Course and Lethality of SARS-CoV-2 Epidemic in Nursing Homes after Vaccination in Florence, Italy

Evidence on the effectiveness of SARS-CoV-2 vaccines in nursing home (NHs) residents is limited. We examined the impact of the BNT162b2 mRNA SARS-CoV-2 vaccine on the course of the epidemic in NHs in the Florence Health District, Italy, before and after vaccination. Moreover, we assessed survival and hospitalization by vaccination status in SARS-CoV-2-positive cases occurring during the post-vaccination period. We calculated the weekly infection rates during the pre-vaccination (1 October-26 December 2020) and post-vaccination period (27 December 2020-31 March 2021). Cox analysis was used to analyze survival by vaccination status. The study involved 3730 residents (mean age 84, 69% female). Weekly infection rates fluctuated during the pre-vaccination period (1.8%-6.5%) and dropped to zero during the post-vaccination period. Nine unvaccinated (UN), 56 partially vaccinated (PV) and 35 fully vaccinated (FV) residents tested SARS-CoV-2+ during the post-vaccination period. FV showed significantly lower hospitalization and mortality rates than PV and UV (hospitalization: FV 3%, PV 14%, UV 33%; mortality: FV 6%, PV 18%, UV 56%). The death risk was 84% and 96% lower in PV (HR 0.157, 95%CI 0.049-0.491) and FV (HR 0.037, 95%CI 0.006-0.223) versus UV. SARS-CoV-2 vaccination was followed by a marked decline in infection rates and was associated with lower morbidity and mortality among infected NH residents.

Caring for nursing home residents with COVID-19: a "hospital-at-nursing home" intermediate care intervention

Background

Nursing home (NH) residents have been dramatically affected by COVID-19, with extremely high rates of hospitalization and mortality.

Aims

To describe the features and impact of an assistance model involving an intermediate care mobile medical specialist team (GIROT, Gruppo Intervento Rapido Ospedale Territorio) aimed at delivering “hospital-at-nursing home” care to NH residents with COVID-19 in Florence, Italy.

Methods

The GIROT activity was set-up during the first wave of the pandemic (W1, March–April 2020) and became a structured healthcare model during the second (W2, October 2020–January 2021). The activity involved (1) infection transmission control among NHs residents and staff, (2) comprehensive geriatric assessment including prognostication and geriatric syndromes management, (3) on-site diagnostic assessment and protocol-based treatment of COVID-19, (4) supply of nursing personnel to understaffed NHs. To estimate the impact of the GIROT intervention, we reported hospitalization and infection lethality rates recorded in SARS-CoV-2-positive NH residents during W1 and W2.

Results

The GIROT activity involved 21 NHs (1159 residents) and 43 NHs (2448 residents) during W1 and W2, respectively. The percentage of infected residents was higher in W2 than in W1 (64.5% vs. 38.8%), while both hospitalization and lethality rates significantly decreased in W2 compared to W1 (10.1% vs 58.2% and 23.4% vs 31.1%, respectively).

Discussion

Potentiating on-site care in the NHs paralleled a decrease of hospital admissions with no increase of lethality.

Conclusions

An innovative “hospital-at-nursing home” patient-centred care model based on comprehensive geriatric assessment may provide a valuable contribution in fighting COVID-19 in NH residents.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-021-01959-z.

Underlying hemodynamic differences are associated with responses to tilt testing

Aim of this study was to explore whether differences in resting hemodynamic parameters may be associated with tilt test results in unexplained syncope. We analyzed age, gender, systolic (SBP), diastolic blood pressure (DBP) and heart rate (HR) by merging three large databases of patients considered likely to be of vasovagal reflex etiology, comparing patients who had tilt-induced reflex response with those who did not. Tilt-induced reflex response was defined as spontaneous symptom reproduction with characteristic hypotension and bradycardia. Relationship of demographics and baseline supine BP to tilt-test were assessed using logistic regression models. Individual records of 5236 patients (45% males; mean age: 60 ± 22 years; 32% prescribed antihypertensive therapy) were analyzed. Tilt-positive (n = 3129, 60%) vs tilt-negative patients had lower SBP (127.2 ± 17.9 vs 129.7 ± 18.0 mmHg, p < 0.001), DBP (76.2 ± 11.5 vs 77.7 ± 11.7 mmHg, p < 0.001) and HR (68.0 ± 11.5 vs 70.5 ± 12.5 bpm, p < 0.001). In multivariable analyses, tilt-test positivity was independently associated with younger age (Odds ratio (OR) per 10 years:1.04; 95% confidence interval (CI), 1.01–1.07, p = 0.014), SBP ≤ 128 mmHg (OR:1.27; 95%CI, 1.11–1.44, p < 0.001), HR ≤ 69 bpm (OR:1.32; 95%CI, 1.17–1.50, p < 0.001), and absence of hypertension (OR:1.58; 95%CI, 1.38–1.81, p < 0.001). In conclusion, among patients with suspected reflex syncope, younger age, lower blood pressure and lower heart rate are associated with positive tilt-test result.

The CHA2DS2-VASc score and Geriatric Multidimensional Assessment tools in elderly patients with persistent atrial fibrillation undergoing electrical cardioversion. A link with arrhythmia relapse?

INTRODUCTION

The CHA₂DS₂-VASc score is widely used for stroke risk stratification in patients with atrial fibrillation (AF). Our endpoints were to evaluate in an old population undergoing electrical cardioversion (ECV) of persistent AF if the CHA₂DS₂-VASc was associated with some of the Geriatric Multidimensional Assessment tools and with the presence of sinus rhythm at the follow-up.

METHODS

We enrolled all the consecutive patients admitted in a day-hospital setting aged ≥60 years. The Mini-Mental State Examination (MMSE; neurocognitive function), the 15-item Geriatric Depression Scale (GDS; depressive symptoms) and the Short Physical Performance Battery (SPPB; physical functioning) were administered before ECV.

RESULTS

Between 2017 and 2019, 134 patients were enrolled (mean age: 77±9 years, range: 60-96; men: 63.4%; EF: 60±12%). Hypertension was the most frequent comorbid condition (82.1%). The CHA₂DS₂-VASc score was 3.8±1.6. Abnormal values of MMSE, GDS and SPPB were observed in 7.9, 19.8 and 22.3% of cases, respectively. There were significant correlations between the CHA₂DS₂-VASc score and the MMSE (p=0.008), the GDS (p<0.001) and the SPPB (p<0.001). Depressive symptoms increased CHA₂DS₂-VASc correlation with SPPB of about 20%. CHA₂DS₂-VASc score was higher in patients with arrhythmia relapse (p=0.048; mean length of follow-up: 195 days). This association persisted even after adjustment for amiodarone therapy.

CONCLUSIONS

The CHA₂DS₂-VASc score significantly correlated with neuro-cognitive performance, depressive symptoms and physical functioning. It was also associated with AF relapse. Accordingly, in the elderly, the CHA₂DS₂-VASc could help quantify thrombo-embolic risk, give an indication of frailty status and help to choose between a rate- and a rhythm-control strategy.

67Atrial fibrillation and depressive symptoms in the elderly: an association with age, CHA2DS2-VASc score and physical performance

Background. Atrial fibrillation (AF) is the most frequent sustained arrhythmia found in clinical practice. Its prevalence significantly grows with age. The proportion of elderly individuals with depression varies between 4.2 and 10.6% according to the different criteria used for diagnosis. Interestingly, AF and depression synergistically act to increase mortality.

Purpose. Aim of this study was to identify the clinical variables associated with depressive symptoms in elderly individuals with persistent AF.

Methods. All patients consecutively admitted in a Day-Hospital setting to undergo electrical cardioversion of AF were enrolled in the study. No exclusion criteria were specified. Population was studied with instruments exploring neurocognitive performance (Mini-Mental State Examination - MMSE; range: 0-30; abnormal values &lt;27) and functional status (Short Physical Performance Battery; range: 0-12; abnormal values &lt;10). With these tools, a better condition is expressed by higher scores. The presence of depressive symptoms was assessed with the Geriatric Depression Scale (GDS; 15-item form; abnormal values &gt;5). In this case, lower scores identified a healthier emotional profile.

Results. Between January 2018 and August 2019, 111 patients were evaluated (age: 77 ± 9 years; women: 39.6%; weight: 78 ± 15 Kg; height: 171 ± 11 cm). Lone AF and brady- tachy- syndrome were diagnosed in 12.6% of cases. Hypertension and structural heart disease (coronary artery disease, heart failure, valvular heart disease) were responsible of the arrhythmia in 30.6% and 56.8% of patients, respectively. Left ventricular ejection fraction was 60 ± 12%, with a heart rate equal to 78 ± 17 bpm. MMSE and SPPB score were 28 ± 3 and 8.7 ± 2.9. An abnormal GDS score was observed in 19.8% of cases (mean: 3.0 ± 2.7). Interestingly, in univariate analysis, depressive symptoms increased with age (p = 0.002) and the CHA2DS2-VASc score (&lt; =2: 1.3 ± 1.7; 3: 1.9 ± 2.3; 4: 3.9 ± 3.2; 5: 4.0 ± 2.4; &gt; =6: 4.4 ± 2.8; p &lt; 0.001), and were inversely related to MMSE (p = 0.004) and SPPB (p &lt; 0.001). The type of oral anticoagulation (NOACs: 64.0%) did not exert any effect on GDS score (VKA: 3.2 ± 2.2 vs. NOACs: 3.0 ± 3.0; p = 0.717). In multivariate analysis (R = 0.711; p &lt; 0.001), depressive symptoms were higher in those who lived alone (+1.35 ± 0.48; p = 0.007) and were taking a renin-angiotensin system blocker (+0.93 ± 0.43; p = 0.032). Age (-0.07 ± 0.03 per year; p = 0.026), height (-0.09 ± 0.03 per cm; p = 0.001), glomerular filtration rate (-0.03 ± 0.01 per mL/min; p = 0.013) and SPPB (-0.39 ± 0.09 per each point; p &lt; 0.001) were inversely associated with GDS.

Conclusions. In a population of elderly patients with persistent AF, the prevalence of depression is not negligible. Importantly, depressive symptoms are significantly associated with the CHA2DS2-VASs score, and, at multivariate analysis, with renal function, to live alone and physical performance. Paradoxically, after adjustment for these factors, GDS score decreases with age per se.

The complex interaction between atrial fibrillation and heart failure in elderly patients

Heart failure (HF) and atrial fibrillation (AF) often coexist. Subjects with permanent AF show the highest prevalence of HF. Patients with incident AF have HF in a great number of cases and, reciprocally, in patients with incident HF, an AF can be frequently found. The simultaneous presence of the two conditions is associated with mortality rates higher than those observed in individuals with only one or none of them. Interestingly, HF and AF could synergistically promote in elderly patients the development of disability and dementia. Inflammatory mechanisms coupled with changes of renin-angiotensin system, hormonal pathways and neuro-mediators could simultaneously promote left atrium remodeling and sustain both HF and AF. Beta-blockers and digoxin seem to have small therapeutic effect and limited influence on prognosis in these very complex patients. Sinus rhythm restoration could slow down the progression of disability in symptomatic subjects. Recent evidence seem to suggest that upstream therapy coupled with rehabilitation, and that AV node ablation associated with cardiac resynchronization therapy could benefit subjects with HF and AF. In conclusion, elderly patients simultaneously presenting problems of cardiac function and arrhythmia are an important challenge for geriatric medicine, and request important efforts to improve their functional profile and prognosis.

DAPT plus anticoagulant therapy: The difficult coexistence post-ACS in older patients with atrial fibrillation

Atrial fibrillation (AF) and coronary artery disease requiring percutaneous coronary intervention (PCI) and stenting often coexist in older patients. This poses the difficult problem of concurrent anticoagulant and double antiplatelet therapy (triple therapy). Current treatment guidelines do recommend triple therapy, especially in the course of acute coronary syndrome (ACS), with limitations due to an excessive risk of bleeding associated with this therapeutic regimen. This review summarizes randomized clinical trials and observational studies that compared triple therapy with a variety of different therapeutic options. Although the available evidence is not completely satisfactory and other studies are urgently needed, alternative regimens to triple therapy in AF patients undergoing PCI and stenting are promising, at least in terms of safety.

Rate-control vs rhythm-control of atrial fibrillation in elderly patients. From new, age-oriented outcomes to a more complex management strategy

Atrial fibrillation (AF) is the most frequent arrhythmia in elderly people. Findings derived from clinical trials seem to demonstrate that a rate-control strategy of AF in aged patients improves prognosis if compared to a rhythm-control one. However, epidemiological studies concordantly show that the arrhythmia is associated to increased hospitalization and mortality rates. In last years, the proportion of patients admitted to hospital for AF has progressively increased; this trend is observed in subjects >75 and >85 years, while no change was found in younger cohorts. Importantly, in aged individuals, probably because of the loss of atrial activity, the increase of heart rate and the irregularity of RR intervals, AF begins a vicious cycle, leading from heart failure, through the compromise of functional and neurocognitive status, to overt disability, dementia and increased mortality. Evidence specifically aimed at clarifying the effects of arrhythmia management on outcomes characteristic of aged people is completely lacking. In the elderly, the question regarding the effects of a rate- or a rhythm-control strategy of AF should be considered as an aspect of a more complex strategy, addressed to reduce disability and hospitalizations, and to improve quality of life and survival.