Kristina Johnell

Older adults have the highest risk of adverse drug events, yet they are regularly excluded from clinical trials where drug safety is evaluated. Apart from age restrictions in clinical trials, exclusion criteria often involve age-related factors such as co-morbidities and concomitant drug use. In this proposal, we aim to systematically evaluate drug safety in older adults using a wealth of European data. With the ultimate goal of producing real-world evidence that can influence regulatory agencies and improve drug safety in clinical practice.In this five-year project we intend to create an improved workflow for evaluating drug safety in older adults using data sources mapped to the OMOP Common Data Model as part of the European Health Data Evidence Network (EHDEN). The workflow will include a model for prioritization of medications for investigation. The model will target drugs used in regular practice, whereas new drugs will be evaluated as they reach the market. Second, we will contribute to the methodological development for integrating co-morbidities, concomitant drug use and frailty in real-world evidence studies of drug safety from routinely collected data. The analyses can be conducted in any of the Swedish register data sources we have direct access to, or within the ≈200 data partners in EHDEN.The findings will improve drug use in older adults, the part of the population with highest drug use and largest risk for adverse drug events.

Research problem and specific questionsMedications play an important role for the mental health and suicidal behaviour (i.e. suicide and self-harm) among older people. This is however an understudied topic, which we aim to change with the proposed project. We aim to investigate in older adults 1) Medication treatment before and after self-harm

2) Medication patterns before suicide

3) Medications, loneliness and bereavement

and 4) Co-designing prevention of suicidal behaviour and involuntary loneliness.Data and methodThe project combines quantitative analyses of high quality Swedish register data (Aim 1-3) with qualitative focus group interviews with key stakeholders (Aim 4). We will analyse longitudinal data from several Swedish registers of people aged ≥65 years (n≈3.1 million). Results from these analyses will serve as a foundation for the semistructured focus group interviews with key stakeholders, including user organisations, health care and eldercare.Relevance This multidisciplinary project integrates different research approaches and uses participatory designs, with the goal of co-designing preventive interventions for older adults. We will use cutting-edge epidemiological methods based on registers with excellent data quality offering the possibility for long-term follow-up. With these methodological advancements and big high quality data, we will be able to address the shortcomings of previous studies. This project will also identify vulnerable high-risk groups for tailored interventions that could increase health and autonomy in older adults.Our focus on medications in this context is novel and highly relevant. Medication treatment is very common among older adults and, thus, a natural point of intervention and potential identifier of loneliness and suicidal behaviour.Plan for project realisation We will start with the register-based studies (Aim 1-3) and the initiation of a Community Advisory Board of older adults. Based on the findings from Aim 1-3, we will design focus group interviews with key stakeholders (Aim 4). We will actively involve end users and health care and eldercare providers in the project to ensure that all important stakeholders are represented and provide input.Feasibility is ensured by availability of all necessary data in-house, and by the combined high and wide competence in our interdisciplinary team.The budget mainly covers funding for a PhD student and a postdoc for the scientific and outreach activities.

Research problem and specific questions Deprescribing is a novel concept relating to a process where medications are reduced or stopped in order to avoid medication-related harms and improve patient outcomes. This proposal addresses two main challenges for deprescribing: (1) integrating deprescribing in routine care for older adults

(2) adapting deprescribing activities to the Swedish context, a country where deprescribing have yet to be introduced.Data and methodThis mixed-method project combines register-based data analysis, with qualitative research and participatory design. We use a mixed approach in order to: (a) describe the current deprescribing activities in Sweden (nation-wide register data covering all older adults in Sweden)

(b) gain detailed knowledge of the barriers and facilitators for deprescribing activities among patient and health care professionals (qualitative research and survey)

and, (c) creating a roadmap for future deprescribing interventions in Sweden (co-design of health care interventions). We believe that that the selected methods are the necessary steps to introduce relevant and patient-centered deprescribing activities in Sweden.Plan for project realisation This participatory research project will be executed in three steps. First, we will conduct analysis of register data to have an up-to-date understanding of the need, current activities, and efficacy and safety of deprescribing in Sweden. Second, we will conduct a series of interviews with patients and health care professionals focusing on barriers and facilitators for deprescribing in the Swedish context, and invite health care professionals to rank their most needed resources to routinely conduct deprescribing. Based on the two first steps, we will conduct a series of workshops with stakeholders (patient representatives and different health care professionals) to co-design a deprescribing intervention that is feasible and scalable in the Swedish setting.RelevanceThe novel process of deprescribing has the potential to reduce the high levels preventable medication-related harms in older adults. Medication-related harms lead to much individual suffering and high economic cost. Ideally, this project will improve medication use in older adults by shifting the attention from prescribing to deprescribing. By including end-users throughout the project, we believe that this project will be highly relevant for patients, policy makers, and health care providers.

We need post-COVID research on the most severely affected group in the pandemic – older adults. Focus has so far mainly been on younger individuals, although older adults are likely to be severely affected because of their lower resilience to stressors. We will therefore provide results based on large unselected longitudinal nationwide data.Among older adults, we aim to 1) Investigate use of healthcare and eldercare among COVID-19 survivors (including creating an indicator of post-COVID in older adults)

2) Identify risk factors for post-COVID

3) Study outcomes of post-COVID

and 4) Explore the role of medications and dementia in post-COVID.We will analyze several Swedish registers of people aged &gt

=65 years (n~2.6 million) and the Swedish Dementia Registry (n~100 000), and also include international comparisons. We will study the use of healthcare (e.g. hospitalizations, medications) and eldercare (home care services, nursing home admission) among COVID-19 survivors compared to non-infected. Adjusted regression models (e.g. Cox proportional hazard, propensity matching) will be used to study outcomes (e.g. mortality) and different risk factors (e.g. sociodemography, multimorbidity, depression and cardiovascular diseases). Also medications (e.g. polypharmacy, diuretics and anticoagulants) and dementia will be analyzed in detail.The findings will lead to mitigating the long-term effects of the pandemic as well as other infectious diseases like the seasonal influenza.

We urgently need research on the most severely affected in the COVID-19 pandemic – older adults. In Sweden, ~90% of the deaths have occurred in people aged &gt

=70 years. Still, few studies on COVID-19 among older adults have based their findings on big data. To address these major knowledge gaps, we will provide results based on large unselected longitudinal nationwide data. Among older adults, we aim to 1) Identify risk profiles for severe outcomes of COVID-19

2) Show outcomes of medication treatment and dementia

3) Study long-term consequences of COVID-19

and 4) Investigate coverage and outcomes of vaccination. We will analyse several Swedish registers of people aged &gt

=65 years (n~2.6 million) and the Swedish Dementia Registry (n~95 000), and also include international comparisons. Adjusted regression models (e.g. Cox proportional hazard, propensity matching, nested case-control design) will be used to estimate independent risk of outcomes (e.g. hospitalisation, mortality, long-term consequences and vaccination) of different factors (e.g. sociodemography, place of residence, nursing home/own home, eldercare, frailty, multimorbidity, polypharmacy, dementia, depression, diabetes, cancer and cardiovascular diseases). Also medications (e.g. ACE inhibitors, statins and anticoagulants) will be analysed. The findings will contribute to mitigating the effects of this pandemic as well as future ones. Thus, long-term advantages are expected, including for the seasonal influenza.