More appropriate support is needed for older residents with dementia in subsidized housing

A recent scoping review, published online in the Journal of Aging and Environment, found that older adults with dementia or cognitive impairment who live in subsidized housing face complex challenges, that left unaddressed, threaten to exacerbate their health and ability to age in place.

An examination of 69 articles on the topic revealed the scope of major problems that can lead to premature institutionalization and underscored the need for the development of an aging-in-place framework and increased support for future research.

“This group of tenants encounters unique physical, mental, social, psychological and behavioral struggles that necessitate targeted services,” says Helen Lam, lead author of the study and a recent graduate of the Factor-Inwentash Faculty of Social Work (FIFSW). “Health care practitioners, policymakers, and key stakeholders should engage collaboratively to improve the quality of life and reduce the risk of health deterioration for these vulnerable tenants.”

The study’s authors—comprised of a team of five Master of Social Work students in the gerontology field of study, now recent graduates from the University of Toronto—found that prevalence of cognitive impairment among residents in subsidized housing was between 10% and 27%, while between 4% and 10% had dementia.

Research has shown that residents with cognitive decline are at risk of premature placement in nursing homes. Older adult residents of subsidized housing with dementia are more likely to be admitted to hospital than all other low-income older adults and are seven times more likely than other community-based older adults to be placed into long term care.

“Some symptoms of dementia, such as a decline in personal hygiene and paranoia, may be labeled as disruptive behaviors,” says co-author Theodora Li. “Furthermore, those with cognitive decline may face challenges with managing the regular payment of rent, utilities and other bills. These problems dramatically increase their risk of being evicted from subsidized housing.”

Eviction may eventually lead to homelessness. Unfortunately, as the scoping review revealed, subsidized housing staff are not adequately trained to screen tenants for dementia or refer them to appropriate service.

“Most subsidized housing facilities have not been designed with population aging in mind,” says co-author Jeff Lee. “There is a need for more comprehensive services and onsite outreach programs to increase assessment and identification of these tenants.”

Many subsidized housing residents with cognitive impairment also were coping with serious physical limitations. More than two in every five cognitively impaired subsidized housing residents reported limitations in activities of daily living such as dressing, bathing and toileting. Cognitive impairment is exacerbated by physical impairments, such as vision and hearing loss, and seriously hinders verbal communication and accessing appropriate medical care. It may also jeopardizes medical compliance. “Dementia worsens social isolation and loneliness,” says co-author Nisha Mendonca. “Loss of social networks, poverty, poor health and stigma about dementia all contributed to the lack of medical care and service utilization among this group of older tenants.”

Co-author Kelly Fleming pointed out the necessity to coordinate multidisciplinary services and fund assessments and programs to enhance the well-being of the tenants. “Financial investment in home-based services and retrofits is fundamental. Our study also suggested attention to the value of purpose-built dementia housing.”

The authors argue that future research needs to focus on evaluating the unique needs of this undervalued population. The study’s findings have important implications for health care practitioners, policy makers and key stakeholders as well.

“The adoption of a framework of aging in place, as well as collaboration and coordination among housing providers and government in the provision of supportive services, will help to achieve greater equity in the lives of subsidized housing tenants living with cognitive decline,” says Helen Lam.