Service provision for older homeless people with memory problems: a mixed methods study

Background: Early or timely recognition of dementia is a key policy goal of the National Dementia Strategy. However, older people who are homeless are not considered in this policy and practice imperative, despite their high risk factors of developing dementia. 
Objectives & study design: This 24-month study was designed to (1) determine prevalence of memory problems among hostel-dwelling homeless older people and the extent that staff are aware of this; (2) identify help and support received, current care and support pathways; (3) explore quality of life among older homeless people with memory problems; (4) investigate service costs for older homeless people with memory problems, compared to those without; and (5) identify unmet needs or gaps in services. 
Participants: Following two literature reviews to help study development, we recruited 8 hostels; 4 in London and 4 in North England. From these, we first interviewed 62 older homeless people, exploring current health, lifestyle and memory. Memory assessment was also conducted with these participants. Of these, 47 were included in the case study groups – 23 had “memory problems", 17 had “no memory problems” and 7 were “borderline”. We interviewed 43 hostel staff who were participants’ keyworkers. We went back 3 and 6 months later to ask further about residents’ support, service costs and any unmet need.
Findings: Overall, the general system of memory assessment for this group was found to be difficult to access and not patient-centred. Older people living in hostels are likely to have several long-term conditions including mental health needs, which remain largely unacknowledged. Experiences of declining abilities were reported frequently by participants and hostel staff were often undertaking substantial care for residents. 
Limitations: Hostels accessed were mainly in urban areas and needs of rural homeless people were not specifically captured. For many residents, we were unable to access NHS data. Many hostel staff referred to this study as “dementia” focussed when introducing it to residents, which may have deterred recruitment. 
Conclusions: To the best of our knowledge, no other study and no policy acknowledges hostels as ‘dementia communities’ or questions the appropriateness of hostel accommodation for people with dementia. Given the declining number of hostels in England, the limits of NHS engagement with this sector, and growing homelessness, this group of people with dementia are under-recognised and excluded from other initiatives. . Future work: A longitudinal study could follow hostel dwellers and outcomes. Ways of improving clinical assessment, record keeping and treatment could be investigated. Dementia diagnosis could trigger sustained care co-ordination for this vulnerable group.