Maricopa County's largest homeless shelter screens older residents for dementia. 91% don't pass
More people over the age of 50 are becoming homeless for the first time. Shelter staff are also seeing more seniors who appear to have some type of dementia or mild cognitive impairment. Now, Maricopa County’s largest shelter is starting to screen its older clients for possible neurological disorders.
“The MoCA takes about 10 minutes of your time and is the last portion of your senior assessment,” said Primrose Dzenga, explaining the Montreal Cognitive Assessment, or MoCA, to a 57-year-old man who asked not to be identified in this story. They sat in a tiny office inside the Central Arizona Shelter Services building, or CASS, in downtown Phoenix. “And we only use it to see how well we can best serve you,” she explained, “to see how your memory is working, and then that just adds tools to how we can serve you.”
“So we’ll begin. Are you ready?”
“Mmhmm,” said the man.
“All right, great,” Dzenga said. “I’m going to ask you to draw for me a line starting from 1 to A; A to 2; 2 to B; B to 3, and so on and so forth.”
The MoCA is widely used to screen for mild cognitive decline and early signs of dementia — it doesn’t diagnose, that requires additional testing, including brain imaging.
Typically the MoCA is used in a primary care setting, and lists questions and challenges, including drawing hands on a clock, naming pictures of animals, and repeating a list of numbers and words.
Historically, it’s not used in settings like CASS, a 600-bed shelter, the largest in Maricopa County.
91% screen positive for dementia
That changed in September, when Heather Ross and her team, including Dzenga, started working with CASS to screen older clients for cognitive impairments. Ross is a professor of health and technology policy at ASU.
She said a score or 26 or higher is considered normal.
“If you score below the 26, then it suggests that you may have some mild cognitive impairment or dementia,” said Ross. “And that’s the trigger for, in a perfect world, where everyone had unlimited access to every specialty health care service, you would have your dementia workup, right?”
At the time of this interview, Ross and her team had screened 107 individuals. Of that, she said that 91% screened positive for dementia.
“That is not a diagnosis. It's just a screen. But it is shocking. It is beyond concerning, right?”
In fact, only 6 individuals had a score of 26 or higher. Most scored between 17 and 21.
“Is cognitive impairment and dementia, is that an independent risk factor for older adults becoming homeless?”
— Heather Ross
“And here's the thing: Nobody has ever gone about screening homeless populations for dementia or cognitive impairment before. There are a couple of papers in the literature that have asked people who are experiencing homelessness if they have a diagnosis of dementia. But nobody has ever blanketly screened older adults in shelter before like this.”
So why now? Phillip Scharf is CASS’s chief operating officer.
“I can say, with confidence, that we are seeing, year over year, a ‘ginormous’ increase in the 55-plus population that's experiencing homelessness,” he said. “From an actual data standpoint, it’s an increase of well over 30%, over the last five years.”
And with an aging homeless population come myriad cognitive concerns. “So, what we're seeing in shelter is people that are going through acute behavioral health crises,” said Scharf.
Stemming from all sorts of things. From traumatic brain injury to substance use disorder and dementia. And keeping someone in shelter who’s agitated or aggressive can be challenging.
“What this is really helping us to better understand is, what are the underlying conditions that a lot, and what we're finding is that a lot of our subsetted population have, that then helps us to understand why some of those behaviors also may happen,” he explained.
In some cases, it could be as simple as a client not being able to remember where their bed is at CASS — they get frustrated and react. So for Scharf, the MoCA is a starting point. Which then will hopefully lead to a diagnosis, followed by support and services.
Reality vs. good intentions
But reality can get in the way of good intentions.
“So, when we started this screening program, there was a real concern that okay, well, somebody screens positive for dementia, how are we going to get them to a dementia specialist?” Ross said.
Because even with private insurance and ample family and community support, it can take weeks or months before getting in to see a specialist. So for this population, it means doing whatever possible to keep them safe. One way to do that is to get them out of a mass shelter. And that’s just what happened late last month.
Lisa Glow is the CEO of CASS. “We're really grateful that we can get 60 of our most vulnerable seniors into a hotel, where they have their own rooms versus staying with hundreds of other people in a mass shelter really makes a huge difference,” she told KJZZ.
And that "huge difference" includes everything from their physical health to, possibly, their MoCA score.
Scharf said everyone who moved in was screened for dementia. In another month, they’ll be rescreened.
“Because that helps us to better understand the impact of not only congregate shelter, but the true impact on congregate shelter, as it relates to our 55 and overpopulation, which is vulnerable and vulnerable and vulnerable,” he said.
But even a hotel where clients have their own room may not be sufficient for those with dementia.
“So, we're trying to find a more appropriate placement for them,” Glow said. “There are dementia care facilities, really hard to get our folks into that some of them are too costly. We have people who can't take care of some of their basic needs who are here, which is why we need to get those folks into nursing homes.”
And there’s perhaps an even bigger question Ross hopes to answer: “Is cognitive impairment and dementia, is that an independent risk factor for older adults becoming homeless?”
More research and time will tell. But given the spike in senior homelessness, answers can’t come soon enough.