Traumatic brain injuries are more prevalent in unhoused populations. How should health care respond?

A UBC study suggests that unhoused and housing-precarious people are at greater risk for traumatic brain injury (TBI), and experience more difficulty accessing care. The researchers hope their study can inform more compassionate policy and treatment options.

Lack of affordable housing and social support places individuals in conditions where they are more likely to develop TBIs. Unhoused people are frequent victims of assault and other violent crimes, which has been cited as being a main cause of TBI in this population.

TBI occurs when there is a sudden trauma to the brain, such as a blow to the head or an object penetrating through brain tissue, that causes an impairment in functioning.

A TBI can range from mild to severe and may present in a variety of ways, including headache, lethargy, issues with memory and concentration, loss of coordination and convulsions.

The study followed a 2008 study on the health of single-room occupancy hotel residents, with the goal to identify areas where healthcare workers could help. “One of the risk factors that kept coming up was traumatic brain injury,” said Stubbs.

Following the hotel study, Stubbs was the first author of a systematic review conducted in 2019 which was the first quantitative estimate of TBI in an unhoused population.

“We found that more than half had a history of any TBI, and more than a fifth had a history of more moderate and severe TBI,” said Dr. Jacob Stubbs, PhD in experimental medicine and current UBC medical student. Meanwhile, only about two per cent of the general Canadian population lives with a TBI.

The meta analysis identified higher suicide risk, worse physical and mental health and increased memory impairment in unhoused and precariously housed individuals who had experienced TBIs.

MRI scans of participants’ brains also paint a worrying picture.

Participants in the 2008 hotel study showed high levels of brain atrophy. In other words, their brains were found to be shrinking much faster when compared to the general population.

Researchers have proposed that accumulation of TBIs coupled with substance abuse “leads to a more older looking brain than would be expected for the age of the participant,” said Stubbs, as brain atrophy is associated with aging.

What this looks like practically is a rapid decline in cognitive functioning that would not usually be observed in the general population until age 70 or above.

Stubbs said that the public and media response to the study has been receptive.

“If some behaviors or challenges in this population were due to a traumatic brain injury, somehow showing that on a brain scan, made it more acceptable to have empathy,” said Stubbs

Underlying biases shape how people have responded to the findings.

Health care professionals can play a big role in helping, or harming, unhoused people dealing with TBIs.

“There's a lot of health care trauma and trauma generally in people who are homeless and precariously housed,” said Stubbs. “And there's a lot of negative interactions that happen when they go into hospitals and seek care.”

Negative health care experiences can cause people to avoid getting care altogether. This can reinforce stigma against unhoused individuals in healthcare professionals, who Stubbs said may develop a prejudiced perspective of unhoused people as unreliable.

Giving people with health care appointments “several reminders on the same day, if it's somebody that struggles with memory concerns,” has proven to be effective, according to the research team’s second longitudinal study on TBI.

Improving health care to be more responsive to unhoused people’s physical and psychological traumas won’t fix the housing market or policies that deprive some populations of shelter. Still, according to Stubbs, their study is a start towards informing better training for health care workers responding to a city in crisis.