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Background: The prevalence of hypothyroidism among older patients hospitalized for COVID-19 and its association with mortality is unclear. This study aims to investigate the prevalence of hypothyroidism in older COVID-19 inpatients and verify if this comorbidity is associated with a specific pattern of onset symptoms and a worse prognosis. Methods: COVID-19 inpatients aged ≥ 60 years, participating in the GeroCovid acute wards cohort, were included. The history of hypothyroidism was derived from medical records and the use of thyroid hormones. Sociodemographic data, comorbidities, symptoms/signs at the disease onset and inflammatory markers at ward admission were compared between people with vs without history of hypothyroidism. The association between hypothyroidism and in-hospital mortality was tested through Cox regression. Results: Of the 1245 patients included, 8.5% had a history of hypothyroidism. These patients were more likely to present arterial hypertension and obesity compared with those without an history of hypothyroidism. Concerning COVID-19 clinical presentation, patients with hypothyroidism had less frequently low oxygen saturation and anorexia but reported muscle pain and loss of smell more commonly than those without hypothyroidism. Among the inflammatory markers, patients with hypothyroidism had higher lymphocytes values. At Cox regression, hypothyroidism was associated with reduced in-hospital mortality only in the univariable model (HR = 0.66, 95% CI 0.45–0.96, p = 0.03); conversely, no significant result were observed after adjusting for potential confounders (HR = 0.69, 95% CI 0.47–1.03, p = 0.07). Conclusions: Hypothyroidism does not seem to substantially influence the prognosis of COVID-19 in older people, although it may be associated with peculiar clinical and biochemical features at the disease onset.

Background and aims: Atrial fibrillation (AF) is often complicated by disabling conditions in the elderly. COVID-19 has high mortality in older people. This study aimed at evaluating the relationship of pre-infection AF with characteristics and survival of older COVID-19 patients. Methods: We retrospectively analyzed inpatients aged ≥ 60 years enrolled in GeroCovid Observational, a multicenter registry endorsed by the Italian and the Norwegian Societies of Gerontology and Geriatrics. Pre-COVID-19 sociodemographic, functional, and medical data were systematically collected, as well as in-hospital mortality. Results: Between March and June 2020, 808 COVID-19 subjects were enrolled (age 79 ± 9 years; men 51.7%). The prevalence of AF was 21.8%. AF patients were older (82 ± 8 vs. 77 ± 9 years, p < 0.001), had a higher CHA2DS2-VASc score (4.1 ± 1.5 vs. 3.2 ± 1.5, p < 0.001) and were more likely to present almost all comorbidities. At multivariable analysis, advanced age, white blood cell count, the presence of heart and peripheral artery diseases were significantly associated with the presence of AF. In-hospital mortality was higher in AF patients (36.9 vs. 27.5%; OR = 1.55, 95% CI = 1.09–2.20; p = 0.015). A decision tree analysis showed that, in AF subjects, preserved functional status at admission was the most important factor associated with survival. In patients without AF, baseline COVID-19 severity was the most relevant variable related to clinical prognosis. Conclusions: AF is frequent in older patients with COVID-19, in whom it associates with clinical complexity and high mortality. Pre-infection disability shapes the prognosis of this extremely vulnerable segment of hospitalized subjects. Clinical trial registration: GeroCovid Observational was registered at www.clinicaltrials.gov (NCT04379440).

Objectives: The spread of COVID-19 has undeniably unsettled the social, psychological and emotional life of the entire world population. Particular attention should be paid to older adults with dementia, given their vulnerability to emotional stressors. The aim of this retrospective study is to evaluate the impact of the first wave quarantine related to Covid-19 on psychological and affective well-being of older adults with mild/major neurocognitive disorders and of their caregivers. Methods: Data on participants' assessment before the quarantine (PREQ) were retrospectively collected. Patients with Mild Cognitive Impairment (MCI) or dementia were recruited from different Centers for Cognitive Decline and Dementia in Italy. During the quarantine, psychological and affective well-being were evaluated by phone through the administrations of scales measuring anxiety and depression (DASS), perceived stress (PSS), coping strategies (COPE) and the caregivers' burden (CBI). The scales' results were compared across participants' PREQ cognitive level (Mini Mental State Examination, MMSE ≥25, 23–24, and ≤ 22) with multiple linear regression models. Results: The sample included 168 patients (64% women) with a mean age of 79 ± 7 years. After adjusting for potential confounders, more severe cognitive impairment was independently associated with higher DASS and PSS score, and poorer coping strategies (p < 0.05). Cognitive functioning was also inversely associated with CBI. Conclusions: The impact of the quarantine on the psycho-affective well-being of individuals with MCI and dementia and on caregivers' burden varies according to the PREQ cognitive functioning with more severely impaired patients having worse outcomes.

Background: Despite the growing evidence on COVID-19, there are still many gaps in the understanding of this disease, especially in individuals in advanced age. We describe the study protocol of GeroCovid Observational, a multi-purpose, multi-setting and multicenter initiative that aims at investigating: risk factors, clinical presentation and outcomes of individuals affected by COVID-19 in acute and residential care settings; best strategies to prevent infection in long-term care facilities; and, impact of the pandemic on neuropsychologic, functional and physical health, and on medical management in outpatients and home care patients at risk of COVID-19, with a special focus on individuals with dementia. Methods: GeroCovid involves individuals aged ≥60 years, at risk of or affected by COVID-19, prospectively or retrospectively observed since March 1st, 2020. Data are collected in multiple investigational sites across Italy, Spain and Norway, and recorded in a de-identified clinical e-Registry. A common framework was adapted to different care settings: acute wards, long-term care facilities, geriatric outpatient and home care, and outpatient memory clinics. Results: At September 16th, 2020, 66 investigational sites obtained their Ethical Committee approval and 1618 cases (mean age 80.6 [SD=9.0] years; 45% men) have been recorded in the e-Registry. The average inclusion rate since the study start on April 25th, 2020, is 11.2 patients/day. New cases enrollment will ended on December 31st, 2020, and the clinical follow-up will end on June 30th, 2021. Conclusion: GeroCovid will explore relevant aspects of COVID-19 in adults aged ≥60 years with high-quality and comprehensive data, which will help to optimize COVID-19 prevention and management, with practical implications for ongoing and possible future pandemics.

Background Frailty status and patient-reported outcomes are especially pertinent in octogenarians following transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) to guide treatment decisions and promote patient-centred care. Aim We aimed to determine if frailty changed 6 months after aortic valve replacement (AVR) in octogenarians, and to describe changes in self-rated health according to frailty status in patients who underwent TAVI or SAVR. Method In a prospective cohort study, frailty and self-rated health were measured one day prior to and 6 months after AVR. Frailty status was measured with the Study of Osteoporotic Fracture index. Self-rated health was measured comprehensively with the disease-specific Minnesota Living with Heart Failure Questionnaire, the generic Medical Outcomes Study Short Form-12 questionnaire (SF-12), and two global questions from The World Health Organization Quality of Life Instrument Abbreviated. Results Data were available for 143 consecutive patients (mean age 83 +/- 2.7 years, 57% women; 45% underwent TAVI). At baseline, 34% were robust, 27% prefrail, and 39% frail. Overall, there was no change in the distribution of frailty status 6 months after baseline (p=0.13). However, on an individual level 65 patients changed frailty status after AVR (40 patients improved and 25 declined). Improvement in frailty status was common in prefrail (33%; n=13) and frail patients (48%; n=27). Patients had improved self-rated health after AVR, with significant differences between frailty states both at baseline (SF-12 physical: 37.4 [robust], 33.1 [prefrail], 31.6 [frail], p=0.03); SF-12 mental: 51.9 [robust], 50.8 [prefrail], 44.5 [frail], p<0.001); and at the 6-month follow-up (SF-12 physical: 45.4 [robust], 38.3 [prefrail], 32.1 [frail], p<0.001); SF-12 mental: 54.9 [robust], 49.6 [prefrail], 46.8 [frail], p=0.002). Conclusions Advanced treatment performed in a high-risk population allowed people to impro

Objectives Sleep disturbances and delirium are frequently observed complications after surgical aortic valve replacement (SAVR) and transcutaneous aortic valve implantation (TAVI), especially in octogenarian patients. However, a knowledge gap exists on patient experiences of sleep and delirium. In particular, patients' long-Term sleep and delirium experiences are unknown. This article explores and describes how octogenarian patients suffering from delirium after aortic valve replacement experience their sleep and delirium situation. Design An explorative and descriptive design with a longitudinal qualitative approach was applied. Qualitative content analysis following the recommended steps of Graneheim and Lundman was performed. Setting Patients were included at a tertiary university hospital with 1400 beds. Delirium and insomnia screening was performed at baseline and five postoperative days after aortic valve treatment. For qualitative data, 10 patients were interviewed 6-12 months after treatment with focus on delirium. Five of these patients were reinterviewed 4 years after treatment, with focus on their sleep situation. Participants Inclusion criteria; age 80+, treated with SAVR or TAVI and had experienced delirium after treatment. Results For the initial interview, we included five men and five women, four following TAVI and six following SAVR, mean age 83. One overarching theme revealed from the content analyses; Hours in bed represented emotional chaos. Whereas three subthemes described the patients' experiences with sleep and delirium, a cascade of distressful experiences disturbing sleep, the struggle between sleep and activity and elements influencing sleep. Four years after the treatment, sleep disturbances persisted, and patients still remembered strongly the delirium incidences. Conclusions For octogenarian patients, sleep disturbances and delirium are long-Term burdens and need a greater attention in order to improve patient care.

Background: Delirium affects nearly half of octogenarian patients after aortic valve replacement, resulting in impaired cognition, reduced awareness and hallucinations. Although healthcare professionals and relatives are often present during episodes, the nature of interactions with them is scarcely studied, and little is known about their long-term experiences. Purpose: The purpose of this study was to explore and describe how octogenarian patients with post-aortic valve replacement delirium experience interactions with healthcare professionals and relatives within the first year and four years later. Method: An explorative design with qualitative content analysis was used. Delirium was assessed for five consecutive days after aortic valve replacement using the Confusion Assessment Method. Delirious patients (n=10) were interviewed 6-12 months post-discharge and four years later (n=5). We used an inductive approach to identify themes in transcribed interviews. Findings: An overarching theme emerged: 'Healthcare professionals' and relatives' responses made a considerable impact on the delirium experience postoperatively and in a long-term'. Three sub-themes described the patients' experiences: 'the need for close supportive care', 'disrespectful behaviour created a barrier' and 'insensitive comments made lasting impressions'. Having healthcare professionals and relatives nearby made the patients feel secure, while lack of attention elevated patients' emotional distress. Four years later, patients clearly recalled negative comments and unsupportive actions in their delirious state. Conclusions: Healthcare professionals and relatives have an essential role in the aortic valve replacement recovery process. Inconsiderate behaviour directed at older patients in delirium elevates distress and has long-term implications. Supportive care focused on maintaining the patients' dignity and integrity is vital.

Background: Sleep disturbance and delirium are complications after surgical aortic valve replacement (SAVR) and transcutaneous aortic valve replacement (TAVI), especially in octogenarian patients. Sedatives and z-hypnotics are medications distributed to promote sleep. However, a knowledge-gap exists on patient experiences with these medications, and sleep and delirium after the cardiac treatment. Aim: To explore and describe how octogenarians suffering from delirium after SAVR/TAVI experience their sleep situation related to sedatives and z-hypnotics, in a long-term perspective. Methods An explorative and descriptive design with a longitudinal qualitative approach was applied. Inclusion criteria; age 80+, treated with SAVR or TAVI and had experienced delirium. Information about administration of sedatives and z-hypnotics was collected from the patients journals. The Confusion Assessment Method (CAM) was used to assess delirium, the Sleep Sufficient Index (SSI) and Minimal Insomnia Symptom Scale (MISS) were used to document self-reported sleep and insomnia. All measures were performed at baseline and daily the five first postoperative days. Ten patients were interviewed 6-12 months after treatment with focus on delirium. Five of these patients were re-interviewed four years later, focusing on their sleep situation. Findings: For the initial interview, five men and five woman, four after TAVI and six after SAVR, mean age 83 were included. One overarching theme revealed; hours in bed represented an emotional chaos. Three sub-themes described the patients experiences with sleep and delirium, a cascade of distressful experiences, the struggle between sleep and activity and elements influencing sleep. In the category physical sleep distractions, sleep medications emerged as a sleep disturbing element but also to evoke delirium. Patients described to be offered sedatives and z-hypnotics in hospital. However, they did not have a positive experience with this as the medicati

Background: Octogenarian patients are an increasing group admitted for advanced cardiac treatment. Little is known about factors disturbing their sleep-wake pattern in the early postoperative phase after transcutaneous aortic valve replacement (TAVI), as current knowledge is based upon studies on younger age groups treated for surgical aortic valve replacement. Aim: To determine factors affecting the in-hospital sleep wake pattern in octogenarian patients after TAVI. Methods: This is a prospective cohort study in a tertiary university hospital. Inclusion criteria were age > 80 years with severe aortic stenosis accepted for TAVI. Actigraphy was used to identify sleep-wake pattern (sleep time night and sleep time day), and the Minimal Insomnia Symptom Scale (MISS) to measure self-reported insomnia daily during the first five postoperative days. Charlson`s comorbidity index was used as a measure of comorbidities and the Visual Analog Scale (VAS) to rate pain severity. Information regarding duration of anesthesia, blood transfusion and parenteral administration of morphine equivalents were derived from the patients’ medical journals. Multiple regression analysis was used to test associations between variables. Results: In all, 65 patients (41 women) were included. Mean age was 85 years (SD 2.8). No significant associations were found between age, comorbidities, blood transfusion and morphine equivalents and sleep. Gender was significantly associated with sleep time night and sleep efficiency as men had shortest duration of sleep from the third to the fifth postoperative night (p < .001, and adjusted R2=.230 to .283). Duration of anesthesia had a significant association with sleep time night and sleep efficiency from the third to the fifth postoperative night (p=.013 to p < .001, and adjusted R2=.230 to .283), where longer duration gave less total sleep and lower sleep efficiency. VAS score correlated with wake time night the third night, where a higher VAS scor

Background: Disturbances of the sleep-wake pattern are known phenomenon in the postoperative phase after aortic valve replacement (SAVR) that have negative impact on the morbidity, quality of life and mortality. Octogenarian patients are an increasing group admitted for cardiac surgery, however knowledge is based on younger patients. Aims: To determine factors associated with disturbances in postoperative sleep-wake pattern in octogenarian patients after SAVR. Methods: A prospective cohort study of octogenarian patients in a single center university hospital. Inclusion criteria were age > 80 years, severe aortic stenosis, accepted for SAVR. Actigraphy was used to identify the sleep-wake pattern (sleep-time, sleep efficiency and wake time night and sleep- and wake-time day) for the five first postoperative days, and the sleep questionnaires Minimal Insomnia Symptom scale (MISS) to measure the selfreported insomnia at baseline and daily for the five first postoperative days. Charlsons comorbidity index was used to score comorbidities and the Visual Analog Scale (VAS), was used to rate pain severity. The patients’ medical journals were used to record duration of anesthesia, duration of cardiopulmonary by-pass, blood transfusions and parenteral administration of morphine equivalents. Multiple regression analysis was used to test associations between variables. Results: In all, 78 patients were included (40 women). Mean age was 82 years (SD 2.0). For the sleep-wake pattern first to fifth postoperative night, mean sleep-time night was 330-370 minutes (SD 32-124). Mean sleep efficiency was 68-77% (SD 21-26). Mean sleep-time day was 545-712 minutes (SD 146-169). Mean insomnia score was 1,8-5,3 (SD 2,6-3,8). On the first postoperative night the pain VAS score correlated with wake time night, where a higher VAS indicated more wake time (p=.014, adjusted R2=.213). No other variable; age, gender, duration of anesthesia, duration of cardiopulmonary by-pass, blood transfusion

Objectives: To determine how development of delirium after surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) could predict activity of daily living (ADL) and instrumental ADLs (IADL) disability, cognitive function, and self-reported health in individuals aged 80 and older. Design: Prospective cohort study. Setting: Tertiary university hospital. Participants: Individuals aged 80 and older undergoing elective SAVR or TAVI (N = 136). Measurements: Delirium was assessed for 5 days using the Confusion Assessment Method. The Barthel Index, Nottingham Extended ADL Scale, and SF-12 were used to determine ADL and IADL ability and self-reported health at baseline and 1- and 6-month follow-up. Cognition was assessed using the Mini-Mental State Examination at baseline and 6-month follow-up. Results: Participants had lower IADL scores 1 month after SAVR than at baseline (baseline 58, 1 month: delirium 42, no delirium 50, P ≤.02), but scores had returned to baseline levels at 6 months. The Medical Outcomes Study 12-item Short-Form Health Survey (SF-12) Physical Component Summary (PCS) score was higher at 6-month follow-up (48) than at baseline (39), especially in participants who did not develop delirium (P <.001). No differences in other outcomes were found. Regression models suggest that delirium may help predict IADL disability 1 month after baseline (P ≤.07) but does not predict large differences in ADL disability, cognitive function, or SF-12-scores. Individuals who underwent TAVI and developed delirium had lower ADL (baseline 19, 1-month 16, P <.001) and IADL (baseline 49, 1-month 40, P =.003) scores at 1-month follow-up. SF-12 PCS score (baseline 30) increased from baseline to 1- (35, P =.04) and 6- (35, P =.02) month follow-up in individuals who underwent TAVI and did not develop delirium. Delirium after TAVI predicted greater ADL and IADL disability at 1-month but not at 6-month follow-up. Conclusion: Individuals who develop, On behalf of the Delirium in Octogenarians Undergoing Cardiac Surgery or Intervention–CARDELIR Investigators

Objectives: To determine whether postoperative delirium predicts first-time readmissions and mortality in octogenarian patients within 180 days after aortic valve therapy with surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI), and to determine the most common diagnoses at readmission. Design: Prospective cohort study of patients undergoing elective SAVR or TAVI. Setting: Tertiary university hospital that performs all SAVRs and TAVIs in Western Norway. Participants: Patients 80+ years scheduled for SAVR or TAVI and willing to participate in the study were eligible. Those unable to speak Norwegian were excluded. Overall, 143 patients were included, and data from 136 are presented. Primary and secondary outcome measures: The primary outcome was a composite variable of time from discharge to first all-cause readmission or death. Secondary outcomes were all-cause first readmission alone and mortality within 180 days after discharge, and the primary diagnosis at discharge from first-time readmission. Delirium was assessed with the confusion assessment method. First-time readmissions, diagnoses and mortality were identified in hospital information registries. Results: Delirium was identified in 56% of patients. The effect of delirium on readmissions and mortality was greatest during the first 2 months after discharge (adjusted HR 2.9 (95% CI 1.5 to 5.7)). Of 30 first-time readmissions occurring within 30 days, 24 (80%) were patients who experienced delirium. 1 patient (nondelirium group) died within 30 days after therapy. Delirious patients comprised 35 (64%) of 55 first-time readmissions occurring within 180 days. Circulatory system diseases and injuries were common causes of first-time readmissions within 180 days in delirious patients. 8 patients died 180 days after the procedure; 6 (75%) of them experienced delirium. Conclusions: Delirium in octogenarians after aortic valve therapy might be a serious risk factor for postoperativ

Background: Octogenarians with aortic stenosis are an increasing population of patients admitted for surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI). Although adequate sleep is important after illness and surgery, it has scarcely been studied in the immediate postoperative phase. Aims: To determine and compare the nature of self-reported sleep and insomnia, and recorded sleep–wake patterns in octogenarians during the in-hospital postoperative phase after SAVR or TAVI. Methods: A prospective cohort design was used that included octogenarian patients undergoing SAVR or TAVI at a regional university hospital. Self-reports were used to document sleep and insomnia, and actigraphy was used to record sleep–wake patterns. Data were collected at baseline preoperatively, and then daily for the first five postoperative days. Results: SAVR patients experienced the most insomnia on postoperative nights later in recovery, while TAVI patients experienced the most insomnia on postoperative nights early in recovery. The median total sleep time, as measured by actigraphy, was 6.4 h, and the median sleep efficiency was 79% for the five postoperative nights, but no differences were found between SAVR and TAVI patients on this parameter. All patients slept more during daytime than at night, with SAVR patients having significantly more total sleep hours for all five days than TAVI patients (p < 0.01). Conclusion: Octogenarians with aortic stenosis had disturbed self-reported sleep, increased insomnia, and disturbed sleep–wake patterns postoperatively, resulting in more daytime sleep and inactivity. In patients undergoing SAVR or TAVI, sleep evolves differently during the in-hospital postoperative phase.

In this paper we outline the relationship between the need to put existing applied health research knowledge into practice (the “know-do gap”) and the need to improve the evidence base (the “know gap”) with respect to the health care process used for older people with frailty known as comprehensive geriatric assessment (CGA). We explore the reasons for the know-do gap and the principles of how these barriers to implementation might be overcome. We explore how these principles should affect the conduct of applied health research to close the know gap. We propose that impaired flow of knowledge is an important contributory factor in the failure to implement evidence-based practice in comprehensive geriatric assessment; this could be addressed through specific knowledge mobilisation techniques. We describe that implementation failures are also produced by an inadequate evidence base which requires the co-production of research, addressing not only effectiveness but also the feasibility and acceptability of new services, the educational needs of practitioners, the organisational requirements of services, and the contribution made by policy. Only by tackling these issues in concert and appropriate proportion, will the know and know-do gaps for CGA be closed.