relative risk of the association between housing status and having an AD/ADRD diagnosis.18
We descriptively compared the demographic characteristics and health care use of veterans with an AD/ADRD diagnosis code stratified by housing status using χ2 and t tests. Finally, we used zero-inflated negative binomial regression to estimate the unadjusted and adjusted association between housing status and number of emergency department visits, inpatient admissions, and psychiatric hospital admissions among veterans living with AD/ADRD. We used logistic regression to estimate the unadjusted and adjusted relative risk between housing status and use of any nursing home and VA-paid home and community-based care among veterans living with AD/ADRD. The study was reviewed and approved by the Providence VA Medical Center Institutional Review Board and Research and Development committees.
3 |. RESULTS
In 2018, 6,580,126 veterans met our study inclusion criteria. Among these veterans, 201,337 (3.06%) experienced homelessness, 101,351 (1.54%) were at-risk for experiencing homelessness, and 6,277,438 (95.39%) were stably housed. The overall prevalence of AD/ADRD diagnoses for homeless, at-risk, and stably housed veterans was 3.66% (n = 7363), 13.48% (n = 13,667), and 3.04% (n = 190,733), respectively (Table 1). The prevalence of AD/ADRD increased with age. Within age ranges, the prevalence of AD/ADRD diagnoses was considerably greater for homeless and at-risk veterans compared to stably housed veterans. The unadjusted/adjusted relative risks (uRR/aRR) of having an AD/ADRD diagnosis were higher in veterans experiencing homelessness (uRR 2.67, 95% confidence interval [CI]: 2.52, 2.82; aRR 1.58, 95% CI: 1.51, 1.66) and at risk for homelessness (uRR 4.29, 95% CI: 4.06, 4.53; aRR 2.98, 95% CI: 2.81, 3.16) compared to stably housed veterans (Table S3 in supporting information).
TABLE 1.
Prevalence of Alzheimer’s disease and related dementias (AD/ADRD) diagnosis among homeless, at-risk, and stably housed veterans in 2018
| Homeless veterans |
At-risk veterans |
Stably housed veterans |
||||
|---|---|---|---|---|---|---|
| Total number of veterans | Number and prevalence of veterans with AD/ADRD diagnosis | Total number of veterans | Number and prevalence of veterans with AD/ADRD diagnosis | Total number of veterans | Number and prevalence of veterans with AD/ADRD diagnosis | |
| Overall | 201,337 | 7,363 (3.66) | 101,351 | 13,667 (13.48) | 6,277,438 | 190,733 (3.04) |
| 18–44 years | 55,772 | 608 (1.09) | 15,073 | 153 (1.02) | 1,283,695 | 3519 (0.27) |
| 45–49 years | 15,983 | 244 (1.53) | 4801 | 91 (1.9) | 378,880 | 1511 (0.4) |
| 50–54 years | 20,454 | 361 (1.76) | 6976 | 161 (2.31) | 409,252 | 2280 (0.56) |
| 55–59 years | 37,579 | 966 (2.57) | 13,794 | 433 (3.14) | 496,089 | 4489 (0.9) |
| 60–64 years | 34,914 | 1410 (4.04) | 15,782 | 799 (5.06) | 577,918 | 9159 (1.58) |
| 65–69 years | 19,466 | 1314 (6.75) | 13,283 | 1701 (12.81) | 955,567 | 23,080 (2.42) |
| 70–74 years | 10,297 | 1116 (10.84) | 11,012 | 2398 (21.78) | 966,965 | 34,588 (3.58) |
| 75–79 years | 3665 | 571 (15.58) | 5749 | 1769 (30.77) | 445,327 | 25,751 (5.78) |
| 80–84 years | 1856 | 390 (21.01) | 5399 | 2058 (38.12) | 353,739 | 31,911 (9.02) |
| 85–89 years | 955 | 270 (28.27) | 5236 | 2311 (44.14) | 264,470 | 32,832 (12.41) |
| 90+ years | 396 | 113 (28.54) | 4246 | 1793 (42.23) | 145,536 | 21,613 (14.85) |
Veterans with an AD/ADRD diagnosis who experienced homelessness (n = 7363) or were at risk (n = 13,667) for being homeless were less likely to be White, less likely to be married, and less likely to live in a rural area compared to stably housed veterans living with AD/ADRD (n = 190,733; Table 2). Compared to stably housed veterans with an AD/ADRD diagnosis, homeless and at-risk veterans had greater rates of most comorbidities including alcohol dependence, substance abuse, liver disease, depression, lung disease, post-traumatic stress disorder, schizophrenia/psychosis, and traumatic brain injury. Most of these comorbidities, including alcohol use disorder (aRR 1.36, 95% CI: 1.23, 1.33), kidney disease (aRR 1.17, 95% CI: 1.15, 1.19), liver disease (aRR 1.12, 95% CI: 1.09, 1.15), depression (aRR 2.23, 95% CI: 2.19, 2.28), diabetes (aRR 1.17, 95% CI: 1.15, 1.18), hypertension (aRR 1.06, 95% CI: 1.05, 1.09), congestive heart failure (aRR 1.38, 95% CI: 1.35, 1.41), valvular disease (aRR 1.13, 95% CI: 1.10, 1.15), lung disease (aRR 1.09, 95% CI: 1.08, 1.11), post-traumatic stress disorder (aRR 1.12, 95% CI: 1.09, 1.15), psychoses (aRR 2.47, 95% CI: 2.39, 2.55), and traumatic brain injury (aRR 3.75, 95% CI: 3.58, 3.93) were also strongly and positively associated with AD/ADRD (Table S3).
TABLE 2.
Characteristics of veterans with an Alzheimer’s disease and related dementias (AD/ADRD) diagnosis in 2018
| Homeless | At-risk | Stably housed | |
|---|---|---|---|
| AD/ADRD N = 7363 | AD/ADRD N = 13,667 | AD/ADRD N = 190,733 | |
| Age, mean (SD) | 64.05 (13.10)*** | 76.96 (11.38)* | 76.73 (11.55) |
| Female, n (%) | 367 (4.98%)*** | 546 (4.00%)*** | 6354 (3.33%) |
| Race, n (%) | |||
| White | 4386 (59.57%)*** | 9415 (68.89%)*** | 145,402 (76.23%) |
| Black | 2383 (32.36%)*** | 2968 (21.72%)*** | 27,821 (14.59%) |
| Other | 594 (8.07%)*** | 1284 (9.39%) | 17,510 (9.18%) |
| Married, n (%) | 1227 (16.66%)*** | 5988 (43.81%)*** | 107,179 (56.19%) |
| Service-connected disability (priority 1 status), n (%) | 1813 (24.62%)*** | 4712 (34.48%)*** | 59,215 (31.05%) |
| Rural, n (%) | 1404 (19.07%)*** | 3392 (24.82%)*** | 64,614 (33.88%) |
| Served in combat, n (%) | 1049 (14.25%) | 2035 (14.89%) | 28,112 (14.74%) |
| Comorbidities, n (%) | |||
| Alcohol | 2722 (36.97%)*** | 1255 (9.18%)*** | 11,862 (6.22%) |
| Substance abuse | 2314 (31.43%)*** | 791 (5.79%)*** | 5916 (3.10%) |
| Rheumatic disease | 109 (1.48%)* | 283 (2.07%) | 3575 (1.87%) |
| Kidney disease | 654 (8.88%)*** | 2198 (16.08%)*** | 23,176 (12.15%) |
| Liver disease | 1165 (15.82%)*** | 776 (5.68%)*** | 7076 (3.71%) |
| Depression | 3383 (45.95%)*** | 3986 (29.17%)*** | 44,633 (23.40%) |
| Diabetes | 2070 (28.11%)*** | 5143 (37.63%)*** | 62,089 (32.55%) |
| Hypertension | 4270 (57.99%)*** | 9076 (66.41%)*** | 117,251 (61.47%) |
| Congestive heart failure | 691 (9.38%) | 1858 (13.59%)*** | 16,994 (8.91%) |
| Valvular disease | 280 (3.80%)** | 771 (5.64%)*** | 8588 (4.50%) |
| Lung disease | 1742 (23.66%)*** | 2812 (20.58%)*** | 32,182 (16.87%) |
| Post-traumatic stress disorder | 2035 (27.64%)*** | 2032 (14.87%)*** | 26,462 (13.87%) |
| Schizophrenia/psychosis | 2475 (33.61%)*** | 2196 (16.07%)*** | 21,623 (11.34%) |
| Traumatic brain injury | 674 (9.15%)*** | 530 (3.88%)*** | 6102 (3.20%) |
Notes: P-values compare homeless to stably housed and at-risk to stably housed:
P < .05,
P < .01,
P < .001.
Abbreviation: SD, standard deviation.
Health care use was higher in homeless veterans with an AD/ADRD diagnosis, with 2.88 (95% CI: 2.66, 3.10) more emergency department visits, 0.64 (95% CI: 0.59, 0.69) more inpatient hospitalizations, and 0.15 (95% CI: 0.13, 0.17) more psychiatric hospitalizations than stably housed veterans living with AD/ADRD (see Tables S4, S5, and S6 in supporting information for marginal effects of all covariates). In addition, homeless veterans with an AD/ADRD diagnosis were 1.57 (95% CI: 1.43, 1.71) times more likely to have used a nursing home compared to stably housed veterans with an AD/ADRD diagnosis (Table 3; see Tables S7 and S8 in supporting information for relative risk of all covariates). There was no difference in the likelihood of using VA-paid home and community-based care between homeless and stably housed veterans with an AD/ADRD diagnosis. At-risk veterans with an AD/ADRD diagnosis also had more inpatient and psychiatric hospitalizations and were more likely to have had a nursing home admission and use VA-paid home and community-based care than their stably housed counterparts (Table 3).
TABLE 3.
Health-care use among veterans with Alzheimer’s disease and related dementias (AD/ADRD) diagnosis in 2018
| Homeless AD/ADRD N = 7363 |
At-risk AD/ADRD N = 13,667 |
Stably housed AD/ADRD N = 190,733 |
|||
|---|---|---|---|---|---|
| Health-care use | Mean (SD) | Adjusted difference versus stably housed (95% CI) | Mean (SD) | Adjusted difference versus stably housed(95% CI) | Mean (SD) |
| Number of emergency department visits, mean (SD) | 5.54 (9.13) | 2.88***(2.66, 3.10) | 2.86(9.44) | 1.25(0.84, 1.67) | 1.17(4.44) |
| Number of inpatient hospitalizations, mean (SD) | 1.30 (1.96) | 0.64***(0.59, 0.69) | 0.66(1.23) | 0.29***(0.25, 0.32) | 0.28(0.77) |
| Number of psychiatric hospitalizations, mean (SD) | 0.48 (1.24) | 0.15***(0.13, 0.17) | 0.06(0.39) | 0.03***(0.02, 0.04) | 0.02(0.21) |
| N (%) | Adjusted RR (95%CI) | N (%) | Adjusted RR (95%CI) | N (%) | |
| Any nursing home use, n (%) | 1046 (14.21%) | 1.57***(1.43, 1.71) | 3814 (27.91%) | 2.56***(2.29, 2.88) | 18,473(9.69%) |
| Any community-based long-term care servicea,n (%) | 1453 (19.73%) | 0.97(0.91, 1.04) | 8489 (66.11%) | 2.23***(2.08, 2.40) | 50,314(26.38%) |
Note: Zero-inflated negative binomial (acute care services) and logistic regressions (long-term care services) controlled for age, sex, race, marital status, priority status, residing in rural or urban area, combat service, and comorbidities. Standard errors were clustered at the medical center level.
Includes adult day health care, home based primary care, homemaker and home health aide care, hospice care, palliative care, and purchased skilled home health care.
Abbreviations: CI, confidence interval; RR, related risk; SD, standard deviation.
4 |. DISCUSSION
We report the prevalence of AD/ADRD diagnoses among veterans who experienced homelessness, were at risk for experiencing homelessness, or were stably housed. Homeless and at-risk veterans were 1.58 and 2.98 times more likely to have an AD/ADRD diagnosis compared to stably housed veterans. Particularly striking is the high absolute prevalence of AD/ADRD diagnoses among veterans <65 years of age experiencing homelessness (1.09% to 4.04%) and at risk (1.02% to 5.06%). It is worth noting the prevalence estimates for Veterans experiencing homelessness are likely underestimates given challenges with conducting comprehensive neuropsychological assessment for AD/ADRD in veterans who are unstably housed, are sporadically engaged in care, and may show high attrition with treatment.19,20 Taken in context with literature-identified AD/ADRD prevalence rates in younger general populations of 0.004% to 1%,21 an important clinical question arises as to the unique features of housing insecure veterans associated with early AD/ADRD diagnoses.
Rare diseases, biological factors, and lifetime exposure can cause dementia in people <65 years of age.21 Consistent with other studies, we observed high rates of traumatic brain injury, post-traumatic stress disorder, and substance abuse in the housing insecure population and these conditions are strongly associated with dementia.1,2,22–24 Furthermore, among people living in poverty, veterans are more likely to experience housing and food insecurity compared to civilians, and socioeconomic factors are strongly correlated with AD/ADRD.25–27 Separating the effect of housing insecurity from frequent co-occurring comorbidities in the population on the risk of having an AD/ADRD diagnosis is challenging. After adjusting for comorbidities, the relative risk of AD/ADRD among homeless veterans decreased by 40%, but the association between homelessness and AD/ADRD was still large and statistically significant (aRR 1.58, 95% CI: 1.51, 1.66). Thus, experiencing homelessness is strongly associated with AD/ADRD, but it is also the accompanying comorbidities that may contribute to having an AD/ADRD diagnosis.
The clinical features of AD/ADRD vary by age. Early onset dementia is associated with faster disease progression, which may mean these veterans need long-term care support sooner and longer compared to older adults with AD/ADRD.28 Ongoing military efforts to reduce the occurrence and severity of traumatic brain injury, post-traumatic stress disorder, and substance abuse may decrease the risk of early onset dementia among veterans <65 years of age.29
Over the next 30 years the prevalence of AD/ADRD is expected to increase at a greater rate in the veteran population than in the general US population. Several factors contribute to the expected increase in the prevalence of AD/ADRD among veterans.22,30 Age is the primary risk factor for AD/ADRD and the veteran population is older than the civilian US population.31,32 Minorities are at greater risk of developing AD/ADRD and the minority veteran population is rapidly growing and aging.33,34 Minorities are also disproportionally represented among veterans experiencing housing insecurity. In the United States, the prevalence of AD/ADRD is nearly two times greater among Blacks and about one and half times greater among Hispanics than Whites.35 Finally, and as noted above, veterans are more likely to experience exposures (e.g., traumatic brain injury) that are associated with AD/ADRD than civilians.
Coordinated outpatient care and low rates of acute care services are markers of high-quality AD/ADRD care.36 The US health-care system has struggled to provide high-quality AD/ADRD care, and on average people living with AD/ADRD have high rates of emergency department visits, hospitalizations, and potentially avoidable hospitalizations.37–39 Consistent with the literature, we find that veterans with an AD/ADRD diagnosis and experiencing housing insecurity used more acute care services and were more likely to have a nursing home stay than their stably housed counterparts. The VA is the largest integrated healthcare system in the United States, and it is uniquely positioned to provide comprehensive AD/ADRD care for veterans experiencing housing insecurity. There are bright spots within the care supplied—we found that veterans with an AD/ADRD diagnosis at risk for homelessness received VA paid home- and community-based services at double the rate of the stably housed with an AD/ADRD diagnosis. In addition, there is an opportunity for innovation in cross-agency collaboration—for example, the VA and Department of Housing and Urban Development housing and case management program may be an ideal setting that can be adapted to support housing insecure veterans living with AD/ADRD.
Most community-based AD/ADRD interventional research incorporates the person living with AD/ADRD and their family/friend/care partner.40 Interventions are needed to help people with AD/ADRD who live alone age safely in the community. The social network of veterans experiencing homelessness is likely fractured. We found that only 9.5% of homeless and 38.4% of at-risk veterans with an AD/ADRD diagnosis were married. In comparison, 53% of stably housed veterans with an AD/ADRD diagnosis were married. The need for interventions that support people living alone is also highlighted by changing demographics. By 2050 the ratio of family caregivers for every high-risk older adult is projected to be 3:1 (currently 7:1), so there will be many more older Americans living alone.41 Without access to a spouse and potentially adult children, housing insecure veterans living with AD/ADRD will become more reliant on the formal health-care system including nursing homes.15 We already found evidence of housing insecure veterans living with AD/ADRD being more likely to have a nursing home stay than their stably housed counterparts. It is important for health systems to develop strategies to provide high-quality economically viable care for beneficiaries who do not have a family caregiving network.
In our study, 19% of homeless and 24% of at-risk veterans with an AD/ADRD diagnosis were living in a rural area. The VA has a network of facilities in urban and rural areas, but rural housing insecure veterans with AD/ADRD may encounter a number of unique challenges to access health care. First, rural areas do not have large public transportation networks and housing insecure veterans may not own a car so many have limited transportation options.42 Second, it is challenging to identify housing insecure veterans in rural areas because emergency shelters are sparse in rural areas, service providers cover large geographic regions, and rural homeless veterans may be more likely to be doubled-up in housing.43 Third, even when housing insecure veterans have internet, broadband in rural areas may be inadequate to support telemedicine.44 Fourth, rural areas have a shortage of health specialists (e.g., neurologists, mental health providers, home health specialists) that are often needed to diagnose and treat AD/ADRD.45 This has resulted in adults in rural communities being diagnosed in the later stages of AD/ADRD compared to their urban counterparts.46
Our study has several limitations. First, we only evaluated AD/ADRD diagnosis as reported in the medical record, so we do not capture true disease prevalence. AD/ADRD is often underdiagnosed in primary care and receiving a diagnosis is dependent on receiving care.47 In addition, diagnosis codes do not capture AD/ADRD severity, and an AD/ADRD diagnosis code may be used to document multiple cognitive disorders. Second, we obtained data only from the VA, and we did not observe diagnoses and use outside of the system. For example, rural homeless veterans may have been less likely to have come in contact with VA health-care providers so the results may not be generalizable to all veterans. Third, we used ICD-10 codes to determine a veteran’s housing status, but due to limitations in administrative data we may underestimate the true number of veterans who experienced housing insecurity. Fourth, we used a cross-sectional study design, and we do not know the causal relationships among housing status, AD/ADRD, comorbidities and health use. Finally, we conditioned our cohort on being alive for all of 2018, so we likely excluded a proportion of veterans with late-stage AD/ADRD who died during the year.
4.1 |. Conclusions and implications
The prevalence of AD/ADRD diagnoses among homeless and at-risk veterans is substantially greater than their stably housed counterparts. Noticeable is the high prevalence of AD/ADRD diagnoses among homeless and at-risk veterans <65 years of age, which are greater than rates among stably housed veterans and the general population. Veterans experiencing housing insecurity and living with AD/ADRD also use more acute care services than their stably housed counterparts. As the VA plans for the expected increase in the prevalence of AD/ADRD, it should consider heterogeneity of the population and the unique needs of homeless and at-risk veterans.
Supplementary Material
RESEARCH IN CONTEXT.
Systematic Review: The housing insecure veteran population is aging. These veterans also have co-occurring substance abuse, medical (e.g., traumatic brain injury), and social needs associated with dementia. Despite these risk factors, the prevalence of dementia among veterans who experience housing insecurity is unknown.
Interpretation: The diagnosed prevalence of dementia is substantially greater among veterans who experience homelessness or are at-risk of experiencing homelessness compared to their stably housed counterparts. Housing insecure veterans with a dementia diagnosis have more emergency department visits and hospitalizations than stably housed veterans with dementia.
Future Directions: Research must examine the temporal relationship between housing status and dementia. Clinical and social circumstances are likely different between people that experience homelessness and develop dementia compared to people living with dementia that become homeless. Understanding these distinct populations can lead to targeted interventions.
Funding information
This research was supported by a Memorandum of Understanding between the VA National Center on Homelessness Among Veterans (Drs. Hooshyar and Tsai) and the VA Health Services Research and Development Center of Innovation in Long Term Services and Supports (Drs. Jutkowitz and Rudolph and Mr. Halladay). The statements and opinions expressed are those of the authors and do not represent the official policy or procedures of the United States Government or the Department of Veterans Affairs.
Footnotes
CONFLICTS OF INTEREST
Dr. Jutkowitz reports grants outside the submitted work from the National Institute on Aging (1R21AG059623, 1R01AG060871, and RF1AG069771) and a Brown University Big Data Collaborative Seed Award. He serves on a Data Safety Monitoring Board for a National Institute on Aging study awarded to the Indiana University School of Nursing. Mr. Halladay has nothing to disclose. Dr. Tsai has nothing to disclose. Dr. Hooshyar reports serving as co-investigator on a VA Rehabilitation Research and Development grant, which does not support her salary. VA supports her travel to attend meetings and conferences. She has not received any support from non-VA sources to attend meetings and/conferences. Dr. Quach reports grants outside the submitted work from the National Institutes of Health (P2CHD065702 and the Claude D. Pepper Older Americans Independence Center P30-AG031679). Dr. O’Toole has nothing to disclose. Dr. Rudolph reports grants outside the submitted work from the VA Health Services Research and Development Center of Innovation in Long Term Services and Supports (CIN 13–419;), VA HSR&D Small Award Initiative For impact (SWIFT) and the Evaluation of Veteran Directed Care (SDR 16–194). He has received travel support from VA Health Services Research and Development and the RECALL Foundation, payments from the Medical University of South Carolina, and participated on a Data Safety Monitoring or Advisory Board for Indiana University, Purdue University, and Regenstreif Institute. He reports an unpaid relationship with the American Delirium Society. This research was supported by a Memorandum of Understanding between the VA National Center on Homelessness among Veterans (Drs. Hooshyar and Tsai) and the VA Health Services Research and Development Center of Innovation in Long Term Services and Supports (Drs. Jutkowitz and Rudolph and Mr. Halladay). The statements and opinions expressed are those of the authors and do not represent the official policy or procedures of the United States Government or the Department of Veterans Affairs.
SUPPORTING INFORMATION
Additional supporting information may be found in the online version of the article at the publisher’s website.
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