Dementia and mild cognitive impairment screening in an emergency homeless shelter

Abstract INTRODUCTION Older adults represent the fastest growing segment of the homeless community. Little is known about the prevalence of dementia and mild cognitive impairment (MCI) in this population. METHODS Dementia and MCI screening using the Montreal Cognitive Assessment (MoCA) was incorporated into the standard senior evaluation for adult clients aged ≥ 55 in a large emergency homeless shelter. RESULTS In a 6‐week period, 104 of 112 (92.9%) assessments were positive for dementia or MCI using a standard cutoff of 26, and 81 (72.3%) were positive using a conservative cutoff of 23. There was no significant difference in MoCA scores based on sex or education level, and no significant correlation between age and MoCA score. DISCUSSION Older adults experiencing homelessness may have a high likelihood of dementia or MCI. Routine MoCA screening in older adults experiencing homelessness is feasible and can help to identify services needed to successfully exit homelessness.

dementia to poverty, coupled with escalating rates of older adults experiencing homelessness, raises concerns that dementia and mild cognitive impairment (MCI) may be independent risk factors for homelessness in older adults.Moreover, in light of current research indicating that homelessness accelerates aging, the cognitive impacts of chronic homelessness may further exacerbate the problem for older adults.
[6][7] Observational studies found 25% to 80% of homeless participants exhibiting some type of impairment. 5,8Population studies of veterans experiencing homelessness found absolute risk ratio (ARR) 1.58 for dementia compared to veterans with stable housing. 9 a prospective study of 100 homeless adults in a single shelter setting for people experiencing homelessness using the Montreal Cognitive Assessment (MoCA) Full (https://mocacognition.com/) for dementia and MCI screening, 65% of participants screened positive for at least MCI with a standard MoCA cutoff score of ≤ 26, higher than normative population expectations.Using a more conservative cutoff of ≤ 23 to account for the cognitive stress associated with homelessness, 10 30% of participants screened positive. 62022 systematic review 4 included nine prospective studies of dementia in older homeless adults.However, the findings were noted to be limited by either selective study engagement or prior engagement with formal health-care services related to dementia.None represented a universal screening effort.Therefore, prevalence findings were likely to be under-representative of the true population experience.To date, there are no reported universal screening programs for dementia and MCI in older adults in emergency homeless shelter settings.We report feasibility and prevalence findings from a novel universal screening program for adults age ≥ 55 in a large, 600bed emergency homeless shelter using the MoCA for its established sensitivity to detect both dementia and MCI.A concern was raised about inconsistent screening conditions, with some screenings conducted in a semi-private area of a congregate dayroom rather than in a private case management office.Of 18 screenings performed in a dayroom as opposed to a case management office, 15 (83%) were positive using the standard cutoff of 26, and 9 (50%)

METHODS
were positive using the conservative cutoff of 23.These findings suggest no deleterious effect of screening in a potentially distractible location compared to screening in a private setting without potential distraction.Universal screening programs may help to describe the true prevalence of dementia/MCI in older adults as well as the social risks associated with dementia/MCI and association of dementia/MCI and length of stay in shelter or chronic homelessness.Future work is needed to establish whether dementia/MCI may be an independent risk factor for homelessness in the United States.A clearer understanding of dementia/MCI prevalence and risk for homelessness may motivate and inform the development of upstream policy and social programs to prevent older adults from becoming unhoused.

DISCUSSION
Comparative studies in international contexts may further illuminate policy opportunities for prevention and response to homelessness in older adults for whom dementia/MCI may be a contributing risk factor.

Limitations
These findings are limited by a single-site setting of older adults in an emergency shelter in a single metropolitan area in the United States.

Future work is needed
to validate these findings with other unhoused older adult populations including unsheltered individuals, individuals in other rural and urban regions in the United States, and individuals in other countries with different social policy structures informing health, housing, and aging structures.
MoCA screening results.There was no significant difference in MoCA score between male and female clients (t 110 = 0.41, P = 0.68).There was no significant difference in MoCA score between clients with 12th grade education or less and those with more than a 12th grade education (t 110 = 1.14, P = 0.26).There was no significant correlation between age and MoCA score (r = −0.142, [SPMSQ]).CASS staff and associated researchers underwent MoCA training and certification.MoCA results were incorporated into the standard case management record.MoCA screenings were administered in a case management office immediately after the senior assessment interview when possible.When a MoCA screening was postponed due to scheduling conflicts, it was conducted on an ad hoc basis in a case management office or in a separated segment of a congregate day room in response to clientRESEARCH IN CONTEXT1.Systematic review: The authors reviewed the literature using traditional (e.g., PubMed) sources and government reports.While there have been a few small studies of dementia in homeless older adults, there is no report of screening programs or prevalence in this population.2.Interpretation: Our findings from a shelter-based screening program suggest a very high prevalence of possible mild cognitive impairment (MCI) or dementia in older adults experiencing homelessness.This hypothesis is elevated from clinical research findings currently in the public domain.3.Future directions: The feasibility and prevalence findings from this single-site screening program should be validated across other homeless shelter sites and geographies.If validated, these findings suggest broad adoption of routine dementia and MCI screening for older adults in homeless shelter settings to assist case managers, as well as primary care and community health settings to identify older adults at risk of homelessness.TA B L E 1 Montreal Cognitive Assessment screening client characteristics.wereapproachedforMoCAscreening.One hundred twelve (83.5%) screenings were completed (Table1).One (0.7%) client who is deaf and unable to verbalize to complete the MoCA-HI (hearing impaired) version deferred screening until an American sign language interpreter was available.Fifteen (11.2%) clients who completed the senior evaluation prior to the initiation of the MoCA screening program did not TA B L E 2 had a positive screen for at least MCI (Table2).Using a conservative cutoff score of 23 to account for cognitive stress associated with homelessness, 6,10 84 (72.3%) of screened clients had a positive screen for at least MCI.Independent sample two-tailed t tests were performed to assess differences in MoCA scores between sexes and education levels (≤ 12th grade or > 12th grade).P = 0.15).