Opinion | Long COVID in Older Adults: An Elusive Geriatric Syndrome

A recent report from the CDC said that nearly 60% of Americans, including 75% of children and adolescents, have been infected by SARS-CoV-2 as of February. As the virus continues to linger and mutate, that number will continue to rise, leading to higher rates of long COVID: a wide range of symptoms that can last more than 4 weeks or longer after the initial infection.

Issues like breathing difficulties, fatigue, high blood pressure, memory difficulties, mental health diagnoses (depression and anxiety), blood clotting, and kidney injury can now become a new, ongoing health battle — possibly worse than the virus itself. Older Americans are once again left at high risk for potentially fatal complications.

In a recent study that included nearly 90,000 adults ages 65 and older who were diagnosed with SARS-CoV-2 infection, 32% reported symptoms of long COVID up to 4 months after infection. These striking findings imply that millions of older adults could be suffering from debilitating symptoms of long COVID. With these staggering numbers, and what we are seeing in our patients in hospitals and primary care facilities, we — as clinicians — need to reframe how we view and address long COVID in this population. We need to improve our approach to and management of long COVID.

The first step is to redefine long COVID in older adults as a geriatric syndrome. A geriatric syndrome is defined as a multifactorial condition that develops and impairs multiple systems. More simply, the term is used to capture the unique features of a health condition in older persons and often describes a set of signs and symptoms that do not fit into a discrete disease category. Common geriatric syndromes include delirium, falls, incontinence, and frailty. These syndromes are associated with poor outcomes and reduced quality of life. Redefining long COVID as a geriatric syndrome will allow us to approach it with the unique lens needed for older adults, a particularly vulnerable population.

Long COVID has many similarities to other geriatric syndromes in that the exact mechanism that leads to the symptoms is complex and not clearly understood. For example, a study that colleagues and I published at the Feinstein Institutes for Medical Research this March found that 13% of older adults had evidence of new dementia within 1 year of COVID-19 hospitalization. Given the unique characteristics that are more common with older age (increased comorbid conditions, polypharmacy, reduced reserve, physiological changes), it is not surprising that older adults are more likely to develop long COVID and should be monitored accordingly.

Unlike other geriatric syndromes, which have a more unified manifestation (e.g., falls, urinary incontinence), long COVID has been more elusive, partly because of its novelty and the vast symptomatology that makes up the diagnosis. Some of the most commonly described symptoms, such as fatigue or brain fog, are hard to objectively measure through clinical examination or blood tests and it is challenging to quantify symptoms that can sometimes be easier to disregard as “normal aging” or “old age.” Even once diagnosed, these symptoms have no simple treatment. The absence of a definitive diagnosis, along with the lack of a clear management strategy, can leave patients and families frustrated and can even lead to a sense of abandonment. We hear it first hand from these often scared and confused patients and caregivers; we get questions like “What now? Can mom get better?” or “What’s the treatment?” And at this point, we really don’t have many answers.

Therefore, like with other geriatric syndromes, the diagnosis and management of long COVID requires a comprehensive approach.

• First, new symptoms in older adults should not be dismissed and instead should signal the need for a detailed history (including a complete medication review) and physical examination.
• Second, ensuring comorbid conditions — such as diabetes, heart disease, and high blood pressure, which may have received less attention during the pandemic — are well-managed is essential.
• Third, we must ensure a stronger focus on the preservation of function, cognition, and socialization. Containment and mitigation strategies (e.g. social distancing), which were necessary during the pandemic, led many older adults to reduce their daily activities, resulting in functional and cognitive decline as well as social isolation.
• Fourth, the COVID pandemic further brought to light health inequities for disadvantaged and underserved populations. Long COVID is just as likely to exacerbate existing disparities. We cannot ignore the health implications of social determinants of health (e.g., food and housing security), which must be incorporated into daily practice.
• Fifth, caregivers are an essential part of the care team and must be included and supported.

At the heart of this discussion is research on post-COVID conditions. My colleagues at Northwell Health and across the nation continue to investigate the COVID impact on older adults. And as new research comes to light, we will be able to better categorize the condition beyond the umbrella term of long COVID, which will lead to better diagnosis and management strategies of this complex syndrome.

In the meantime, we must remain vigilant when seeing our patients who fall into this high-risk category for long COVID, refrain from dismissing symptoms as just “old age,” and listen to the caregivers and loved ones who are on the front lines of helping care for these patients.

Liron Sinvani, MD, is a hospitalist with geriatrics training. She is the director of Geriatric Hospitalist Service for Northwell Health and assistant professor at the Feinstein Institutes for Medical Research whose research focus is on improving quality of care of hospitalized older adults.