the homeless patient - special populations
Women and Children
Women and children comprise a rapidly increasing proportion of the homeless population. Women may present for routine medical problems or as a result of domestic violence or rape, for which they are at particularly high risk. Some women may resort to prostitution to support themselves or their children. Preventive gynecologic care is often inadequate and extends from inadequate screening for cervical cancer and venereal diseases to insufficient or absent prenatal care. The consequences are devastating. Children born to homeless mothers often have lower birth weights, higher rates of prematurity, and higher rates of infant mortality. Iron-deficiency anemia, malnutrition, elevated blood lead concentrations, and a higher rate of asthma are found in homeless children, as in other impoverished children, compared to the general population.3 Unlike impoverished domiciled children, homeless children are more likely to be inadequately immunized and suffer disproportionately from developmental delay or a lack of progression in school. The long-term psychological, social, and educational consequences of homelessness have yet to be rigorously evaluated.
Homeless adolescents, especially runaways, have high rates of alcoholism, illicit substance use, violent encounters, and psychiatric illness. Engaging in sex for survival has resulted in high rates of unplanned pregnancy, sexually transmitted disease, and HIV infection. Patients should be offered a variety of resources, including education regarding safe-sex practices, counseling, and the location and availability of drop-in centers. Social workers, psychiatrists, and adolescent specialists can cooperatively provide support for homeless runaways regardless of their chief medical complaint.
The Elderly
There are few studies of the homeless elderly. Limited, fixed incomes with progressively increasing housing costs account for the displacement of many elderly people from their homes. Another factor may be gradual changes in cognitive and psychosocial performance, which may not be realized on a brief medical examination. For all people at risk, reassessment for organic disease, dementia, and depression is essential to ensure an appropriate care plan.
Substance Use
Patients who are dependent on alcohol or illicit substances should be identified in order to facilitate appropriate disposition. For homeless patients who present intoxicated and sedated, close monitoring of body temperature, blood glucose monitoring, and serial evaluations for arousability should be performed in addition to a thorough physical examination. Whenever possible, a specific history of substance use should be obtained. A specific history of withdrawal from any sedative-hypnotic agent or ethanol should alert the clinician to the need for careful observation while primary evaluation of the chief complaint is undertaken. The patient should be asked whether he or she has a past history of participating in detoxification programs and whether that is a current desire.
Mental Illness
Some homeless patients without documented history of chronic psychiatric illness or substance dependence may present to the ED with psychiatric complaints. The stresses of sustaining life without a home are associated with a variety of diagnoses, including adjustment disorders, substance use, and major depression. Alternatively, some homeless patients have a chronic history of psychiatric illness, including schizophrenia or bipolar disorder, that may be partially responsible for precipitating homelessness. The psychiatric assessment of homeless patients is important to facilitate adequate disposition of medical problems whose management may be compromised by mental illness. In addition, primary pharmacologic therapy can be evaluated or instituted in patients with chronic psychiatric disorders. All patients should have an assessment for fear and risk of suicide as part of the routine screening.
Emergency Department Treatment
ED management includes adjuncts to care, such as use of vitamin supplements and food, dispensing medications, updating immunizations, and reviewing documentation of past medical care. Pregnancy status and potential for sexually transmitted diseases should be investigated in homeless women of childbearing age. Appropriate gynecologic care, prenatal care, or family planning services can thus be arranged. Once a diagnosis and treatment plan is defined, patients should be assessed for language barriers, literacy, and capacity to comply with routine care instructions, medical regimens, or follow-up. An old chart may indicate immunization status, forgotten or disregarded health problems, and the ability of homeless patients to establish continuous care.
A lower threshold for hospitalization should be maintained for patients with an impaired ability to manage their own care. This decision is easily acceptable if one appreciates how the patient arrived at the condition in question and how difficult, if not impossible, outpatient care may be under certain circumstances. A public health approach to managing communicable diseases should be incorporated into admission criteria. A multidisciplinary approach to care, including social workers and nursing, medical, and psychiatric staff, may offer the most supportive environment for homeless patients. Such compassionate care in the ED, using trained and motivated individuals, will ensure that patients receive essential care, increase patient satisfaction, and reduce the rate of recidivism among frequent users of the ED.
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