The Aging of the Homeless Population: 

Fourteen-year Trends in San Francisco

Judy Hahn, Margot Kushel, David Bangsberg, Elise Riley, Andrew Moss

BackgroundChanges in homelessness in the US• 1930’s

– Young transient men in search of work• 1950’s to 1970’s:

– “Skid row”, single older low income white men, unstable housing (flophouses, SROs, missions)

• 1980’s onward: – Loss of SRO hotels and affordable housing in urban centers– Shelter capacities nationwide increased– More families and minorities, younger– Poorer living conditions compared to Skid row

Rossi, American Psychologist 1990

BackgroundIn San Francisco,• Continued decline in the number of low cost housing and

SRO units in the 1990s– Units lost due to earthquakes, fires and gentrification

• The response to homelessness– Establishment of emergency shelters and soup kitchens and

large shelters with services (1980s)– Policing programs (mid 1990s)– Supportive housing (some late 1990s, most starting 2004),

leveraging Federal $

Ilene Lelchuk, San Francisco Chronicle September 7, 2003.

Objectives

• We have studied HIV and TB in the homeless and marginally housed in San Francisco from 1990 to 2003.

• In this analysis, we sought to examine changes in the homeless population over time in:– Demographics – age, race, sex– Housing– Health status– Health service utilization– Drug use

Methods

Wave 2:

1996-1997

Wave 1:

1990-1994

Wave 3:

1998-2000

Wave 4:

2003

• Four cross sectional studies (“waves”) conducted at shelters and free meal programs

• Over the entire study period we conducted sampling at a total of 13 shelters and 8 free meal programs

Methods

• Inclusion criterion: Age 18 and older

• 45 minute interviewer-administered survey

• HIV antibody testing and counseling, TB testing (waves 1 and 2)

• $10-$20 remuneration for participating

• Anonymous

Analysis

We included in this analysis:• Shelters and meal programs that were sampled in

at least ¾ of the “waves” – 4 shelters and 2 free meal programs (78% of those

sampled)

• Study participants who were “literally homeless” in the prior year – 87% of those sampled

RESULTSDemographics (n=3534)

Male 77%Race

African American 52%Caucasian 33%Other, or mixed race 15%

Veterans (of the men)33%

Substance use and mental illness

Psychiatric hospitalization, ever 23%Crack use, ever

63%Injection drug use, ever 38%Heavy alcohol use, prior 30 days 35%

At least one of the above 80%Two or more of the above 49%

3737

4141 4242

4646

30

35

40

45

50

1990 1995 2000 2005Year

Med

ian

age

Age trends

38%22% 15% 15%

50%

60%65%

52%

11% 18% 20%32%

0%

20%

40%

60%

80%

100%

1990-1994 1996-1997 1998-2000 2003

Age >=50Age 35-49Age <35

Age trends by group

1% overall >= age 65

Demographics

53%49%

56%

47%

36%

28%31%

0%

10%

20%

30%

40%

50%

60%

1990 1995 2000 2005

African American

Veterans (% ofmales)

Women

Housing

12

24

30

40

0

6

12

18

24

30

36

42

48

1990 1995 2000 2005

Months

0%

10%

20%

30%

40%

50%

60%

Median durationever homeless

Lived on street,prior year

Lived in own apt,prior year

Self-reported health

21%

15%14%

8%6%

10%10%

0%

5%

10%

15%

20%

25%

1990 1993 1995 1998 2001 2004

Hypertension

Psychiatrichospitalizations

Diabetes

Emphysema

Hospital utilization

52%

42%43%

31%

21%21%

0%

10%

20%

30%

40%

50%

60%

1995 2000 2005

Visitedemergencydepartment

Admitted tohospital

Drug/alcohol use

29%31%30%

40%

4%

12%9%

0%

10%

20%

30%

40%

50%

60%

1990 1995 2000 2005

Drank heavily

Used crack cocaine

Injected drugs

Usedmethamphetamine

30

35

40

45

50

1980 1985 1990 1995 2000 2005Year

Med

ian

age

San Francisco

Los Angeles

St. Louis

Pittsburgh

Toronto

New YorkCity

Aging in 6 cities

Conclusions and Implications• The homeless population is getting older.

• This aging indicates that the homeless population is static and not regenerating itself in time.– A dynamic population would have as many new young people joining

the population as old people leaving the population and would have a constant age over time.

• Good news: resources spent on housing the homeless now may be finite.

Conclusions and Implications• Of concern: the homeless will increasingly need health care

services -- either to control their chronic disease or to treat the more serious outcomes of unmanaged chronic disease.

• Control of chronic disease will be very difficult to deliver to persons not in housing.

Recommendations• Provide supportive housing with onsite medical services for those age 50 and

older in order to intervene in the course of chronic disease early

• Base on the model of San Francisco Department of Public Health’s Direct Access to Housing– Houses 1000 people in 12 buildings– 3 buildings dedicated to seniors– Psychiatrists, nurses, physicians assistants– Case worker : resident ratio: 1:20– 80% stay at least 1 year

AcknowledgmentsREACH field staff and study participantsGrants: NIH 5R01DA004363, 1R01MH054907,

R01DA010164, and K08HS11415.

Contact info: Judy Hahn, Ph.D.Assistant ProfessorEPI-Center, Department of Medicine University of California, San FranciscoSan Francisco, CA 94143-1372jhahn@epi-center.ucsf.edu

Bonus data!

Younger vs. older homeless2003 data wave

Age<50 (n=384) Age50 (n=140)

Median age (IQR) 40 (33-45) 53 (51-58)Sex=Female* 25% 15%Race/ethnicity* African American Caucasian Mixed/other

43%34%23%

55%28%17%

*p<0.05

Younger vs. older homelessHousing

Age<50 (n=384) Age50 (n=140)

Median total months homeless (IQR)*

36 (9-76) 48 (18-108)

Median years since first homeless (IQR)*

6 (1.5-12.5) 7 (3-16)

Lived on streets/outdoors, prior year 51% 50%Lived in shelter, prior year 82% 87%Lived in SRO, prior year 40% 46%Lived in own apt, prior year* 23% 10%

*p<0.05

Younger vs. older homeless Health

Health issue, prior year Age<50 (n=384) Age50 (n=140)Visited ED 49% 44%Admitted to hospital 29% 26%Mental health admission 8% 5%Any days ill (prior 30) 35% 36%Chronic health problem Heart disease* 3% 10% Hypertension* 14% 34% Diabetes 6% 6% Emphysema* 3% 9% Asthma 13% 15%

*p<0.05

Younger vs. older homeless Substance use

30 day use Age<50 (n=384) Age50 (n=140)

Heavy drinking 28% 23%Injected drugs* 18% 9%Drugs used: Crack cocaine 32% 29% Powder cocaine 7% 4% Heroin 13% 8% Methamphetamine* 18% 8%

*p<0.05

Summary of bonus data

• Many older homeless persons are using drugs or drinking heavy amounts of alcohol, though somewhat fewer than younger homeless persons

• Older homeless persons have the same rate of ED visits and inpatient hospitalizations though higher rates of chronic disease