COVID-19 and Older Adults
With its critical impacts on many populations, especially older adults, the COVID-19 pandemic has sounded a global wake-up call. Advanced age increases a person’s risk for contracting COVID-19, regardless of variant type. Older individuals with age-related chronic conditions, including type 2 diabetes, hypertension, and cardiovascular disease, are at particular risk for contracting COVID-19 and are much more likely than their younger and healthier counterparts to end up in intensive care and to die (CDC, 2021a). Whether in the community or in long-term care facilities, public health care measures—including proactive screening for symptoms common in older people and adherence to personal protective measures, such as mask-wearing, physical distancing, and handwashing—can protect older people (CDC, 2021a). However, the implementation of these measures has varied across locations, offering inconsistent levels of protection.
COVID-19 has impacted aging populations in other ways as well. In doing so, it has revealed gaps, inequities, and cultural and system-level challenges that can lead to poor health outcomes for far too many people.
This appendix outlines the factors associated with the pandemic that have impacted life expectancy and driven excess morbidity and mortality among older adults; highlights the pandemic’s impacts on health systems; and describes its social, behavioral, and economic effects. It concludes with lessons learned from the pandemic in areas relevant to older adults, which, moving forward, can be built on for improving future responses to emergencies.
THE PANDEMIC’S IMPACT ON LIFE EXPECTANCY
The COVID-19 pandemic has set back years of progress toward increasing longevity, although the effects have varied considerably around the world, with life expectancy decreasing by 1.5 years from 2019 to 2021 in the United States while rising in other countries (CDC, 2021b; World Bank, 2021). In Japan, for example, mortality rates from COVID-19 were lower than those of many other countries, and during the same period (2019–2021), mortality rates from pneumonia and cancer improved; the result was a 0.2 percent increase in life span for both men and women (Ishida, 2021).
Data from the Centers for Disease Control and Prevention show that life expectancy among American adults has dropped by around 1.5 years, the largest decline since World War II (CDC, 2021b). However, life expectancies for U.S. Black and Latinx populations are estimated to have declined by 2.10 and 3.05 years, respectively—several times more than the reduction of 0.68 years for Whites (Andrasfay and Goldman, 2021; Arias et al., 2021). These findings highlight the disproportionate burden of the pandemic on Black and Latinx Americans, reflecting structural inequities that increase the risk of exposure to the virus and mortality.
Outside the United States, several studies have used modeling to predict the impact of the COVID-19 pandemic on life expectancy, as mortality data for 2020 are still being gathered. In countries experiencing more severe COVID-19 outbreaks, decreases in life expectancy are projected based on available 2020 data. For example, relative to 2019 levels, life expectancy at birth in England and Wales fell by 0.9 years for females and 1.2 years for males (Aburto et al., 2021). In Italy, life expectancy at birth (not broken down by sex) fell by 1.2 years between 2019 and 2020 (OECD, 2021). In Brazil, a decline in life expectancy of 0.94 years as of 2020 is estimated (Castro et al., 2021). A model produced by the University of California, Los Angeles, showed estimated reduction in life expectancy between 2019 and 2020 by 2.2 years in Panama, and 2.09 years in Peru (Heuveline and Tzen, 2021). Another phenomenon was observed in South Korea, where deaths in 2020 exceeded live births for the first time, with high death rates among those aged 90 and above (Yeung and Bae, 2021). While countries across the globe saw increases in life expectancy over the past decade, the COVID-19 pandemic has significantly altered life expectancy trajectories.
FACTORS DRIVING EXCESS MORBIDITY AND MORTALITY
Biological and Physiological Factors
Older adults respond to viruses including COVID-19 differently from younger adults. These differences are complicated by the presence of chronic diseases and progressive changes in the immune system. Inflammation, for exam-
ple, is exaggerated with advancing age—a phenomenon termed “inflamm-aging” that is exacerbated during infection as the result of the release of proinflammatory cytokines in a so-called cytokine storm (Bartleson et al., 2021). In COVID-19, this response is reflected in a dramatic accumulation of inflammation-related fluid in the lungs, impairing lung function and potentially leading to tissue damage, shock, respiratory failure, and death. Beyond this inflammatory response, other components of the immune system, such as the cells that fight off invading organisms directly (T cells) and the release of antibodies (B cells), become less effective in old age (Bartleson et al., 2021).
In addition to changes in the immune system, age-related reductions in organ function, including the lungs, heart, and kidneys, even in the absence of disease, place older persons at excess risk of adverse health outcomes by decreasing their physiologic reserve. Frailty also has contributed to the vulnerability of older persons during COVID-19 and is associated with need for mechanical ventilation, hospital length of stay, and risk of mortality (Labenz et al., 2020; Tehrani et al., 2021). Additionally, the pandemic has led to reductions in functional capacity among older adults in some places, presumably because of lockdowns, in which people were limited in how often and where they leave their homes. For example, average walking speed decreased for older populations in Japan (Obuchi et al., 2021). Although lockdowns were important for minimizing the spread of COVID-19, they reduced opportunities for physical activity among older adults, with direct implications for functional and cognitive capacity.
Clinical and Social Factors
It is common for many diseases, such as pneumonia, to present different symptoms in older adults than in younger populations (Gómez-Belda et al., 2021). Older adults presented symptoms of COVID-19 that were atypical in other populations, including sore throat, delirium, and lower oxygen in the blood (Nanda et al., 2020). At the onset of the pandemic, older patients with such atypical symptoms were often deemed ineligible for testing, leaving their infections undetected and left to worsen without appropriate attention (Rowe, 2020).
Additionally, as discussed above, frail patients with multiple chronic diseases are more likely to die from COVID-19 because of an increased risk of clinical adverse events (Yang et al., 2021). Severe underlying illnesses, such as diabetes, cancer, and heart failure, are aggravated by COVID-19 and lead to more serious illness in older adults (CDC, 2021c). As discussed in Chapter 4, many older adults face inequitable social determinants of health, such as lack of access to nutritious foods and health care, similar to those determinants affecting minority populations (CDC, 2022).
Complicating the enhanced risk of infection and serious illness in older people is the heightened risk of anxiety and depression, with these conditions affecting 30 percent of the global population during the pandemic (Santomauro
et al., 2021). Social isolation has contributed to increased rates of loneliness among older people, who have often been separated from family and friends (WHO, 2021c).
THE PANDEMIC’S IMPACTS ON HEALTH SYSTEMS
While the response of health systems—including public health, health care, and long-term care—has varied dramatically across countries during the pandemic, older people have been the most severely affected segment of the population.
Public Health Systems
In 2019, prior to the pandemic, two comprehensive indices were established for assessing the capacity of countries to respond to an epidemic. These indices—the Global Health Security (GHS) Index and the Epidemic Preparedness Index—though distinct from each other, were both based on traditional measures thought to be reliable reflections of “readiness” (GHS, 2021). Similarly, the World Health Organization (WHO) conducted joint external evaluations to assess countries’ abilities to respond to public health risks (WHO, 2021b). Its measures included public health prevention systems, infrastructure, detection and reporting capacity and communications, wealth, general health system capacity, and compliance with international norms. The metrics were calculated for most countries.
Of interest, country-specific scores on the GHS Index were not predictive of access to health care during the pandemic. For instance, the two countries rated highest overall on the indices, the United States and United Kingdom, fared poorly on health care access compared with many other countries that were ranked lower overall (GHS, 2021). The GHS Index report, released in 2021, also points to the need for metrics with a greater emphasis on inequalities; the role of community-based factors and civil society; the effects of globalization; centralized versus fragmented governance; uncoordinated funding; and political factors, especially the importance of political leaders embracing science-based advice (GHS, 2021). The use of metrics that reflect these additional considerations would enable public health systems to incorporate them into planning and preparedness efforts ahead of emergencies.
Health Care Systems
The COVID-19 pandemic had dramatic, often crushing, effects on the acute health care system. These effects had disproportionate impacts on older people, who generally use and depend more on the delivery of acute health care services than younger people. Immediate effects in areas with high community transmission of COVID-19 included surges of hospitalized patients, many requiring
intensive care and respiratory support that placed a strain on intensive care units (Grimm, 2021). Acute care capacity was often overwhelmed, requiring the establishment of supplemental resources, such as field hospitals (CDC, 2020).
Due to closures and capacity limitations, routine preventive and maintenance outpatient visits, acute care visits, elective surgeries, and hospital admissions for non-COVID-19 conditions surged (Heist et al., 2021). Dramatic increases in the use of telemedicine services ameliorated some gaps in care by enabling people to access health care services in the comfort of their home instead of risking exposure to the virus in health care facilities (CDC, 2021d). Countries that lowered existing barriers to the adoption of virtual care (e.g., by allowing reimbursement for telemedicine appointments) saw large increases in use of these virtual platforms (Weigel et al., 2020). But such visits cannot include the blood tests and other diagnostic and screening measures ancillary to in-person visits, thus requiring visits to a laboratory. Additionally, many older people lack access to or are unable to use the technologies required for telemedicine. Inequities in health care access within and across countries have lasting implications for population health and for those most impacted by barriers to care, including older people (UN, 2020).
The long-term effects of this dramatic disruption in health care services are yet to be determined. There is substantial concern that delays in the detection and treatment of conditions such as cancer will increase morbidity and mortality over the coming years. Additionally, reductions in routine blood tests and other diagnostics that are generally included in office visits but not in telemedicine suggest less rigorous monitoring and control of chronic disorders such as diabetes.
The COVID-19 pandemic has disproportionately affected older individuals receiving long-term care, especially those residing in nursing homes. There are 1.5 million nursing home residents in the United States, 83.5 percent of whom are aged 65 and older (Su et al., 2021). According to The New York Times database, long-term care facilities in the United States accounted for 31 percent of COVID-19-related deaths nationwide, with other high-income countries having similar experiences (The New York Times, 2021). In low- and middle-income countries, the proportion of older adults in long-term care facilities is lower, but several issues, such as limited testing and inability to disaggregate COVID-19 data in long-term care settings, are barriers to conducting analysis of the pandemic’s impacts in long-term care facilities.
At the outset of the pandemic, long-term care facilities faced challenges in accessing or procuring personal protective equipment and COVID-19 tests, and infection control training. They found it difficult to reduce congregate care in order to protect both patients and staff while prioritizing well-being to avoid isolation and loneliness (Whitman, 2020). These challenges were exacerbated by the fact that home-based and residential long-term care services share the limited
supply of physicians and nurses with training and expertise in geriatrics (Global Coalition on Aging, 2021).
The pandemic has made clear that, despite the clinical status of many nursing home residents and the numerous challenges facing these facilities, infection, serious illness, and death are not inevitable in this patient population. Data from the National PACE (Program of All-Inclusive Care for the Elderly) Association show that infection rates were much lower for older adults receiving home-based care compared with those in long-term care facilities (PACE, 2021). The data also suggest that providing home-based services, expanding the use of telehealth, using mobile health vans, and providing social supports through engaging activities can reduce infection rates.
In addition to placing greater emphasis on home-based care, it will be important going forward to redesign long-term care facilities to provide more programmatic flexibility and greater protection from contagion during epidemics. Distributing people across rehabilitation centers, hospice, and memory care centers, and ideally smaller long-term care settings, could help to avoid some of the challenges experienced in 2020 and 2021. The adverse experiences of long-term care facilities with COVID-19 will likely have generated increased interest and investment in hospital-based extended care units, home-based care, and other community-based care models.
SOCIAL AND BEHAVIORAL EFFECTS
In addition to the impacts on life expectancy and morbidity resulting directly from COVID-19, the pandemic had negative social and behavioral impacts on older adults in several areas discussed in this report, including ageism, isolation and loneliness, the digital divide, as well as intergenerational impacts. At the same time, research conducted throughout the pandemic has found that older adults are often more resilient than their younger counterparts.
Impacts of Ageism
Pervasive ageism predates the COVID-19 pandemic and has been a critical public health problem for years (see Chapter 4). Ageist attitudes can be seen in government, business, education, health and social institutions, and popular culture. But the pandemic elevated awareness of and revealed ageist attitudes in new and disturbing ways. The early public messaging on the virus incorporated ageist narratives. Media outlets often paired the terms “vulnerable” and “older people” when describing the pandemic (Swift and Chasteen, 2021). In some countries, including China, this messaging intensified the perception among younger generations that older people were a threat to public health (Zhang and Liu, 2021). Although there are signs that the pandemic exacerbated generational divides, there are also cases of younger generations making significant sacrifices
to protect the health of older adults by complying with pandemic restrictions, such as mask wearing and online school and work.
Social media played a role in elevating ageist narratives about aging and older adults during the pandemic. Some messaging about COVID-19 characterized older adults as helpless and expendable, as represented by references to “#BoomerRemover” on Twitter. The response to the pandemic was influenced by the negative stereotype that older adults are dependent, frail, and sickly, and the pandemic fed that stereotype. An analysis of activity on Twitter suggested that large numbers of tweets posted during the onset of the pandemic could be considered ageist because they implied that the lives of older adults were less valuable than those of younger people (Malik et al., 2020).
Ageist expectations have impacted health care policy and practice during the pandemic. During the pandemic, calls for rationing care and sacrificing older adults for the greater good were reported (Sonmez, 2020). Reports from Italy suggested that, because of strain on hospital resources, policies were in place to care for those—often younger patients—who stood to benefit most and had the greatest chance of surviving (Rosenbaum, 2020). This commission understands that some rationing of care may be unavoidable in the midst of a global pandemic, but determinations should be based on medical judgments on a patient-by-patient basis, not on top-down mandates. Chronological age alone should never be a barrier to care.
The impacts of ageism during the pandemic have extended beyond health. As discussed below, job losses and forced retirements, particularly for the most vulnerable older adults, increased during the pandemic. Reports of elder abuse, including family violence, neglect, and financial exploitation, increased in the United States (Chang and Levy, 2021). Additionally, because of social isolation, opportunities for elder abuse to be detected by caregivers and others were reduced (Makaroun et al., 2020). However, community-level responses across the globe have shown solidarity in supporting the physical and mental well-being of older adults. For example, community health workers in Rwanda are monitoring the health and social conditions of older adults in communities while giving them vital information about the pandemic and providing much-needed social interactions (Louis et al., 2022). In another example, Chile launched the Major Protection plan to reinforce care for adults over age 80 who must remain at home during lockdowns (UN, 2020).
The stereotype embodiment theory holds that “negative age stereotypes can be internalized by people of all ages and when these views become self-relevant, influencing older persons’ beliefs about their own aging, they can detrimentally impact health” (Ayalon et al., 2021, p. e49). While segregating and quarantining older people to protect them from the virus may have been a necessary public health measure, that distancing elevated ageist stereotyping. The health consequences of the portrayal during the pandemic of older adults as vulnerable and weak and younger adults as healthy and less susceptible—and the influence of
that portrayal on older adults’ attitudes about their own aging—will be understood only with future study (Swift and Chasteen, 2021).
The United Nations (UN) and WHO are focused on combating ageism through a global strategy and action plan on aging and health. The Decade of Healthy Ageing, along with the related work of member states, agencies, and civil society organizations, is aimed at combating ageism and improving health, increasing opportunity, reducing costs, and enabling flourishing at any age (WHO, 2021a).
Impacts of Isolation, Loneliness, and the Digital Divide
Social isolation and loneliness increased during the pandemic as older adults sheltered in place. The distancing that was a critical safety measure for vulnerable individuals separated them from friends and coworkers; children and grandchildren; and a range of traditional support networks, such as senior centers and faith institutions. The United Nations suggests that the psychosocial and mental health needs of older people were less likely to be met during lockdowns because of the breakdown of social networks (UN, 2020).
The lack of human contact during the pandemic has been especially difficult, but social isolation (defined as a lack of meaningful connection with others) has been an underappreciated public health challenge for older people for many years. A University of Michigan study found that more than half of older adults in the United States reported “feeling isolated from others,” and about half of adults aged 50–80 felt “more isolated” since the start of the pandemic (Piette et al., 2020, p. 1).
Technology served as a bridge for many people during the pandemic. As previously discussed, telemedicine allowed people to receive basic levels of care while not risking exposure to the virus. Digital technology allowed people to connect with loved ones virtually and helped reduce feelings of social isolation and loneliness. However, the benefits of these virtual connections were not shared equitably. Barriers to using technology—negative attitudes toward internet usage, limited access to broadband, and lack of digital literacy—created corresponding barriers to accessing critical information and communication about COVID-19 (UN, 2020). Older people have disproportionately limited access to and usage of internet technologies, and this is especially true for older people in lower-income countries (UN, 2020). Thus, it is important to assess the needs of older people who are isolated and determine safe ways to provide them with accessible social support. Additionally, information sources, such as print notifications, that provide critical information about COVID-19 can be personalized to reach older community members who may not have access to technology. Efforts to improve digital literacy skills, as discussed in Chapter 4, would also help mitigate the isolation and loneliness felt by those who lack familiarity with online social platforms.
The health and social benefits of intergenerational connections have been confirmed by research over many years. Teaching and mentoring programs, co-housing arrangements, social networks, and other programs have demonstrated value for both younger and older people (see Chapter 4). Yet, despite widespread efforts to foster intergenerational comity and collaboration, the stresses of the pandemic have impeded and tested intergenerational relations in dramatic ways.
At the societal level, public health mandates, social isolation, economic stresses, and other factors associated with the pandemic appear to have increased generational divides. According to research sponsored by AARP, the economic effects of the pandemic have forced families to merge households for financial survival (Binette and Vasold, 2018). But despite its many benefits, intergenerational living also resulted in increased risk of contracting COVID-19 for older adults as younger people brought SARS-CoV-2 home from school or work.
The global nature of the pandemic and the future risks it has highlighted have led some to call for a reimagining of intergenerational health. The commission advocates for an approach not just focused on the health of individuals and families but also recognizing that health exists at the intersection of the environment and society and cannot be approached from a purely biomedical perspective.
The economic impacts of the pandemic have varied significantly, reflecting wide disparities across societies. Older adults have been not only at higher risk of serious illness if they contract COVID-19 but also financially vulnerable if the pandemic has led to a sustained drop in their income and retirement savings (Koma et al., 2020). Studies suggest, for example, that more than one-third of U.S. adults aged 65 or older live in counties that rank in the top percentages of both COVID-19 prevalence and the highest costs of living (Li and Mutchler, 2020).
A recent study completed in Mexico found that low-income patients who tested positive for COVID-19 were four times more likely to require hospitalization than higher-income patients (Arceo-Gomez et al., 2022). Additionally, research conducted by the United Nations suggests that the risk of poverty increases with age, and more than 80 percent of the aging population lives in poverty in some lower- to middle-income countries (UN, 2020). Therefore, older adults faced the negative implications of the correlation between low income levels and hospitalizations during the pandemic.
Older adults in general suffer declines in wealth during such economic downturns as that experienced in 2020, and they have less time than younger adults to make up such losses to secure their retirement. Older adults in minority populations are especially likely to experience significant declines in financial
well-being in times of economic stress, exacerbating economic disparities that have existed during most of their working years (Li and Mutchler, 2020). The economic downturn resulting from the pandemic has greatly impacted older women in lower- to middle-income countries in particular because of their limited access to income and pension programs (UN, 2020).
Finally, in the United States, about 11 percent of those aged 65 and older—approximately 1.1 million people—have lost their jobs during the pandemic, threatening their financial security at a time of life when economic recovery may be unlikely (Jacobson et al., 2020). According to a Pew Research Center study (Horowitz et al., 2021), more than one-quarter of U.S. adults aged 50 and older believe the pandemic will affect their ability to retire and achieve their financial goals.
While much has been learned during the pandemic regarding effective approaches for protecting older persons and the general public going forward, five general areas emerge as especially important.
The disproportionate adverse effects of advancing age on the risk of COVID-19, even in the absence of significant preclinical morbidity, have clearly underlined the rudimentary state of understanding of the aging-related physiological changes that bring greater susceptibility to infection, severe illness, and death. Given the dramatic increases globally in the number and proportion of older persons, much greater investment in basic and clinical research is essential to better understand the pathophysiology of diseases and develop effective therapeutics.
The need to revise current risk assessment strategies is clear from the fact that internationally recognized indices, such as the GHS Index, that were designed to indicate the levels of countries’ preparedness for an epidemic failed to accurately predict the pandemic’s toll on individual countries. Revised approaches could rely less heavily on issues of biosafety and include more consideration of the effects of globalization, especially differences between high- and low- or middle-income countries; community-based and civil society–related issues; ability to establish effective supply systems; the prevalence of digital-access skills, particularly in older and underprivileged groups; and political risks. In addition, given the disproportionate risks for certain subsets of the population, such as older persons with COVID-19 and children with malaria or other infections,
future indices need to assess readiness with respect to defined subpopulations in addition to countrywide metrics.
One major lesson of the COVID-19 pandemic has been the need for significant collaboration between the public and private sectors and among various disciplines within the public sector. During the pandemic, sharing of expertise, data, and resources within both the public and private sectors, as well as across sectors, was unparalleled and yielded some extraordinary outcomes. For example, intense collaboration among academic and government institutions and pharmaceutical firms yielded the rapid development, mass production, and distribution of personal protective equipment, vaccines and syringes, coronavirus test kits, and therapeutics. An essential, and often overlooked, aspect of preparedness is pre-epidemic establishment of effective mechanisms to facilitate rapid and intensive collaboration, including sharing of best science, expertise, and resources, within and between the public and private sectors, as well as enhanced communication and collaboration between local and state regulators.
Data and Analytics
While data and analytics clearly inform readiness assessments, data sharing and use of real-time data have been shown to be critical for effective decision making about health care during the pandemic. These tools have been key to effective intersectoral collaboration and the rapid advances made in artificial intelligence, machine learning, and predictive modeling. The capacity to identify important underlying actionable trends in large datasets warrants special attention to these issues. Data sharing is an essential component of effective and productive collaboration across and within sectors to ensure that the most cutting-edge approaches are being applied to interrogation of the most up-to-date and valid data.
Rebalancing and Redesigning Health Care Systems
It has long been clear that many countries have overinvested in acute care, fueled in part by demographic trends, lack of regulatory controls, and new technologies, to the disadvantage of public health and long-term care (see Chapter 6). Countries around the world need to rebalance and redesign their health care systems. It will be important for these efforts to include assessment of public health system infrastructures, which are often badly in need of major investments to enhance preparedness to protect the population, especially older people. And as discussed above, long-term care systems, including nursing homes, home-based care, and community-based elements of care, need to be redesigned with greater flexibility and capacity to protect and serve older people, particularly during epidemics.
Aburto, J. M., R. Kashyap, J. Schöley, C. Angus, J. Ermisch, M. C. Mills, and J. B. Dowd. 2021. Estimating the burden of the COVID-19 pandemic on mortality, life expectancy and lifespan inequality in England and Wales: A population-level analysis. Journal of Epidemiology and Community Health 75(8):735–740.
Andrasfay, T., and N. Goldman. 2021. Reductions in 2020 US life expectancy due to COVID-19 and the disproportionate impact on the Black and Latino populations. Proceedings of the National Academy of Sciences 118(5):e2014746118.
Arceo-Gomez, E. O., R. M. Campos-Vazquez, G. Esquivel, E. Alcaraz, L. A. Martinez, and N. G. Lopez. 2022. The income gradient in COVID-19 mortality and hospitalisation: An observational study with social security administrative records in Mexico. The Lancet Regional Health-Americas 6:100115.
Arias, E., B. Tejada-Vera, and F. Ahmad. 2021. Provisional life expectancy estimates for January through June, 2020. Washington, DC: U.S. Department of Health and Human Services
Ayalon, L., A. Chasteen, M. Diehl, B. R. Levy, S. D. Neupert, K. Rothermund, C. Tesch-Römer, and H.-W. Wahl. 2021. Aging in times of the COVID-19 pandemic: Avoiding ageism and fostering intergenerational solidarity. The Journals of Gerontology: Series B 76(2):e49–e52.
Bartleson, J. M., D. Radenkovic, A. J. Covarrubias, D. Furman, D. A. Winer, and E. Verdin. 2021. SARS-CoV-2, COVID-19 and the ageing immune system. Nature Aging 1(9):769–782.
Binette, J., and K. Vasold. 2018. Home and community preferences: A national survey of adults age 18-plus. Washington, DC: AARP Research.
Castro, M. C., S. Gurzenda, C. M. Turra, S. Kim, T. Andrasfay, and N. Goldman. 2021. Reduction in life expectancy in Brazil after COVID-19. Nature Medicine 27(9):1629–1635.
CDC (Centers for Disease Control and Prevention). 2020. Key considerations for transferring patients to relief healthcare facilities when responding to community transmission of COVID-19 in the United States. https://www.cdc.gov/coronavirus/2019-ncov/hcp/relief-healthcare-facilities.html (accessed March 3, 2022).
CDC. 2021a. COVID-19 risks and vaccine information for older adults. https://www.cdc.gov/aging/covid19/covid19-older-adults.html (accessed March 3, 2022).
CDC. 2021b. Life expectancy in the U.S. declined a year and half in 2020. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/202107.htm (accessed March 3, 2022).
CDC. 2021c. People with certain medical conditions. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html (accessed March 3, 2022).
CDC. 2021d. Using telehealth to expand access to essential health services during the COVID-19 pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html (accessed March 3, 2022).
CDC. 2022. Health equity considerations and racial and ethnic minority groups. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html#anchor_1595551025605 (accessed March 3, 2022).
Chang, E.-S., and B. R. Levy. 2021. High prevalence of elder abuse during the COVID-19 pandemic: Risk and resilience factors. The American Journal of Geriatric Psychiatry 29(11):1152–1159.
GHS (Global Health Security). 2021. 2021 Global Health Security Index. https://www.ghsindex.org (accessed March 3, 2022).
Global Coalition on Aging. 2021. Building the caregiving workforce our aging world needs. New York: Global Coalition on Aging.
Gómez-Belda, A. B., M. Fernández-Garcés, E. Mateo-Sanchis, M. Madrazo, M. Carmona, L. Piles-Roger, and A. Artero. 2021. COVID-19 in older adults: What are the differences with younger patients? Geriatrics & Gerontology International 21(1):60–65.
Grimm, C. A. 2021. Hospitals reported that the COVID-19 pandemic has significantly strained health care delivery. Washington, DC: U.S. Department of Health and Human Services.
Heist, T., K. Schwartz, and S. Butler. 2021. Trends in overall and non-COVID-19 hospital admissions. https://www.kff.org/health-costs/issue-brief/trends-in-overall-and-non-covid-19-hospital-admissions (accessed March 3, 2022).
Heuveline, P., and M. Tzen. 2021. Beyond deaths per capita: Comparative COVID-19 mortality indicators. BMJ Open 11(3):e042934.
Horowitz, J. M., A. Brown, and R. Minkin. 2021. A year into the pandemic, long-term financial impact weighs heavily on many Americans. Washington, DC: Pew Research Center.
Ishida, N. 2021. Japan’s average longevity hits record high of 87.74 years for women, 81.64 for men. The Mainichi, August 2.
Jacobson, G., J. Feder, and D. C. Radley. 2020. COVID-19’s impact on older workers: Employment, income, and Medicare spending. https://doi.org/10.26099/pdhk-xe54 (accessed March 3, 2022).
Koma, W., T. Neuman, G. Claxton, M. Rae, J. Kates, and J. Michaud. 2020. How many adults are at risk of serious illness if infected with coronavirus? Washington, DC: Kaiser Family Foundation.
Labenz, C., W. M. Kremer, J. M. Schattenberg, M.-A. Wörns, G. Toenges, A. Weinmann, P. R. Galle, and M. F. Sprinzl. 2020. Clinical frailty scale for risk stratification in patients with SARS-CoV-2 infection. Journal of Investigative Medicine 68(6):1199–1202.
Li, Y., and J. E. Mutchler. 2020. Older adults and the economic impact of the COVID-19 pandemic. Journal of Aging & Social Policy 32(4–5):477–487.
Louis, E. F., D. Eugene, W. C. Ingabire, S. Isano, and J. Blanc. 2022. Rwanda’s resiliency during the coronavirus disease pandemic. Frontiers in Psychiatry 12:589526.
Makaroun, L. K., R. L. Bachrach, and A.-M. Rosland. 2020. Elder abuse in the time of COVID-19—Increased risks for older adults and their caregivers. The American Journal of Geriatric Psychiatry 28(8):876.
Malik, M., H. Burhanullah, and C. Lyketsos. 2020. Elder abuse and ageism during COVID-19. Psychiatric Times, September 29.
Nanda, A., N. V. R. K. Vura, and S. Gravenstein. 2020. COVID-19 in older adults. Aging Clinical and Experimental Research 32(7):1199–1202.
Obuchi, S. P., H. Kawai, M. Ejiri, K. Ito, and K. Murakawa. 2021. Change in outdoor walking behavior during the coronavirus disease pandemic in Japan: A longitudinal study. Gait & Posture 88:42–46.
OECD (Organisation for Economic Co-operation and Development). 2021. Life expectancy at birth. https://data.oecd.org/healthstat/life-expectancy-at-birth.htm (accessed March 3, 2022).
PACE (Program of All-Inclusive Care for the Elderly). 2021. COVID data demonstrate PACE model is safer than nursing home care. https://www.npaonline.org/about-npa/press-releases/covid-data-demonstrate-pace-model-safer-nursing-home-care (accessed March 3, 2022).
Piette, J., E. Solway, D. Singer, M. Kirch, J. Kullgren, and P. Malani. 2020. Loneliness among older adults before and during the COVID-19 pandemic: National Poll on Healthy Aging. Ann Arbor, MI: University of Michigan.
Rosenbaum, L. 2020. Facing COVID-19 in Italy—Ethics, logistics, and therapeutics on the epidemic’s front line. New England Journal of Medicine 382(20):1873–1875.
Rowe, J. W. 2020. COVID-19 sickens seniors differently. Here’s why. The Washington Post, June 29.
Santomauro, D. F., A. M. M. Herrera, J. Shadid, P. Zheng, C. Ashbaugh, D. M. Pigott, C. Abbafati, C. Adolph, J. O. Amlag, and A. Y. Aravkin. 2021. Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. The Lancet 398(10312):1700–1712.
Sonmez, F. 2020. Texas Lt. Gov. Dan Patrick comes under fire for saying seniors should “take a chance” on their own lives for sake of grandchildren during coronavirus crisis. The Washington Post, March 24.
Su, Z., D. McDonnell, and Y. Li. 2021. Why is COVID-19 more deadly to nursing home residents? QJM 114(8):543–547.
Swift, H. J., and A. L. Chasteen. 2021. Ageism in the time of COVID-19. Group Processes & Inter-group Relations 24(2):246–252.
Tehrani, S., A. Killander, P. Åstrand, J. Jakobsson, and P. Gille-Johnson. 2021. Risk factors for death in adult COVID-19 patients: Frailty predicts fatal outcome in older patients. International Journal of Infectious Diseases 102:415–421.
The New York Times. 2021. Nearly one-third of U.S. coronavirus deaths are linked to nursing homes. The New York Times, June 1.
UN (United Nations). 2020. Policy brief: The impact of COVID-19 on older persons. New York: United Nations.
Weigel, G., A. Ramaswamy, L. Sobel, A. Salganicoff, J. Cubanski, and M. Freed. 2020. Opportunities and barriers for telemedicine in the US during the COVID-19 emergency and beyond. San Francisco, CA: Kaiser Family Foundation.
Whitman, D. 2020. COVID-19 has laid bare the cracks in long-term care. Here’s how to fix them. Geneva, Switzerland: World Economic Forum.
WHO (World Health Organization). 2021a. Global report on ageism. Geneva, Switzerland: World Health Organization.
WHO. 2021b. Joint external evaluation (JEE). https://www.euro.who.int/en/health-topics/health-emergencies/international-health-regulations/monitoring-and-evaluation/joint-external-evaluation-jee (accessed March 3, 2022).
WHO. 2021c. Social isolation and loneliness among older people: Advocacy brief. Geneva, Switzerland: WHO.
World Bank. 2021. Life expectancy at birth, total (years). https://data.worldbank.org/indicator/SP.DYN.LE00.IN (accessed March 3, 2022).
Yang, Y., K. Luo, Y. Jiang, Q. Yu, X. Huang, J. Wang, N. Liu, and P. Huang. 2021. The impact of frailty on COVID-19 outcomes: A systematic review and meta-analysis of 16 cohort studies. The Journal of Nutrition, Health & Aging 25(5):702–709.
Yeung, J., and G. Bae. 2021. South Korea reports population drop, with more deaths than births for first time. CNN, January 4.
Zhang, J., and X. Liu. 2021. Media representation of older people’s vulnerability during the COVID-19 pandemic in China. European Journal of Ageing 18(2):149–158.