The public health emergency may have ended, but COVID-19 is here to stay. And while anyone can get COVID-19, it is essential to pay special attention to age as a risk factor. Hospitalization among older adults reached a record high in the winter of the Omicron surge and dropped significantly in the summer. But compared with other age groups, hospitalizations have remained higher among patients 65 or older.
Older people have always been known to be at the highest risk of death from COVID-19, but last fall they made up a larger share than ever before. The week ending Nov. 19, Americans 65 or older made up 92% of all deaths from the virus, according to data from the Centers for Disease Control and Prevention. It was also the first time since the pandemic began that older adults made up more than nine in 10 deaths. And it was a drastic increase from about 58% of fatalities they accounted for in the summer of 2021.
The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines, especially throughout the COVID-19 pandemic.
For this installment, AMA member Devang Sanghavi, MD, took the time to discuss what patients need to know about COVID-19 and age. Dr. Sanghavi is an intensivist and medical director of the medical intensive care unit at Mayo Clinic in Jacksonville, Florida.
“Along with people of any age who are immunosuppressed, older adults fall into this unique group,” Dr. Sanghavi said. “For most of us, life has come back to normal. Many hospitals have removed restrictions, and people live their everyday lives in public life.
“But these two groups are unique in that they’re at very high risk,” he added. “Overall, the cases have come down, and we will hopefully continue to see it a plateau, but for older adults, they seem to be more susceptible, and there are reasons why just like any other viral disease or disease.”
For example, “older adults have an outsized impact of flu, not just that they may or may not get infected at the same rate—maybe they get infected at a higher rate—but the actual physical manifestation of the disease is much more severe,” Dr. Sanghavi explained.
“We know that immunity wanes as you age. So, even with vaccines, your immunity would wane after a certain point,” Dr. Sanghavi said. “This particular virus is a very smart, mutating virus, which shape-shifts every so often and tries to escape the immunity available to the human population in nature or through vaccines.”
“When you talk about waning immunity, assuming there are two shots that you got maybe two years back, one and a half years back would still work,” he said. “That may not be the case because your immunity may wane.”
Older adults are also more likely to have health problems that put them at increased risk for severe effects from COVID-19.
“Now, you’re talking about the same risk factors—heart disease, lung disease, kidneys not working well, and being overall frail—that expose you to potentially a severe illness and even mortality,” Dr. Sanghavi said. “That’s why for older adults, if not the general population, it is imperative to keep up with the booster regime.
Even though the COVID-19 public health emergency has ended, “if variants are floating around in the air, there is a risk to this patient population,” he added. “And that risk is more pronounced in older adults than any other group.”
“Older adults have outsized comorbidities because as you age, you tend to get chronic diseases like diabetes, hypertension, heart disease, your kidneys are not working as well or your liver,” Dr. Sanghavi said. “So, all those comorbidities added to the phenomena of waning immunity as you age leads to you getting an outsized physical manifestation, which is much more severe if you compare it to a younger, healthier individual.
“And that’s what you would see as this pandemic goes into an endemic phase,” he added, noting that “your age is the single most risk factor for you to get severe disease and mortality. And then you start adding up other comorbidities as you age.”
For example, “if you have lung disease, asthma, pulmonary hypertension, from a lung perspective, you are at increased risk. If you have chronic kidney disease, your immunity isn’t as robust as another healthy individual,” Dr. Sanghavi said. “Then you add vascular disease, stroke, cardiovascular disease, hypertension, all that adds to your disease burden.”
“Now, if you plug in a new variant for which the vaccine or other therapeutics that we have available don’t work, that’s a different story,” Dr. Sanghavi said. “Then we are looking at another surge wherein your general population may be more at risk than with the variant that is currently more prevalent.”
“Right now, the XBB.1.5 Omicron subvariant is the predominant variant in the country, and whatever is a prevalent variant would affect all individuals,” he said. “But older adults remain at a higher risk because of waning immunity and chronic conditions. So, they would proportionately be more impacted.”
“A new variant coming in would be a risk to the population. If you are not careful, it can get a foothold and spread like wildfire,” Dr. Sanghavi said. “Hopefully, with the immunity built into our general population, that may not be the case this time with XBB.1.5.”
“With more data forthcoming on long COVID, the condition is more common in those who experience severe disease, which is of particular concern among older people,” Dr. Sanghavi said. “If you have severe disease, you may manifest long COVID or have severe symptoms of long COVID.
“So, anyone infected or reinfected is at risk for long COVID, especially older adults,” he added. “At this stage in the pandemic, they are at higher risk. If they get infected, they can get long COVID, or newer symptoms may arise because of the inflammation and other pathways we know about from long COVID.”
“With older adults, the vaccination rate with the COVID-19 vaccine primary series is the highest of any cohort,” Dr. Sanghavi said. “More than 94% of older adults completed the primary series.”
“And if you take a look at the bivalent booster dose, the rate even drops further, and now it’s close to 40% of older adults,” he said, noting, “there may be various reasons for that.”
“If you look at high-risk individuals—patients who are immunosuppressed patients and the older patient population—that risk of getting severe COVID-19 disease and mortality outweighs any risks of the vaccines,” Dr. Sanghavi said. “That has to be an individual decision with your doctor, but I would still encourage all those patients to get vaccinated because what we are seeing in the hospital is those at-risk patient populations getting admitted.”
In April, the Food and Drug Administration authorized a second bivalent COVID-19 booster for adults 65 or older and immunocompromised patients. Older adults may now get an additional bivalent booster dose at least four months after their last dose. For adults with immunocompromising conditions, they can get their additional booster at least two months after their last dose.
The bivalent booster targets Omicron subvariants BA.4 and BA.5 as well as the original SARS-CoV-2 strain. While BA.4 and BA.5 subvariants are no longer circulating in the United States, the bivalent booster works on other Omicron subvariants that have become the predominant strains of the virus. As the virus changes and your immunity naturally decreases over time, you may lose some protection, but receiving a second bivalent booster helps to bolster that protection.
“For older adults, the risk is still there, so masking and physical distancing when possible” is still a good idea, said Dr. Sanghavi. “I’m not saying social isolation but being mindful if they’re exposed if they go to a social event and they think they are infected if they have any signs or symptoms of this disease to test themselves promptly.
“Then, getting the prescriptions of medications that are recommended. There are oral medications available, which would certainly help older adults, as we saw in President Biden’s case,” he added. “He falls into that age group where he becomes high risk, so he took that medication (Paxlovid), which helps reduce the intensity of the virus and the disease that is manifested.”
“So, protect yourself, be mindful of your surroundings, mask if you’re going to be in a big gathering where you don’t know who may be infected, and then take the precautions of washing your hands and distancing,” Dr. Sanghavi said. “Our older adult population is tired too. They want to live and enjoy their life.
“But just being extra careful will help them and help overall fight this virus even at this stage of the pandemic where we are moving into the endemic phase,” he added.
“We’ve come a long way, and thankfully we are not in that position where we are seeing severe disease as we saw early on in this pandemic” due to the availability of vaccines and therapeutics, said Dr. Sanghavi. “But we should not let our guard down. We should be aware of this virus and its ability to mutate and cause more problems.”
“We are all tired. We want to move on. We want to lead our lives normally, but for certain individuals like our older adult population and high-risk patients who are immunocompromised, this could be a matter of life and death,” he said. “That’s why vaccination and preventive measures still matter.”