Changes in Sleep Duration and Sleep Timing in the General Population from before to during the First COVID-19 Lockdown: A Systematic Review and Meta-Analysis.

BACKGROUND: The COVID-19 lockdown had a profound effect on everyday life, including sleep health. This systematic review and meta-analysis evaluated changes in quantitative sleep parameters during the first lockdown compared with pre-lockdown in the general population. METHODS: A search in scientific databases was performed to identify eligible observational studies from inception to 8 February 2023. We performed a random effects meta-analysis of those studies reporting (a) means of sleep duration, time in bed (TIB), and sleep timing (bedtime and wake-up time); (b) the percentages of atypical sleep duration before and during the lockdown; (c) the percentages of change in sleep duration and sleep timing. RESULTS: A total of 154 studies were included. A small increase in sleep duration (0.25 standardized mean difference, 95% CI 0.180-0.315) was found, with 55.0% of the individuals reporting changes, predominantly an increase (35.2%). The pooled relative risk for sleeping more than 8/9 h per night was 3.31 (95% IC 2.60-4.21). There was a moderately significant delay in sleep timing and a surge in napping. CONCLUSION: An increase in sleep duration and napping, and delayed sleep timing were observed. High-quality studies should evaluate whether these parameters have now become chronic or have returned to pre-lockdown values.

Recurrence of Clostridioides difficile infection and mortality in older inpatients.

PURPOSE: The prevalence of Clostridioides difficile infection in older and frail population is extremely high and adverse outcomes, including future recurrences and premature mortality, are common. Nonetheless, the clinical risk profile for Clostridioides difficile recurrence in older people is still controversial. We aimed to investigate: 1) the association between Clostridioides difficile recurrence and 6-month mortality; 2) the risk factors for Clostridioides difficile recurrence after hospital discharge. METHODS: This is a retrospective study on adults with a first episode of Clostridioides difficile infection admitted to all Internal Medicine and Geriatrics Units of the University Hospital of Ferrara (Italy) between January 2018 and December 2020. For each patient, sociodemographic, clinical and laboratory data were collected through hospital database system. The primary and secondary outcomes were mortality and recurrence within 6 months from the first infectious episode, respectively. RESULTS: The mean age of the 386 enrolled patients was 77.8 years; 61.7% were females. Twelve percent patients had Clostridioides difficile recurrence and 32.1% patients died during the 6-month follow-up. At Cox analysis, after adjustment for the potential confounders, participants with recurrence reported a twofold risk of death compared to those without recurrence (HR, 95% CI 2.45, 1.59-3.78). Compared to patients treated with metronidazole, those treated with vancomycin showed a lower risk of recurrence (log-rank p < 0.001). CONCLUSION: Clostridioides difficile recurrence is associated with a higher risk of mortality and it may itself be a marker of frailty and vulnerability. Vancomycin treatment during the infectious episode was associated with lower recurrence rate, as compared to metronidazole.

Patterns of multimorbidity in primary care electronic health records: A systematic review.

Background: Multimorbidity, the coexistence of multiple chronic conditions in an individual, is a complex phenomenon that is highly prevalent in primary care settings, particularly in older individuals. This systematic review summarises the current evidence on multimorbidity patterns identified in primary care electronic health record (EHR) data. Methods: Three databases were searched from inception to April 2022 to identify studies that derived original multimorbidity patterns from primary care EHR data. The quality of the included studies was assessed using a modified version of the Newcastle-Ottawa Quality Assessment Scale. Results: Sixteen studies were included in this systematic review, none of which was of low quality. Most studies were conducted in Spain, and only one study was conducted outside of Europe. The prevalence of multimorbidity (i.e. two or more conditions) ranged from 14.0% to 93.9%. The most common stratification variable in disease clustering models was sex, followed by age and calendar year. Despite significant heterogeneity in clustering methods and disease classification tools, consistent patterns of multimorbidity emerged. Mental health and cardiovascular patterns were identified in all studies, often in combination with diseases of other organ systems (e.g. neurological, endocrine). Discussion: These findings emphasise the frequent coexistence of physical and mental health conditions in primary care, and provide useful information for the development of targeted preventive and management strategies. Future research should explore mechanisms underlying multimorbidity patterns, prioritise methodological harmonisation to facilitate the comparability of findings, and promote the use of EHR data globally to enhance our understanding of multimorbidity in more diverse populations.

SARS-CoV-2 vaccination and risk of infectious diseases in hospitalized older patients.

PURPOSE: Vaccinations, for example flu vaccine, may be a cause of cross-reactive immunostimulation that prevents a larger spectrum of infections. However, whether SARS-CoV-2 vaccinations may also determine this effect is unclear. This study aims, first, to assess the incidence of infections at hospital admission and during the hospitalization in older inpatients vaccinated and unvaccinated against SARS-CoV-2; second, to compare length of hospital stay and in-hospital mortality between vaccinated and unvaccinated individuals. METHODS: This retrospective study included 754 older inpatients admitted to the Geriatrics and Orthogeriatrics Units of the University Hospital of Ferrara (Italy) between March 2021 and November 2021. Sociodemographic and health-related data, and the diagnosis of infections at hospital admission and during hospitalization were collected from medical records. RESULTS: The sample's mean age was 87.2 years, 59.2% were females, and 75.5% were vaccinated against SARS-CoV-2. Vaccinated individuals had 36% lower odds of intra-hospital infections (OR = 0.64, 95%CI 0.44-0.94) and 39% lower in-hospital death (HR = 0.61, 95%CI 0.39-0.95), also after adjusting for potential confounders, while no significant results emerged about infections at hospital admission. Considering the hospitalization's endpoints, SARS-CoV-2 vaccination was associated with a lower probability of being transferred to long-term care or other hospital departments than returning home (OR = 0.63, 95%CI 0.40-0.99). CONCLUSIONS: In older inpatients, SARS-CoV-2 vaccination seems to be associated with a lower likelihood of intra-hospital infectious diseases not caused by SARS-CoV-2 and all-cause in-hospital mortality. The vaccination coverage in the older population could limit not only the onset and severity of COVID-19 but also the occurrence of other infectious diseases.

Frailty trajectories in ICU survivors: A comparison between the clinical frailty scale and the Tilburg frailty Indicator and association with 1 year mortality.

PURPOSE: To test the agreement of the Clinical Frailty Scale (CFS) and the Tilburg Frailty Indicator (TFI), their association with 3, 6 months and 1-year mortality and the trajectory of frailty in a mixed population of ICU survivors. MATERIAL AND METHODS: This is a prospective, multicenter, longitudinal study on ICU survivors ≥18 years old with an ICU stay >72 h. For each patient, sociodemographic and clinical data were collected. Frailty was assessed during ICU stay and at 3, 6, 12 months after ICU discharge, through both CFS and TFI. RESULTS: 124 patients with a mean age of 66 years old were enrolled. The baseline prevalence of frailty was 15.3% by CFS and 44.4% by TFI. Baseline CFS and TFI correlated but showed low agreement (Cohen's K = 0.23, p < 0.001). Baseline CFS score, but not TFI, was significantly associated to 1 year mortality. Moreover, CFS score during the follow-up was independently associated 1-year mortality (OR = 1.43; 95% CI: 1.18-1.73). CONCLUSIONS: CFS and TFI identify different populations of frail ICU survivors. Frail patients before ICU according to CFS have a significantly higher mortality after ICU discharge. The CFS during follow-up is an independent negative prognostic factor of long-term mortality in the ICU population.

Changes in sleep quality and sleep disturbances in the general population from before to during the COVID-19 lockdown: A systematic review and meta-analysis.

Introduction: This systematic review and meta-analysis aims to explore changes in sleep quality and sleep disturbances in the general population from before to during the COVID-19 lockdown. Methods: The protocol was registered in PROSPERO (CRD42021256378) and the PRISMA guidelines were followed. The major databases and gray literature were systematically searched from inception to 28/05/2021 to identify observational studies evaluating sleep changes in the general population during the lockdown with respect to the pre-lockdown period. A random effects meta-analysis was undertaken for studies reporting (a) the means of the Pittsburgh Sleep Quality Index (PSQI) global scores or the means of the sleep onset latency (SOL) times (minutes - min) before and during the lockdown, (b) the percentages of poor sleep quality before and during the lockdown, or (c) the percentages of changes in sleep quality. Subgroup analysis by risk of bias and measurement tool utilized was carried out. A narrative synthesis on sleep efficiency, sleep disturbances, insomnia and sleep medication consumption was also performed. Results: Sixty-three studies were included. A decline in sleep quality, reflected in a pooled increase in the PSQI global scores (standardized mean difference (SMD) = 0.26; 95% CI 0.17-0.34) and in SOL (SMD = 0.38 min; 95% CI 0.30-0.45) were found. The percentage of individuals with poor sleep quality increased during the lockdown (pooled relative risk 1.4; 95% CI 1.24-1.61). Moreover, 57.3% (95% CI 50.01-61.55) of the individuals reported a change in sleep quality; in 37.3% (95% CI 34.27-40.39) of these, it was a worsening. The studies included in the systematic review reported a decrease in sleep efficiency and an increase in sleep disturbances, insomnia, and in sleep medication consumption. Discussion: Timely interventions are warranted in view of the decline in sleep quality and the increase in sleep disturbances uncovered and their potentially negative impact on health. Further research and in particular longitudinal studies using validated instruments examining the long-term impact of the lockdown on sleep variables is needed. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021256378, identifier CRD42021256378.

Presepsin levels and COVID-19 severity: a systematic review and meta-analysis.

Plasmatic presepsin (PSP) is a novel biomarker reported to be useful for sepsis diagnosis and prognosis. During the pandemic, only few studies highlighted a possible correlation between PSP and COVID-19 severity, but results remain inconsistent. The present study aims to establish the correlation between PSP and COVID-19 severity. English-language papers assessing a correlation between COVID-19 and PSP from MEDLINE, PubMed, Google Scholar, Cochrane Library, MeSH, LitCovid NLM, EMBASE, CINAHL Plus and the World Health Organization (WHO) website, published from January 2020 were considered with no publication date limitations. Two independent reviewers performed data abstraction and quality assessment, and one reviewer resolved inconsistencies. The protocol was registered on PROSPERO (CRD42022325971).Fifteen articles met our eligibility criteria. The aggregate study population included 1373 COVID-19 patients who had undergone a PSP assessment. The random-effect meta-analysis was performed in 7 out of 15 selected studies, considering only those reporting the mean PSP levels in low- and high-severity cases (n = 707).The results showed that the pooled mean difference of PSP levels between high- and low-severity COVID-19 patients was 441.70 pg/ml (95%CI: 150.40-732.99 pg/ml).Our data show that presepsin is a promising biomarker that can express COVID-19 severity.

Clinical Features of SARS-CoV-2 Infection in Older Adults.

Covid-19 clinical presentation is extremely heterogenous, especially in older patients due to the possible presence of atypical symptoms, such as delirium, hyporexia and falls. The clinical characteristics at onset are influenced by the presence of common health-related conditions in older people, such as comorbidity, disability and frailty, and not simply by chronological age. Few studies investigated the tendency of Covid-19 symptoms to aggregate in cluster and the use of cluster approach might better describe the clinical complexity of the acute disease. Concerning the prognostic significance of Covid-19 clinical presentation in older people, the available literature still provides discordant results.

Prevalence and impact of polypharmacy in older patients with type 2 diabetes.

BACKGROUND: Polypharmacy is a prevalent condition in older adults, especially those with multiple chronic diseases, and has been largely associated with adverse outcomes, including disability, hospitalizations, and death. AIMS: This systematic review focused on diabetes and aimed to investigate the prevalence and impact of polypharmacy in older adults affected by such disease. METHODS: Observational (either cross-sectional or longitudinal) or experimental studies investigating the frequency and impact of polypharmacy in older adults with diabetes were identified from scientific databases and grey literature until August 2021. The prevalence and the 95% Confidence Interval (95% CI) of polypharmacy in older people with diabetes were summarized by a random-effects meta-analysis. RESULTS: From a total of 1465 records, 9 were selected for the qualitative synthesis, and 8 for the quantitative synthesis. Most studies defined polypharmacy using a cut-off for the minimum number of medications ranging from 4 to 6 drugs/day. The pooled prevalence of polypharmacy in older people with diabetes was 64% (95% CI 45-80%). Considering studies that used the same definition of polypharmacy (i.e. ≥ 5 drugs/day), the pooled prevalence was 50% (95% CI 37-63%). The between-studies heterogeneity was high. Across the selected studies, polypharmacy seemed to negatively influence both diabetes-specific (poor glycemic control and risk of hypoglycemia) and health-related (risk of incident falls, syncope, hospitalization, and death) outcomes. CONCLUSION: This systematic review confirms the high prevalence of polypharmacy in older people with diabetes and its strong impact on several health-related outcomes, including mortality. These results strengthen the need to improve care strategies for management of these patients.

COVID-19 as a Paradigmatic Model of the Heterogeneous Disease Presentation in Older People: Data from the GeroCovid Observational Study.

COVID-19 may have a heterogeneous onset, especially in older age. However, whether and how COVID-19 signs and symptoms may present and aggregate together according to sociodemographic and health factors is unclear, as well as their prognostic value. This study included 981 COVID-19 inpatients who participated in the GeroCovid Observational study. Signs/symptoms at disease onset, sociodemographic, health, cognitive status, and mobility were systematically recorded. Clusters of signs/symptoms were identified through agglomerative hierarchical clustering. The associations of single signs/symptoms and symptom clusters with longer hospitalization (≥16 days) and in-hospital mortality were explored through logistic and Cox regressions. The signs/symptoms most reported in our sample (age 78.3 ± 9.39 years; 49.4% women) were fever (62.5%), cough (45.5%), and dyspnea (62.7%). Atypical symptoms were reported by up to one-third of patients, and delirium by 9.1%. Atypical symptoms were more frequent with advancing age and with lower pre-COVID-19 cognitive and mobility levels. Older men more likely reported respiratory symptoms than women. Dyspnea (hazard ratio [HR] = 1.47, 95% confidence interval [CI]: 1.02-2.12), tachypnea (HR = 1.53, 95% CI: 1.14-2.07), low oxygen saturation (HR = 1.95, 95% CI: 1.32-2.88) and delirium (HR = 1.60, 95% CI: 1.13-2.28) were associated with higher in-hospital mortality. Four symptom clusters were identified. Compared with the mild respiratory symptoms cluster, the severe clinical impairment cluster was associated with higher mortality (HR = 2.57, 95% CI: 1.58-4.18). The severe clinical impairment and aspecific symptoms clusters were associated with longer hospitalization (odds ratio [OR] = 2.38, 95% CI: 1.56-3.63, and OR = 1.75, 95% CI: 1.08-2.83, respectively). Multiple health aspects influence COVID-19 clinical presentation. A symptom clusters approach may help predict adverse health outcomes in older patients. In addition to respiratory symptoms, delirium is independently associated with mortality risk. ClinicalTrials.gov (NCT04379440).

A New Early Predictor of Fatal Outcome for COVID-19 in an Italian Emergency Department: The Modified Quick-SOFA.

Background: Since 2019, the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is causing a rapidly spreading pandemic. The present study aims to compare a modified quick SOFA (MqSOFA) score with the NEWS-2 score to predict in-hospital mortality (IHM), 30-days mortality and recovery setting. Methods: All patients admitted from March to October 2020 to the Emergency Department of St. Anna Hospital, Ferrara, Italy with clinically suspected SARS-CoV-2 infection were retrospectively included in this single-centre study and evaluated with the MqSOFA and NEWS-2 scores. Statistical and logistic regression analyses were applied to our database. Results: A total of 3359 individual records were retrieved. Among them, 2716 patients were excluded because of a negative nasopharyngeal swab and 206 for lacking data; thus, 437 patients were eligible. The data showed that the MqSOFA and NEWS-2 scores equally predicted IHM (p < 0.001) and 30-days mortality (p < 0.001). Higher incidences of coronary artery disease, congestive heart failure, cerebrovascular accidents, dementia, chronic kidney disease and cancer were found in the deceased vs. survived group. Conclusions: In this study we confirmed that the MqSOFA score was non-inferior to the NEWS-2 score in predicting IHM and 30-days mortality. Furthermore, the MqSOFA score was easier to use than NEWS-2 and is more suitable for emergency settings. Neither the NEWS-2 nor the MqSOFA scores were able to predict the recovery setting.

Prevalence of obesity and diabetes in older people with sarcopenia defined according to EWGSOP2 and FNHI criteria.

BACKGROUND: Although the prevalence of sarcopenic obesity is increasing, nowadays a universally accepted definition still does not exist. Because, this clinical entity is defined as the combination of obesity and sarcopenia, the diagnosis appears to be strictly linked to criteria used for sarcopenia and the available prevalence data are not uniform. To investigate the prevalence of sarcopenic obesity in older persons according to EWGSOP2 and FNIH criteria. Second, to evaluate the prevalence of diabetes in patients with sarcopenia diagnosed by the two definitions. METHODS: Observational multicenter study performed in 2014 on older patients admitted to 12 Italian hospitals (GLISTEN Study). Data were collected through standardized questionnaires, which assessed: socio-demographic data, cognitive status, functional abilities, pharmacological therapy, comorbidities, and blood tests. Moreover, muscle mass and strength and physical performance were evaluated. RESULTS: Six hundred and ten were included in the analyses. Among sarcopenic patients, the prevalence of sarcopenic obesity was 30.8% with FNIH and 0% with EWGSOP2 criteria. According to EWGSOP2 criteria, 23.7% of sarcopenic and 30.8% of non-sarcopenic patients were affected by diabetes (p = 0.101); otherwise, using FNIH criteria, 36.3% of sarcopenic and 26.9% of non-sarcopenic patients were diabetic (p = 0.030). After adjustment for potential confounders, diabetic patients had a 73% higher probability of being sarcopenic according to FNIH criteria (OR 1.73; 95% CI 1.13-2.64). CONCLUSIONS: The EWGSOP2 and FNIH sarcopenia criteria are differently related to the prevalence of obesity and diabetes. The EWGSOP2 criteria seem to be not suitable to identify people with sarcopenic obesity.

Prognostic interplay of kidney function with sarcopenia, anemia, disability and cognitive impairment. The GLISTEN study.

BACKGROUND: Interactions between chronic kidney disease (CKD) and several comorbidities may potentially affect prognosis of older hospitalized patients. This study aims at evaluating the prognostic interactions between estimated glomerular filtration rate (eGFR), anemia, sarcopenia, functional and cognitive dysfunction, and 3-year mortality among older patients discharged from acute care hospitals. METHODS: Our series consisted of 504 older adults enrolled in a multicenter observational study carried out in twelve Acute Geriatric and Internal Medicine wards throughout Italy. CKD was defined as an eGFR< 60 ml/min/1.73 m2. Anemia, Short Portable Status Mental Questionnaire (SPMSQ), Basic Activities of Daily Living (BADL), sarcopenia, and Charlson index were considered in the analysis. 3-year survival was investigated by Cox regression and prognostic interactions among study variables were assessed by survival tree analysis. Accuracy of different survival models was investigated by C-index. RESULTS: eGFR < 30 mL/min/1.73 m2, anemia, sarcopenia, SPMSQ ≥ 5, and impairment in 1 or more BADL were significantly associated with mortality. Survival tree analysis showed that patients with eGFR < 35.32 ml/min/1.73 m2 and SPMSQ ≥ 5 had the highest risk of mortality [hazard ratio (HR): 5.49, 95%CI: 3.04-9.94] followed by those with eGFR < 35.32 ml/min/1.73 m2, hemoglobin < 11.95 g/dL and SPMSQ < 5 (HR:3.65; 95%CI: 2.21-6.02) and those with eGFR 35.32-47.99 ml/min/1.73 m2 and sarcopenia (HR:3.65; 95%CI: 1.99-6.69). Survival tree leaf node membership had good accuracy in predicting the study outcome (C-index: 0.73, 95%CI:0.70-0.76). CONCLUSIONS: Interactions among study risk factors designed distinct risk profiles in older patients discharged from acute care hospitals, that may help identify patients needing targeted interventions and appropriate follow-up after discharge.

Predictive value of geriatric-quickSOFA in hospitalized older people with sepsis.

BACKGROUND: QuickSOFA, a prognostic score proposed for patients with infection, has shown a poor predictive value in the geriatric population, probably because of the inappropriateness of the Glasgow Coma Scale (GCS) in assessing acute alteration of mental status in older patients. Indeed, the GCS might result chronically low in older patient with pre-existing cognitive disorders. The aim of this study was to develop an alternative quickSOFA (geriatric-quickSOFA), using the presence of delirium, assessed according to DSM-5 criteria, instead of GCS assessment, to predict mortality in hospitalized older patients with sepsis. METHODS: Retrospective observational study in Acute Geriatrics Unit of St. Anna Hospital of Ferrara (Italy). The study enrolled 165 patients hospitalized between 2017 and 2018 with diagnosis of sepsis or septic shock. Demographic, clinical data and 30-day survival were collected for each patient. Based on arterial blood pressure, respiratory rate, and the presence of delirium, geriatric-quickSOFA was calculated at admission. Primary outcome was 30-day mortality. RESULTS: One hundred sixty-five patients were enrolled with a median age of 88 years; 60.6% were men. High quickSOFA score was not significantly correlated neither with in-hospital nor 30-day mortality. High geriatric-qSOFA score was significantly related to both in-hospital (13.3%vs 51.5%, p = 0.0003) and 30-day mortality (30.0%vs 84.3%, p < 0.00001). CONCLUSION: Geriatric-quickSOFA is significantly associate with short-term mortality risk in older patients with sepsis. Geriatric quickSOFA seems to represent a more suitable and useful predictive tool than the traditional quickSOFA in the geriatric population.

Vitamin D Deficiency and Sarcopenia in Older Persons.

Vitamin D deficiency is a common health problem worldwide, in particular among older people. Vitamin D regulates and modulates the physiology and function of multiple human systems, including the skeletal muscle. The effect of vitamin D on the muscle has been widely investigated, suggesting that this hormone can stimulate the proliferation and differentiation of skeletal muscle fibers, maintaining and improving muscle strength and physical performance. Older persons have a higher prevalence of low Vitamin D levels as a consequence of low dietary intake and reduced ultraviolet irradiation of the skin. Therefore, older people with vitamin D deficiency might be at risk of sarcopenia, a geriatric syndrome characterized by the progressive loss of skeletal muscle mass and strength often complicated by adverse events, such as falls, disability hospitalization and death. Several randomized clinical trials have been conducted to investigate the effect of oral vitamin D supplementation in older patients to prevent or treat sarcopenia, but results are still controversial. In this narrative review we summarize the biological, clinical and epidemiological evidence supporting the hypothesis of a causal association between Vitamin D deficiency and an increased risk of sarcopenia in older people.