Homelessness & Brain Injuries: Cause or Effect?

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Caitlin Atkinson
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1 Homelessness & Brain Injuries: Cause or Effect? Stephen Hwang, MD, MPH Research Scientist, Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael s Hospital; Department of Medicine, University of Toronto. May 26, 2008 Let s Get Talking Community Discussion Series St. Christopher House, Toronto 1

2 The Centre for Research on Inner City Health (CRICH) is dedicated to reducing health inequities through innovative research affecting social change. We are Canada s first and only interdisciplinary and hospital-based research centre working to improve the health of socially and economically disadvantaged urban populations. 2

3 Roadmap 1. Homelessness in Toronto - a quick overview 2. What is Traumatic Brain Injury (TBI)? 3. How might homelessness and traumatic brain injury be connected? 4. How common is traumatic brain injury among people who are homeless? 5. What are the implications for treating and supporting homeless individuals who have a history of traumatic brain injury? 3

1. Homelessness in Toronto 29,000 individuals used shelters in 2005 5,000 people homeless on any given

4 1. Homelessness in Toronto 29,000 individuals used shelters in ,000 people homeless on any given night 4,000 in shelters 1,000 on the street, in hospitals, in jails Uncounted thousands of hidden homeless 4

5 Individuals using Shelters City of Toronto, 1990 to

6 Diversity of Homelessness In Toronto: 50% single men 20% single women 20% youth (15-24) 10-15% parents with children 6

7 2. Traumatic Brain Injury (TBI) Traumatic Brain Injury is caused by a blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. 7

8 Traumatic Brain Injury TBI is most commonly caused by falls, motor vehicle trauma, unintentional impacts, assaults, and sports-related injuries. TBI is a leading cause of permanent disability in North America. In Canada, 18,000 patients are admitted to hospital with brain injuries annually. 8

9 Types of Traumatic Brain Injury 9

10 Skull Fracture 10

11 Mechanism of Brain Injury 11

12 Lobes of the Brain 12

13 Signs and Symptoms of TBI Immediate Dazed or stunned Loss of consciousness Headache Nausea or vomiting Dizziness Clumsiness or balance problems Fuzzy or blurry vision Sensitivity to light or noise 13

14 Signs and Symptoms of TBI Immediate or Long-term Difficulty thinking clearly, concentrating, or remembering Difficulty following conversation or directions Answering questions more slowly or repeatedly Feeling tired all of the time, having no energy Irritable or more emotional Depression or anxiety Sleeping more or less than usual 14

15 3. Possible Connections between TBI and Homelessness Homelessness TBI Homelessness exposes individuals to unsafe environments and higher risk of injuries and assault 15

16 Possible Connections between TBI and Homelessness Abuse as Child TBI Homelessness Physical abuse during childhood increases risk of homelessness as an adult, and can also result in TBI 16

17 Possible Connections between TBI and Homelessness TBI Homelessness Substance Abuse Substance abuse increases risk of homelessness, and also increases risk of TBI 17

18 Possible Connections between TBI and Homelessness TBI Homelessness Brain dysfunction from previous TBI may contribute to the onset and perpetuation of homelessness 18

19 Homelessness and brain injuries: Abuse as Child Cause or effect? TBI Homelessness TBI Substance Abuse 19

20 Possible Connections between TBI and Homelessness Providing care for homeless individuals is sometimes difficult due to problematic behaviors Severe or repeated TBI can cause cognitive impairment, attention deficits, disinhibition, impulsivity, emotional lability In people who are homeless, are we seeing some of the long-term consequences of TBI? 20

21 4. How common is traumatic brain injury among people who are homeless? No research studies have addressed this specific question 21

22 Research Study Representative sample of homeless individuals in Toronto Homelessness defined as living in a shelter, public place, vehicle, abandoned building, or someone else s place within the last 7 days; and not having a place of one s own 22

23 Research Study Recruited participants at 50 shelters and 18 meal programs in Toronto over 12 months in % of participants recruited at meal programs Male-to-female ratio of 2:1 Homeless families not included in the information presented here 23

24 Research Study 1,679 individuals screened Excluded if not homeless, unable to communicate in English, unable to give informed consent, or never had an OHIP number 1,190 individuals eligible 76% agreed to participate Data on 904 individuals Payment for participation: $15 24

25 History of TBI Have you ever had an injury to the head which knocked you out or at least left you dazed, confused, or disoriented? Number of head injuries Date or age at time of head injuries Whether unconscious after head injury Duration of unconsciousness 25

26 History of TBI Mild TBI: no loss of consciousness, or unconsciousness less than 30 minutes Moderate/Severe TBI: unconsciousness more than 30 minutes 26

27 Demographics Average Age: 37 years Male 67%, Female 34% Place of birth: Canada 73% Outside Canada 27% 27

28 Race / Ethnicity White Black First Nations Other

29 Education Less than HS 27 High School College or more

30 Demographics Average age at first episode of homelessness: 29 years Average lifetime duration of homelessness: 4.4 yrs 30

31 Lifetime History of TBI Percentage Men Women Overall 31

32 Number of TBIs in Lifetime or more

33 Severity of Worst TBI 11 Mild Moderate or Severe Unknown

34 TBI History Average age at first TBI: 18 years Average age at first episode of homelessness: 29 years 34

35 Time of first TBI compared to first episode of homelessness Number of individuals Years before first episode of homelessness Years after first episode of homelessness 35

36 Association of TBI with Seizures Odds Ratio No TBI 1.0 Mild TBI 2.6 Mod/Severe TBI 3.1 Model adjusted for sex, age, race, place of birth, education, and lifetime duration of homelessness 36

37 Association of TBI with Mental Health Problems Odds Ratio No TBI 1.0 Mild TBI 1.3 Mod/Severe TBI

38 Association of TBI with Alcohol Problems Odds Ratio No TBI 1.0 Mild TBI 1.5 Mod/Severe TBI

39 Association of TBI with Drug Problems Odds Ratio No TBI 1.0 Mild TBI 1.7 Mod/Severe TBI

40 Association of TBI with Mental Health Status Ave. Difference No TBI 0 Mild TBI -4.5 Mod/Severe TBI -8.1 Mental health status is measured on a 0 to 100 scale in which 0 is worst, 100 is best, and 50 is the average. 40

41 Association of TBI with Physical Health Status Ave. Difference No TBI 0 Mild TBI -3.9 Mod/Severe TBI -5.9 Physical health status is measured on a 0 to 100 scale in which 0 is worst, 100 is best, and 50 is the average. 41

42 Summary of Research Findings TBI is very common in a representative sample of homeless people 58% in men, 42% in women These rates are more than 5 times higher than in the general population, and are comparable to the rates found among prison inmates 42

43 Summary of Research Findings History of TBI is strongly associated with a number of adverse health outcomes Seizures Mental health problems Drug and alcohol problems Worse mental health Worse physical health 43

44 Summary of Research Findings First TBI usually happened before the first episode of homelessness Is TBI a causal factor contributing to the onset of homelessness? 44

45 Homelessness and brain injuries: Abuse as Child Cause or effect? TBI Homelessness TBI Substance Abuse 45

46 5. Implications for Service Providers Clinicians should routinely screen individuals who are homeless for history of TBI TBI should be considered a possible cause of cognitive dysfunction and behavioral problems among individuals who are homeless 46

47 Implications for Service Providers Persons with brain injuries may have attention deficits, making it difficult for them to focus on tasks and understand, remember, or respond to directions These individuals may need more time to follow instructions; slowness should not be misinterpreted as a lack of effort or cooperation TBI-related brain dysfunction can predispose to irritability or impulsivity that should be understood in the context of the person s previous injury 47

48 Implications for Housing Provision of permanent supportive housing may be necessary to end homelessness among individuals with significant impairments due to TBI 48

49 Implications for Prevention Prevention of TBI may play a role in the prevention of homelessness Child abuse Substance use during adolescence Risk behaviors during adolescence Rehabilitation after TBI may play a role in the prevention of homelessness Especially in disadvantaged populations 49

50 Research Team Angela Colantonio, PhD, O.T. Reg. Shirley Chiu, MA George Tolomiczenko, PhD, MPH, MBA Alex Kiss, PhD Marko Katic, BA Laura Cowan, BScN Donald A. Redelmeier, MD, MSHSR Wendy Levinson, MD 50

51 Acknowledgments This project was supported by grants from: Agency for Healthcare Research and Quality (R01 HS ) Canadian Institutes of Health Research Ontario Ministry of Health and Long-Term Care Ontario Neurotrauma Foundation Toronto Rehabilitation Institute Foundation 51

52 Thank you! 52

53 53

54 Demographics Race and Place of Birth strongly linked. % Born in Canada: White: 89% First Nations: 98% Black: 31% Other races: 35% 54

55 History of TBI Age at which the participant first experienced homelessness was determined at a separate point much earlier in the survey interview This information was used to determine the temporal relationship between first TBI and first episode of homelessness 55

56 TBI vs. no TBI TBI No TBI Sex Male 73% 59% Female 27% 41% 56

57 TBI vs. no TBI TBI No TBI Race White 68% 52% Black 10% 27% First Nations 10% 11% Other Race 10% 12% 57

58 TBI vs. no TBI TBI No TBI Place of Birth Canada 82% 64% Outside Canada 18% 36% 58

59 TBI vs. no TBI TBI No TBI Age at first episode of homelessness Lifetime years of homelessness

60 TBI vs. no TBI TBI No TBI Seizures (ever) 22% 8% Mental health problems 43% 33% Alcohol problems 42% 28% Drug problems 57% 40% 60

61 TBI vs. no TBI TBI No TBI SF-12 Mental subscale SF-12 Physical subscale

62 Limitations History of TBI based on self reports, subject to recall bias Self-reports not confirmed through review of health records Information not collected on the mechanism or circumstances of TBI Participants did not undergo formal testing for neuro-psychological dysfunction 62

The effect of traumatic brain injury on the health of homeless people

CMAJ Research The effect of traumatic brain injury on the health of homeless people Stephen W. Hwang MD MPH, Angela Colantonio PhD OT Reg, Shirley Chiu MA, George Tolomiczenko PhD MPH, Alex Kiss PhD, Laura