Conocimiento científico sobre las infecciones por el nuevo coronavirus en los ancianos: scoping review

Tavares, Darlene Mara dos Santos; Oliveira, Nayara Gomes Nunes; Diniz-Rezende, Marina Aleixo; Bitencourt, Graziele Ribeiro; Silva, Marcos Barragan da; Bolina, Alisson Fernandes

doi:10.1590/0034-7167-2020-0938

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REVIEW • Rev. Bras. Enferm. 74 (Suppl 1) • 2021 • https://doi.org/10.1590/0034-7167-2020-0938 linkcopiar

Conocimiento científico sobre las infecciones por el nuevo coronavirus en los ancianos: scoping review

Autoría SCIMAGO INSTITUTIONS RANKINGS

Objetivo: mapear el conocimiento científico sobre COVID-19 en ancianos.

Método: revisión de la literatura del tipo scoping review. Se realizó una búsqueda en las bases de datos PubMed, CINAHL, Web of Science y LILACS. Se incluyeron artículos originales que respondieron a la pregunta orientadora: ¿qué conocimiento científico está disponible en el mundo sobre el COVID-19 en los ancianos?

Resultados: se incluyeron 31 artículos, la mayoría realizados en China (n=23) y con un diseño retrospectivo (n=13) y estudios de casos/series de casos (n=13). A partir de los hallazgos, surgieron seis categorías temáticas: signos y síntomas clínicos (n=12); otra información (n=9); resultados/complicaciones adversos resultantes de COVID-19 (n=8); relación de edad y mayor gravedad de COVID-19 (n=8); variables relacionadas con la muerte por COVID-19 (n=8); hallazgos diagnósticos (n=8).

Conclusión: los hallazgos refuerzan la mayor vulnerabilidad de los ancianos al agravamiento del COVID-19, así como las complicaciones derivadas de la enfermedad, incluida la mayor ocurrencia de muerte.

Descriptores:
Anciano; Coronavirus; Síndrome Respiratorio Agudo Grave; Infecciones por Coronavírus; Enfermería Geriátrica

Objetivo: mapear el conocimiento científico sobre COVID-19 en ancianos.

Author, year, and country	Type of study	Study participants/period	Main results
Ahn YJ et al., 2020 (Korea)⁽¹⁰⁾	Case studies	- 02 patients with COVID-19 with acute respiratory syndrome (71 years and 67 years). - Period: February and March 2020.	-When receiving lopinavir/ritonavir and hydroxychloroquine, older adults maintained persistent fever, hypoxemia, and progressive bilateral infiltrations. - After plasma infusion, patients showed improvement in oxygenation and chest X-ray, and a decrease in inflammatory markers and viral loads. - After application of methylprednisolone, before plasma infusion, there was a rapid improvement in serial laboratory and oxygenation standards.
Valentina S, Alessio P, Hans-Ulrich I, 2020 (Italy)⁽¹¹⁾	Case studies	- 02 patients with COVID-19 (couple), the woman being treated with chemotherapy for recurrent breast cancer, and her husband considered healthy (controlled hypertension). Both 60 years old. - Period: March 2020.	- Both patients were treated with darunavir/cobicistat and hydroxychloroquine. - The immunocompromised woman evolved, without the need for intensive care and was discharged after 6 days. - The husband needed intensive care and his recovery was slow, although he was also discharged from the hospital.
Chantal Tapé BA et al., 2020 (United States)⁽¹²⁾	Case study	- 01 female older adult with COVID-19 (79 years). - Period: not specified.	- Older adult with previous cardiovascular disease presented with syncope episode; she was afebrile, with a normal chest X-ray and with no suspicion of COVID-19. - In 03 days, she developed a fever and tested positive for COVID-19. - Syncope may be a symptom of COVID-19 in older adults with cardiovascular diseases.
Yuan Y et al., 2020 (China)⁽¹³⁾	Case series	- 06 patients with COVID-19, being 04 older adults (02 men - 65 and 64 years old; and 02 women - 64 and 71 years old). -Period: January 2020	- All older adult patients had malnutrition; - Nutritional status can be useful in identifying older adults at high risk with COVID-19.
Suwanwongse K et al., 2020 (United States)⁽¹⁴⁾	Case study	- 01 patient with COVID-19 (88 years). - Period: not specified.	- Patient with hypertension, chronic kidney disease, heart failure with reduced ejection fraction, benign prostatic hypertrophy, bilateral knee osteoarthritis, and mild cognitive impairment. - Entered the emergency room with symptoms of rhabdomyolysis, including muscle pain and weakness. - In the initial assessment, she had low fever, tachypnea, and 94% oxygen saturation. - The COVID-19 polymerase chain reaction test of the nasopharyngeal swab was positive.
Chen X et al., 2020 (China)⁽¹⁵⁾	Case study	- 03 patients with COVID-19, one of whom is an older adult (67 years old). Period: not specified.	- Chest CT scan without contrast showed multiple, bilateral, irregular ground-glass opacities with a paving pattern. Using an antiviral (Abidore) did not help to reduce the patient's temperature, nor to improve her breathing pattern. - After four days, chest computed tomography was repeated, and demonstrated increased multiple consolidation, ground-glass nodules and ground-glass nodules adjacent to the pleura. - The patient received intravenous administration of methylprednisolone (40 mg qd), oral administration of γ-immunoglobulin and traditional Chinese medicine and non-invasive positive pressure ventilation. The dynamic computed tomography showed irregular consolidation and partially absorbed nodules, indicating that the symptoms were alleviated.
Moreira BL et al., 2020 (Brazil)⁽¹⁶⁾	Case study	- 01 older adult with COVID-19 (73 years). - Period: not specified.	- On chest radiography, he presented ill-defined pulmonary opacities, notably on the periphery of the left lung. - On chest computed tomography, he presented ground-glass opacities, predominantly peripheral, involving all pulmonary lobes.
Quin C et al., 2020 (China)⁽¹⁷⁾	Case series	- 04 patients with COVID-19, 01 older adult (woman and 61 years old) - Period: January 13th to 20th, 2020	- The older adult patient had back pain and a dry cough, mild leukopenia, peripheral ground-glass opacities, and pulmonary consolidations in more than two pulmonary lobes.
Lescure FX et al., 2020 (France)⁽¹⁸⁾	Case study	- 05 patients with COVID-19, one of whom is an older adult (80 years old). - Period: January 2020.	- The older adult patient presented rapid evolution to multiple organ failure and high and persistent viral load in the lower and upper respiratory tract. - The older adult patient died 24 days after the disease; and everyone else recovered and was discharged.
Okada P et al., 2020 (China) ⁽¹⁹⁾	Case study	- 02 female older adults with COVID-19 (60 years and 70 years). - Period: January 2020.	- Genomes of the cases are identical. These genomes have no direct link to the Huanan Seafood Market, but their genomes are identical to four Wuhan strings, collected on December 30, 2019, indicating a potentially wider distribution in the city.
Wang Z et al., 2020 (China)⁽²⁰⁾	Case series	- 04 patients with COVID-19, 02 older adults (63-year-old woman; 63-year-old man). - Period: January 21th and 24th, 2020.	- Signs and symptoms in older adult patients: fever and cough. The woman also had vertigo and constipation. - On tomography, the man presented unilateral pneumonia, and the older adult, bilateral. - Both older adults received oxygen therapy, treatment with antibiotics and antivirals with lopinavir/ritonavir (Kaletra®), arbidol and Shufeng Jiedu Capsule. The woman was on mechanical ventilation. - The man improved the symptoms associated with pneumonia, and the first test was negative. - At the end of data collection, the woman showed signs of improvement in pneumonia.
Zang W, 2020 (China)⁽²¹⁾	Case study	- 01 male older adult (75 years old). - Period: not specified.	- Hypertensive and diabetic older adults were diagnosed with severe COVID-19 pneumonia associated with Severe Acute Respiratory Syndrome and septic shock. - In the physical exam he did not present fever; however, even though using non-invasive oxygen therapy, oxygen saturation was 91%. - The three-dimensional reconstruction of bilateral lung injuries provided a fundamental clue for early identification of COVID-19.
Chan JFW et al., 2020 (China)⁽²²⁾		06 people, 05 with a diagnosis of COVID-19, being 03 older adults, 02 female (65 and 66 years old) and 01 male (66 years old). Period: January 2020.	- Older adults showed more systemic symptoms (fever ≥38.2ºC), extensive ground-glass radiological changes, lymphopenia, thrombocytopenia and increased levels of C-reactive protein and lactic dehydrogenase.

Author, year, and country	Type of study	Study participants/Period	Main results
Zhang G et al., 2020 (China)⁽¹⁾	Retrospective study	-95 patients with pneumonia by COVID-19, 17 of whom are older adults (> 60 years old). - Period: January 16^th to February 25^th (2020).	- 41.2% of older adults were severe cases of COVID-19 and reached the compound endpoint (admission to an Intensive Care Unit, mechanical ventilation, or death).
Pan A et al., 2020 (China)⁽⁵⁾	Cohort study	- 32,583 patients with COVID-19, 13,818 older adults (≥ 60 years old). - Period: December 8^th (2019) to March 8^th (2020).	- The risk of severity of COVID-19 increased with age. Older adults aged 80 years or older had a higher risk of having severe COVID-19 (41.3%; OR: 3.61 [95% CI, 3.31-3.95]).
Verity R et al., 2020 (China)⁽²³⁾	Analytic study	- 194 deaths and 30,763 infected in people <60 years old/829 deaths and 13,909 infected people aged ≥60 years old - Period: cases reported in China until February 8^th and outside China until February 25^th (2020).	- The estimated rate, by the parametric method, of case fatality was lower in those under 60 years old (1.4% [0.4-3.5]) compared to those aged 60 and over (4, 5% [1.8-11, 1]). - It was observed a higher proportion of more severe cases as the age group increases: 11.8% (7.01-24.0) between 60-69 years old; 16.6% (9.87-33.8) between 70-79 years old and 18.4% (11.0-37.6) ≥80 years.
Lian J et al., 2020 (China)⁽²⁴⁾	Retrospective study	- 788 patients with COVID-19, 136 older adults (≥ 60 years old). - Period: January 17th to February 12^th (2020).	-The presence of comorbidities was higher in older adults (55.1%) compared to younger ones (21.9%) (p <0.001). - Higher proportion of older adults among the most severe patients (16.2%; p <0.001) and critically ill (8.8%; p <0.001), with shortness of breath (12.5%; p <0.001) and fever> 39.0℃ (14.0%; p=0.010). - There was no statistically significant difference between the groups regarding the time of disease onset and first consultation (p=0.867), confirmation of diagnosis (p=0.410), and hospitalization (p=0.945). - The highest proportion of admissions to Intensive Care Units (9.56%; p <0.001) and applications of methylprednisolone (28.68%; p <0.001) was among older adults.
Grasselli G et al., 2020 (Italy)⁽²⁵⁾	Retrospective study	- 1,591 patients with COVID-19, 961 older adults (≥ 61 years). - Period: February 20^th to March 18^th (2020).	- All long-lived patients (100%) and 76% of older adults aged 60 and over had at least one comorbidity. - Invasive mechanical ventilation was used in 89% of older adults. - Non-invasive ventilation was used in 10% of older adults. - Mortality in Intensive Care Units was higher in older adults (36%; p <0.001). - Percentage of patients discharged from Intensive Care Units was lower among older adults (11%; p <0.001).
Wang L et al., 2020 (China)⁽²⁶⁾	Retrospective study	- 339 older adults (> 60 years) with COVID-19. - Period: January 1^st to February 6^th (2020).	- Mean age was 71 ± 8 years; 51% were female; 23.6% were critically ill patients; 46.9% were critically ill patients; 29.5% were moderate cases. - Common comorbidities: hypertension (40.8%), diabetes mellitus (16.0%), and cardiovascular diseases (15.7%). The most common symptoms were fever (92.0%), cough (53.0%), dyspnea (40.8%), and fatigue (39.9%). - Lymphocytopenia was a common laboratory finding (63.2%). - Common complications: bacterial infection (42.8%), abnormalities of liver enzymes (28.7%), and acute respiratory distress syndrome (21.0%). - 26.8% were discharged and 19.2% died. - A shorter length of stay was found among those who died (5 days) compared to survivors (28 days) (p <0.001). - Dyspnea symptoms (OR: 2.35; p=0.001), comorbidities, including cardiovascular disease (OR: 1.86; p=0.031) and chronic obstructive pulmonary disease (OR: 2.24; p=0.023) and syndrome acute respiratory distress (OR: 29.33; p <0.001) were strong predictors of death. A high level of lymphocytes was predictive of a better result (OR: 0.10; p <0.001
Chen TL et al., 2020 (China)⁽²⁷⁾	Retrospective study	- 203 patients with COVID-19, 55 older adults (≥ 65 years). - Period: January 1^st to February 10^th (2020).	- Among patients aged 65 and over, the mortality rate was 34.5%, significantly higher than that of older adults ≤ 65 years of age (4.7%) (p <0.001). - Common symptoms of older adult patients with COVID-19 included fever (94.5%), dry cough (69.1%), and dyspnea (63.6%). -Older adults aged 65 and over had higher initial comorbidities (p <0.001), more severe symptoms (p <0.001) and more likely to multiple organ failure (p <0.001), compared to younger patients.
Wu J et al., 2020 (China)⁽²⁸⁾	Retrospective study	- 280 patients infected with SARS-CoV-2, being 69 older adults (≥65 years old). - Period: January 20^th to February 19^th (2020).	- Among the older adults, a greater proportion of the severe condition of the disease was evidenced in relation to the mild one (p <0.001). -In an multivariate analysis, the age group of 65 years and over was an independent risk factor for COVID-19 (OR=81.2; CI=1.10-5988.12).
Chen Z et al., 2020 (China)⁽²⁹⁾	Retrospective study	- 98 patients with COVID-19, 20 older adults (≥ 60 years old). - Period: January 20^th to February 17^th (2020).	- Differences between clinical manifestations (fever and sputum) in infected patients of different age groups were not statistically significant (p> 0.05), nor was there a statistically significant difference in the interval between the first onset of symptoms and high-resolution computed tomography (p=0.921). - A greater number of cases of bilateral pulmonary involvement was found in patients ≥ 60 years old in relation to the others (p <0.05). - The number of lung lesions observed by high-resolution computed tomography in patients aged 60 years or older was higher compared to those younger than 18 years old (p=0.019). - Involvement of peripheral lung injuries in the older adult group was greater than the group of children under 18 years old (p=0.005).
Wang R et al., 2020 (China)⁽³⁰⁾	Descriptive study	- 125 patients diagnosed with COVID-19, 14 older adults (≥ 59 years old). -Period: January 20^th to February 9^th (2020).	-Patients were classified as non-critical (mild, common) and critical (severe; critical). Critical patients were older (p=0.003) and had more underlying disease than non-critical patients (p=0.009).
Li Q et al., 2020 (China)⁽³¹⁾	Descriptive study	- 425 patients with pneumonia caused by the new coronavirus, 240 older adults (≥ 60 years old). - Period: until January 22^th (2020).	- Characteristics of the cases in three periods: the first period was for patients with disease onset before January 1st, the date on which the Huanan Wholesale Seafood Market was closed (older adults - 65 years and over - represented 23%); the second period was for those beginning between 1 and 11 January, which was the date on which the RT-PCR reagents were supplied to Wuhan (older adults - 65 years or older - represented 42%); and the third period were those with onset of the disease on or after January 12 (older adults - 65 years or older - represented 37%). - It was noted that few of the first cases occurred in children, and almost half of the 425 cases were in adults aged 60 years and over.
Liu K et al., 2020 (China)⁽³²⁾	Retrospective study	- 56 patients with COVID-19 pneumonia, 18 older adults (≥ 60 years old). - Period: January 15^th to February 18^th (2020).	- 22.3% of older adults received mechanical ventilation in an Intensive Care Unit. - 5.56% of older adults died; - Proportion of older adults with severe grade IV and V pneumonia index was higher than that of young and middle-aged patients (p <0.001). - Proportion of impairment of multiple lung lobes was higher in the older adult group, compared to the young and middle-aged group (p <0.001). - Proportion of lymphocytes in the older adult group was lower compared to the young and middle age group (p <0.001). - The older adults, compared to the younger group, presented higher percentages of complications during hospitalization, being: severe acute respiratory syndrome (22.2%; 5.3%), acute cardiac injury (16.7%; 10.5%), acute liver and kidney injury (38, 9%; 7.9%), secondary infection (22.2%; 13.2%) and shock (5.6%; 5.3%), respectively. However, the difference was not significant (p=0.337).
Chen N et al., 2020 (China)⁽³³⁾	Retrospective study	- 99 patients with 2019-nCoV pneumonia, 37 older adults (≥ 60 years old). -Period: January 1^st to 20^th (2020).	- 11.0% died, seven of whom were 60 years old and over. - The first two deaths were male, had no chronic diseases and were 61 (patient 1) and 69 years old (patient 2). Both patients had severe pneumonia and severe acute respiratory syndrome after hospitalization, being transferred to the Intensive Care Unit, where they received respiratory therapy assisted by an intubated ventilator. The intervals between the onset of symptoms and the use of ventilator-assisted breathing in the two patients were 3 and 10 days, respectively. The course of the disease and lung injuries progressed rapidly in both cases and both developed multiple organ failure in a short time.
Wolf MS et al., 2020 (United States)⁽³⁴⁾	Cross-sectional study	- 630 adults with one or more comorbidities, being 153 older adults (≥ 65 years old). -Period: March 13^th to 20^th (2020).	- The threat of a COVID-19 outbreak was rated as most serious by older adults aged 70 and over. - Older adults showed less knowledge about the prevention and symptoms of COVID-19 compared to young people, but no significant difference was identified.
Kirigia JM et al., 2020 (China)⁽³⁵⁾	Retrospective study	- 2,595 deaths associated with COVID-19. -Period: from February 24^th, 2020.	- Deaths by COVID-19 had a total discounted tax value (by 3%) of 924,346,795 international dollars in China. Being, 27.8% with people from 50 to 64 years old and 9.0% among those with 65 years old and over.
Zhu T et al., 2020 (China)⁽³⁶⁾	Retrospective study	-72 symptomatic patients with COVID-19, 28 older adults (> 60 years old). - Period: January 18^th to February 3^rd (2020).	- Patients were divided into two groups, being: young group (n=44; 47.5 ± 8.7 years old) and older adult group (n=2; 68.4 ± 6.0 years old). - The proportion of involvement of the pulmonary lobes was higher in the older adult group (71.4%) compared to the young group (36.4%) (p=0.009). - The subpleural line (50.0%; p=0.030) and pleural thickening (71.4%; p=0.011) occurred in a greater proportion among older adults, compared to the young group (25.0%; 40, 9%, respectively).
Liu R et al., 2020 (China)⁽³⁷⁾	Retrospective study	- 4,880 nucleic acid (NAT) tests, with 1449 older adults (≥ 60 years old). - Period: January 22^th to February 14^th (2020).	- There was a higher proportion of positive NAT test rates as the age group increased, with 61.81% for cases> 70 years and 47.86% between 60 and 69 years old (χ²= 58.835; p <0.001). - The positive test in fever clinics had a higher significant proportion among those older (p <0.001), being 57.33% and 76.69% among those aged 60 to 69 years and> 70 years old, respectively. - Binary logistic regression analysis showed that age was the risk factor for SARS-CoV infection (OR=1033; CI=1.029-1.037).
Wang Z et al., 2020 (China)⁽³⁸⁾	Retrospective study	- 69 patients with confirmed SARS-CoV-2 infection. - Period: January 16^th to 29^th (2020).	- The cases were divided into two groups: adequate saturation (SpO₂≥90%) and inadequate saturation (SpO₂<90%). - The mean age for the SpO₂ ≥90% group was 37.0 years, while for SpO₂ <90%, it was 70.5 years. - All deaths occurred in the SpO₂ <90% group formed by older patients, with more comorbidities and higher plasma levels of IL6, IL10, lactate dehydrogenase and C-reactive protein.

Thematic categories (number of articles)	Results of studies
Adverse outcomes/Complications from COVID-19 (n=8)	Higher proportion of hospitalizations in Intensive Care Units⁽²⁴⁾ and severe pneumonia⁽³²⁾; Lower proportion of discharge from Intensive Care Units⁽²⁵⁾; High occurrence of composite endpoint (Intensive Care Unit and/or mechanical ventilation and/or death)⁽¹⁾; High use of mechanical ventilation⁽²⁵^.³²⁾ Higher mortality rate⁽²³^,²⁵^,²⁷^,³³⁾ Higher percentages of complications during hospitalization: severe acute respiratory syndrome⁽²⁶^,³⁷⁾; injuries - acute cardiac⁽³²⁾, hepatic⁽²⁶^.³²⁾ and acute renal⁽³²⁾; secondary infection⁽²⁶^.³²⁾; shock⁽³²⁾; acute respiratory distress syndrome(26); multiple organ failure⁽¹⁸⁾ and pneumonia⁽³¹⁾.
Relationship between COVID-19 age and severity (n=8)	Advanced age⁽⁵^.²³^-²⁴^.²⁷^-²⁸^.³⁰^-³²^.³⁴⁾.
Variables related to death by COVID-19 (n=8)	Acute respiratory distress syndrome and chronic obstructive pulmonary disease⁽²⁶⁾; Advanced age⁽¹⁷^-¹⁸^,²³^.²⁵^.²⁷⁾; Presence of comorbidities and symptoms of dyspnea⁽²⁶⁾; Greater development of serious charts⁽⁵^,²³^,²⁸^,³²⁾
Other information (n=9)	High costs related to deaths due to COVID-19⁽³⁵⁾ High prevalence of comorbidities in older adults and/or a higher proportion in relation to young people⁽²⁴^-²⁵^,²⁷⁾; Common comorbidities: hypertension, diabetes mellitus and cardiovascular diseases⁽²⁶⁾; Higher occurrence of infection by the new coronavirus in older adults⁽³⁷⁾; Treatment of COVID-19 with plasma infusion⁽¹⁰⁾; Clinical evolution of COVID-19 in an immunodepressed patient⁽¹¹⁾; Genomic characteristics⁽¹⁹⁾.
Clinical signs and symptoms (n=12)	Dyspnea ⁽²⁴^,²⁶^-²⁷⁾ ; Fever⁽¹²^.²⁰^,²²^-²⁴^,²⁶^-²⁷⁾; Cough⁽¹⁷^,²⁰^,²⁶^-²⁷⁾; Vertigo and constipation⁽²⁰⁾; Fatigue⁽²⁶⁾ Lower oxygen saturation rates (<90%)⁽³⁸⁾ (<91%)⁽²¹⁾; Syncope⁽¹²⁾; Malnutrition⁽¹³⁾; Rhabdomyolysis⁽¹⁴⁾.
Diagnostic findings (n=8)	Greater involvement of the pulmonary lobes in relation to young people⁽³²^,³⁶⁾; Higher proportion of subpleural line and pleural thickening compared to young people⁽³⁶⁾; Lower proportion of lymphocytes⁽³²⁾; Lymphocytopenia⁽²⁶⁾; Higher number of lung injuries observed⁽²⁹⁾; Greater bilateral pulmonary involvement and peripheral injuries⁽²⁹⁾; Ground-glass opacities involving the pulmonary lobes⁽¹⁵^-¹⁷^,²²⁾.

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