In June 2020, shortly after the start of the pandemic, people recovering from infection with COVID-19, especially young women, began to call attention to a range of debilitating symptoms that lingered well past the acute viral illness. They described symptoms affecting nearly every organ and often lasting weeks to months—in some cases, years. The symptoms included cognitive slowness and inability to concentrate (often referred to as “brain fog”), fatigue, shortness of breath, lightheadedness and tachycardia (a heart rate of more than 100 beats per minute). Some people reported muscle pains and tremors. The symptoms puzzled medical professionals, as diagnostic tests came back normal, which is often a perfect recipe for being dismissed by the health system.
Since then, however, many more people have reported prolonged symptoms, now called Long COVID, including Olympic athletes and others at the height of their careers. According to the Centers for Disease Control and Prevention (CDC), nearly one in five people infected with COVID suffer from symptoms that persist beyond four weeks.
‘Older people who were critically ill and hospitalized had higher rates of needing hospitalization in the following year.’
The mysterious nature of the symptoms may best be described as a post-infectious syndrome, often seen after other viral illnesses like Epstein-Barr virus or the bacterial infection of Lyme disease. It also has been likened to chronic fatigue syndrome. The symptoms may be a sign of an abnormal immune response or a new biological mechanism potentially “turned on” by COVID. Certainly, there are different variants of Long COVID, which can make it difficult to differentiate from other types of illness.
Effect on Older Adults
Perhaps surprisingly, research shows that it is older adults who are most at-risk for developing Long COVID. The same symptoms first reported by younger adults are also common in older adults but are sometimes not immediately identified. Older adults may assume it takes longer to recover and not seek treatment, or the symptoms may be attributed to another medical condition. This is not necessarily a misdiagnosis.
In fact, several studies show that there is an increased risk for hospitalization following COVID due to conditions such as heart attacks, blood clots, strokes and lung infections. The risk of developing an acute illness following COVID is associated with the severity of the acute illness from having COVID (see Cohen et al., 2022, and Al-Aly et al., 2021). That is, older people who were critically ill and hospitalized had higher rates of needing hospitalization in the following year. Still, for many older adults, especially those with relatively mild COVID infections that did not require hospitalization, symptoms can linger, impacting quality of life and vitality.
Scientists are finding some explanations for these symptoms, although they are not always detected with routine testing. In some cases, there is dysregulation of the metabolic system that feeds oxygen to muscles in the body, resulting in extreme fatigue, poor exercise tolerance, and exhaustion following any type of mental or physical exertion. In other cases, the lining of the blood vessels known as the endothelial layer, which regulates the diameter of the blood vessels, responds abnormally to molecular signals, triggering spasm of the blood vessel that causes chest discomfort and shortness of breath. There is another syndrome known as Postural Orthostatic Tachycardia Syndrome (or POTS), in which the body is in a dehydrated state and tries to compensate by increasing the heart rate, resulting in extreme lightheadedness and tachycardia when standing for prolonged periods. Underlying this dysregulation may be altered immune responses following infection with COVID, but research is ongoing.
‘One of the lessons from the pandemic is that baseline health matters.’
What does this mean for older people? One of the lessons from the pandemic is that baseline health matters. People with obesity, hypertension, and diabetes were most at risk for severe illness and death. With vaccines, severe illness is less common, but still possible. Eating healthily, getting daily physical activity, keeping a healthy weight, and taking medication to control conditions like hypertension and diabetes, are essential.
Vaccination has unequivocally been demonstrated to lessen the risk of severe illness from COVID and is a mainstay of keeping healthy. Also new data shows that vaccinated people may be less likely to develop Long COVID.
Communication and Connection Are Key
A second lesson is the importance of communication and connection. Although this mostly refers to social engagement among family and friends, it is also true for clinicians and patients. The doctor-patient relationship is ever more important with unexplained symptoms or medical illnesses. Although the world is more alert to Long COVID, many patients continue to be dismissed by the medical system when tests turn up normal. This needs to change, and older adults have an important role to play.
Older adults are more likely to have a trusted healthcare provider and may be more comfortable and experienced with ensuring their needs are met. The patient narrative is of greatest importance and raising attention to persisting symptoms is necessary to drive the science forward, even if doctors don’t have all the answers. A mainstay of treatment is physical therapy, which can have enormous impact for older adults—increasing strength, balance and exercise tolerance, and potentially improving mental health.
The pandemic has already halted the lives of so many older adults, disrupting retirement plans, travel and connection with family and friends. The symptoms of Long COVID can further exacerbate this disconnection. It is time to bring attention to Long COVID in older adults and develop tailored recovery programs that are aimed to improve total well-being.
Erica Spatz, MD, MHS, is an associate professor of Cardiovascular Medicine and Epidemiology, a clinical investigator at the Center for Outcomes Research and Evaluation and directs the Preventive Cardiovascular Health Program at the Yale School of Medicine. She is a Principal Investigator of a CDC-funded study on Long COVID.