Review Article

pISSN 2508-4798 eISSN 2508-4909

Ann Geriatr Med Res 2020;24(3):166-172
https://doi.org/10.4235/agmr.20.0027

Effects of COVID-19 Pandemic on Health and Wellbeing of Older People: A

Comprehensive Review
Raveen Lekamwasam1, Sarath Lekamwasam2
1
Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
2
Department of Medicine, Faculty of Medicine, Population Health Research Center, Galle, Sri Lanka

Corresponding Author:
Sarath Lekamwasam, MD, PhD The pandemic is unavoidable; in addition to increased morbidity and mortality, they profoundly
Department of Medicine, Faculty of affect people and economies at every level. The negative effects of pandemics are more severe in
Medicine, Population Health Research marginalized populations such as older adults who have higher risks of acquiring infection, more
Center, Galle, Sri Lanka
disease-related complications, and increased risks of death. Furthermore, older people are affect-
E-mail: [email protected]
ed by policy decisions and containment measures taken during pandemics. With rapid patient
ORCID:
turnover and overwhelmed health care facilities, this older population may not receive proper
https://orcid.org/0000-0002-3541-9982
medical care. In addition to poor clinical outcomes, such measures have profound negative ef-
Received: May 1, 2020 fects on the mental health of older populations.
Revised: June 13, 2020
Accepted: June 15, 2020 Key Words: COVID-19, Aged, Pandemics

INTRODUCTION asymptomatic or paucisymptomatic and do not require hospital-

ization or specific treatment. Some patients, however, gradually
The current pandemic caused by the newly described severe acute deteriorate, with the involvement of internal organs such as the
respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to lungs, kidneys, and heart.4)
spread, with devastating effects on the functioning of society and Pandemics lead to social disruption and economic downturns
the world economy. By June 4, 2020, 6,416,828 people had been both regionally and globally, as well as uncertainty and anxiety
infected, with 382,867 deaths worldwide. While new cases are de- among populations. The effect of pandemics on economies and
clining in some countries in the European region, the disease con- healthcare systems is enormous. Furthermore, pandemics are as-
tinues to spread, almost unchanged, in the United States, and a sociated with overcrowding of healthcare facilities, as well as health
steady increase in the number of infections in the African region care staff exhaustion and burnout, resulting in the disruption of
has been reported.1) The first case of coronavirus disease 2019 routine care provided to patients with other illnesses. Pandemics
(COVID-19) was reported in Wuhan in the Hubei province of affect individuals differently; the resultant negative effect may be
China on December 12, 2019, the origin of which was traced to more pronounced on marginalized populations,5) including older
the Huanan seafood market in Wuhan; moreover, genomic studies adults, refugees, and people living in slums. However, the effect of
confirmed that the causative organism to be of bat origin.2) pandemics on these marginalized populations has not been ade-
COVID-19 mainly spreads via droplets from saliva and nasal quately studied.
discharge of infected people, and its common symptoms include Older adults are considered a vulnerable population for a multi-
fever, dry cough, shortness of breath, diarrhea, and vomiting.3) tude of reasons. Besides age, multiple diseases; long-term drug use;
COVID-19 is predominantly observed in young and middle-aged and poor social habits, nutrition, and living conditions increase the
people with no significant sex difference. Most infections are either vulnerability of older adults to infection. Policy decisions and ac-

Copyright © 2020 by The Korean Geriatrics Society

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 COVID-19 and Older People 167

tions to curb pandemics may aggravate these conditions, resulting microbial infection were associated with treatment failure and
in poor access to healthcare, drug shortages, limited food supplies, poor clinical recovery in older patients with hospital-acquired
and movement restrictions. pneumonia. Also, negative effects of comorbidities on the clinical
The special needs of older populations during critical periods of outcomes of both acute and chronic diseases is well known. Co-
pandemics should be a focus of healthcare and other services. It is morbidities may alter clinical symptomatology, leading to delays in
intuitive to believe that the effects of pandemics are globally uni- seeking treatment and diagnosis, especially during the pandemic
form and vary according to ethnicity and geography. Therefore, in- where respiratory involvement predominates and clinicians rely on
terventions to safeguard older people should be country or ethnic- respiratory symptoms to identify patients. Further underlying dis-
ity specific and must be adjusted and modified according to the eases such as renal and liver diseases may interfere with manage-
beliefs, attitudes, behaviors, health, etc., of older people. This as- ment protocols.
sessed the effect of the COVID-19 pandemic on older people
based on the interactions among the virus, patients, and environ- COVID-19 AND OLDER ADULTS
ment to suggest possible interventions. This study is a more gener-
al review and not specific to a particular ethnic group or geograph- Older adults are a highly vulnerable group during the pandemic.
ical area. We searched the PubMed, Ovid, and World Health Orga- The effect of COVID-19 on older adults has been assessed in
nization (WHO) COVID-19 databases for current scientific infor- terms of percentage infected and rates of hospitalization and mor-
mation, as well as other sources such as printed media from coun- tality. The proportions infected or hospitalized may not reflect the
tries, including the UK and the United States, to collect general in- true disease effect on older people because they may not be con-
formation. We found a rapid increase in scientific literature during sidered a priority group for screening and hospitalization during
recent months; this review includes only studies available through the pandemic. When healthcare facilities are overburdened during
June 4, 2020. the pandemic, it may not be possible to equally cater to all patients;
moreover, reports indicate that some countries adopted an age-
OLDER ADULTS AS A VULNERABLE GROUP based triage during the current pandemic, in which younger pa-
tients were given priority over older adults to receive healthcare.9)
In general, older adults are prone to both acute and chronic infec- Furthermore, older adults may be underrepresented in screening
tions owing to reduced immunity. Immune senescence, which is programs owing to poor communication and restricted mobility.
the downregulation of the immune system at multiple levels, is During pandemics, systematically documented mortality rates
mainly attributed to aging and makes this population vulnerable to may be a better reflection of the disease effect on older popula-
a multitude of infections6) and leads to reduced cell-mediated im- tions.
munity and poor antibody response to immunogens. In addition Analyses of age-dependent mortality rates have consistently
to this acquired immunity insufficiency, other factors such as re- shown an exponential increase in mortality of COVID-19 patients
duced cough and gag reflexes, urine and fecal incontinence, and re- aged more than 50 years. Reanalysis of combined data of the
duced skin barrier also contribute to high infection susceptibility WHO–China joint mission on February 28, 2020, which included
among older adults.6) Furthermore, comorbidities such as diabetes, 55,924 confirmed cases,10) and data from the Chinese Center for
chronic renal failure, and neuromuscular disorders and the long- Disease Control and Prevention report from February 17, 2020,
term use of medications such as glucocorticoids and proton pump based on 72,314 confirmed, suspected, or asymptomatic cases,11)
inhibitors make older adults more vulnerable to infections.6) showed mortality rates below 0.4% among patients aged < 50
In addition to host-related factors, environmental or social fac- years, with an exponential increase in those older than 50 years. In
tors contribute to the high infection risk among older adults. These this analysis, the mortality rates among the 50–59, 60–69, 70–79,
include poor living conditions, nutrition, ventilation, sanitation, and 80 or above age groups were 1.3%, 3.6%, 8.0%, and 14.8%, re-
and overcrowding, especially among older adults in long-term care. spectively.12)
The interactions between host and environmental factors that Furthermore, analysis of COVID-19-related deaths in the Unit-
make older adults susceptible to infections are complex. These fac- ed States between February 1 and April 11, 2020 according to pa-
tors, apart from making older adults susceptible to infections, also tient age showed that only 746 of the 8,259 deaths during the
interfere with the clinical recovery of patients.7) Yamamoto et al.8) study period occurred in patients aged < 55 years.13) The number
reported that severe underlying disease, poor general condition, of deaths in patients aged > 55 years, however, increased substan-
aspiration, bacterial resistance to drugs, superinfection, and poly- tially, at 1,086 for those aged 55–64 years, 1,821 for those aged 65–

Ann Geriatr Med Res 2020;24(3):166-172

168 Raveen Lekamwasam and Sarath Lekamwasam

74 years, 2,248 for those aged 75–84 years, and 2,358 for those ever, infection is highly transmissible among older adults, particu-
aged 85 years or above. While most of these deaths (6,120) oc- larly among those with comorbidities. Furthermore, the rapid de-
curred in inpatient healthcare settings, a substantial number (830) terioration of the clinical condition leading to acute respiratory
occurred in nursing homes/long-term care facilities, most likely in distress syndrome (ARDS), circulatory shock, metabolic acidosis,
older patients.14) and death occurs more frequently in older adults.18) The rapid clin-
Apart from higher mortality, older adults have a high risk of hos- ical deterioration of the clinical condition of older patients has
pitalization during epidemics. An analysis of COVID-19-associat- been reported by Wang et al.19) and Yang et al.20)
ed hospitalization rates among patients admitted during March Delirium is reportedly common among older people with
2020 in the United States showed that among 1,482 patients hos- COVID-19 and can be the only presenting feature. Beach et al.21)
pitalized, 74.5% were aged ≥ 50 years and 54.4% were male. While indicated that delirium could result from direct infection of the
the hospitalization rate among all patients during this period was central nervous system and proposed the need to include delirium
4.6 per 100,000 population, a higher rate of hospitalization (13.8) in COVID-19 screening programs. In a comparative study, Benussi
was observed among those aged ≥ 65 years.15) Furthermore, 89.3% et al.22) reported a 26.8% rate of incident delirium among older pa-
of adults aged ≥ 65 years had one or more underlying conditions. tients with COVID-19 compared with 7% among test-negative in-
While hypertension was the most common comorbidity observed dividuals. A study in Switzerland indicated that typical symptoms
in 49.7% of cases, 48.3% were obese, 34.6% had chronic lung dis- such as fever and cough were uncommon and that atypical features
ease, 28.3% had diabetes mellitus (28.3%), and 27.8% had cardio- such as falls, delirium, and unusual fatigue were more frequent
vascular disease (27.8%).15) among older patients with COVID-19.23)
The poor clinical outcomes observed among older adults during
the COVID-19 pandemic prompted the Centers for Disease Con- EFFECTS OF SOCIAL DISTANCING AND ISOLATION
trol and Prevention (CDC) to categorize this population, especial- ON OLDER PEOPLE
ly those with multiple diseases, as a high-risk group14) and prescribe
special precautionary measures for them. According to the CDC, 8 Although social distancing could save the lives of older people, it
out of 10 deaths reported in the United States were adults aged 65 also adds to their loneliness. Social constraints subsequent to social
years or above. distancing and isolation lead to significant limitations of daily ac-
tivities, inaccessibility to health workers on whom the older people
CLINICAL FEATURES AND INVESTIGATIONS are reliant, financial constraints, and difficulty in adjusting to new
social barriers created in activities such as online shopping.24)
Older adults, in general, tend to have atypical presentations, espe- Social distancing and isolation have significant health and psy-
cially those with infectious diseases. They often have blunted fever chological effects on older adults. Unlike younger adults, older
responses even in the presence of overwhelming infections. Stud- people are often unable to use technology to mitigate isolation and
ies comparing clinical presentations and disease progressions of its psychological effects.25) Older adults who engage in frequent so-
COVID-19 between older and other age groups are sparse. Liu et cial interactions such as social groups, societies, and frequent visits
al.16) compared the clinical course of 18 older patients to that of 38 to relatives have far lower morbidity rates than individuals in isola-
young or middle-aged COVID-19 patients and observed more se- tion.26) The ability to engage in these social activities is severely re-
vere disease and higher mortality in the former patient group. Al- duced during social distancing. Older people often make less use
though presenting symptoms were similar in the two groups, older of technology, especially virtual technology, and they are less driv-
patients had a higher Pneumonia Severity Index (PSI) than young en to learn new technology-related skills.27) Furthermore, older
and middle-aged patients. Furthermore, the proportion of patients people are less likely to use technology even if specifically tailored
with PSI grade 4 or 5 was higher among older patients. In addition, for them. The main reason for the poor use of technology among
they had more multilobar involvement, lower lymphocyte propor- older adults is not a lack of access to technology or connectivity
tion, and lower C-reactive protein concentration than young and but rather the lower expectations that are put on older people with
middle-aged patients. regard to technology use and the assumption of risk owing to the
In an update in Military Medical Journal, Guo et al.17) highlighted knowledge gap.27) Technology is essential in long-term social dis-
differences between older and younger COVID-19 patients. tancing to satisfy psychological needs and access services.
COVID-19 is mainly affecting young and middle-aged patients, Social isolation in older people can lead to psychological mor-
with the median age of affected patients being 47–59 years. How- bidities such as depression, poor sleep quality, impaired executive

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 COVID-19 and Older People 169

function, accelerated cognitive decline, and physiological distur- er adults.38) A report from Scotland indicated that contact tracing
bances such as poor cardiovascular function and impaired immu- in care homes was limited to those with COVID-19-positive pa-
nity.28) Depression rates are also higher among older people in iso- tients, with only sporadic testing in care facilities without con-
lation and more so in males and those with medical morbidities.29) firmed patients. 39)
The quality of living of older adults is also reduced following social Besides comorbidities, frailty has become a decisive factor in se-
isolation.30) A cohort study of 800 senior citizens in Chicago re- lecting older people for specialized care during the COVID-19
ported an increased risk of Alzheimer disease among adults in iso- pandemic. The National Institute for Care and Excellence (NICE)
lation.28) In contrast, a study of over 1,000 subjects in Stockholm in the UK proposed using the Clinical Frailty Scale (CFS) as a
reported social isolation to be a protective factor for dementia.31) A guide in providing specialized care for this age group. The CFS,
study including more than 5,000 men and women aged > 50 years which is scored from 1 to 7, is a judgment-based tool used to assess
found that loneliness was associated with an increased risk of car- the overall health of people aged 65 years and above. The NICE
diovascular disease (odds ratio = 1.27; 95% confidence interval, set an arbitrary cut-off point of 5 to determine the benefit of inten-
1.01–1.57).32) sive care in older COVID-19 patients.40) Similar to frailty, patients
Plagg et al.33) suggested that decisions regarding the prolonged with dementia may also encounter difficulties in the current pan-
social isolation of older people should be made after considering demic. They are less likely to access health information and com-
short-term advantages and short- and long-term disadvantages. ply with safeguard and sanitary measures. Furthermore, patients
The disadvantages highlighted in this review include vascular and with dementia may have limitations in telecommunications. Ac-
neurological diseases, premature mortality, cognitive impairment, cording to the NICE, the CFS is also suitable for application in de-
risk of Alzheimer disease, emotional distress, anxiety, and accelera- mentia patients.
tion of existing conditions. The use of the strategy of building herd immunity over that of
isolation increases the risk in older adults.41) Herd immunity re-
MARGINALIZATION OF OLDER ADULTS IN THE quires more than 60% of the population to gain active immunity,42)
COVID-19 PANDEMIC which further enhances the risk of infection in older adults already
at an increased risk.41) This strategy is considered to be more eco-
Some reports have indicated the marginalization of the health of nomically savvy as it allows for normal economic function. The
older adults during the current COVID-19 pandemic, especially in COVID-19 crisis has showcased how older people are marginal-
countries with mitigation strategies. This is probably an attempt to ized in countries with high disease burdens owing to a lack of re-
bring about herd immunity. A crisis management document pro- sources and in countries with low to medium disease burden at the
duced in Turin by the Piedmont authorities during the peak of the value of economic development.
COVID-19 epidemic in Italy proposed to exclude patients aged
> 80 years and older people with comorbidities as determined by MEASURES TO SAFEGUARD OLDER PEOPLE
the Charlson Comorbidity Index from treatment.34) Following the DURING A PANDEMIC
rapid increase in cases in Spain, instances have been reported
wherein staff departed from care homes, leaving the occupants to Prior preparedness is critical for successfully facing a pandemic.
their fates.35) Preparedness requires attention to the needs of marginalized pop-
Anomalous reporting of COVID-19-related deaths in care ulations such as older adults. A comprehensive assessment of their
homes has been a major concern as it underestimates the threat of immediate, short-term, and long-term needs will help in planning
the current pandemic on older adults in those countries. While their health and other services. These can be broadly divided as
thousands of deaths in care home facilities in the UK may not have follows.
been counted,36) similar observations have been made in Italy.37) (1) Preventive measures: The special needs of older adults
Furthermore, the global approach for COVID-19 screening is not should be considered when implementing preventive measures.
uniform. While countries such as South Korea launched extensive This population may require more supervision during isolation.
searches for infected individuals, other countries limited testing to While adequate ventilation may reduce the risk of cross-infection,
symptomatic individuals.38) Restricted testing fails to estimate the the safety of the living environment should be ensured to prevent
extent of the infection and in turn facilitates the spread of the dis- falls. Adequate facilities should be provided for frequent hand-
ease in the community. Many countries have realized the impor- washing.
tance of testing critical masses such as health care workers and old- (2) Health: Proper control of comorbid conditions is para-

Ann Geriatr Med Res 2020;24(3):166-172

170 Raveen Lekamwasam and Sarath Lekamwasam

mount to preserve immunity, prevent unnecessary hospitaliza- essary flexibility in treating older people during pandemics because
tions, and thereby reduce the infection risk. Facilities should be they have higher risks of acquiring the infection, more aggressive
provided for home monitoring of temperature, blood pressure, and clinical courses, and worse outcomes.
blood sugar. More supervision is required to identify early and
atypical symptoms of infections, and the screening criteria should ACKNOWLEDGMENTS
be flexible in older people. Age should not be the sole criterion for
prioritizing healthcare, and more holistic approaches should be ad- CONFLICT OF INTEREST
opted. Early and aggressive screening and treatment of older pa- The researchers claim no conflicts of interest.
tients may avoid the need for intensive care and life support mea-
sures. AUTHOR CONTRIBUTIONS
(3) Nutrition: The maintenance of proper nutrition is import- Conceptualization, RL, SL; Data curation, RL, SL; Investigation,
ant during pandemics. Older adults are prone to acute malnutri- RL, SL; Methodology, RL, SL; Project administration, RL, SL;
tion, which can compromise immunity; thus, this population Writing–original draft, RL, SL; Writing–review & editing, RL, SL.
should be given priority in food supply programs. Furthermore,
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