Maureen Crane

Quality of life in dementia: a systematically conducted narrative review of dementia-specific measurement scales

Objectives: Ascertaining the quality of life (QoL) in people with dementia is important for evaluating service outcomes and cost-effectiveness. This paper identifies QoL measures for people with dementia and assesses their properties. Method: A systematic narrative review identified articles using dementia QoL measures. Electronic databases searched were AMED, CINAHL, EMBASE, Index to Theses, IBSS, MEDLINE, PsycINFO, Sociological Abstracts, and Web of Science. All available years and languages (if with an English language abstract) were included. Results: Searches yielded 6806 citations; 3043 were multiple duplicates (759 being true duplicates). Abstracts were read; 182 full papers were selected/obtained, of which 126 were included as relevant. Few measures were based on rigorous conceptual frameworks. Some referenced Lawtons model (Dementia Quality of Life [DQOL] and Quality of Life in Alzheimers Disease [QOL-AD]), though these tapped part of this only; others claimed relationship to a health-related QoL concept (e.g. DEMQOL), though had less social relevance; others were based on limited domains (e.g. activity, affect) or clinical opinions (Quality of Life in Late-Stage Dementia [QUALID]). Many measures were based on proxy assessments or observations of people with dementias QoL, rather than their own ratings. The Bath Assessment of Subjective Quality of Life in Dementia (BASQID) was developed involving people with dementia and caregivers, but excluded some of their main themes. All measures were tested on selective samples only (ranging from community to hospital clinics, or subsamples/waves of existing population surveys), in a few sites. Their general applicability remains unknown, and predictive validity remains largely untested. Conclusion: The lack of consensus on measuring QoL in dementia suggests a need for a broader, more rigorously tested QoL measure.

Evictions and Prolonged Homelessness

This paper examines the connections between homelessness among older people and both evictions by statutory housing providers and repossessions by mortgage institutions. The evidence is from 45 single homeless people (among 313 in a succession of ethnographic studies) who reported that eviction made a contribution to their homelessness. Using preceding states and events as criteria, a taxonomy of these once-evicted older homeless people is proposed. For the majority, eviction followed a protracted failure to meet their financial obligations or to keep their property in good condition, and for many, mental health problems or exceptionally low competence in basic domestic skills were contributory factors. The experiences of the group strongly suggest that homelessness can be prevented if support is provided to vulnerable people as difficulties mount. Six risk factors for eviction and subsequent homelessness are identified, and the paper concludes that these markers could be used in experiments to recognise marginally housed people and as a primary prevention measure for homelessness.

Homelessness among older people and service responses

This paper reviews the limited evidence on the causes of homelessness in old age and on the circumstances and problems of older homeless people, and it describes the few services dedicated to the group. Health care and social care professionals rarely encounter homelessness among the many problems of older people that present to them, but in many developed countries there is evidence that the number of older homeless people has recently been growing. Some among them have been homeless intermittently or continuously for years, but many became homeless for the first time in later life. The reasons for becoming homeless and the problems and needs of the group are exceptionally diverse. Many have been estranged from their family or have no living relatives, and they have a high prevalence of health problems and functional limitations. Although services for homeless people in general have improved since the early 1990s, few have targeted the needs of older people.

The outcomes of rehousing older homeless people: a longitudinal study

ABSTRACT Older people who become homeless have attracted increasing attention in North America, Western Europe and Australia over the last 20 years, but there have been few projects dedicated to their support, and even fewer studies of the outcomes. This paper reports a longitudinal study of the resettlement of 64 older people who were rehoused into permanent accommodation from homeless peoples hostels in England. Their progress was monitored for two years by face-to-face interviews. The theoretical model was that the outcomes of rehousing are a function of personal factors and behaviour, the support that people receive, and the characteristics of the new home. After 24 months, 28 respondents were housed and ‘settled’, 10 were housed but ‘unsettled’, 11 had abandoned their accommodation, and six had been evicted (nine had died or ceased contact). The factors that significantly associated with remaining housed and settled included: previous stable accommodation histories, revived contacts with relatives, taking up activities, and regular help from housing-support workers. Unsettledness and tenancy failure associated with prolonged prior homelessness, worries about living independently, and continuing contacts with homeless people. Rehousing older homeless people successfully is difficult, particularly among those with long histories of homelessness and instability, and more needs to be known about the types of accommodation and the types of support that promote tenancy sustainment.

The associations between mental illness and homelessness among older people: An exploratory study

Rough sleeping has increased in Britain since the late 1980s, and there is a known high prevalence of mental illness in this population. There have been few studies of older homeless people however, and little is known about the association between mental illness and homelessness among this group. This paper explores the role of mental illness in contributing to the entry to homelessness, and its prevalence among a sample of older homeless people. Through an intensive field study which lasted for 15 months, multiple semi-structured interviews were conducted with 225 subjects over the age of 55 years in four British cities. There was a high prevalence of mental illness among the subjects and this was a factor in the entry to homelessness in many cases. There were indications that some subjects with mental health problems became homeless because their needs had been neglected or undetected. Mental health problems also had an impact on the circumstances of older homeless people and affected their ability to ...

RESPONDING TO THE NEEDS OF OLDER HOMELESS PEOPLE : The effectiveness and limitations of British services

The article examines why the statutory and voluntary- (non-profit) sector services in Britain do not fully meet the needs of vulnerable older people or prevent homelessness among them. Britain has a relatively comprehensive welfare safety net for vulnerable people, and since the early 1990s central government has taken a more directive and strategic role in the development of services specifically for homeless people. As a result, service provision has greatly expanded, diversified and specialized, but nonetheless, many older people still become and remain homeless. An underlying reason is that there is a gap between the behaviour of some very vulnerable people and the general assumption of the welfare state services that people in need will request help. Some older people, through mental health problems, alienation or apathy, do not ask for help, and the lack of a duty among most statutory services to ‘seek out’ unmet needs means that this group is neglected. Outreach work or active case finding is not normally undertaken by mainstream health and housing providers, while its provision by voluntary organizations has until recently been limited to the largest cities. Moreover, government policies and many homeless services target the needs of young homeless people, and consequently the organization and ‘culture’ of many homeless services are unsuited to the problems and needs of older homeless people. The article concludes with a discussion of the uncertain future for services for older homeless people in Britain.

The Causes of Homelessness Among Older People in England

A comparative study of the causes of new episodes of homelessness among people aged 50 years and over has been undertaken in Boston, Massachusetts, Melbourne, Australia and four English cities. This paper presents the findings from England, where information was collected from 131 respondents and their key-workers about the circumstances and problems that contributed to homelessness. Two-thirds of the respondents had never been homeless before. The many reasons why they became homeless involved interactions between personal disadvantages and weaknesses, negative events and inadequate welfare support services. For some, their behaviour rather than external factors triggered homelessness. Other cases involved deficiencies with the administration of services and social security payments, the failure or limitations of agencies to detect and respond effectively to vulnerability, and poor collaboration or information co-ordination among housing providers and welfare agencies.

Homelessness and Mental Health: Old and homeless in London and New York City: a cross-national comparison

Introduction Persons aged 50 and over are estimated to comprise about one fifth of the homeless in New York City (NYC) and nearly one third of the homeless in London (Weeden & Hall, 1985; Kelling, 1991). The proportion of those aged 50 and over living in substandard singleroom occupancy (SRO) hotels or hostels may be even higher (Keigher, 1991). However, older homeless have been an unwanted stepchild of both the fields of homelessness and geriatrics. In contrast to the scholarly literature on younger homeless that has mushroomed in recent years, there have been relatively few papers written about ageing homeless (Cohen, 1996). On a service level, most senior citizen centres have shown little interest in this group, and public shelters have been typically avoided by older homeless persons because of fear of aggression by younger homeless, insensitive staff and accommodations that are not suitable for their physical disabilities (Coalition for the Homeless, 1984). Finally, governmental policy has failed to recognize the special needs of this ageing group, and even when statutory entitlements exist, many older homeless have not obtained such benefits (Kelling, 1991; Crane, 1993). Although the absolute numbers of homeless persons in London are lower than in NYC, the former has the highest number of homeless persons among Western European cities (Adams, 1986; Toro & Rojansky, 1990; Schmidt, 1992). This commonality of large-scale homelessness in both cities creates an opportunity to undertake cross-national comparisons of ageing homeless. Such comparisons can provide answers to: (a) the proportionate contribution to the causes of homelessness of individual pathology and behaviour versus socio-political (structural) forces;

Factors that Influence the Outcomes of Single Homeless People's Rehousing

This paper examines the influences of biographical, behavioural, housing and neighbourhood attributes on housing satisfaction, settledness and tenancy sustainment for 400 single homeless people who were resettled into independent accommodation. It draws on evidence from FOR-HOME, a longitudinal study in London and three provincial English cities of resettlement outcomes over 18 months. There was a high rate of tenancy sustainment: after 15/18 months, 78 per cent of the participants were in their original tenancy, 7 per cent had moved to another tenancy and only 15 per cent no longer had a tenancy. Tenure greatly influenced tenancy sustainment, with moves into private-rented accommodation having the lowest rate of success. Several housing and neighbourhood characteristics had strong associations with the outcomes. The biographical and behavioural attributes that were influential in determining outcomes were being young, frequent family contacts, having been in care as a child and some features of the recent episode of homelessness.

Older homeless people: increasing numbers and changing needs

Evidence from England, Australia, Canada, Japan and the USA indicates that the single homeless population is ageing, and that increasing numbers of older people are homeless. This paper reviews evidence of changes in the age structure of the single homeless population, and the factors that are likely to have had an influence on the growth of the older homeless population. In many Western cities, the housing situation of older people is changing and there is a growing reliance on the private rented sector. Unemployment is also having an impact on older people who are under the official retirement age. An increasing number of older people are experiencing problems linked to alcohol, drugs, gambling and criminality, and these are all behaviours that can contribute to homelessness. Despite high levels of morbidity and disability among older homeless people, they are a relatively neglected group and receive little attention from policy makers and mainstream aged care services.