At MedStar Washington Hospital Center in the nation’s capital, things are finally starting to slow down after what infectious disease chief Glenn Wortmann, M.D., says was “a pretty busy” time.
Washington was one of the first cities to get caught up in omicron’s swift surge. And despite the variant’s reputation for being less virulent than its predecessor, the delta variant, the highly contagious strain sent hospital admissions soaring to new heights, stretching health care facilities and providers thin. Deaths caused by omicron also spiked throughout the U.S., from about 1,100 a day in early November to more than 3,000 a day in mid-January, and similar to trends tracked throughout the pandemic, older adults are shouldering the burden with illness and mortality rates that are much higher than those for their younger peers.
“Omicron is not the common cold,” the World Health Organization’s Maria Van Kerkhove cautioned during a January press briefing. “It can still cause severe disease, particularly among people who are not vaccinated, [as well as] people of older age and people with underlying conditions.” Centers for Disease Control and Prevention (CDC) Director Rochelle Walensky echoed this warning during a recent press briefing, explaining that when it comes to omicron, “milder does not mean mild.”
Symptoms are “all over the map”
If omicron isn’t necessarily mild, what is it? Robert Wachter, M.D., professor and chair of the Department of Medicine at the University of California, San Francisco, describes the symptoms of the new variant as “all over the map.”
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For most vaccinated and boosted adults — about 86 million Americans — an omicron infection may produce some sniffles, a mild cough or a sore throat. Feeling flu-like for a few days is another common outcome; so is having no symptoms at all.
“The better vaccinated you are, the more likely you are to have a very mild case,” Wachter says. “But that’s part of the challenge” when it comes to some older adults whose “level of reserve is less,” he says. A flu-like illness might sideline a healthy 40-year-old for a few days, but for someone who is older and frailer, it could trigger a loss of appetite or a state of delirium that spirals into something more serious.
“It might be enough to tip them over,” Wachter says about an otherwise mild infection. “And that's true of COVID, and it's true for urinary tract infections, and it’s true for skin infections.”
For unvaccinated people — including about 25 percent of U.S. adults — COVID-19 caused by omicron “is still a very severe illness,” says Andrea Ciaranello, M.D., an infectious disease physician at Massachusetts General Hospital in Boston and an associate professor of medicine at Harvard Medical School, even if it’s a notch down from delta’s level of severity.
Unvaccinated adults who are 65 and older are 52 times more likely to be hospitalized with COVID-19 than their vaccinated and boosted peers, according to the latest CDC data, which takes into account the early weeks of omicron. And for those who do end up in the hospital, the symptoms of a severe infection can be life-threatening.
“The biggest thing we worry about is that it causes inflammation in the lungs, and then you cannot oxygenate [the body,]” Washington Hospital Center’s Wortmann says. “We are still seeing people get sick with COVID and die with COVID.”
COVID-19 Deaths by Age Group
Omicron can inflame underlying conditions
To complicate matters, doctors are starting to see more patients who test positive for COVID-19 after being admitted to the hospital for other conditions.
For some of these people, a COVID-19 diagnosis is truly unrelated to their admission — for example, a patient coming in for a routine surgery or for injuries sustained in a car crash. Wachter chalks this up to the ubiquitous nature of omicron, which has shattered previous records for new infections.
But for many patients who test positive for COVID-19 upon admission, the virus likely “contributed meaningfully to the reasons they're in the hospital,” Wachter says.
Take for instance a patient with mild dementia who seeks care for confusion and tests positive for COVID-19 while being screened in the emergency room. “Absent your COVID infection, you would not have gotten sick, in the same way that in many older people, a urinary tract infection or even a small pneumonia ... is enough to make their chronic condition worse,” Wachter says.
In Boston, Ciaranello says she’s seen a fair share of diabetics come in with dizziness or chest pain, not respiratory symptoms, and test positive for COVID-19. “Especially in older folks, what we're seeing is that having had COVID may have actually played a role in whatever brought them into the hospital, even if it's not the typical sort of pneumonia-type presentation.”
“When older adults get the flu or cold, very often their other medical conditions sort of unravel a bit,” explains Mark Lachs, M.D., director of geriatrics for the NewYork-Presbyterian hospital system and a professor of medicine at Weill Cornell Medicine. About 80 percent of adults 65 and older have at least one chronic condition, according to the CDC, which can potentially be worsened by an illness like COVID-19.
Omicron is also messing up matters when it comes to length of stay in hospitals. Someone who is admitted for, say, a heart condition but then tests positive for COVID-19 and develops delayed symptoms may need closer monitoring. And patients who require rehabilitation after surgery, for example, have to wait several days until they are no longer infectious before moving to another facility.
“What normally would have been a two-day hospitalization for trauma or for fracture or for congestive heart failure now turns into a five-day hospitalization because of COVID,” Wachter says. And longer hospital stays usher in a whole new set of risks for older adults, including infection, delirium and falls.
“My general rule for everybody, but particularly for older folks, is that you want them absolutely in the hospital for when they need to be there. And when they don't need to be there, you really want them out of there,” Wachter adds.
Not all doom and gloom
Even with the high rates of illness and death throughout the country, experts say we’re at a much different place in the pandemic compared to previous surges. For starters, the vaccine formulas developed in 2020 continue to hold their ground against new variants like omicron, most notably after a booster dose.
Medical conditions that increase risk for severe COVID-19
- Chronic kidney disease
- Chronic liver disease
- Chronic lung diseases
- Dementia and other neurological conditions
- Heart conditions
- Weakened immune system
- Overweight and obesity
This list is not exhaustive but includes many of the chronic conditions that affect older adults.
Recent research out of the United Kingdom shows that protection against death with omicron is about 95 percent in adults 50 and older who are boosted. Similarly, a study led by CDC researchers found that boosters were about 90 percent effective at preventing COVID-19–associated hospitalizations during the early days of the omicron era.
“It’s very clear, particularly with omicron, that the third shot adds a huge amount of additional protection,” Wachter says — especially for older adults. “If you've had three shots, you have brought your risk down to that of a relatively young, healthy person.”
So far about 65 percent of eligible adults aged 65 and older have received their booster dose; for adults 50 and older, that number drops to about 56 percent, federal tallies show.
Advances in treatments for COVID-19 have also changed the game for those at increased risk for severe illness. In addition to remdesivir and monoclonal antibodies, which are typically administered to infected patients in a health care setting, two new prescription pills from Pfizer and Merck were recently authorized for at-home use. These antiviral medications were shown in clinical trials to significantly reduce the likelihood that high-risk adults infected with the coronavirus end up in the hospital.
The pills are currently in short supply, but federal officials have announced plans to make them — and testing, since a quick diagnosis is key — more accessible. “I feel like that will be a big turning point,” Ciaranello says.
Balancing caution with connectedness is key for older adults
As the omicron wave crests and infections fall, Wachter predicts that one of the biggest challenges for older adults — particularly those who have been in “hunker-down mode for two years” — will be trying to decide when it’s safe to resume a more normal state of life.
“We’re not there yet, because the case rates are still quite high,” he says. But he’s hopeful that in several more weeks, people who are vaccinated and boosted can feel better about visiting with family and traveling for pleasure, depending on their individual risks and comfort levels.
In the meantime, don’t get complacent, Lachs says. Make sure you’re up to date on your vaccines, upgrade your mask to a well-fitted respirator like an N95, and if you have access to at-home tests (you can order four free kits per household here), swab your nose before socializing with others. Also, if you are immunocompromised, talk to your doctor about a monoclonal antibody therapy that may help prevent a coronavirus infection.
“If I were in a high-risk group, I would button up for the next two to three weeks. Let this blow through, and then hopefully by mid-February or March, this will be past us and you can kind of start returning to normal life,” Wortmann says.
It’s also important to balance vigilance with your mental and emotional health; staying connected with others until omicron abates can help.
“Loneliness and isolation is a real risk,” Lachs says — one that can also worsen the health of older adults, according to the CDC. Lachs suggests meeting outside with others when the weather allows or coordinating online dinner parties with friends if in-person gatherings aren’t an option. There are also online exercise classes that can help you stay active. (AARP has a step-by-step guide on how to set up a Zoom account and use it to stay in touch with family and friends, as well as resources to help ease social isolation during the winter season.)
“[The pandemic] has been trying, socially and medically,” Lachs says. "However, it has also demonstrated the incredible resilience of many older adults and their strengths and their creativity.”
Rachel Nania writes about health care and health policy for AARP. Previously she was a reporter and editor for WTOP Radio in Washington, D.C. A recipient of a Gracie Award and a regional Edward R. Murrow Award, she also participated in a dementia fellowship with the National Press Foundation.