What Older Adults Need to Know About the COVID-19 Vaccine

Adults over age 65 have been disproportionately affected by COVID-19. Now that the Food and Drug Administration (FDA) has started authorizing vaccines against COVID-19, older adults are among the first in line to receive them.

The Advisory Committee on Immunization Practices (ACIP), a panel of independent experts advising the Centers for Disease Control and Prevention (CDC), has recommended that people living in long-term care facilities, as well as those age 65 and older, be included in Phase 1 of the COVID-19 vaccination program.

The ACIP met on Dec 1 ahead of the FDA’s decisions to grant an emergency use authorizations to the COVID-19 vaccines from Pfizer-BioNTech and Moderna. The ACIP recommended that healthcare workers and those living in long-term care facilities be the first to receive the vaccine (Phase 1a).

The ACIP met again on December 20 and updated its recommendations to include Phase 1b and Phase 1c priority groups. At this meeting, the ACIP put adults ages 75 and older in Phase 1b and adults ages 65 to 74 in Phase 1c.

States, which are in charge of distributing shipments of the vaccine, are not required to follow the CDC’s recommendations, but many are including older adults and long-term care residents among the initial vaccine recipients.

On January 12, the Department of Health and Human Services announced at a press briefing that vaccination should begin for people 65 and older and those with underlying medical conditions that are considered high risk for COVID-19. President Joe Biden also announced plans to increase eligibility, including to those 65 and older.

“The seriousness [of COVID-19] is underscored by [the fact that] mortality rates, or risk of dying, is highest in senior patients,” Ardeshir Hashmi, MD, the Director of the Center for Geriatric Medicine and Chair of Geriatric Innovation at the Cleveland Clinic, tells Verywell. "It is incredibly important to get the vaccine."

Hashmi doesn't think there should be any hesitation in proceeding to get vaccinated if it's available to high-risk people and seniors, "unless they’re [presently] sick or if they’ve had COVID before."

An At-Risk Population

According to the CDC, older adults are more likely than the general population to require care when they contract COVID-19. Compared to adults ages 18 to 29, adults who are between 65 to 74 years old are five times more likely to require hospitalization and 90 times more likely to die from COVID-19. Outcomes get worse for every subsequent age bracket.

One reason is that people of any age who have comorbidities (or multiple chronic medical conditions) are more susceptible to COVID-19. Chronic health conditions tend to be more prevalent among older adults. Approximately 77% of older adults have at least two chronic diseases, such as chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure), cardiovascular disease, or diabetes.

Compounding the risk for COVID-19 for older adults is a weakened immune system. Hashmi says that the immune system generally weakens with age and adds that older adults do not have the same immune cells that can fight off and remember infections to provide future protection. Therefore, it’s important that older adults get a vaccine to help their bodies form a defense against COVID-19.

“You always need to be very, very cautious because they are more susceptible to COVID-19," Hashmi says, adding that the risks of having a weakened immune system and the greater likelihood of comorbidities "are unique to the senior patient population.”

Prioritizing Long-Term Care Residents

On February 29, 2020, the CDC and the state of Washington reported the presumed first COVID-19 related hospitalizations: a resident and employee at a long-term care facility (LTCF). They also reported the first death—a man in his 50s. Since then, LTCF and prisons have continued to be COVID-19 hotspots.

LTCFs are seeing approximately 5,000 deaths per week related to COVID-19 and more than 1,000 long-term care workers have died from the virus, says Mark Parkinson, the president and CEO of The American Health Care Association and National Center for Assisted Living (AHCA/NCAL), which represents more than 14,000 long-term care facilities across the country.

“It is a staggering statistic that less than 1% of the COVID cases in the United States have hit people in long-term care but over 40% of the deaths have occurred there,” Parkinson said in a statement to the media. “And as tragic as that statistic is, it gives us an incredible opportunity to make a huge difference in the mortality rate, just by focusing the initial rounds of vaccine distribution and actual vaccination on this very vulnerable population.”

“The risk is if one person gets COVID-19, and you are living in a community where there are a lot of other seniors who also have decreased immune systems, many comorbidities and are also older, the chances of very rapid spread in the community are very high,” Hashmi says. “You want those communities of seniors who are all at high risk to be prioritized ahead of the general population."

Hashmi says that for the general population and those who are younger, their immune systems will be better prepared to fight the infection. "They’re still at risk," says Hashmi, "But they are not as at risk as [those] in the older population."

The Effort to Inoculate

Hashmi expects that the process to inoculate older adults living in LTCFs will be fairly straightforward because it's easier to get vaccines to people in a defined geographical setting.

However, Hashmi also thinks that it will be more difficult to prioritize older people who live in the general community and get them to a vaccine distribution center—especially if they are frail or do not have easy or reliable transportation.

Those distribution details will be worked out in the coming weeks, but Hashmi's larger concern is convincing older adults to get vaccinated in the first place.

According to a Pew Research Center survey, in November 2020, an estimated 60% of Americans said they would "definitely" or "probably" get a COVID-19 vaccine if it were available today.

When the responses were broken down by age, 75% of adults age 65 and up said that they would "definitely" or "probably" get vaccinated—the highest likelihood among all age groups. Interestingly, that percentage had decreased from 84% when people were surveyed back in May.

“I think that it is going to be more important to speak to that anxiety and to reassure [people] that this has been approved by the FDA, which has its own incredibly rigorous process of approving any new vaccine or any new medication for that matter,” Hashmi says. “One way to help allay that anxiety may be to make a clear plan when someone gets the vaccine to remain in close touch with your doctor just in case you need to report how you’re feeling and that you’re doing OK and if you have any questions. As long as you can do that, I think you should be fine.”

Why Older Adults Are Excluded From Trials

In a research letter published in September 2020 in JAMA Internal Medicine, the authors detailed their review of 847 COVID-19 treatment and vaccine trials to evaluate their risk for the exclusion of older adults—something the authors note there is a history of in clinical trials.

“Such exclusion will limit the ability to evaluate the efficacy, dosage, and adverse effects of the intended treatments,” the authors wrote. “We acknowledge that some exclusions for severe or uncontrolled comorbidities will be essential to protect the health and safety of older adults. However, caution must be taken to avoid excluding otherwise eligible participants for reasons that are not well-justified.”

Hashmi says that the exclusion of older adults in drug development and research is not unusual—largely because of the same anxiety many people are feeling now about safety, adverse side effects, and efficacy.

From a research perspective, there are also ethical considerations when involving a population with potential memory concerns because they have to give their consent to participate. 

Preserving Quality of Life

Hashmi says that by and large, he's hearing that the vaccine is universal and that no patients should be outright excluded. However, the decision of when and whether patients should be vaccinated needs to be consistent with the goals of care for every patient.

“What we are seeing both in the hospital as well as the community is the infection tends to last a lot longer in our older patients because they just don’t have the homeostenosis—the ability to fight back and recover from this virus sooner," Hashmi says. In these cases, the hospital stays are longer and the risk of being admitted to the intensive care unit or dying is much higher.

Hashmi says that if a vaccine can prevent people from getting COVID-19, it's a huge boon for their quality of life—even if they're in hospice. The virus causes symptoms such as diarrhea, fatigue, confusion, fever, and shortness of breath—which can make the last phase of life difficult and uncomfortable.

Patients who are concerned about getting vaccinated while on chemotherapy to treat cancer or immunosuppressant medications, such as post-transplant, should talk to their healthcare providers. Patients should also ask their doctors about the optimal time to get their first and second doses.

"When organizations like the ACIP and the FDA advocate for people to get the vaccine, they really mean it," Hashmi says.

The information in this article is current as of the date listed, which means newer information may be available when you read this. For the most recent updates on COVID-19, visit our coronavirus news page.