‘Part of the bigger puzzle’
The coronavirus has been devastating for people over 80, but many are surviving
Anna Marie Bresnan, who lives in a retirement community, is 84 and has chronic obstructive pulmonary disease.
John and Kitty Stagliano are both 82 and have diabetes and high blood pressure.
Norma Cammisa is 93, has dementia, takes medicine for high cholesterol and lives in a nursing home.
All of them caught the coronavirus. All of them survived.
Why they did so well when thousands of other people over 80 have succumbed to the new disease is a mystery that intrigues and heartens physicians and aging experts. In New Jersey, nearly half of the 11,880 people who have died of coronavirus were 80 and older. As of May 29, 44% of Pennsylvania’s
5,464 deaths were in that age group. Age, plus chronic health problems such as heart and lung disease or diabetes, greatly increase the odds that people with COVID-19 will get very sick or die.
Even in nursing homes, which are populated by frail elders who need hands-on care, a high percentage of residents who test positive for the virus have had no symptoms or mild ones. Most survive.
Joshua Uy, a Penn Medicine geriatrician who is the medical director of a West Philadelphia nursing home that had the city’s first coronavirus outbreak, said about a third of the 22 residents there with confirmed coronavirus were asymptomatic, a third had mild symptoms and the remainder got very sick. Five died.
“We had a 96-year-old guy who never had a symptom,” Uy said. Some with mild symptoms have “recovered and it’s like nothing ever happened to them.”
Uy couldn’t predict which residents at Renaissance Healthcare and Rehabilitation Center would be fine and which would “crump” or go into rapid respiratory failure. Patients with obesity — another big risk factor — and frailty sometimes lived. One resident with serious lung disease survived. “It’s really amazing to me,” he said. “It blows my mind.”
Early in his center’s two-week outbreak, he felt hopeless. “On my worst day, I was worried that they were all going to die, to be honest.” Then widespread testing revealed how many residents were asymptomatic. Some with symptoms began getting better.
“When you look at the numbers,” he said, “I think most people will survive it. It just doesn’t feel like it at the moment.”
Other nursing home medical directors described similar proportions of residents with mild illness and equally surprising survivors. Nina O’Connor, chief of the University of Pennsylvania Health System’s palliative care program, cared for a 101-yearold coronavirus patient with no symptoms. Jim Wright, medical director of Canterbury Rehabilitation and Healthcare Center near Richmond, Virginia, where 136 residents tested positive and 56 died, said one 91-year-old had poor oxygenation for a long time and kept removing her oxygen mask.
“She’s in our memory center now,” Wright said in wonderment. “Her favorite thing to say is, ‘I love you.’ She says it every time.”
Wright has started analyzing the numbers at his facility and found no clear trends. He said patients there for rehabilitation, who tend to be younger and stronger than full-time nursing home residents, were more likely to survive. There were no racial differences.
Scientists will sort this out eventually. In the meantime, speculation focuses on differences in the immune system, genetics and possibly medications that could alter response to the virus. One doctor suspects that hydration and even sleeping position could be important.
George Anesi, a pulmonary and critical care doctor at Penn Medicine who sees only hospitalized patients, said the virus is harder on people the older they are. Those with low bloodoxygen levels and high inflammation levels do the worst. Those whose problems are confined to their lungs fare much better than those with multiorgan failure.
But that doesn’t explain why people have such different reactions to the disease, a question at all ages.
“It likely has to do with idiosyncrasies in their immune system and their genetics,” said Amesh Adalja, a Johns Hopkins infectious disease specialist and spokesman for the Infectious Diseases Society of America. “That’s part of the bigger puzzle with this virus.”
The immune system wanes and becomes less efficient with age. These changes could affect both the initial response to the new virus and the more sustained response, experts said.
Chronic illness can accelerate aging. When it comes to fighting infection, chronological age is less important than biological age. An 80-year-old still living independently is more likely to survive than an 80-year-old who is sick enough to be in a nursing home. But the body can also age unevenly. “They might have Alzheimer’s, but their immunity is pretty good,” said Nir Barzilai, director of the Einstein Institute for Aging and scientific director of the the American Federation for Aging Research. “Their liver can be younger than their brain.”
Barzilai thinks certain common medications, including the diabetes drug metformin, may improve immune functioning. Nicole Osevala, a Penn State geriatric medicine specialist, wonders about angiotensin-converting enzyme (ACE) inhibitors, which recently were shown to decrease the risk of hospitalization in older people with COVID-19. Because COVID-19 can increase blood clotting, Stefan Gravenstein, director of geriatrics and palliative care at Alpert Medical School of Brown University, wonders whether people on blood thinners could be protected.
Viral load, or how much virus a patient was exposed to, may also be a factor, Barzilai said.
Because reflux can bring the virus up from the digestive system and lead to aspiration into the lungs, Gravenstein also said older people who go to sleep immediately after a meal — this increases reflux — could be at higher risk. Sleeping with the head elevated could be protective, although that’s hard to test.
He is among many who think that maintaining hydration is crucial for elders with this disease. Nursing-home survivors may have been better at drinking enough liquids, he said.