INTRODUCTION Advanced age and chronic disease comorbidities are indicators of poor prognosis in COVID-19 clinical progression. Fatal outcomes in patients with these characteristics are due to a dysfunctional immune response. Understanding COVID-19’s immunopathogenesis helps in designing strategies to prevent and mitigate complications during treatment.

OBJECTIVE Describe the main immunopathogenic alterations of COVID-19 in patients of advanced age or with chronic non-communicable diseases. DATA

ACQUISITION We carried out a bibliographic search of primary references in PubMed, Elsevier, Science Direct and SciELO. A total of 270 articles met our initial search criteria. Duplicate articles or those unrelated to at least one chronic comorbidity, senescence or inflammation and those that studied only patient clinical characteristics, laboratory tests or treatments were excluded. Finally, our selection included 124 articles for analysis: 10 meta-analyses, 24 original research articles, 67 review articles, 9 editorials, 9 comments, 3 books and 2 websites.

DEVELOPMENT Hypertension and diabetes mellitus are the most common comorbidities in COVID-19 patients. Risk of developing severe manifestations of the disease, including death, is increased insenescent and obese patients and those with cardiovascular disease, cancer or chronic obstructive pulmonary disease. Low-grade chronic inflammation is characteristic of all these conditions, reflected in a pro-inflammatory state, endothelial dysfunction, and changes to innate immunity; mainly of the monocyte-macrophage system with changes in polarization, inflammation, cytotoxicity and altered antigenic presentation. In the case of SARS-CoV-2 infection, mechanisms involved in acute inflammation overlap with the patient’s pro-inflammatory state, causing immune system dysfunction. SARS-CoV-2 infection amplifies already-existing alterations, causing failures in the immune system’s control mechanisms. The resulting cytokine storm causes an uncontrolled systemic inflammatory response marked by high serum levels of inflammatory biomarkers and a pro-inflammatory cytokine profile with decompensation of underlying diseases. In asthma, chronic eosinophilic inflammation protects against infection by producing a reduced interferon-mediated response and a reduced number of ACE2 receptors.

CONCLUSIONS Low-grade chronic inflammation present in advanced age and chronic diseases—but not in bronchial asthma—produces a pro-inflammatory state that triggers a dysregulated immune response, favoring development of severe forms of COVID-19 and increasing lethality.

KEYWORDS SARS-CoV-2, COVID-19, inflammation, aging, chronic disease, immune system

Worldwide, there has been a progressive demographic shift over the past 50 years resulting in a larger proportion of older adults in the general population. Aging itself is a complex biological phenomenon characterized in part by changes in the immune system known as “immunosenescence”, which makes older adults more susceptible to infectious, cardiovascular and autoimmune diseases, as well as cancers. Several strategies have been proposed in an attempt to reverse immunosenescence, including use of hormones, cytokines and thymic factors. A promising drug in the search to restore the thymic microenvironment (which plays an important role in the regulation and maintenance of the immune system) in older adults is Biomodulina T, a Cuban product registered for use in patients with recurrent respiratory infections. The administration of Biomodulina T increases the number of naïve T lymphocyte, CD4-positive cells that have recently migrated from the thymus gland (recent thymic emigrants) and memory CD8-positive T lymphocytes, which have characteristics akin to stem cells (stem cell-like memory). Furthermore, the expression of programmed cell death in CD4-Positive T lymphocytes and CD8-Positive T lymphocytes decreases, and the proliferative capacity of CD4-Positive T lymphocytes increases, without changes in the frequency of regulatory T lymphocytes. These results suggest that the administration of Biomodulina T could be used to restore immunity in older adults and in other immunocompromised individuals, improve response to other immunotherapies in cancer patients, and increase the efficacy of vaccinations in older adults. Its use has been approved for immune system restoration in COVID-19 patients.

KEYWORDS Immunosenescence, aging, immunotherapy, immunomodulation, antineoplastic protocols, Cuba

ABSTRACT
Cuba has one of the fastest aging populations in Latin America and the Caribbean (20.4% of the population aged ≥60 years by 2018) and life expectancy has climbed to nearly 79 years. This demographic shift has prompted a number of initiatives to address the needs of older adults and promote active, healthy longevity.

At the community level in Cienfuegos Province, an educational program was implemented designed to foster a more active role in society for older adults and improve their quality of life upon retirement, as well as to reinforce a positive culture of aging. The program ran from June 2010 to June 2018 in the Mental Health Department of the Dr Enrique Barnet Polyclinic in the Santa Isabel de las Lajas Municipality. Twenty-two groups were constituted of 330 older adults who were trained for 10 weeks in techniques of self-awareness, personal growth, development of social skills, use of social support networks, adoption of healthy lifestyles and formulation of retirement plans. Results were assessed for each group one year after program completion and the information summarized.

Participants whose definitions of “older adult” and “retirement” were rooted in nondiscriminatory concepts increased from 53 to 303 and retirees not incorporated into active social/economic life decreased from 228 to 36. At the outset, only 22% had coping mechanisms to manage their new role as retirees and 9% had a life plan for retirement. One year after finishing the program, 318 (96%) reported they were prepared to face this new stage in their lives and 294 (89%) had completed life plans; at the start, 116 (35%) were taking antidepressants and one year later, 103 of them had reduced or eliminated the drugs. The program enriched participants’ culture of aging, as well as relationships with their families and their communities.

KEYWORDS Retirement, aging, community health planning, Cuba

Cuba’s public health outcomes are rooted in political and social phenomena that have favored achievement of health indicators well above expectations for an economy of its size. A less studied causal component of Cuba’s development in health is the creation, from early in the 1960s, of scientific research capacity throughout the health system, including use of science to launch a domestic industry for manufacturing high-tech products. This component should play an even greater role in meeting Cuba’s 21st century health challenges, especially the demographic and epidemiological transitions, increasing prevalence of chronic diseases, rapid emergence of a complex-product biotechnology pharmacopoeia, greater molecular stratification of diseases, rising health costs, and the need to maintain communicable diseases under control in a global context of climate change and more population mobility.

Tackling these challenges will demand greater scientific influence in the health system, application of a scientific approach in all activities and at all levels, and integration with scientific endeavors of other sectors such as agriculture, industry and education.

KEYWORDS Public health, science, health care costs, health workforce, chronic disease, biotechnology, immunology, aging, Cuba

The Panama Aging Research Initiative is a cohort study of 423 adults aged ≥65 years recruited from an outpatient geriatric department of Panama’s largest public hospital, the Social Security Fund’s Dr Arnulfo Arias Madrid Hospital Complex (Complejo Hospitalario Dr Arnulfo Arias Madrid de la Caja de Seguro Social). The study provides the first reports of modifiable and non-modifiable risk factors of cognitive impairment and dementia, as well as various health conditions common among older adults in Panama, including chronic illnesses, polypharmacy and rates of comorbidity. The initial study, conducted September 2012–May 2016, included a clinical interview; physical assessments of body mass index and handgrip strength; and cognitive testing, plus non-fasting blood draws for measurements of genetic (Apolipoprotein E genotype) and blood-based biological markers.

Information was collected regarding limitations in activities of daily living, symptoms of depression and fall incidents. A subsample of participants provided cerebrospinal fluid to measure proteins related to Alzheimer’s disease; another subsample underwent ultrasonography and electroencephalography.

This report describes the general study design and highlights lessons learned and future directions. In particular, drawing on lessons learned from this clinical research, a community-based prospective cohort study is currently under way among older adults in Panama to validate a blood-based biomarker profile for detecting mild cognitive impairment and Alzheimer’s disease, as well as risk factors for cognitive decline.

KEYWORDS: Dementia, biomarkers, Latin America, aging, cognition, chronic disease, Panama

INTRODUCTION Population aging is a worldwide phenomenon. It is estimated that by 2050, one of five persons will be aged ≥60 years. In Chile, 15.8% of the population is now aged ≥60 years, and this figure will reach 30.7% by 2050. In 2006, a national program was implemented to provide assistive devices to older adults aged ≥65 years with limited mobility or difficulty performing activities of daily living. To date, there have been no assessments of the program’s effectiveness.

OBJECTIVE Assess the effectiveness of an assistive devices policy in Chile on improving functional capacity of older adults aged ≥65 years, and beneficiaries’ perceptions of the services received, including changes in their quality of life.

METHODS This was a before–after longitudinal study. A cohort of 309 persons was recruited, consisting of patients who received care at a public hospital in Santiago, Chile during 2014–2015. They were assessed before delivery of assistive devices, then followed for seven months, with repeated evaluations made in their homes. The following indicators were measured: functional capacity (Tinetti scale and Barthel Index); changes in perceived quality of life related to use of assistive devices; and other sociodemographic, clinical and protocol-compliance variables. A longitudinal analysis of before–after progress was carried out, as well as a description of service delivery and medical followup.

RESULTS Sixty-eight percent of those surveyed were women; median age was 74 years, average schooling was 6 years, and 93% had low income (monthly income <US$398). Assistive devices increased independence in activities of daily living, improved mobility and perceived quality of life, and decreased fall risk and pain. One hundred percent felt satisfied with the service received, 91% were trained in use of the device, and delivery deadlines were met in 83% of cases, but only 2% were followed up. One negative aspect is that the program covers only 25% of estimated need.

CONCLUSIONS This assistive device program helps improve functional capacity and perceived quality of life in vulnerable patients who are able to access it. It addresses a real need and is highly valued by patients. Although delivery schedules were fulfilled, followup care schedules were not.

KEYWORDS Aging, mobility limitation, assistive devices, activities of daily living, health care system, health care reform, quality of life, Chile

Aging and Alzheimer is a prospective, longitudinal cohort study involving 2944 adults aged ≥65 years from selected areas in Cuba’s Havana and Matanzas Provinces. This door-to-door study, which began in 2003, includes periodic assessments of the cohort based on an interview; physical exam; anthropometric measurements; and diagnosis of dementia and its subtypes, other mental disorders, and other chronic non-communicable diseases and their risk factors. Information was gathered on sociodemographic characteristics; disability, dependency and frailty; use of health services; and characteristics of care and caregiver burden. The first assessment also included blood tests: complete blood count, blood glucose, kidney and liver function, lipid profile and ApoE4 genotype (a susceptibility marker). In 2007–2011, the second assessment was done of 2010 study subjects aged ≥65 years who were still alive. The study provides data on prevalence and incidence of dementia and its risk factors, and of related conditions that affect the health of older adults. It also contributes valuable experiences from field work and interactions with older adults and their families. Building on lessons learned, a third assessment to be done in 2016–2018 will incorporate a community intervention strategy to respond to diseases and conditions that predispose to dementia, frailty and dependency in older adults.

KEYWORDS Dementia, Alzheimer disease, chronic disease, aging, chronic illness, frailty, dependency, cohort studies, Cuba

Dementia is a great challenge to public health in Cuba due to its impact on society and families. Cuba’s National Intervention Strategy for Alzheimer Disease and Dementia Syndromes is designed to address this challenge. The Strategy includes working guidelines for primary and secondary care, education about rights of people with cognitive impairment, professional development, research, and health promotion and dementia prevention. An associated action plan, focused on primary care, includes proposals for creation of memory clinics, day centers and comprehensive rehabilitation services for cognitive stimulation. Short-term measures proposed include increasing early detection; creating a dementia morbidity and mortality registry; promoting professional training; providing support for families; and promoting basic and clinical research on dementia. Medium-term proposals aim to reduce dementia incidence and mortality by controlling risk factors and promoting healthy lifestyles, offering new treatment options and optimizing early detection. A set of indicators has been developed to evaluate strategy implementation. With this strategy, Cuba joins the small number of developing countries that have responded to WHO’s call to improve care for patients with dementia and alleviate its impact on society and families.

KEYWORDS Dementia, Alzheimer disease, aging, national health programs, social stigma, primary prevention, health promotion, civil rights, Cuba

INTRODUCTION With a rapidly aging society, geriatric mental health is emerging as an important public health concern. According to the WHO, prevalence of depression in adults aged ≥60 years in developed and developing countries was 0.5 million and 4.8 million respectively in 2004. In India, increased life expectancy led to a rise in the older adult population between 2001 and 2011, expected to reach 324 million by 2050.

OBJECTIVES To estimate the prevalence of depression and assess association between sociodemographic parameters and depression among older adults in a rural Indian community.

METHODS A cross-sectional descriptive study was conducted in February and March 2012 in the rural village of Sembakkam, Kancheepuram District in the state of Tamil Nadu, India; the village has a population of 5948, 3.1% of whom are aged ≥60 years. Universal sampling technique was employed, in which every household in the community was visited and all elderly persons were selected. After obtaining written informed consent (a thumbprint was taken if the person was illiterate), participants were assessed face to face for depression using the Short Form Geriatric Depression Scale. The inclusion criterion was a score >24 on the mini-mental state examination. Final sample size was 103. Study variables included sociodemographic parameters such as age, sex, education, occupation, socioeconomic status, and marital status. Data entry and statistical analysis used SPSS version 17.

RESULTS Of 103 respondents interviewed, 73 (70.9%) were aged 60–69 years and 58 (56.3%) were male. Forty-four (42.7%) individuals (17 males, 27 females) were found to be depressed; 23 (22.3%) with mild depression, 14 (13.6%) moderate depression and 7 (6.8%) severe depression. Female sex and widowhood were significantly associated with depression.

CONCLUSIONS Depression, particularly mild depression, is common in this rural population of older adults, particularly among women and widowed elderly. These study findings can help program managers implement a more comprehensive strategy in this community for timely interventions to promote mental health and prevent geriatric depression.

KEYWORDS Depression, aging, elderly, rural, mental health, India

In Cuba, various factors have led to nearly zero population growth and a rapidly aging society. In a few years, the rush of baby-boomers reaching retirement will stand the population pyramid on its head, as the country’s life expectancy already nears 80 years. Almost 20% of all Cubans live in Havana, demographically and structurally an aging city. Yet, the city is not prepared to offer its older inhabitants the spaces, services and housing options they require for a healthy quality of life. Studies must be undertaken to address this issue comprehensively, generating creative alternatives for wise use of limited resources to fulfill the material, social and spiritual needs of this growing population sector.

KEYWORDS Aging, quality of life, social environment, urban health, housing for the elderly, Cuba

Introduction Approximately 24.2 million persons throughout the world suffer dementia with 4.6 million new cases reported annually. Only 10% of dementia and Alzheimer’s disease studies are conducted in developing countries where 66% of sufferers live. Cuba, a developing country, exhibits health indicators similar to those of developed nations. Its population of 11.2 million is aging rapidly: by the year 2020 it is estimated that personas aged ≥60 years will comprise 21.6 % of the population, making Cuban society the “oldest” in Latin America.

Objectives Ascertain and characterize behavior of dementia, its etiologies and risk factors in persons aged ≥65 years in the Havana City municipality of Playa.

Methods A two-phase, cross-sectional, door-to-door study was conducted in the municipality targeting all persons aged ≥65 years, achieving a 96.4% response rate (n=18,351). Folstein Mini Mental State Examination (MMSE), Hughes Clinical Dementia Rating (CDR) and a structured interview on risk factors were applied. DSM-IV, NINCDS-ADRDA and NINDS-AIREN criteria were used to determine dementia diagnosis, as well as other criteria for diagnosing Alzheimer’s and other specific forms of dementia.

Results Dementia prevalence was 8.2% of adults aged ≥65 years, with a slight predominance in males. The most frequent cause of dementia was Alzheimer’s disease, followed by mixed dementias. Dementia-associated risk factors were: history of stroke, hypertension, depression, skull-brain trauma, family history of dementia, low educational level and advanced age.

Conclusions This study corroborates that dementia and Alzheimer’s disease constitute an important and growing health problem for our country due to the accelerated aging of the Cuban population. It also underlines the importance of early diagnosis and proper treatment of hypertension and other vascular risk factors, as well as the need for a national public health program for the prevention and early diagnosis of dementia and Alzheimer’s disease, targeting elderly and at-risk populations.

Keywords Brain diseases, dementia, mental disorders, neurodegenerative diseases, Alzheimer’s disease, aging

The following errata have been corrected in all versions of this article.

Page 29, Abstract, Introduction, final sentence should read: “Its population of 11.2 million is aging rapidly: by the year 2020 it is estimated that personas aged ≥60 years will comprise 21.6 % of the population, making Cuban society the “oldest” in Latin America.”

Page 29, Introduction, paragraph 4 should read: “Cuba is a developing country with health indicators similar to those of developed countries and a rapidly aging population of 11.2 million. By the year 2020 Cuba will have the oldest population in Latin America, with adults aged ≥60 years accounting for 21.6% of total population.”