Chronic homelessness often linked to brain injuries

This is an admittedly unusual assignment for psychologist Kristen Ryan, who's seated in a hard chair at the head of a long table in a colorless conference room at the Dorothy Day Center. Just outside the locked doors, dozens of homeless people are milling about the shelter.

"This isn't exactly how it would go in a clinical kind of setting or an outpatient clinic or something, where you kind of expect people to show up, and you expect that you're going to be able to do all the testing and that maybe people even want to be there," she says.

Despite their reluctance, Ryan has convinced about 50 homeless people to take a psychological evaluation since she started working on this project six months ago. Of those 50, she says about 20 have shown moderate to severe cognitive impairment. These are people who have been on the streets for many years, maybe even decades.

Ryan says there's not a lot that's known yet about why so many chronically homeless people appear to have brain dysfunctions. But she suspects that for many, their mental decline happened slowly over a period of years. Some might have started out with developmental issues as children. Others might have experienced trouble at home and dropped out of school early.

Ryan says those setbacks are usually followed by drug and alcohol abuse and a hard life on the streets.

"I fell a good 12 to 25 feet. I was really not intoxicated, but ... I mixed pain pills with the alcohol and then when I got ready to stand up ... I went backwards and bam."

"With that usually comes a series of head injuries, assaults. So then you have all of these factors that create a very vulnerable picture later on in life, that usually, by kind of late 40s or early 50s, develops into some kind of dementia process," she says.

That seems to be what happened to a 51-year-old man we'll call James. For a while, James lived in a cardboard box behind a St. Paul business. Lately he's been staying in a friend's garage. He hasn't been able to hold down a job for several years.

James life didn't start out this way.

He graduated from high school and even went on to complete some technical training. But over the years problems with his family and substance abuse led him to a life on the streets. That life has taken a toll on his brain. Last fall he was hanging out with some buddies when he took a severe tumble and landed on his head.

"I fell a good 12 to 25 feet and that's on concrete. And I was really not intoxicated, but I could feel the alcohol take over my brain. The stress level was so high on me that a 12 pack didn't do me," he says. "I was greedy because what I did was I mixed the pain pills with the alcohol and then when I got ready to stand up, my head got light. I went backwards and bam."

James woke up in the emergency room at Regions Hospital. He says it was not the first time he has injured his head.

Kristen Ryan won't talk about James' case specifically because she thinks he's not mentally competent to give her his consent to talk about his medical record. But she does allow MPR to observe while she spent four hours testing his perception, reasoning and judgment skills. She quizzed him on everything from math and history to his ability to recall things he had seen moments earlier.

None of the test was easy for James, but he seemed to get the most frustrated when he had to draw upon his memory. "I guess I'm the one that's the dumb one. I'm the one that's dumb," he says. "I'm trying to remember here. I'm trying to remember. I'm trying to think. God bless it..."

A bit later, on another part of the test that measures a person's ability to alternate between letters and numbers in a sequence, James becomes thoroughly confused between letters and numbers.

Seconds after Ryan gets him back on track, James breaks the sequence again.

"That is a number and a letter," he says. "Oh, I see what you're saying. Okay. So this is wrong."

The whole sequencing process took James more than five minutes to complete, when it probably would have taken most people less than a minute. Ryan says sequencing may not seem like an important skill but it's vital even in seemingly simple jobs like office filing.

After James finishes his exam, it appears that his cognitive impairment is so severe, he probably will not be able to keep a steady job and he probably will qualify for social security benefits. Those payments, ranging from $500 to $1000 a month, could get James off the streets and into an apartment. If he qualifies for the payments, he would be assigned a case worker and maybe even a guardian to help him manage his money.

It's a ray of hope for James after many years of struggling to survive on the streets. Of the 20 people that Ryan has recommended for benefits so far, 19 have been approved.

Ryan believes there are countless more who could be helped by her testing program.

"If we can get people properly evaluated, if we're not just seeing them for a few minutes here and a few minutes there and driving them to an appointment, if we're really trying to figure out what's going on, what the underlying problems are, then we're in a much better position to make a difference," she says.

A couple of similar psychological testing projects are also underway in other parts of the country. One California researcher has reported results very similar to Ryan's findings in Minnesota.

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