Poor Housing Affordability, Quality Raise Risks of Serious Geriatric Conditions, Death in Older Adults

Poor housing affordability and substandard housing conditions are significantly associated with the development of serious geriatric conditions and increased mortality risk among community-living older Americans, according to a study recently published in JAMA Network Open.¹

Research Gaps Persist as Older Adults Face Disproportionate Housing Burdens

Housing insecurity, encompassing affordability, quality, and stability, is an increasingly recognized social determinant of health (SDOH). Prior research has linked it to poor self-rated health and higher rates of emergency department use. However, studies focused specifically on older adults have been limited in scope, relying on cross-sectional designs, narrow subpopulations, or nonrepresentative samples.

Notably, no prior study had comprehensively evaluated whether housing insecurity predicts the onset of frailty, disability, or dementia in this population. Given that more than 1 in 3 community-living older Americans are estimated to be housing insecure, researchers identified this as a critical knowledge gap.² To close this gap, they conducted a study to examine the associations between housing insecurity and the development of frailty, disability, and dementia, as well as mortality.¹

The study drew on data from the National Health and Aging Trends Study (NHATS), a nationally representative cohort of Medicare beneficiaries, spanning 2015 to 2020. The researchers evaluated 3 distinct forms of housing insecurity: poor housing affordability, defined as spending at least 30% of monthly income on housing costs; poor housing quality, based on trained-interviewer observations of interior and exterior home conditions; and poor neighborhood quality, assessed via indicators such as litter, graffiti, and vacant buildings. All 3 exposures were treated as time-varying across the follow-up period.

Primary outcomes included time to onset of frailty, disability, and dementia, along with all-cause mortality over 5 years. Researchers used discrete cause-specific hazard models to estimate relative risk ratios for geriatric conditions and time-varying Cox regression for mortality, with adjustment for age, sex, race and ethnicity, education, Medicaid eligibility, household income, smoking status, and comorbidity.

Poor Housing Affordability, Quality Linked to Worse Outcomes

The analytic sample included 7499 community-living adults aged 65 and older, representing approximately 40.7 million survey-weighted individuals. They had a mean (SD) age of 78.2 (7.8) years, and 55.3% (n = 4335) were female. At baseline, 8.9% (n = 813) had poor neighborhood quality, 17.2% (n = 1371) had poor housing affordability, and 19.5% (n = 1579) had poor housing quality.

After full covariate adjustment, poor housing affordability was associated with significantly elevated risks of frailty (relative risk ratio [RRR], 1.23; 95% CI, 1.01-1.49), disability (RRR, 1.24; 95% CI, 1.01-1.54), dementia (RRR, 1.37; 95% CI, 1.11-1.69), and mortality (HR, 1.51; 95% CI, 1.34-1.70). Similarly, poor housing quality was associated with higher risks of frailty (RRR, 1.30; 95% CI, 1.04-1.62), disability (RRR, 1.33; 95% CI, 1.13-1.57), and mortality (HR, 1.15; 95% CI, 1.01-1.32) but not dementia.

By contrast, poor neighborhood quality was not independently associated with any outcome after adjustment, which the researchers noted suggests its apparent effects may be attributable to underlying socioeconomic factors.

Adjusted risk differences ranged from 1.9 (95% CI, 0.2-3.1) percentage points for housing quality and mortality to 11.1 (95% CI, 7.9-14.3) percentage points for housing affordability and disability. They highlighted that even the modest mortality difference associated with poor housing quality could correspond to approximately 150,000 additional deaths among persons living in poor-quality housing over 5 years at the population level.

Amid Limitations, Findings Point Clearly to Housing as a Health Driver

The researchers acknowledged that the study has notable limitations. For example, as an observational study, the associations identified cannot be interpreted as causal. Additionally, NHATS does not capture indicators of housing instability such as eviction, frequent moves, or foreclosure, meaning the study could not assess these dimensions of housing insecurity. Still, they expressed confidence in their findings.

“These findings underscore the need to recognize housing insecurity as an important and clinically relevant SDOH in older persons,” the authors concluded.

References

1. Wang Y, Davis-Plourde K, Vander Wyk B, Paredes LG, Gill TM, Becher RD. Housing insecurity, incident geriatric conditions, and mortality in community-living older persons. JAMA Netw Open. 2026;9(5):e269335. doi:10.1001/jamanetworkopen.2026.9335
2. Paredes LG, Wang Y, Keene DE, Gill TM, Becher RD. Population-based estimates of major forms of housing insecurity among community-living older Americans. J Am Geriatr Soc. 2024;72(12):3773-3783. doi:10.1111/jgs.19167