Housing Insecurity, Incident Geriatric Conditions, and Mortality in Community-Living Older Persons

Importance: Housing insecurity is a key social determinant of health, yet its association with health outcomes among older persons has been understudied. Objective: To examine the associations between housing insecurity and the development of frailty, disability, and dementia, as well as mortality. Design, Setting, and Participants: This prospective cohort study was based on data from the National Health and Aging Trends Study (NHATS) from 2015 to 2020. Data analysis was conducted from August 2024 to February 2026. Participants were community-living persons aged 65 years or older in the contiguous US. Exposures: Three forms of housing insecurity derived from the NHATS annual survey: poor housing affordability, poor housing quality, and poor neighborhood quality. Main Outcomes and Measures: The primary outcomes were time to onset of frailty, disability, and dementia, and time to death over 5 years. Geriatric conditions were obtained from the NHATS annual survey, and all-cause mortality from linked Medicare records. Discrete cause-specific hazards models accounting for the competing risk of death (equivalent to multinomial logistic regression) were used to estimate relative risk ratios (RRRs) for geriatric conditions, and time-varying Cox regression models were used to estimate hazard ratios (HRs) for mortality. Results: Among the 7499 participants (mean [SD] age, 78.2 [7.8] years; 4335 [55.3%] female), after adjustment for age, sex, race and ethnicity, education, Medicaid eligibility, household income, smoking status, and comorbidity, poor housing affordability was significantly associated with higher risks of frailty (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 significantly 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 (RRR, 1.16; 95% CI, 0.90-1.49). Poor neighborhood quality was not associated with any outcome in the adjusted analyses. The adjusted risk differences ranged from 1.9 percentage points (95% CI, 0.2-3.1 percentage points) for housing quality with mortality to 11.1 percentage points (95% CI, 7.9-14.3 percentage points) for housing affordability with disability. Conclusions and Relevance: In this cohort study of community-living older US persons, poor housing affordability was associated with higher risks of frailty, disability, dementia, and mortality, and poor housing quality was associated with higher risks of frailty, disability, and mortality. These findings highlight housing insecurity as a clinically relevant social determinant of health among older persons.