Does presbygeusia really exist? An updated narrative review.

This review critically assessed the existence of presbygeusia, i.e., the impairment in taste perception occurring in the elderly, as a natural part of the aging process and its potential clinical implications. Several factors might contribute to age-related taste alterations (TAs), including structural changes in taste buds, alterations in saliva composition, central nervous system changes, and oral microbiota dysbiosis. A comprehensive literature review was conducted to disentangle the effects of age from those of the several age-related diseases or conditions promoting TAs. Most of the included studies reported TAs in healthy elderly people, suggesting that presbygeusia is a relatively frequent condition associated with age-related changes in the absence of pathological conditions. However, the impact of TAs on dietary preferences and food choices among the elderly seems to be less relevant when compared to other factors, such as cultural, psychological, and social influences. In conclusion, presbygeusia exists even in the absence of comorbidities or drug side effects, but its impact on dietary choices in the elderly is likely modest.

Atypical Course of SarsCov-2 Infection in a Patient with Multiple Myeloma Treated with Autologous Stem Cell Transplantation.

Covid-19 infection has more relevant consequences in frail and comorbid patients, but little is known about its course in patients with hematologic malignancies. In this report, we would like to present the case of a patient with multiple myeloma treated with recent autologous bone marrow stem cell transplantation and affected by Covid-19 pneumonia, presenting with a possible reinfection or an extremely long viral shedding.

Predictors of In-Hospital Mortality in Older Inpatients with Suspected Infection.

OBJECTIVES: To determine the rate and predictors of death in older individuals with suspected infection at any time during hospital stay in a geriatric acute ward and the prognostic ability of different tools [quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA), Modified and National Early Warning Scores (MEWS) and (NEWS)] in such population. DESIGN: Prospective observational single-center cohort study. SETTING AND PARTICIPANTS: Among patients admitted to an acute geriatric unit of an Italian University Hospital with at least 1 sepsis risk factor, all subjects with suspected infection at admission or during hospital stay (defined as antibiotic prescription and associated culture test) were considered. METHODS: A geriatric assessment including comorbidity and social, functional, and cognitive status was performed for each patient. Clinical parameters were evaluated at least twice daily throughout hospital stay; qSOFA, MEWS, and NEWS were derived, with positive cutoffs set at ≥2, ≥5, and ≥7, respectively. RESULTS: Among 305 older inpatients (median age 86.0 years, 49.2% female), 21% died during hospital stay. Sepsis was diagnosed in 31.8% of the overall sample and in 64.1% of deceased patients. Deceased patients showed a significantly higher prevalence of prior institutionalization, functional dependence, cognitive impairment, and multimorbidity. The prognostic accuracy of the qSOFA score at infection onset was only fair (area under the receiver operating characteristic curve 0.72; 95% CI, 0.65-0.79, P < .001) and comparable with that of MEWS and NEWS. After multivariable analysis, in-hospital death was positively associated with male sex [odds ratio (OR), 2.11; 95% CI, 1.01-4.44; P = .048] and abnormal white blood cells count (OR, 4.93; 95% CI, 2.36-10.29; P < .001), platelet count (OR, 2.61; 95% CI, 1.10-6.16; P = .029) and serum creatinine (OR, 2.70; 95% CI, 1.30-5.61; P = .008), along with any of the score considered, and negatively associated with autonomy in instrumental activities (OR, 0.78; 95% CI, 0.68-0.90; P < .001). CONCLUSIONS: Prognosis in older inpatients with infection or sepsis appears to be determined both by the geriatric characteristics and by the severity of the acute event, expressed by recommended tools and blood test results.

Comparison of Diagnostic Accuracies of qSOFA, NEWS, and MEWS to Identify Sepsis in Older Inpatients With Suspected Infection.

OBJECTIVES: To determine and compare the accuracies of the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) and Modified and National Early Warning Scores (NEWS and MEWS) to identify sepsis in older inpatients with suspected infection. DESIGN: Prospective diagnostic accuracy study. SETTING AND PARTICIPANTS: Patients admitted to an acute geriatric unit of an Italian University Hospital with at least one sepsis risk factor and suspected infection defined as antibiotic prescription and associated culture test during hospital stay. METHODS: Sepsis diagnosis was defined as the presence on discharge documents of International Classification of Diseases, Ninth revision, Clinical Modification codes for severe sepsis, septic shock, or for infection and acute organ disfunction. For each patient, clinical parameters were evaluated at least twice daily throughout hospital stay; qSOFA, NEWS, and MEWS were derived, and worst scores recorded. Positive cutoffs were set at ≥2, ≥7, and ≥5, respectively. Sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively), and positive and negative likelihood ratios, as well as areas under the receiver operating characteristic curve (AUROCs) were calculated. RESULTS: Among 230 geriatric patients with suspected infection at risk for sepsis (median age 86 years, 49% women), 30.9% had a sepsis diagnosis. A qSOFA ≥2 was recorded in 111 (48.3%) patients, a MEWS ≥5 in 65 (28.3%), and a NEWS ≥7 in 115 (50.0%). The qSOFA showed the highest sensitivity [81.7%, 95% confidence interval (CI) 71.7%-89.5%], but low specificity (66.7%, 95% CI 59.1%-73.7%), resulting in a high NPV (89.1%; 95% CI 82.7%-93.8%) and poor PPV (52.3%, 95% CI 43.0%-61.4%). The AUROC for qSOFA was 0.76 (95% CI 0.69-0.83), comparable with that of NEWS (0.74, 95% CI 0.67-0.81, P = .44), but significantly higher than that of MEWS (0.70, 95% CI 0.63-0.77, P = .04). CONCLUSIONS AND IMPLICATIONS: Repeated qSOFA determinations are useful to rule out sepsis in geriatric inpatients with suspected infection, but poorly support its diagnosis due to low specificity. More complex MEWS and NEWS do not perform better. Implementation of clinical scores to reliably identify sepsis in older patients is urgently needed.

Evidence and uncertainties in the management of atrial fibrillation in the elderly.

Atrial fibrillation (AF) is the most common cardiac sustained arrhythmia, whose incidence and prevalence increase with age, representing a significant burden for health services in western countries. Older people contribute to most patients affected from AF. Although oral anticoagulant therapy represents the cornerstone for the prevention of ischemic stroke and its disabling consequences, several other interventions - including left atrial appendage occlusion (LAAO), catheter ablation (CA) of AF, and rhythm control strategy (RCS) - have proved to be potentially effective in reducing the incidence of AF-associated clinical complications. Scientific literature focused on the three items will be discussed. Practical treatment of older AF patients is presented, including approach and management of patients with geriatric syndromes, selection of the most appropriate individualized drug treatment, clinical indications, and potential clinical benefit of LAAO and CA in selected older AF patients. Older people carry the greatest burden of AF in real world practice. Within a shared decision-making process, the patient centered approach needs to be put in the context of a comprehensive assessment, in order to gain maximal net clinical benefit and avoid futility or harm.

Delirium symptoms duration and mortality in SARS-COV2 elderly: results of a multicenter retrospective cohort study.

BACKGROUND: Since the occurrence of the SARS-COV2 pandemic, there has been an increasing interest in investigating the epidemiology of delirium. Delirium is frequent in SARS-COV2 patients and it is associated with increased mortality; however, no information is available on the association between delirium duration in SARS-COV2 patients and related outcomes. AIMS: The aim of this study is to investigate the association between the duration of delirium symptoms and in-hospital mortality in older patients with SARS-COV2 infection. METHODS: Retrospective cohort study of patients 65 years of age and older with SARS-CoV 2 infection admitted to two acute geriatric wards and one rehabilitation ward. Delirium symptoms duration was assessed retrospectively with a chart-based validated method. In-hospital mortality was ascertained via medical records. RESULTS: A total of 241 patients were included. The prevalence of delirium on admission was 16%. The median number of days with delirium symptoms was 4 (IQR 2-6.5) vs. 0 (IQR 0-2) in patients with and without delirium on admission. In the multivariable Cox regression model, each day with a delirium symptom in a patient with the same length of stay was associated with a 10% increase in in-hospital mortality (Hazard ratio 1.1, 95% Confidence interval 1.01-1.2; p = 0.03). Other variables associated with increased risk of in-hospital death were age, comorbidity, CPAP, CRP levels and total number of drugs on admission. CONCLUSIONS: The study supports the necessity to establish protocols for the monitoring and management of delirium during emergency conditions to allow an appropriate care for older patients.

Prevalence, determinants and practical implications of inappropriate hospitalizations in older subjects: A prospective observational study.

In a context of high demand for hospital services among older people, we aimed to assess the rate and determinants of inappropriate hospitalizations of older patients, and to what extent they were associated with inappropriate hospital stay. This prospective observational multicentre study evaluated a random sample of consecutive patients aged ≥ 70 years accessing the Emergency Department (ED) of two Italian tertiary hospitals. A standardized comprehensive geriatric assessment was carried out in each patient, including the Blaylock Risk Assessment Screen Scale (BRASS) for identification of patients at risk of difficult discharge. Inappropriate hospitalization was defined by the ED physician when patients did not necessitate hospital-provided procedures but was due to social reasons or lack of an alternative care-setting. Among 1877 patients (median age 80.7 years, 50.1% male), with a high prevalence of functional dependence and social isolation (around 30% and 25%, respectively), 767 (40.9%) were hospitalized. Incidence of inappropriate hospitalization was 14.6% (95% CI 12.1%-17.1%) and was associated with moderate-high risk of difficult discharge at BRASS (OR = 1.98, 95% CI 1.16-3.39, p = 0.013) and the presence of dementia with behavioural disorders (OR = 1.79, 95% CI 1.10-2.91, p = 0.020). Compared with patients appropriately admitted, inappropriate hospitalizations had shorter length of hospital stay but accounted for 1059/9154 days of stay (11.6%). Inappropriate hospitalizations occurred in less than 15% of cases, mainly accounted for by patients no longer manageable at home, but contributed to the greatest proportion of inappropriate hospital stay. These findings highlight the need of implementing appropriate home-care services and ensuring rapid access to suitable care-facilities for community-dwelling frail older patients.

Telemedicine-assisted care of an older patient with COVID-19 and dementia: bridging the gap between hospital and home.

Hospital at Home (HaH) has been proposed as a solution to relieve pressure on hospital beds during the COVID-19 pandemic; however, caregivers' feelings of inadequacy and concerns on the need for tighter clinical monitoring might lead to unnecessary and potentially harmful hospital admissions in frail older patients with mild or atypical COVID-19. Here we report the case of a 91-year old woman with severe dementia and atypical COVID-19 that could be successfully managed by our HaH thanks to her highly motivated caregivers and the support of a telemedicine solution (TMS) to provide caregiver training and support as well as supplementary telemonitoring. Despite some well-known issues on TMS use, the hybrid in-person and tele-visit approach of TMS-assisted HaH could help to create a "secure" environment, empowering caregivers to manage frail older adults with COVID-19 at home, avoiding unnecessary admissions to closed wards and their negative physical, functional and psychological outcomes.

Off-label use of reduced dose direct oral factor Xa inhibitors in subjects with atrial fibrillation: a review of clinical evidence.

In real-world clinical practice, underdosing, i.e. off-label use of reduced doses (RDs), of oral factor Xa inhibitors (oFXaIs) is quite common in stroke prevention in non-valvular atrial fibrillation, possibly reflecting the hope to increase safety without reducing efficacy in selected patients. To assess whether this strategy is associated with some clinical benefit, we used a physician-centred approach to evaluate whether current evidence supports the hypothesis that a substantial proportion of underdosing may be voluntary rather than casual, whether and to what extent oFXaIs' dose rather than patients' characteristics are associated with bleeding events, and which are the safety and efficacy clinical implications of oFXaIs' underdosing. Our review found consistent evidence that underdosing is often an intentional strategy; however, available studies do not demonstrate a sizeable net clinical benefit of using off-label RD oFXaIs.

Does solar ultraviolet radiation play a role in COVID-19 infection and deaths? An environmental ecological study in Italy.

A significantly stronger impact in mortality and morbidity by COVID-19 has been observed in the northern Italian regions compared to the southern ones. The reasons of this geographical pattern might involve several concurrent factors. The main objective of this work is to investigate whether any correlations exist between the spatial distribution of COVID-19 cases and deaths in the different Italian regions and the amount of solar ultraviolet (UV) radiation at the Earth's surface. To this purpose, in this environmental ecological study a mixed-effect exponential regression was built to explain the incidence of COVID-19 based on the environmental conditions, and demographic and pathophysiologic factors. Observations and estimates of the cumulative solar UV exposure have been included to quantify the amount of radiation available e.g., for pre-vitamin D3 synthesis or SARS-CoV-2 inactivation by sunlight. The analysis shows a significant correlation (p-value <5 × 10-2) between the response variables (death percentage, incidence of infections and positive tests) and biologically effective solar UV radiation, residents in nursing homes per inhabitant (NHR), air temperature, death percentage due to the most frequent comorbidities. Among all factors, the amount of solar UV radiation is the variable contributing the most to the observed correlation, explaining up to 83.2% of the variance of the COVID-19 affected cases per population. While the statistical outcomes of the study do not directly entail a specific cause-effect relationship, our results are consistent with the hypothesis that solar UV radiation impacted on the development of the infection and on its complications, e.g. through the effect of vitamin D on the immune system or virus inactivation by sunlight. The analytical framework used in this study, based on commonly available data, can be easily replicated in other countries and geographical domains to identify possible correlations between exposure to solar UV radiation and the spread of the pandemic.

Type 2 diabetes affects bone cells precursors and bone turnover.

BACKGROUND: Here we study the effect of type 2 diabetes (T2DM) on bone cell precursors, turnover and cytokines involved in the control of bone cell formation and activity. METHODS: We enrolled in the study 21 T2DM women and 21 non diabetic controls matched for age and body mass index (BMI). In each subject we measured bone cell precursors, Receptor Activator of Nuclear Factor κB (RANKL), Osteoprotegerin (OPG), Sclerostin (SCL) and Dickoppf-1 (DKK-1) as cytokines involved in the control of osteoblast and osteoclast formation and activity, bone density (BMD) and quality trough trabecular bone score (TBS) and bone turnover. T2DM patients and controls were compared for the analyzed variables by one way ANOVA for Gaussian ones and by Mann-Whitney or Kruskal-Wallis test for non-Gaussian variables. RESULTS: RANKL was decreased and DKK-1 increased in T2DM. Accordingly, patients with T2DM have lower bone turnover compared to controls. BMD and TBS were not significantly different from healthy controls. Bone precursor cells were more immature in T2DM. However the number of osteoclast precursors was increased and that of osteoblasts decreased. CONCLUSIONS: Patients with T2DM have more immature bone cells precursors, with increased number of osteoclasts and decreased osteoblasts, confirming low bone turnover and reduced cytokines such as RANKL and DKK-1. BMD and TBS are not significantly altered in T2DM although, in contrast with other studies, this may be due to the match of patients and controls for BMI rather than age.

Extent of, and variables associated with, blood pressure variability among older subjects.

BACKGROUND: Blood pressure variability (BPV) may have prognostic implications for cardiovascular risk and cognitive decline; however, BPV has yet to be studied in old and very old people. AIMS: Aim of the present study was to evaluate the extent of BPV and to identify variables associated with BPV among older subjects. METHODS: A retrospective study of patients aged ≥ 65 years who underwent 24-h ambulatory blood pressure monitoring (ABPM) was carried out. Three different BPV indexes were calculated for systolic and diastolic blood pressure (SBP and DBP): standard deviation (SD), coefficient of variation (CV), and average real variability (ARV). Demographic variables and use of antihypertensive medications were considered. RESULTS: The study included 738 patients. Mean age was 74.8 ± 6.8 years. Mean SBP and DBP SD were 20.5 ± 4.4 and 14.6 ± 3.4 mmHg. Mean SBP and DBP CV were 16 ± 3 and 20 ± 5%. Mean SBP and DBP ARV were 15.7 ± 3.9 and 11.8 ± 3.6 mmHg. At multivariate analysis older age, female sex and uncontrolled mean blood pressure were associated with both systolic and diastolic BPV indexes. The use of calcium channel blockers and alpha-adrenergic antagonists was associated with lower systolic and diastolic BPV indexes, respectively. CONCLUSIONS: Among elderly subjects undergoing 24-h ABPM, we observed remarkably high indexes of BPV, which were associated with older age, female sex, and uncontrolled blood pressure values.

Prevalence of and factors associated with prolonged length of stay in older hospitalized medical patients.

AIM: To characterize elderly medical patients and identify factors associated with prolonged length of stay. METHODS: The present prospective observational study evaluated consecutive patients aged ≥65 years admitted in acute geriatric and medical wards. A comprehensive assessment including demographic, clinical, functional and cognitive variables was carried out. Delayed discharge was defined when patients were discharged later than the date they were deemed medically ready for discharge by physicians. The analysis was initially carried out on the total sample and subsequently according to whether hospital admission had been from home, or from intermediate or long-term facilities. RESULTS: Among 1568 patients (age 81.3 ± 7.3 years, 712 men), we observed a high prevalence of functional dependence, cognitive impairment, chronic immobilization and frailty (50%, 25%, 20% and 40%, respectively). Overall, delayed discharge occurred in 442 cases - resulting in 2637 days of prolonged hospital stay - and was independently associated with impairment in activities of daily living, frailty, high comorbidity and inappropriate admission. Among patients admitted from home (roughly 90% of the sample), delayed discharge occurred in 392 patients, and was independently associated with cognitive impairment, functional dependence, low severity of comorbidity and inappropriate admission (OR 3.39). Among patients admitted from intermediate or long-term facilities, lower cognitive impairment and greater severity of functional dependence were independently associated with prolonged stay. CONCLUSIONS: Poor health conditions and high prevalence of geriatric syndromes are extremely common among older medical inpatients. Delayed discharge was mainly observed in patients admitted from home, and associated with cognitive impairment (OR 1.12) and functional dependence (OR 1.49).