Hospital care for elderly COVID-19 patients

Objective: to analyze the newspaper articles on hospital care for elderly COVID-19 patients in online newspapers. Method: documentary, retrospective, descriptive and exploratory research. The data were collected from articles published on open-access websites of 12 newspapers from the following countries: Brazil, Spain, United States, France, Italy and Portugal. Results: out of 4,220 newspaper articles identified in this regard, 101 were selected after applying the inclusion criteria, the majority coming from Italy. The data analysis revealed three thematic categories: the care for patients with COVID-19 in the health system; the work process of the health team and its concern with contagion; and ethical dilemma in care for the elderly during hospitalization. Conclusion: the COVID-19 pandemic presented itself quickly and was widely reported in all countries. The health systems need to reorganize for care to the global population, especially the elderly, considering their weaknesses and also the lack of prior professional training to offer care to this population.


Introduction
Public health has been facing one of the biggest pandemics of this century, caused by the novel coronavirus (SARS-CoV-2), which causes COVID-19.
The first cases of the disease were reported in Wuhan-China in December 2019 (1) . COVID-19 is an acute respiratory disease, transmitted from person to person, which presents high mortality among the elderly (2) .
Being a respiratory disease, the incubation period varies between five and 14 days, and the transmission period is five days after the appearance of the first symptoms (5) . The differential of this disease is the severe acute respiratory syndrome (SARS), which has affected between 17% and 29% of patients. In addition, in 75% of these, atypical bilateral pneumonia occurs, detected by computerized tomography (6) .
Given the severity of the disease, on January 1, 2020, the World Health Organization (WHO) started several actions to combat the outbreak. COVID-19 was already considered a public health emergency on January 30 and, on March 11, it became characterized as a pandemic, after infecting 118,000 people in 114 countries and leading to 4,291 deaths (7) . This disease is highly infectious and 20% of the infected people develop respiratory disorders (6) .

On May 25, 2020, WHO and the Johns Hopkins
Center for Health Security confirmed 5,453,784 cases of the disease and 345,886 deaths in 185 out of 195 countries in the world (8) . In addition to the effects on public health, which show the deterioration of public health systems in the face of the demand for care, the crisis caused by the pandemic causes serious problems in the economy and accentuates the social inequality of the population, in view of the unavailability of equipment and protection products for all, in an equal manner (9) .
Furthermore, a collapse of the health systems is noted in different countries without infrastructure, human resources, equipment and material for simultaneous care to thousands of infected patients.
In addition, the hospitalization period in the Intensive Care Unit (ICU) has been long, which increases the waiting time for patients in severe conditions. This situation requires care protocols and imposes on health professionals the difficult decision to choose who can live or die (10) . The recommendation not to offer ventilation equipment to people over 80 years of age (11) when the demand exceeds the supply aggravates this situation even further.
Currently, although hospitals are caring for and treating people infected with this disease using more advanced resources, there is worldwide carelessness for elder elderly with suspected or confirmed COVID-19. Thus, given the above and considering that the media influences public opinion on several topics, we aim to understand how the worldwide written press has reported on the hospital treatment offered to elderly people with COVID-19. Therefore, the following guiding question was elaborated: How are newspaper articles on hospital care for elderly patients with COVID-19 reported in online newspapers?
As online dissemination represents a revolution in the continuous news production, distribution, and updating model, expanding the knowledge of content published on websites about health, as well as about its interrelations and determinants, is important to inform and educate society. In addition, it can influence individual actions, the general population, the medical community, and public policy makers (12) .
In that sense, the objective of this article is to analyze the newspaper articles on hospital care for elderly COVID-19 patients in online newspapers.  (13) .

Method
To analyze the selected subjects, the thematic analysis technique was adopted, which is used in health to analyze the ideas expressed, words or other symbols that make up the content of the articles (14) .
All newspaper articles were grouped according to the country of origin and composed a database, which was subsequently analyzed using the software  (15) .
The first analysis permitted the construction of word clouds, which represent a simpler lexical analysis, which groups and graphically organizes the words according to how frequently they are used.
This analysis was chosen to identify the contents most reported in each newspaper and considered the frequency greater than ten, in order to generate more understandable figures.
In the second analysis, the thematic categories were constructed, which emerged from reading and textual analysis using the Reinert method, known as descending hierarchical classification (DHC), which permits analyzing the occurrence of terms in a specific segment of the text. In this type of analysis, the software permits identifying co-occurrences of terms in the same segments, distributing them in classes by proximity to rank the relative presence of each term in the created classes. One DHC was elaborated for each language, as the software does not permit the joint analysis of different languages. Based on the DHC, the phrases with thematic proximity were extracted and then grouped into the categories described by the researchers (16) .
Two researchers validated the analyses to guarantee results in line with the objectives of the study and the proposed theme. Then, two authors validated the content in order to respect the criteria of scientific publication and ensure the appropriate language.
As the study used only publicly accessible and free information available on the websites of selected newspapers, no ethical approval was necessary, in accordance with CNS Resolution 510/2016 (17) . Figure     In the category Work process of the health team and its concern with contagion, the contents of the newspaper articles pointed to the daily concern of the press with the work process of health professionals and with their own safety, due to the risk of contagion with (United States, 10).

Discussion
The results obtained using the word cloud technique In all analyses, COVID-19 was identified as the main and recurring theme. Nevertheless, the selected contents contain words that refer to elderly patients, indicating the press' concern with disseminating news about the care for this part of the population.   (20) . when severe complications arise (10) . apply the same principles to all patients with COVID-19 and non-COVID-19 (21) .
All newspapers published news from their own countries and others that were being affected by the coronavirus. And in the understanding of the categories, it should be kept in mind that there were differences in the spread of the disease within each country, the care of the elderly by the health system, and how the authorities dealt with this problem.
The first European country to be the focus of the pandemic was Italy, where, until May 10, more than 30,000 deaths by COVID-19 were recorded. The lethality in the country reached 7%, almost twice the global average (3.4%). In addition, 60% of the confirmed cases involved people over 65 years of age (17) . The higher incidence in this age range is explained by the country's population characteristic, in which the elderly represent about 22% of the population (22) .

Spain was the third most affected country in
Europe, with more than 200 thousand cases (8) , 57,106 of which needed hospitalization. In this group, 24.1% were between 70 and 79 years old, 19% between 80 and 89 and 5.1% over 90 years of age (23) . In longterm institutions, many elderly people were found dead because the funeral system, burdened by the health crisis, did not support the demand for its services (24) .  (26) .
Portugal was the last country in Europe to have to deal with COVID-19, which provided a timely opportunity for local authorities to organize themselves and start control and prevention measures earlier (27) . In the age composition of the contaminated population, there was a high percentage (20.7%) of people over 65 years of age (22) , an aspect that made the implementation of preventive measures even more urgent. Nevertheless, the country, even in the face of several attempts to control the spread, faced a total of 1.6 thousand confirmed cases, especially in the elderly (28) .  (8) , with a lethality rate of 6.8% (33) . The first cases reported as fatal by COVID-19 were elderly, who, according to studies, have a higher mortality rate, especially when hospitalized (rates between 11 and 15%). Approximately 10% of the infected elderly develop the severe form of the disease and 5% should receive treatment in intensive care units (6,34) . This information supports the data in Figure 2, as it shows differences in the countries studied, that is, that the elderly are the population with the greatest vulnerability to the disease and that, when hospitalized, the risk of death increases.
In Brazil, most of the elderly with COVID-19 are being treated in hospitals and the peak of the pandemic has not yet been established, which generated little news in this regard in the course of the study period.
According to research, the disease was introduced into the country by people who had been in other countries and returned from travel. At first, these individuals were isolated, as well as their contacts, in order to prevent the spread of the virus (35) .
Most deaths among the elderly are related to chronic diseases, such as cardiovascular diseases. This entails important implications for the way in which public health and clinical responses should be developed, but this problem has been ignored in high (36) , middle and low-income countries, which house 69% of the world's population aged ≥60 years and where health systems are weaker and are therefore collapsing more rapidly with the increase in the number of patients (19) .
In Spain, Italy, France and the United States, the growing number of people with COVID-19 cared for in nursing homes or similar institutions was worrying.
Most of the residents in these institutions, for the most part, are highly dependent on the caregiver or health professional, and an outbreak in these places can affect up to 60% of the population (37) , with severe implications for the well-being and, potentially, the survival of their residents (19) . That is probably why the newspapers have published more articles in this respect and the professionals were contaminated because they were dealing with a fragile population highly affected by the virus.
According to the data shown in Figure 1, measures to combat the disease were taken in order to avoid the overcrowding of hospitals and, therefore, the collapse of the health system. Countries like Spain, France, Italy, Portugal and the United States have established the quarantine, that is, restriction of movement and isolation of symptomatic individuals and healthy people who may have been exposed to the virus, with the aim of monitoring their symptoms and ensuring the early detection of cases (38) . It is important to mention that, to prevent the progression of this disease (40) .
It is interesting to note that, amidst a pandemic, than 100 news items about the care of the elderly in hospitals and deaths resulting from this severity.
According to researchers, the high infectivity of SARS-CoV-2 cannot yet be faced using vaccines, which exponentially raises the risks and explains the need for non-pharmacological interventions such as the use of masks, social distancing and others, in order to contain the spread of the virus (42) .
In this pandemic, never before has the right to life become so important, as it is inherent in the human rights of all people, without discrimination based on age. This right is largely protected in various documents: Universal