Analysis of multimorbidity, prescribed medication use and mortality over the Covid-19 pandemic period, with a specific focus on those with dementia – a longitudinal study of persons aged forty or more in 2011 in Northern Ireland

Older people are at high risk for Covid-19 and may have been impacted (and psychologically distressed) by the quarantine – entailing disconnection from family, community and usual health, social support and planned treatments. These may be amplified for people in rural areas where services are limited and both transport and digital-based communication services relatively poor. These issues may be more challenging for people living with dementia, generally associated with ageing, functional decline (Melis et al., 2013) and increased prescribing (Browne et al., 2017; Clague et al., 2017).

We will develop analysis based on a specific interest with problematic polypharmacy, defined pragmatically as a situation – where specific medication types should not be taken by a patient simultaneously, or where unexpected negative interactions between medications occur. This occurs mainly due to multimorbidity and is recognised as a serious problem for older people which can reduce life expectancy (NICE, 2019). In the UK dementia prevalence is considerable and for those with dementia polypharmacy can increase confusion, cognitive and physical decline and falls, and inappropriate prescribing of antipsychotic medications may arise when agitation and other physical needs are misinterpreted (Pryor & Clarke, 2017). However, evidence is limited. For people with dementia there are concerns about anti-depressant efficacy and anti-psychotic medication for treatment of mood and agitation respectively. Additionally, pain is often problematic and is underdiagnosed in this population (Hanson et al. 2018), while poor pain management (Dening, 2017) can increase discomfort and distress, delirium, sedation and confusion.

Engagement with our community sector partners (including the Alzheimer’s Society and the Commission for Older People for Northern Ireland) indicates that people with dementia have experienced increased agitative behaviour during the C-19 period, distressing both for patients and caregivers, raising concerns about accelerated deterioration.

Aim: to investigate the health impact of the pandemic and lockdown on older people, including those living with dementia. This includes examination of:

• Prescribing patterns for psychotropic medication and pain medication across the whole period of interest, with specific focus on comparisons between the pandemic quarantine period and selected pre-Covid periods (see * below);
• problematic polypharmacy – again examined as below*;
• changes in all-cause/cause-specific mortality over the whole study population, focussing on risks associated with (a) multi-morbidity, (b) the range of contextual data provided with the 2011 Census – this will allow us a preliminary examination (determined by the available mortality downloads) of putative changes that may be accounted for by the pandemic/lockdown; and finally,
• changes in dementia mortality over the noted periods* – in relation to multimorbidity; medication use and socio-demographic context (note – assumes we can include later downloads of the mortality data).

*: periods of specific interest in relation to the Covid-19 pandemic include the following –

    a: 01/2011-12/2012;        b: 01/2018-12/2019 ;     c: 01/2020-03/2021 (or latest update) allowing us to analyse prescribing patterns over these specific sentinel periods, for example.

    Temporal comparisons can include:  a->b .. analysis of pre-Covid trends;   b->c .. immediately pre-Covid and initial Covid period.

    Please note that the periods are indicative only – periods used in analysis will be determined in-situ.