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COVID-19 and elderly care: recommendations for long-term institutions


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and elderly care

Recommendations for Long-Term Institutions


ORGANIZING TEAM Authors Vilani Medeiros de Araújo Nunes (PhD in Health Sciences. Associate Professor of UFRN’s Department of Collective Health) Flávia Christiane de Azevedo Machado (PhD in Collective Health. Associate Professor of UFRN’s Department of Collective Health)

Míria Mendonça de Morais (Specialist in Occupational Nursing. Graduating in Collective Health at UFRN)

Larissa de Albuquerque Costa (Nutritionist. Specialist in Functional Clinical Nutrition and Public Health) Izabel Cristina Santos do Nascimento (Nurse. Specialist in Gerontology by UFRN) Thaiza Teixeira Xavier Nobre (PhD in Health Sciences. Associate Professor at UFRN).

Maria Eloiza da Silva (Technician in Administration. Graduating in Collective Health at UFRN)

Coordination Vilani Medeiros de Araújo Nunes

Writing and general content organization Vilani Medeiros de Araújo Nunes Flávia Christiane de Azevedo Machado Translation Raniery de Oliveira Souza Contributors Grupo Longeviver Instituto Envelhecer

President of UFRN José Daniel Diniz Melo General Vice-President Henio Ferreira de Miranda EDUFRN Administrative Board Graco Aurélio Câmara de Melo Viana (Director)

Helton Rubiano de Macedo (Associate Director)

Bruno Francisco Xavier (Secretary)


Helton Rubiano de Macedo Kamyla Alvares Proofreader Wildson Confessor Editorial Design Rafael Campos Estéfane Melquíades Maria Eloiza da Silva

Flávia Christiane de Azevedo Machado


Vilani Medeiros de Araújo Nunes


Natal 2020


and elderly care

Recommendations for Long-Term Institutions


COVID-19 and elderly care [electronic resource] : recommendations for long-term institutions / Vilani Medeiros de Araújo Nunes... [et al.]. – Natal, RN : EDUFRN, 2020.

67 pages: il. PDF; 10,1 MB

Modo de acesso: http://repositorio.ufrn.br ISBN 978-65-5569-040-8

1. Respiratory tract diseases - Elderly. 2. Coronavirus - Elderly. 3. Institutional care - Elderly. I. Nunes, Vilani Medeiros de Araújo.

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In this book it shall be addressed simple advice directed to Long-Term Institutions for the Elderly (LTIE), in which it has been inserted recommendations as to protective and control measures that may be adopted during the assistance to the residents, especially with respect to suspect cases or COVID-19 confirmed cases. The recommendations follow the directions announced by the World Health Organization (WHO), by the Ministry of Health, through the Brazilian Health Regulatory Agency (ANVISA), and by the scientific literature.

However, these recommendations may be complemented with new information, documents and updated technical notes by the Ministry of Health in our country, taking into account that it involves a pandemic caused by a new microorganism, there being little evidence about it.

In addition to the dissemination of relevant information about the new coronavirus pandemic, intended for administrators, professionals and those individuals interested in this theme, in this leaflet you may find hints and important information about health protection measures for the good operation of the institutions both with respect to COVID-19 prevention and to prevention of other diseases that require further attention from the administrators and the team of health professionals and caregivers of institutionalized elderly individuals.

Vilani Medeiros de A. Nunes




COVID-19: general information

Elderly individuals: lifecycle with more vulnerability to COVID-19

The context of Long-Term Institutions for the Elderly (LTIE)

Main precautions that must be adopted in the LTIE

Measures to be implemented in the event of elderly individuals showing symptoms indicative of respiratory impairment Measures to be implemented in the event of employees with respiratory symptoms Food, COVID-19 and good

Practices in the LTIE

Mental Health in times of Coronavirus Immunization of Elderly Individuals Some Words to learn

Final Considerations References

















What is


COVID-19 is an acute respiratory disease, often severe, caused by the new coronavirus (2019-Ncov or SARS-CoV-2). The new coronavirus emerged in Wuhan, China, in late 2019. The disease, then of a local nature, spread across several parts of the world, becoming a pandemic.


What do we

know about the


The first human coronaviruses were isolated for the first time in 1937. However, it was in 1965 that the virus was described as coronavirus, as a result of its microscopic profile, which resembles a crown.

Coronaviruses cause respiratory disease of variable severity, ranging from the common cold to a fatal pneumonia. There are seven known human coronaviruses (HCoVs), among them SARS-CoV (which causes severe acute respiratory syndrome) and SARS-CoV-2 (the virus that causes the COVID-19 disease).



The virus has a high transmission power and may remain in the surface of objects for hours and even days.

Stainless steel

72 hours (3 days)


72 hours (3 days)


24 hours (1 day)


4 hours



How does the



The entrance of the virus into the organism takes place through the mucosas of the eyes, nose or the mouth and it reaches the airways.


How to reduce

the chances of


The general recommendations to reduce the chances of contagion by the Coronavirus are:

Do not touch the eyes, nose and mouth without first sanitizing (washing the hands with water and soap or 70% alcohol).

Avoid contact with sick people.

Avoid closed environments (without windows or with closed windows), with few circulation of natural ventilation.

Avoid crowds.

Avoid greeting people with kisses on the face, handshaking or hugging. Avoid long periods without drinking water.

Avoid holding the food packages without prior sanitization with 70% alcohol (in the absence of 70% alcohol, wash the hands after contact with the packages).


COVID-19 Signs

and symptoms

COVID-19, in most cases, resembles an ordinary flu, but there are signs that serve as a warning to seek help. Let’s get to know COVID-19 signs? FEVER ABOVE 37º C SHORTNESS OF BREATH HEADACHE REDUCTION OF TASTE SENSITIVITY REDUCTION OF SMELL SENSITIVITY PAIN ALL OVER THE BODY SENSATION OF TIREDNESS COUGH DIARRHEA

The most common symptoms are fever, tiredness and dry cough.


Symptoms may appear between

2 and 14 days after exposure to the virus. This happens because the incubation of the virus in the body without exhibiting symptoms may

take up to 14 days.

The clinical and epidemiological assessment must be taken into consideration, as fever may not occur in some exceptional cases (children, elderly, immunosupressed individuals or individuals who used antipyretic drugs).


Some people are infected, but

they show no symptoms. This situation makes it even more important to adopt

measures to prevent contagion. Most people recovers from the disease (around 80%) without the need of any special treatment.

One out of six people who contracts COVID-19 falls severely ill and develops difficulty breathing.

In the event of signs indicative of the severe form of COVID-19

(fever, difficulty breathing), one has to seek help in the health centers or contact health professionals.

Who is at higher

risk of developing


In general, people with chronic diseases, such as high blood pressure, diabetes, heart diseases or preexisting pulmonary diseases, are at higher risk because of immune response impairment. The possibility of the intensity of the virus replication may lead to pulmonary impairment, thus aggravating the individual’s situation.

However, remember: all people can eventually be infected by the new coronavirus.









The elderly have been pointed out as the most vulnerable populational group. This is so because this group is more susceptible to developing the most severe form of the disease, especially elderly individuals who suffer from

heart diseases, such as high blood pressure, in addition to diabetes, kidney diseases, pulmonary diseases, cancer, and immunocompromised individuals.

Immunosenescence (deterioration of the immune system) is a natural process of aging, increasing, in general, the incidence of infectious diseases in elderly individuals, such as flu, ordinary colds and COVID-19.

When the elderly exhibit comorbidities

(diseases such as diabetes, high blood pressure, heart disease and pulmonary diseases), the risk of infection and complications increase.


14.8 8.0 3.6 1.3 0.4 0.2 0.2 0.2 0 0-9 10-19 20-29 30-39 age (years)

Source: Chinese Center for Disease Control and Prevention (CCDC), announced on February 17th, 2020 mortality rate 40-49 50-59 60-69 70-79 more than 80

People above

60 years of age

are at higher risk

Percentage of infected individuals who died in Wuhan, China

The World Health Organization, the British Medical Journal Lancet and the CCDC (Chinese Center for Disease Control and Prevention) indicate that the new coronavirus kills more often

individuals aged 80 or older (14.8% of those individuals of this age group who were infected eventually died).

When one takes into consideration

the group of people above 60 alone,

the mortality rate reaches 8.8% (a rate 3.82 times higher than the general average).

On average, COVID-19 kills

2.3% of those infected. At the age group 70 to 79,

the mortality rate is 8%.

Therefore, adult people above 60 years of age

are at higher risk of developing the most severe forms of COVID-19.


What elderly

individuals must

do in order to

avoid being infected

with COVID-19?

They must adopt the

same protective measures

indicated to all lifecycles (children, adolescents, adults and elderly).

However, it is important to stress that they

must not interrupt the use of their everyday medication.








The elderly individuals who reside at LTIEs are considered

at high risk of being infected with coronavirus because they usually exhibit:

An important aspect is the frequent habit of drinking a small amount of water. CHRONIC DISEASES HEADACHE DRY FECES OPAQUE EYES






What are the signs of dehydration?








A series of actions related to the operation of the Long-Term Institutions for the Elderly (LTIEs) need to be implemented. These actions involve a change in the rules of operation (restricted access and restriction to the circulation of people, adoption of protocols to guide the sanitization of surfaces and hands, precautions to be observed by the professionals who work in the LTIES in order to prevent transmission of the virus); a more attentive look at the good practices in terms of food safety; monitoring of the mental health of professionals and elderly residents, as well as the monitoring of COVID-19 suspect cases.



for administrators

and health care


Institutions for the elderly must establish

medical leave of absence policies

that are not punitive, in order to allow professionals and caregivers who show respiratory infection symptoms to stay home.

Professionals and caregivers who have contact, outside the institutions, with

people with symptoms of respiratory

infection or, knowingly of COVID-19, must not have contact with the elderly who reside in the LTIE, and they must not circulate in the same areas as these elderly individuals.

Advise the employees to conduct the correct and

frequent sanitization of the hands

with water and liquid soap or 70% alcohol gel.

Sanitize the hands

before and after contact with the residents.

Sanitize the hands

before and after contact with the elderly dormitories.

Sanitize the hands after contact

with potentially contaminated surfaces or equipment. Sanitize the hands before

and after using personal protective equipment (PPE).


Provide updated guidance about COVID-19 for professionals/caregivers and family members, stressing

the need to adopt prevention and control measures.

Restrict access to the institution to employees, health professionals while in the exercise of their duties and regulatory agencies.

Restrict the visit of professionals

who render everyday services and of volunteers, such as, for instance, hairdressers, podiatrists, religious groups, etc. If it is strictly necessary, the LTIE must ensure that none of these people show signs of respiratory infection before getting in contact with the elderly.

Intensify the health practices,

sanitizing environments and surfaces (grab bars, handrails, door handles, restrooms, etc).

Change clothes and shoes when arriving

in the LTIE before starting the activities, reserving clean clothes and shoes for exclusive use inside the institution.

Forbid the elderly to leave the institution

and suspend group activities (parties, religious cults, academic volunteering campaigns, among others).


Isolate elderly individuals with symptoms

of flu (cough, sneezing, shortness of breath) from contact with people and seek assistance in health services, informing the person responsible for the elderly and notify the health service closest to the LTIE about COVID-19 suspect cases.

Contact a health service in order to plan

the best form of carrying out vaccination

(protection against influenza) of the elderly and of the health professionals who work in the LTIE.

Prepare a contingency plan to avoid

the transmission of COVID-19, in accordance with the institution’s

peculiarities and with ANVISA [Brazilian Health Regulatory Agency]’s directions. Supervise and provide directions with respect to the processes conducted by the professionals, in all the stages of the direct and indirect care of the elderly, emphasizing the importance of the strict compliance with the technical standards established by the health legislation.



about directions

to administrators

and health care


Reduce the time the elderly spend at the institution’s common areas

to avoid crowds, ensuring the minimum distance of 2 meters between each individual. The elderly must leave the bedrooms for a walk in common areas, sunbathing, etc, in accordance with a

schedule established by the institution. Serve the meals, preferably, in the elderly’s bedrooms, or organize the meals in such a way that the team may manage the amount of people (keeping the minimum distance of 1 meter between them), and to provide for the appropriate period of time for cleaning and disinfection of the environment.

The elderly with respiratory infection symptoms must wear surgical masks

(ordinary), whenever they are outside the bedrooms. The elderly should preferably be allowed to stay outside the bedrooms when the others are not, when possible.

Suspension of group activities.

Isolate elderly individuals with symptoms of flu and communicate to the person responsible for the elderly. Be attentive to the emergence

of symptoms such as fever, cough and tiredness. Inform the Health


Assess/monitor the elderly on a daily basis with respect to the presence of fever, respiratory symptoms and other signs and symptoms of COVID-19.

Ensure the correct and daily cleaning,

and, whenever necessary, of the surfaces in the common areas, dormitories and other environments used by the elderly.

Provide conditions for sanitization

of the hands with water and liquid soap; washbasin/sink, with liquid soap dispenser; paper towel dispenser; paper towel; step-on hands-free trash can.

Assess the elderly’s respiratory

infection symptoms at the time of admission into the LTIE or while returning to the institution. One must implement appropriate practices for preventing infection for the symptomatic elderly. Emphasize the need that

the elderly drink at least

2 liters of water.

Help the elderly

that can’t sanitize their hands.


Advise and encourage the elderly

and professionals to frequently sanitize their hands with water and liquid soap or 70% alcohol gel. vacinação (proteção contra a influenza)

Make sure that the professionals and caregivers who work for the LTIE have

taken the recommended shots, according to the immunization schedule. Make sure that the elderly have taken all

the recommended shots, in accordance with the elderly immunization schedule (as defined by the Ministry of Health’s National Immunization Program),

especially the vaccines related to infectious respiratory diseases. In the event of the need to update the

immunization card, check with the Municipal Health Bureau the possibility of conducting vaccination within the institution, in order to avoid the commuting of the elderly.

Provide 70% alcohol gel for hand

sanitization in the hallways, receptions, living rooms, leisure areas, doctor’s rooms, dining halls, elderly’s bedrooms, and in other common areas of the institution.












In the event of elderly individuals with respiratory symptoms or under suspicion (or confirmation) of having been infected with COVID-19, it must be carried out

the cleaning and disinfection of surfaces,

utensils and products used by the elderly residents.

How to do it?

Cleaning with water and neutral soap/ detergent followed by disinfection. Disinfection may be carried out with chlorine-based products, such as sodium hypochlorite, 70% liquid alcohol or other standardized disinfectant by the service, provided that it is approved by ANVISA.

Most commonly touched surfaces: safety rails of the elderly beds, chairs, bedside tables and dining tables, telephone devices, tables, light switches, handrails, and grab bars, toilet flush buttons/handles, faucets, etc.

It is recommended to carry out the cleaning and disinfection at least twice a day. One must carry out the cleaning and

disinfection of equipment (stethoscopes, sphygmomanometers, thermometers, etc), health products and utensils (dishes, glasses, cutlery, etc) that have been used by the residents with respiratory symptoms, under suspicion or with confirmation of being infected with COVID-19.

The disinfection of restrooms must be carried out carefully, as diarrhea may occur as a symptom of COVID-19, thus leading to the possibility of orofecal

It is extremely important to pay more attention to the cleaning and disinfection


Guidance in case of cough If you cough or sneeze,

cover your nose and mouth

with the folded elbow or paper tissue.

Use disposable paper tissue

for nose hygiene (throw it away immediately after the use and clean the hands).

Clean the hands

after coughing or sneezing.

Provide disposable paper tissue

for the nasal hygiene of the elderly.

Provide step-on trash can

for the disposal of paper tissues.

Instruct the employees to help

the elderly who have difficulty to implement the directions.

Place banners with instructions

about hand hygiene, respiratory hygiene and cough etiquette in the hallways and in strategic places of the institution.


In addition to these measures, it is

recommended to carry out an assessment

of the severity of the flu-like syndrome in the elderly on a daily basis. This is so because at the onset of COVID-19, the signs and symptoms resemble a flu caused by other viruses.


One must be attentive to signs such as fever and respiratory symptoms in order to implement timely measures.

Mas, como fazer isso?

In order to facilitate the identification

of signs that demand further care, a Checklist was created to help the assessment of the elderly individual with Flu-like Syndrome related to the Coronavirus or to other viruses such as that of Influenza and the Syncytial Respiratory virus.

The Checklist enables the stratification of the severity of the Flu-like Syndrome, making it possible an adequate and timely conduct in each case. In order to facilitate the everyday assessment of the checklist, it is recommended to place it at the headboard, next to the elderly (See Image 1).


Checklist of signs

and symptoms of the

flu-like syndrome

How does the Checklist work? When assessing the elderly person, the examiner (healthcare professional or the caregiver who is providing care to the elderly person) must check the signs and symptoms present at stage 1.

Then, he/she must observe the signs and symptoms present at stages 2 and 3. From that, it is obtained a classification of the elderly individual with respect to the severity of the flu signs and symptoms as mild or severe.

In view of this classification, one

identifies the need for isolation (Yes/No), and whether the care of the individual must be implemented in the LTIE itself or in a Health center.

Mild cases (Flu-like syndrome with mild symptoms, without signs of respiratory discomfort or an increase in the respiratory rate – shortness of breath or the signs and symptoms of severity): elderly individuals who may be fully monitored within the Long-Term Institution for the Elderly (LTIE) / Primary HealthCare / Family Health Strategy, taking into account the lesser severity of the case.

Severe cases (flu-like syndrome that shows signs of respiratory discomfort or increase of the respiratory rate – shortness of breath or the signs and symptoms of severity): elderly individuals who are considered to be of greater severity, and, therefore, need to be stabilized in the LTIE/Primary Healthcare/Family Health Strategy and referral to a Reference Center/Emergency/Hospitals for 24-hour observation or interventions that require greater technological density.


The assessment of the elderly must be carried out on a daily basis, in order to monitor the flu-like syndrome’s evolution. Checklist benefits:

Rapidly identifying suspect cases of Severe Acute Respiratory Syndrome (SARS), thus constituting an important tool to implement a new culture of care in the LTIE, contributing to reduce morbidity and mortality in the elderly residents. It’s important to stress

the relevance of notifying the cases. Como notificar um caso de síndrome


How to notify a suspect case of Flu-like Syndrome or Severe Acute Respiratory Syndrome, treated as suspect

for COVID-19?

Through the fastest available

communication means, no later than 24 hours after becoming aware of a case that fits the definition of a suspect case, the health center closest to the institution where the elderly person resides, with a view to the adoption of the appropriate measures as recommended by the Ministry of Health. Human infection by Covid-19 is an Public Health Emergency of International Concern. Therefore, it is a public health event of immediate notification. All cases must be registered by public and private services, through the electronic form available at


within the first 24 hours from the clinical suspicion.


Signs and symptoms

Stage 1 –

Characteristics present in the elderly person

Stage 2 – Flu-like syndrome – MILD

Stage 3 – Severe acute respiratory syndrome – SEVERE


* Fever (Body temperature > 37.8º C

( ) Yes Yes, and with a sudden onset Yes, and with a sudden onset ( ) No

* Cough ( ) Yes Yes Yes

( ) No Breathing rate

How to observe? Count the breathing rate for 1 minute, observing the expansion of the rib cage and the abdominal movements, during inspiration. Eupneic breathing (12-20 mpm) – normal breathing Tachypneic breathing ( > 20 mpm) – increased breathing rate Yes Bradypneic breathing ( <12 mpm) – reduced breathing rate SpO2 saturation <95% in ambient air How to observe? Through the oximeter

SpO2= Yes * Shortness of breath/ dyspnea ( ) Yes Yes ( ) No * upper respiratory

symptoms (coryza and/ or nasal obstruction)

( ) Yes Yes

( ) No

Table 1

Checklist of signs and symptoms

of flu-like syndrome.


* Feeling of tiredness/fatigue

( ) Yes Yes Yes

( ) No * Pain in the


( ) Yes Yes Yes

( ) No

Headache ( ) Yes Yes

( ) No Change in taste sensitivity ( ) Yes ( ) No Change in smell sensitivity ( ) Yes ( ) Yes Diarrhea (unusual) ( ) Yes ( ) No Hypotension (Low

blood pressure: systolic pressure below 90 mmHg and/or diastolic pressure below 60 mmHg) ( ) Yes Yes ( ) No ADDITIONAL WARNING SIGNS AND SYMPTOMS: • Deterioration of the clinical status of base diseases;

• Change of the mental state, such as confusion and lethargy;

• Persistance or increase of fever for more than 3 days or return of fever after 48 hours without fever


*COVID-19 indicative signs










Ask the employees

to wear masks;

Remove them from their duties; Send them to the doctor

to be diagnosed as soon as possible;

Inform the health authorities

about the occurrence of suspect case(s) of human infection by the new coronavirus (COVID-19).

With respect to the use of masks, the mask needs to be appropriately adjusted to the face in order to ensure its efficacy and reduce

All professionals must be instructed as to how wear, remove and dispose of the mask, stressing the need to sanitize the hands before and after its use.

How to properly use the masks?

Place the mask carefully to cover the mouth and nose, and tie it firmly,

to minimize the spaces between your face and the mask; While in use, avoid touching the mask; Remove the mask using the appropriate technique (that is, do not touch its outside part, but instead untie the straps); After removal, or whenever you inadvertently touch the used mask, sanitize your hands using alcohol or water and liquid soap (or foam); Immediately throw the mask away

after removal. Reusing disposable masks is not allowed; In the event the mask becomes wet, replace it with a new, clean and dry one.



In the event of employees with a confirmed diagnosis of infection by the new coronavirus (COVID-19):

In accordance with the current rules,

the employee must be removed from his/her duties for the period of time recommended by the doctor, and it must be stressed the need for natural ventilation in the environments, thus reducing the use of air conditioners as much as possible.









It’s important to provide the elderly with safe food, reinforcing the Good Practices of Manufacturing and Manipulation of Food, in accordance with the legislation already in force (especially RDC 216), as well as the Technical Documents 18/2020 and 23/2020.

In addition, it’s important to keep in mind that:

• A varied diet, rich in vitamins and minerals, is of paramount importance for keeping the elderly healthy with respect to the immune response to diseases. • The frequent and correct washing of the hands is one of the most effective strategies for reducing the risk of

transmission and of contagion by the new coronavirus.

Recommendations related to the

receiving of food in view of the possibility of contamination by people who handle the food, by professionals who work in the LTIE and by elderly residents, through contact with contaminated food or with contaminated packages.

a) With respect to the receiving of food:

• Check whether the product package is intact.

• Before storing, wash the packages with water and soap and spray 70% alcohol or chlorine solution (dillution according to the manufacturer).

• Eggs must be stored in recipients with lid and kept under refrigeration conditions.

• Fruit and vegetables that cannot be immediately sanitized must have their packages changed.

• Encourage the full use of the food, in order to avoid waste.

• For longer durability, fruit, vegetables, roots and tubers can be chopped, portioned and frozen.


• For the disinfection of surfaces, it can be used, for instance: 1% hypochlorite solution, that is, bleach in the dillution recommended in the label, 70% liquid alcohol or gel, and the disinfectants themselves (follow the label recommendation).

• Intensify the sanitization of the hands. • Do not use gloves randomly. It must be analyzed if, for instance, the appropriate washing of the hands alone is more effective and efficient.

• Analyze on a case by case basis the use of masks by the food handlers. It must be followed the Ministry of Health’s recommendations, which recommends the use of surgical mask and N95/PFF2 prioritarily for healthcare professionals. The manufacture and correct use of homemade masks are described in the informative document no. 3/2020. • Stress the necessary measures to guarantee that all contributors are carrying out their duties adequately. • Intensify the efforts of cleaning and disinfection of environments. b) With respect to the sanitization

of fruit, greens and vegetables consumed RAW:

• Wash them in fresh running water; • Leave the vegetable soaked in chlorine solution, observing the dillution and the period of time recommended by the manufacturer;

• Wash them again in plenty of fresh running water;

• Leave the water drip or dry them with paper towel;

• Keep them in a closed container under refrigeration until the moment of consuming them.

c) With respect to the good

practices related to food, one stresses recommendations already addressed in this material:

• Evaluate the routine of sanitization of premises, equipment, furniture and utensils. Emphasizing the importance of sanitizing most often touched surfaces, such as door handles, handrails, among others.





Which factors can contribute to aging with reduction of the quality of life?

• Situations of helplessness and lack of encouragement caused by the perception of not feeling taken care of and welcomed

• Chronic diseases

• Lack of support from the family, leading to the situation of abandonment

The psychological well-being and happiness in the old age are related to social involvement, health, longevity, well-being, balance between aspirations and accomplishments in life.

In addition, performing educational and motivational activities, aimed at promoting and protecting health, are important for the strengthening of the cognitive capabilities of elderly individuals, increasing the chances of a successful aging process. And what does ‘successful aging’ mean?

That is aging while enjoying quality of life.

Which factors contribute

to the quality of life of elderly people?

• Health

• Family relationship • Emotional support • Satisfactory income • Social participation.


In this context, the individual learns to have new habits, such as a time to bathe, to entertainment him/herself, to eat, to take medication and activities that may improve his/her interaction, the physical, emotional and social well-being, and to receive medical care, food, hygiene and security, promoting a more successful aging process.

Institutionalized elderly individuals are more introverted and show greater difficulty with respect to social skills. This results from them being in an environment that often does not allow them to perform diversified activities, it being up to the institution to provide the elderly with better conditions of life. It is essential to consider that, as they focus on full and specialized care, the LTIEs need to adapt to the elderly’s needs, making the environment more sociable, tight-knit and with qualified care. For this purpose, the LTIEs seek to carry out collective activities for the celebration of religious cults, manual activities (writing, drawing, painting, craftsmanship, crochet, sewing/knitting), games (chess, checkers/draughts, domino, cards, board games in general), parties, workout practice, encouragement to visitation by family members and friends, as well as external tours for the elderly residents.

But, what does Quality of Life mean? It is the well-being related to self-esteem and personal well-being and encompasses a series of aspects, such as funcional capacity, socioeconomic level, emotional state, social interaction, intellectual activity, self-care, family support, his/her own health status, the cultural and ethical values, religiosity, lifestyle, pleasure with daily activities and the environment where one lives in. The idea of residing at a Long-Term Institution for the Elderly (LTIE) is related to family abandonment and the belittlement of the individual, something that can negatively impact the elderly person as a result of the prejudice of abandonment, as well as his/ her own life history that triggered the institutionalization.

Institutionalization requires adapting to a timetable, sharing the premises with unknown individuals and distance from the family.

In spite of this stigmatization and adaptation difficulties, the LTIEs may and must constitute a favorable and adequate place, relying on professional teams to welcome, care for and adapt the elderly to the new reality.


But, in times of a pandemic such as COVID-19, a disease that presents greater risk of mortality in elderly people and that, as a result, has social isolation as one of its prevention measure, how is it possible to have strategies for encouraging mental health?

Strategies to keep Social Interaction with the Family and implement Social isolation

• Talking to people you like and whom you trust is one of the best ways of reducing anxiety, loneliness or annoyance during the isolation period.

• In order to choose the best strategies, it’s important to know the elderly and their preferences, encouraging activities that may promote relaxation and well-being.

Thus, it is recommended to the caregivers of the elderly person: • Using phone, e-mail, messages, social networks in order to keep in touch with friends and family members. One recommends, preferably, to conduct video calls, in view of the comfort brought by seeing and listening to the beloved ones. The institution’s administrator must suggest to the elderly individuals’ families that suspend face-to-face visits and request routine and frequent monitoring through video calls.

• Encouraging the elderly individuals to carry out hobbies during the social isolation period, such as: reading, movies, listening to music, organization of personal belongings, of photos, participation in social network groups, among others. • Taking pictures of the elderly conducting activities to send to the families, showing an example of the elderly’s well-being, in such a way as to easy the concern of family members and friends.

• Suggest the writing of diaries as a means of encouraging the expression of feelings for those who enjoy writing.


In order to implement these strategies, it is essential to pay close attention to the sanitization of the hands and of the objects used in the telecommunication (computer, tablet, mobile phone). Thus, administrators, healthcare professionals and elderly residents of the LTIE must be vigilant with respect to these basic precautions.

As a result of the lack of physical contact through kissing, hugging and face-to-face reunions, it is possible that there may be reactions caused by the social isolation. Thus, it is important to observe the professionals that work in the LTIEs as well as the elderly residents.





IMPORTANT: If you notice in the elderly residents reactions such as stress, nervousness or extreme anxiety, difficulty falling asleep, excessive or reduced eating, incapacity to carry out the daily activities or a craving for alcohol, or for medication to deal with the situation, one should seek communicating with the family and seek psychosocial and healthcare team support.

During the period of social isolation, the elderly may occasionally exhibit the following reactions:




SEEK TO CARRY OUT CHORES TOGETHER (read a book, draw, paint, manual works, watch movies or favorite shows, crosswords, jigsaw puzzle, play “patience”, organize photo albums, dye the nails and hair, gardening, prayers).



CARRY OUT SIMPLE BREATHING EXERCISES, seeking to breath in (fill the lungs with air), and breath out (expell the air from the lungs) in a slow and peaceful manner.

SEEK TO CARRY OUT SHORT MOVEMENTS WITH THE HANDS, FEET, MOVE THE HEAD, ARMS AND LEGS (Seek exercises recommended for your physical capability and under the guidance of the LTIE’s healthcare professionals).

What to do in case these reactions, resulting from social isolation, are identified?


Advice to professionals who work in the LTIES to reduce potential stress related to social isolation

Healthcare professionals and caregivers of elderly persons at LTIE are professionals exposed to situations that can cause

physical and emotional wear.

In the context of the pandemic, the

odds the caregiver may suffer from wear

increases, as he/she is required to perform a series of repetitive and routine activities (help the elderly take a shower; go to the bathroom to help the elderly; help the elderly change their clothes; administer medication and help the elderly swallow food, among others) whose exertion depends on the degree of functional dependency of the elderly being assisted, there is also the stress caused by social isolation, there is the possibility of the

caregiver being infected, because,

as he/she performs an essential service,

he/she is required to keep performing his/her duties, thus being more exposed to contagion.

Once he/she is infected, it is possible to transmit COVID-19 to the elderly, resulting in the possibility of hospitalization and death, leading to a

significant emotional stress.

Therefore, these professionals must

receive support and assistance

in order to implement relaxation activities in their daily lives.







The vaccines recommended in the elderly immunization calendar, as determined by the Brazilian Immunization Society, in conjunction with the Brazilian Geriatrics and Gerontology Society, are 4 AGAINST:

FLU (Influenza) TETANUS, DIPHTHERIA (Double Adult - dT) HEPATITIS PNEUMONIA (Pneumococcal)

What is the importance of immunization?

The popular saying “prevention is better than cure” applies perfectly to immunization. Many common diseases in Brazil and around the world ceased being a public health problem because of the immunization campaigns carried out in the population.The SUS (Unified Healthcare System) of our country possesses a large amount of vaccines in the Basic Health Centers (UBS), recommended by the Ministry of Health at national level.

But, what are vaccines?

Vaccines are biological products that protect people from certain diseases. They contain previously weakened or dead pathogens (viruses or bacteria that cause diseases) or fragments of these pathogens. Their role is to stimulate an immune response from the body, which then starts producing antibodies without having contracted the disease.




Made up of dead viruses. As it is a virus that mutates every year, a new vaccine is developed, because one takes into consideration the types of viruses that are circulating in the period, taking into consideration the types of viruses that must be used to produce the vaccine. What are the benefits of the vaccine? Protection against influenza or flu, a disease which is characterized by high fever, chills, headache, malaise, dry cough and muscle pain, and which may cause complications, such as acute respiratory infections.

The vaccine against flu does not protect against common colds, which are caused by other types of viruses and are usually characterized by milder symptoms, with no fever.Quando deve ser aplicada?

When must it be administered?

The World Health Organization (WHO) recommends 1 shot every year.

How is it administered?

By intramuscular injection in the upper arm - deltoid muscle.

Who must take it? People aged 60 or older. When one has to take it?

Once a year, between April and May, when the national elderly




Obtained from a purified substance of the bacterium that causes pneumonia. What are the benefits of the vaccine? Protection against pneumonia caused by pneumococcus. Pneumonia is a severe respiratory infection, which is characterized by fever, cough with phlegm, and, in many cases, requires hospitalization. It may result in death, if it is not treated properly.

When must it be administered? In a single dose. An extra dose must be administered five years after the first dose.

How is it administered?

Through intramuscular or subcutaneous injection into the upper arm.

Who has to take it?

People aged 60 or older, bedridden patients as well as those who reside in closed institutions, such as hospitals, nursing homes, long-term institutions for the elderly, as they are at higher risk of contracting pneumonia.

When one must take it?

During the immunization campaigns targeting elderly persons, in April/May.



Type Double DT, manufactured with bacteria products (toxins).

What are the benefits of the vaccine? Protection against diphtheria and tetanus. Diphtheria is caused by a bacillus that produces a toxin substance, which affects the tonsils, the pharynx, the nose and the skin, where it causes white-greyish patches. It is transmitted from a contaminated person to others by coughing or sneezing.

Tetanus is an infection caused by a bacillus that produces a substance that enters the body through wounds or lesions in the skin (accidental tetanus) and reaches the central nervous system. It is characterized by contractions and spasms, difficulty swallowing and stiffness of the neck.

How is it administered?

By intramuscular injection into the upper arm – deltoid muscle – or in the thigh’s vastus lateralis muscle. Unvaccinated persons must take three doses (zero, two, four months). People who have already been administered the three doses must take an extra dose every ten years. Who has to take it?

People aged 60 or older. When one must take it? Adults who have never been

administered this vaccine may take it at any age, following the Ministry of Health’s scheme.



Recombinant surface antigen of the purified virus.

What are the benefits of the vaccine? Protection against Hepatitis B, characterized as a disease caused by a virus and that causes inflammation of the liver.

How is it administered? By intramuscular injection into the upper arm – deltoid muscle.

When one must take it?

There are three doses. The classical scheme is zero, one and six months. Adults belonging to risk groups for contracting the infection must also be immunized.

Adults who have never been administered the vaccine may take it at any age, following the Ministry of Health’s scheme.


IT’S IMPORTANT TO KNOW Vaccines may and must be taken even when the elderly person has a common cold, is currently taking medication or has skin diseases.

DO VACCINES CAUSE REACTIONS? Yes. Some momentary and mild reactions can emerge after the

administration of the vaccines, such as fever, tiredness, pain and local redness. It occurs because the vaccine stimulates the production of antibodies and the body’s immune system.


Vaccine Protectionagainst

Number of doses

Recommended age


between doses Administration route/site Basic

schemi Extra doses Recom. Min. Influenza Influenza 1 dose Annual dose 60

years of age ---

---Intramuscular, into the deltoid muscle 23-valent pneumococcal polysaccharide vaccine (1) Bacterial meningitides, Pneumonias 1 dose If necessary, 5 years after the

1st dose


years of age --- --- Intramuscular into the deltoid muscle


Tetanus (dT) DiphtheriaTetanus

Start or complete 3 doses, in accordance with the immunization record Every 10 years. In case of severe wounds, this interval must be reduced to 5 years. --- days60 days30 Intramuscular (deltoid, thigh’s vastus lateralis, dorsogluteal) Hepatitis B (recombinant HB ) Hepatitis B Start or complete 3 doses, in accordance with the immunization record --- ---2nd dose 1 month after the 1st dose, 3rd dose 6 months after the 1st dose 2nd dose: 1 month after the 1st. 3rd dose 4 months after the 1st dose Intramuscular into the deltoid muscle

Yellow Fever (Weakened)


Yellow Fever Single dose

Extra dose, if the person has been administered a dose of the vaccine before celebrating 5 (five) years of age

--- --- --- Subcutaneous, into the deltoid region


SOURCE: Ministry of Health. Accessed at

https://www.saude.gov.br/images/pdf/2020/marco/04/Calendario-Vacinao-2020-Adulto-Idoso.pdf (1) This vaccine is indicated to people aged 60 or older in special clinical conditions (bedridden, hospitalized or institutionalized) and indigenous populations starting from 5 (five) years of age. (2) Yellow fever vaccine is recommended for the entire territory of Brazil. The vaccination scheme takes into account the age group and immunization status. For people aged 60 or older, the health service must assess the pertinence of the immunization, in accordance with the epidemiological scenario of the disease. * It may vary according to the manufacturer. Check indication in the Normative Instruction of the National Immunization Calendar.





Unified Health System (SUS)

It’s one of the largest and most complex public health systems in the world, encompassing from a basic blood pressure test, at a Primary Health center, up to the transplantation of organs conducted in large public hospitals that are part of this healthcare service and surveillance system, which ensures full, universal and free service for the entire population of Brazil. It encompasses a network of professionals and public spaces that take care of the Brazilian population’s health.

The network that makes up the SUS is broad and encompasses both health actions and services. It encompasses primary, medium and high complexity healthcare systems, the emergency services, hospitals, the epidemiological, health and environmental surveillance actions and services, as well as pharmaceutical assistance. Ministry of Health

National administrator of the SUS, which establishes, regulates, oversees, monitors and assesses policies and actions, in conjunction with the National Health Council. Its structure comprises: Fiocruz, Funasa, Brazilian Health Regulatory Agency (ANVISA), National Health Agency, National Cancer Institute, Federal Hospitals, among others.


It’s the time when several people fall ill at the same time in a given place. When it occurs all over the world, it is called pandemic.


They are responsible for our breathing and for filtering the air. They are located inside our chest, close to the heart. It’s a part of our body significantly affected by COVID-19.

World Health Organization (WHO) It’s a world organization that monitors the coronavirus pandemic and help countries to make decisions and disseminate information. Spread

It’s when the virus spread through the population.


It’s a test doctors make in the patient to know whether he/she has a given disease, such as COVID-19.


The signs our body gives when we have a disease.

Autoimmune diseases

Our body is full of natural defenses that protect us from several diseases. But the autoimmune disease reduces our ability to naturally defend ourselves from viruses, bacteria or other microorganisms.


Tiny beings that one cannot see. They can only be seen with the use of microscopes in labs.




It is recommended that the advice contained in this book be printed out and placed in the places with the largest circulation of the LTIE. It is necessary the adequacy of collective practices that contribute to instruct professionals, family members and caregivers of the elderly, specially with respect to the adequacy and search for quality of the care provided to elderly individuals.



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This book was produced by the EDUFRN team



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