The cognitive-functional needs of the chronically homeless: Examination of practice data to inform assessment and rehabilitation.

Sylvain Roy, Ph.D. C.Psych. Neuropsychologist, Inner City Family Health TeamLead clinician, Psychosocial Rehabilitation Assessment Service, Centre for Addiction and Mental Health (CAMH)

Only a small proportion of the homeless population has schizophrenia. The lifetime prevalence of schizophrenia is only 6% among Toronto’s homeless population (higher in the US). Hwang 2001

My objectives for today

1. Provide you with a glimpse of what frontline clinical neuropsychology looks likes (In a FHT) and discuss some of the challenges we face.

2. Discuss the neuropsychology of homelessness

3. Going forward, present my vision on how health care can do better by intergrading primary health care, community rehabilitation, intense case management and homecare.

4. Secretly recruit you to come join us in the frontlines.

Frontline neuropsychology (ICFHT)

Who we are: • Small FHT at Queen/Yonge – linked to Seaton House Shelter

for Men (who has own city staff)

Multidisciplinary team:• 3 nurses, 1 nurse practitioner, 1 physician assistant,

Chiropodist, 3 admin assistants, 2 social workers, 1 health promoter

• Several ICHA Family doctors• A neuropsychologist, psychiatrist, internists (all part time

consultants).

Frontline neuropsychology (ICFHT)

What we do:Provide primary health care (e.g. family medecine) to homeless men living or previously living at Seaton House (e.g. Hostel, Annex [alcohol program], or Long Term care floor).

What makes us unique:• We serve people turned down by other agencies• We are a multidisciplinary team (with some leeway

with mental health care delivery).

Frontline neuropsychology (ICFHT)

2012: Hiring of a neuropsychologist – At the time I was already involved with the homeless at Fred

Victor & Community Head Injury Resource Services.

Told of:– high prevalence of traumatic brain injury in the population

(above 50%) & neurological dysfunction (e.g. severe mental illness, addictions, dementia, ABI).

– Homeless people with complex and co-occurring medical/psychological disorders are included in the 1 to 5% of the population who account for 60-70% of health care costs.

Frontline neuropsychology (ICFHT)

Challenges:• Traditional neuropsychology does not work well (e.g. full day Ax). • Most patients can’t tolerate more then 2 hours of testing.• Instability and memory impairments result in missed appointments• Physicians don’t understand the role and scope of practice of

psychology and especially neuropsychology (that’s a little on us) resulting in unusual referrals.

• 1 part time neuropsychologist in the FHT network dedicated to homeless men. Unsure about CHC. Some other psychologist do some work with homeless person (e.g. JVS Toronto, CAMH).

• Little time for education and research• Little time for psychological interventions

What do we know about the Neuropsychology of homelessness?

1) Not very much (yet)

2) Very heterogenous profile

Question:

Based on what you know about homelessness what do you expect to see in terms of brain funtioning?

Does brain functioning affect community participation, ADLs, indepedent functioning in the homeless?

Or is more about social determinants of health (e.g. lacking money, rent to high etc.)?

70%

What might drive poor neuropsychological performances?

• Addictions?• Mental Illness (e.g. anxiety, depression, psychosis)?• Brain damage?• Dementia?• Poverty?• Psychological Trauma (e.g. PTSD)?• Developmental disorders?• Neglect and abuse in childhood?

Addictions: Alcohol• Alcohol affects state of membranes and modifies a variety of ion channels

or receptors (no binding like cocaine).

• Up to 2 million alcoholics in the US develop permanent and debilitating conditions that require lifetime custodial care (Rourke, Loberg, 1996).

• Abstinence will lead to some improvements in brain structure/function in the first year. Depending on various factors, some cognitive impairments may be permanent.

• Chronic alcohol use can can affect frontal lobe functions (executive skills) (e.g. 15-23 % neuronal loss (Harper, 1998)), the cerebellum’s (Vermis) white matter volume and Purkinje cells (motor function) and subcortical structures e.g. hypothalamus (mammillary bodies) involved in memory.

• Hepatic encephalopathy due to cirrhosis of the liver – Chronic fluctuating neuropsychiatric symptoms due to Increase in

nitrogenous compounds & Decreases in synthesis of proteins– Memory, psychomotor speed, executive skills (Catafau et al., 2000)

• Wernicke-Korsakoff’s syndrome: – Pure amnestic state secondary to server thiamine (B1) depletion.

Poor executive, visual-spatial.

• Alcohol-related dementia: – Mild minimally progressive dementia syndrome (controversial) which

often affects other cognitive systems.

Addictions: Alcohol

Addictions: Crack / cocaine• Approximately 2 million users of cocaine and 567,000 users of

crack in US (USDHHS, 2002).

• Heavy use of cocaine is associated with alterations of neurotransmitter systems, abnormalities in cerebral blood flow and cerebral glucose metabolism in the prefrontal cortex and limbic system. These in turn provide the substrate of the neurobehavioural effects (cognitive & psychiatric).

• Affects dopamine uptake, Blocks transports resulting in accumulation of dopamine in synaptic cleft which May be responsible for reinforcing effects of the drug. Also affects regions involved in decision making, inhibition of inappropriate responses, evaluation of saliency of reward

• Cerebral blood flow was reduced by up to 30% after cocaine use (Wallace et al., 1994). Results in increased arterial pressure that persist even after 28 days abstinence.

• Increases risk of Ischemic/haemorrhagic strokes. The prefrontal cortex appears to be particularly vulnerable.

Addictions: Crack / cocaine

• Persistent changes with chronic use– Lower grey matter density in insula, temporal cortex, frontal

lobes (Franklin et al., 2002; Matochik et al., 2003)– Memory, attention, executive functions, concentration, motor

functions, abstraction– Dose related and persist even after 6 months.

Addictions: Crack / cocaine

Schizophrenia & HomelessnessSchizophrenia is (up to) 10x more common in the homeless population than normal population. Hwang (2003) suggested that about 6-7% of the homeless had schizophrenia.

Deficits may include: Cognitive speed, mental flexibility, memory problems found. See: Stergiopoulos et al. (2011) for link to function (homeless vs. housed with schizophrenia)

Symptoms can precede psychosis (as early as age 14), albeit milder in presentation (Valgimigli et al., 2013)

Acquired brain injuryStephen Hwang et al (2008)• 904 men and women in shelters surveyed• 53% were likely to have a TBI over lifetime• 12% of cases having moderate or severe TBI.• 70% of cases, TBI occurred prior to homelessness: causal pathway?

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Measuring severity of TBI

Science, vol 341 (2013)

• Field study that used quasi-experimental variation in actual wealth. Indian sugarcane farmers receive income annually at harvest time.

• As a result, they experience cycles of poverty—Compare cognition in same farmer when poor (pre) vs. richer (post-harvest). Randomly selected 464 farmers (India). About 60% of income from sugarcane.

• Tasks: • Numeric Stroop task, which is appropriate for participants with low

literacy rates. In a typical trial, participants would see “5 5 5” and have to quickly respond “3,” which is the number of 5s in the sequence, rather than “5” that comes to mind most naturally.

• The Raven’s test involves a sequence of shapes with one shape missing. Participants must choose which of several alternatives best fits in the missing space. Raven’s test is a common component in IQ tests and is used to measure “fluid intelligence,”

Science, vol 341 (2013)

Science, vol 341 (2013)

The effects observed correspond to estimated 13 IQ points variation.

What happens when you have co-occuring diagnoses?

• HIV• HEP-C• Diabetes• Hypertension• Traumatic Brain Injury• Stroke• PTSD• Poverty• Neglect/abuse in Childhood• Addictions• Anxiety and depression• Schizophrenia• Dementia

• Precise “neurological” condition (e.g. stroke in hospital), important, but less relevant in this sector.

• Can rule-in or rule-out major conditions affect brain functioning, but evolving multidisciplinary diagnoses the rule. Patients often “moving targets”

• Testing current level of cognition, social cognition, personality, psychopathology important. E.g. access to services, medical adherence etc.

• At the end of the day we need to treat was is treatable. Re-Assess as needed once housed, medically stabilized, addictions in check etc.

Brain injury: Where does it fit in?

Mental health Substance useCD

CAMH link: fb.me/18oduXQv2

• 30% of people with mental illness will have substance use disorder• 37% of people diagnosed with alcohol disorder will have a mental health disorder• 53% of people with a substance use disorder will also have a mental health disorder

CASE STUDY

• I chose the following case because it is not “neuropsychologically speaking” prototypical of the homeless guys I see.

• The case is complex and constitute a sobering reality that measures such as IQ & overall cognitive skills does not always equate in functional independence.

CASE 1 – KMMale, Right

handed, 50yrs old, English

speaking, Grade 9 education,

WSIB

Him & sister abused by mom, Dad MIA, Taken by children's aid at 3. Labeled ADHD-Oppositional as child. Bounced from home to homeLeft system at age 16

Was in relationship & has 5 kids and now grand kids. His relationship with his kids are strained and they do not understand why he is homeless.

History of alcohol abuse starting in his 20' s. At his peak, he drank a "26 oz.per day", which lasted a "couple years". He now drinks approximately 6 beers per week. He occasionallysmokes marijuana and has used cocaine on rare occasions.

1st TBI: 16yrs. Hit in mouth with 2X4 with LOC. 2nd: mid-20's, he was hit in the head (left orbital/tempo) w/ steal pipe. 3rd: 1990's in a fight with 5 men “injured pretty badly".4th: 2012, hit over head with fire extinguisher in his sleep.

1987: Fall from building (spinal inj.)

Development: Social:

Substance Abuse: Neuro:

• Assaulted with a fire extinguisher at Seaton House while sleeping 2012 – Several bilateral hematomas/contusions, right-frontal drain PTA = 1w – mTBI reported of file (brief LOC)? GCS=13, intoxicated during assault– 1 month at St-Mikes, then TRI, (+1 month) then Regent Park

• At (TRI) ambulating independently, but had poor orientation, attention, memory, judgment and insight. His sleep was also poor. MoCA 23/30 prob. abstract thinking and delayed recall.

• At Regent Park, headaches, fearful about falling asleep. Depressed and irritable. No Hallucinations/mania. MSE: Calm, cooperative, good eye contact, mood depressed. His thought content focused on childhood, and feelings of distress and frustration with his current living and financial status. No active SI or HI. His insight and judgment seemed fair.

CASE # 1

Referral: Problems w/ memory, attention, depression, anxiety and PTSD. Goals: Move out of the shelter system, maintain contact with his children, return to work.Income: $700/m WSlB - not sufficient to pay for an apartment in the city of Toronto.

Physical symptoms: Frequent headaches, excessive fatigue, right arm weakness (due to peripheral injury). Numbness feelings in the right side of his right hand due to nerve damage. Partial blindness in the left eye. Can 't hear well in his right ear due to the assaults. He can't smell anything (broken nose). His sense of taste is okay. History of “hearing” music and voices in the past and was hospitalized for this in the 1990's in Whitby.

Cognitive symptoms: Poor planning and organization, spatial orientation, memory (faces, keys, remote & what he should be doing). Attention reportedly okay, but tangential. Poor judgment (don’t assess long term ramifications of behaviours, impulsive. Insight is fair.

Psychiatric symptoms; Severe anxiety associated with trauma. Trouble falling and staying asleep, experience occasional nightmares about his abuse and assault, gets frustrated more easily, and has less energy than before. Avoids looking at people, afraid of what "might happen”

CASE # 1

Behavioural observations:

• Pleasant and mild mannered. • Comfortable disclosing his complex history. • His speech was quick and pressured • Frequently interrupted the examiner, though he quickly apologized for the interruptions. • He appeared tired• Very tangential during the interview for which he required cuing and redirection. • Needed frequent smoke breaks, coffee after 35 minutes of testing (sustained attention?). • Gait and posture appeared normal. • Language comprehension and expression also appeared normal. • Appeared motivated to do well, • Rapport was sufficient for testing purposes.

CASE # 1

CASE # 1

CASE # 1

Case 1: What went wrong?

• Cognition okay – so why is he homeless?• Tools lack specificity?• Should we have looked at something else?

Such as personality? Neurobehavioural functioning? Executive functions?

• Thoughts?

Question: What roles can psychologists play in addressing homelessness?

Eliminating homelessness in Ontario

Moving forward• Challenges:

– Creating assisted housing environments that are designed for those with moderate to severe brain injury, neurobehavioural problems, limited self-awareness, poor social support structures, addictions, mental illness.

– Who would want to house someone who does not care for themselves or who could burn the place down? (e.g. a place like CHIRS in North York).

Moving forward• Neuropsych screen to assess functional capacity & supports needed in housing

transition (1.5 hours long) For now: Mostly at Seaton House (Annex, LTC, Hostel), possibly at Sistering

• Tests include: o Interview, Beck Hopelessness scale, Brief Cognitive Exam Status (WMS-IV)

(abstraction of MoCA), CVLT-II (short form), D-KEFS trails, Practical Problem Solving (KBNA), Math subtest (KBNA), Word reading(WRAT-IV), Emotion recognition (ACS), Gait & speech video recorded.

• Benefits: Short, function driven, evaluates level of disability, informs intervention and need for in-depth assessments.

• Outcome: Simple 1 page report, no lingo, with broad findings with implication for community functioning and top three recommendations, MRPs get same date feedback. Can support ODSP applications (and reviews), court diversion, sufficient to get the person moving forward.

What You See What You Do

Forgetfulness Use memory aids, calendars, reminders, signs, easy lists - kept in the same place.

Poor concentration, distractedness

Keep it simple, remove distractions, plan brief activities, use cues to bring attention back.

Impaired planning and organization

Encourage routine/structure, break instructions down into small components.

Slowed response & info. processing

Allow extra time to process, limit choices, pause 5-7 seconds after a request, do not assume an immediate response.

Poor initiative, appears to lack motivation, difficulty following through.

Structure, routine, limited choice and prompts to start.

What You See What You Do

Inflexibility of thinking, difficulty seeing more than one view.

Write summary of what discussed and give client a carbon copy.

Impulsivity Repeat → Stop, Think, Plan.

Encourage awareness of social rules.

Emotional lability – inappropriate, out of context.

Identify and avoid triggers. Watch for overstimulation, stress, fatigue. Shorten episode.

Egocentricity, impatient, demanding

Set clear limits of what can be done. Give clear feedback about other’s feelings. Do not take personally.

Irrationality or temper control.

Employ risk management measures. Remain calm. “Lower your voice or I will leave.”

Moving forward• Challenges:

– Assessing chronically homeless across province– I’m the only neuropsychologist working directly with

the homelessness (to the best of my knowledge)– OTs in the sector are rare– Family docs, nurses, and social workers are not

interested in AX and have little time. – Limited budget to hire postdocs & interns

How can you be aware you’re not aware, when you’re not aware you’re not aware? (Dr. Proulx)

Applies to patients, clinicians and policy makers!

Is it denial or Anosognosia (A lack of knowledge or unawareness of cognitive impairment)?