Recurrent hypothermia and undiagnosed cognitive impairment in older adult experiencing homelessness: a case report

: Background Housing insecurity is associated with increased mortality, Emergency Department (ED) utilization, and higher prevalence of cognitive impairment, including dementia in older adults. However, social determinants may preclude routine outpatient evaluation or connection to appropriate social support, and instead these patients may be seen chiefly in the context of ED visits. Case A 70-year-old male experiencing chronic homelessness presented to the ED with 12 episodes of hypothermia over a one-year period. His care was complicated by refusal of care, incontinence, and intermittent agitation. Four episodes of hypothermia were associated with a diagnosis of pneumonia, four episodes were attributed to environmental exposure, one episode was associated with elevated troponin levels, and the remaining episodes did not have a clear attribution. With escalating visits and behavioral disturbances, a multidisciplinary team including clinical psychologists, geriatric emergency medicine, hospital medicine, and speech therapy diagnosed him with dementia. Ultimately, after receiving state guardianship, he was placed in a long-term care facility. Why should an emergency physician be aware of this? Increasing ED utilization patterns and recurrent diagnoses of syndromes such as hypothermia, pneumonia, or behavioral changes may be indicative of underlying neurocognitive disease in older adults with housing insecurity or social barriers to outpatient care, and the ED may be only source of their care.