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Thank you for revising your manuscript to address the reviewers' concerns. Reviewer 2 now recommends acceptance and I am also satisfied with your response to the earlier comments of reviewer 1. The manuscript is now ready for publication.
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Introduction and background clearly show context:
The introduction thoroughly presents the demographic context of elderly emergency care in China, defines geriatric syndromes, and builds a solid rationale for the study. The importance of sleep in the development of these syndromes is well explained.
Literature is well referenced and relevant:
The references are recent (mostly post-2020), relevant, and comprehensive. The literature review adequately supports the study rationale.
Clarify which sleep-related questions were used—the study mentions four, but their exact wording or structure isn't fully provided.
Note the limitations of convenience sampling in the Methods, not only in the Discussion.
State the rationale for merging “mild cognitive impairment” and “dementia” into one group—this may mask differences in risk.
Causality appropriately avoided:
Mostly yes. The authors state this is a cross-sectional study and avoid strong causal claims. However, in some places, phrases like “sleep may be a contributing factor” could be slightly softened (e.g., “associated with increased risk”) to reinforce non-causality.
Generalizability is limited:
Correctly acknowledged in the limitations, but could be emphasized more strongly. As the sample is from a single hospital and based on convenience sampling, the results may not be fully representative of all elderly ED patients in China.
The study uses validated assessment tools (RGA, structured sleep questions) and appropriately applies adjusted logistic regression to control for common confounders. The findings are both statistically robust and clinically relevant.
That said, the manuscript would benefit from moderate revisions in the following areas:
Minor language polishing for fluency and consistency
Formatting corrections in Table 3 (currently difficult to read)
Slight moderation of causal phrasing, especially in the conclusions
Stronger emphasis in the abstract and discussion on the limitations due to convenience sampling and single-center design
The manuscript titled Sleep and geriatric syndromes in elderly emergency patients in China: a cross-sectional survey (#117409), is an important study to understand association of sleep quality with prevalent geriatric conditions in geriatric cohort. It is well known that geriatric population is on rise globally with increased longevity and rightly stated by the authors regarding the highest population of elderly in China as per 2023 data. Such studies are the need of the time to understand regional differences of sleep and geriatric syndromes so that viable policies for geriatric care could be improvised based on more recent inputs. However, there are a few major concern that require attention:
Introduction:
From line 72 onwards, authors described role of sleep in health. The statement: “Despite this, sleep disorders are prevalent among elderly patients” needs modification. Sleep is dynamic process which changes from birth to death. Expression “Despite this” is confusing as it is not conveying any message rather riding on the later statement that is correct by all means.
Moreover, there is omission of one crucial reference that can be quoted for this statement as ref 13 (Gulia KK, Kumar VM (2018). Sleep disorders in the elderly: A growing challenge. Psychogeriatrics, 18: 155-165).
**PeerJ Staff Note:** It is PeerJ policy that additional references suggested during the peer-review process should only be included if the authors are in agreement that they are relevant and useful.
Regarding geriatric syndromes, authors have taken standard Morley scale RGA. However, for sleep no standard questionnaire is taken for the assessment of sleep quality. Nevertheless, this preliminary study attempted to study correlation of sleep quality by making 3 groups. Sleep in elderly is a complex issue. There is no subjective estimation of total daytime naps duration, and moreover people generally might have wrong perception about their sleep duration and quality. Age related melatonin rhythm is also less robust that can also disturb their circadian rhythm making sleep shallow with lesser deep sleep (age dependent deterioration). Thus a statement of expected sleep quality and quantity in Introduction would be advisable (Ref is already given in 1st point).
This part is fine
Association of sleep with GS is interesting but it is a futuristic question to address cause and effect relationship of age related reduced deep and sarcopenia, frailty etc. Caution should be taken to express such relationships. However, disrupted glymphatic clearance during old age explains dementia, cognitive decline and AD.
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