Title: Older, homeless and experiencing memory problems: How to support a multiply disadvantaged population
Funder: Department of Health and Social Care

Abstract: 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 trialSetting: 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.

Lay abstract: Why is this important? The older homeless population with memory problems is growing, and people who are homeless are likely to have one or more additional vulnerability, such as longstanding physical and mental health problems, drug and alcohol addictions and a history of head injury. Therefore they are more likely, than those who have not been homeless, to have memory loss and other problems in functioning similar to those of people diagnosed with dementia. I have consulted widely with people experiencing memory problems and homelessness, charities, statutory services, hostel workers and managers. They tell me that people experiencing homelessness and memory problems find it more difficult to accomplish moving from temporary hostels to permanent accommodation than other homeless people, and use more health and social services than those with secure accommodation. What is already known? There is only one recent UK study on dementia and memory problems in people who are homeless. Existing research has focused on how many people experience homelessness and memory problems and how to assess them. There is little known about how to support this group and only one Australian study has tested new approaches to support. We do not know how homeless people with memory problems experience homelessness and how frontline staff support them. It remains unclear how best to support both of these groups. What will I do? I will interview a total of 45 people, including homeless people with memory problems, hostel staff and managers; and practitioners working in support services. I will also directly observe staff in hostels supporting older people with memory problems, learning about what currently works and what challenges exist. I will bring together a team of experts by experience (people who have experienced homelessness and memory problems), researchers and people working in related areas to help design the intervention; learning from my interviews and observations and what we know already. I expect that the intervention will be delivered to groups of staff, and focus on practical, individualised strategies, supporting staff to: recognise, assess and deliver the help residents aged over 50 years with memory problems need to move on successfully and manage the challenges that memory problems bring. I will try out the intervention in one hostel, making changes based on feedback I will complete a study with 40 hostel staff and residents, to see if the intervention is feasible (if hostel staff and residents agree to take part and if I can collect necessary information) and acceptable (if people completed and liked the intervention). I will consider what would be the best outcome measure for a full trial and how to measure how people use services and the intervention cost. I will collect information about how the intervention was delivered, how it was received and what people feel should be changed and how, if it proves useful, it could be rolled out.How will I involve service users? I will work with people experiencing homelessness and memory problems in designing the intervention and to guide me in running the project ethically, efficiently and as promised. I know it may not be easy for people with memory and other complex problems to contribute, but I will work with them and their supporters to find practical and acceptable ways for them to contribute. What impact will this research have? This research will potentially help those who are homeless, the workforce supporting them and those delivering and commissioning services. If the intervention is feasible and acceptable, I will use the results to design a full randomised controlled trial testing whether it works and is financially feasible.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: NEUROLOGICAL;MENTAL HEALTH