Jonas Wastesson

Research problem and questions. Even if dementia cannot be cured, older persons with this condition and their relatives can still have a long-lasting good quality of life if offered appropriate medical and social care. As recently discussed in a FORTE-funded national symposium organized by the main applicant, the integrated person-centered model is recognized as a promising approach for improved health and service utilization outcomes, but questions remain about how to organize, provide, and assess such care. This project intends to answer the following questions concerning older adults with dementia: 1) How can we ensure a person-centered and holistic assessment and follow up? 2) What are the predictors and clinical/care consequences of major acute events? and 3) How can we facilitate their seamless transfer across care settings?Data and methods. Three studies will be implemented. Study 1 will leverage on data from an existing, multi-center, population-based cohort (Swedish National Study on Aging and Care, SNAC) to examine the predictive capacity of the Health Assessment Tool (HAT) for detecting progression from cognitive impairment to dementia. Study 2 will explore, based on data from the Swedish Dementia Registry, the predictors of common major acute events (i.e. falls, pneumonia, myocardial infarction) and how the latter impact dementia progression and health/social care use, including unplanned hospitalizations. Finally, Study 3 will identify and map care transitions within and between medical and social care settings using an integrated national register dataset, with special emphasis on the rehabilitation and hospital discharge phases of care trajectories.Relevance and utilization. The present project is a contribution to the long-awaited need for integrated person-centered care throughout the dementia continuum, which will add quality to the many years older persons may live with cognitive impairment and dementia by slowing down their progression.Plan for project realization. We will draw on our team’s longstanding multidisciplinary expertise on aging and dementia research, already established collaborations, the involvement of key partners representing the councils of Elderly Research and Cognitive Disorders at the National Board of Health and Welfare, and the ease of access to the proposed longitudinal databases and register data. This will facilitate, not only the feasibility of the project, but also the timely implementation of its findings.

Research problem and specific questionDEM(H)CARE is an interdisciplinary program to develop forms of cooperation and working structures for interventions for older people with dementia at home. The aim of the program is to find solutions to problems of cooperation and to develop models for coordination between different actors in care for older persons: home care, municipal home health care and primary care, which today have different roles in providing care for people with dementia at home.Data and methodThe program uses both quantitative and qualitative methods, including register and survey studies at national level, and the collection and analysis of surveys, interviews and focus groups at local level.Societal relevance and utilizationThe results will be disseminated through scientific channels to practitioners through workshops and seminars aimed at municipalities and regions, and a final program report will be published for decision-makers. The program will produce evidence-based knowledge about existing social and health care interventions for older people with dementia, focusing on how to develop coordinated care at home. The fact that the field is unexplored - and that systematic analysis of how dementia care is organized within the Swedish elder care system - means that the program will be able to generate important knowledge that will contribute to development of well-coordinated care for older people with dementia in the future.Plan for project realizationThe program is divided into five work packages. 1) National comparisons - aims to map and compare the performance of care interventions for people with dementia in all municipalities in Sweden. 2) Dementia care in different types of municipalities - aims to identify specific challenges and solutions for organizing dementia care in large cities, medium-sized municipalities and rural municipalities. 3) Well-functioning municipalities - identified in WP1. Success factors for organizing well-functioning dementia care will be explored in a selection of high-performing municipalities. 4) Summary and implementation of good practice - a summary of the results of the first three work packages. 5) Management and organization - to coordinate and control the program. The majority of the requested funding is reserved for the salaries of the applicants. We apply for both junior and senior researchers, as well as funds to organize workshops and seminars for collaboration and dissemination of results.

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 questionsLoneliness is associated with poor health and mortality, but the causal relationships between loneliness, mental health and care use are not well understood, and there is a lack of evidence-based methods for care professionals to recognise and respond to loneliness. This programme takes a holistic perspective on loneliness in older adults, how loneliness is understood and experienced, and its relationship with mental health. Our work packages (WPs) will address research gaps to support evidence-based approaches to identify, assess and address to loneliness in practice by:examining inequalities in risk factors and consequences of loneliness, and causal associations between loneliness, mental health and careexploring subjective experiences of loneliness and mental health from a life-course perspectivedeveloping an instrument to assess loneliness in practicecreating a loneliness literacy training programme for care professionalsenhancing care professionals’ response to lonelinessData and methodIn WP1, panel studies will be combined with register data to examine inequalities in loneliness and its causal associations with mental health and care use. In WP2, older adults’ experiences of loneliness and mental health will be explored in interviews, which will also support the development of an instrument to assess loneliness. In WP3, researchers and care professionals will co-design a loneliness literacy training programme to improve care professionals’ competencies to address loneliness. WP4 integrates research across WPs, embeds it in practice and promotes dissemination of findings. Workshops with stakeholders will explore how to enhance care professionals’ response to loneliness.Relevance and utilisationOur research will advance the understanding of risk factors and avoidable consequences of loneliness, produce the first instrument for assessing loneliness validated for use with older adults in Swedish care practice, and develop a unique loneliness literacy programme for care professionals. Close collaboration with stakeholders will ensure our findings can support social care and civil society in addressing loneliness and mitigate its negative outcomes.Plan for project realisationThe programme will be realised by an experienced multidisciplinary team with expertise in loneliness, mental health, gender and socioeconomic inequality, health literacy and care in old age. Collaboration with pensioner and mental health organisations and authorities ensures representation of older adults and the programme’s relevance and feasibility for practice. Scientific quality is supported by an international academic reference group. There will be thorough dissemination to academic, policy and practice communities.A budget of SEK 23.8 million includes staff costs (SEK 15.1 million)

running costs (e.g., meetings, fieldwork, dissemination, administration, IT, offices

SEK 4.4 million)

and indirect costs (SEK 4.3 million).

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.