Older, homeless and experiencing memory problems: How to support a multiply disadvantaged population

Research question: Is an intervention to support older people with memory problems living in temporary hostel accommodation feasible and acceptable?

Background: People who are homeless have chronic physical and mental health problems, substance misuse1-3, and high levels of traumatic brain injury4; experiencing accelerated ageing and more memory problems than non-homeless populations5.

This homeless population is growing rapidly6 7, yet their health, housing and social care needs remain unmet by existing policy and services and their experiences overlooked8. I have consulted widely with stakeholders who say they urgently need this new intervention.

Objectives: Co-produce an intervention for older people in hostel accommodation with memory problems with experts by experience, professionals and academics.

Test it in a trial for acceptability and feasibility to inform continuation to full clinical and cost-effectiveness RCT. Confirm meaningful, practical primary outcome and data for main trial's sample size calculation.

Explore how stakeholders understand and experience support for older people with memory problems in hostels, what determines current support, what challenges exist and what facilitates changes. Trial economic measures for feasibility and calculate intervention costs. Conduct a mixed-methods process evaluation assessing intervention acceptability and required refinements.

Work with stakeholders throughout to facilitate future implementation.

Methods: Work package (WP)1: Ethnographic study (3-21m) I will conduct 45 in-depth interviews with people with memory problems who are homeless, hostel staff, managers and practitioners and 6-8 participant observations in three hostels.

WP2: Co-production and initial testing (pre-feasibility trial) (15-30m) I will convene a co-production group with users, professionals and researchers, iteratively developing the intervention, informed by WP1 and previous research. I will trial in one hostel, revising based on feedback.

I expect the intervention will be manual-based, delivered to staff groups; using practical, individualised strategies to support staff in recognising and delivering the help residents aged ≥50-years with memory problems require to move on successfully and for staff to manage challenges that memory problems bring.

WP3: Feasibility Trial (30-57m) Design: Non-randomised feasibility trial Setting: Hostels with older (≥50) residents, London and Southern England.

Participants: Staff expected to stay 6-months and residents (≥50) with dementia diagnosis or memory problems (NPC proxy screening). Measures: Baseline and 6m. Hostel: Characteristics (baseline) and staff turnover. Staff: Socio-demographic and employment (baseline). Burnout (MBI), dementia care competence (SCIDS).

Resident: (proxy) Socio-demographic data, dementia (if diagnosed) and severity (CDR) (baseline).

Neuropsychiatric symptoms (NPI), medication, service use and unpaid care (CSRI), functioning (DADS), quality of life (EQ5D). At 6m - where living (hostel, streets, hospital, settled accommodation) Intervention: Attendance, costs.

Sample size: With 40 staff-participants = Proportion adhering to intervention (75%, 95% CI: 59-87%) and proportion with 6-month outcomes (75%, 95% CI 59-87%).

WP 4: Implementation and process evaluation (cross-cutting theme) I will consider future implementation throughout, recording intervention attendance, rating fidelity and interviewing 6-8 hostel workers and managers receiving intervention.

Anticipated impact for: Older people who are homeless and workforce Services and policy and commissioning Research capacity and knowledge; through intervention manual, implementation toolkit, publications, presentations, public engagement and an RCT grant application.