COVID-19 in the older adult — presentation and management

Why older adults are the highest-risk group. Immunosenescence and inflammaging, multimorbidity, reduced pulmonary and cardiac reserve, and frailty make age the single strongest predictor of severe disease and death. Residents of long-term care facilities are at particular risk because of close cohabitation and shared staff. The great majority of COVID-19 hospitalisations occur in those ≥65 years, with the highest rates over 75.

Atypical presentation. Delirium or acute confusion may be the sole presenting feature. Also falls, functional decline, anorexia, generalised weakness, unexplained tachypnoea and "silent hypoxia" — significant desaturation without breathlessness. Fever may be absent because of the blunted febrile response of ageing; anosmia is reported less often than in younger patients.

Assessment. Pulse oximetry is essential (target SpO 94–98%, or 88–92% if at risk of hypercapnia); respiratory rate; 2 CBC (lymphopenia), CRP, renal and liver function, blood glucose, D-dimer, ECG and chest imaging; RT-PCR or rapid antigen test. Document a Clinical Frailty Scale score and comorbidity — used alongside, never instead of, clinical assessment when making escalation decisions. Screen for delirium with the 4AT.

Mild-to-moderate disease in a high-risk older adult. Start an antiviral within 5 days of symptom onset. Nirmatrelvir/ritonavir is first line — dose-reduce if eGFR 30–60 mL/min, avoid if eGFR <30, and check for CYP3A4 interactions, which are the major geriatric pitfall (statins, calcium-channel blockers, amiodarone, DOACs, tacrolimus, some antipsychotics — many need temporary suspension or dose reduction). Alternatives: remdesivir (3-day IV course) or molnupiravir.

Severe disease (hypoxia). Controlled oxygen, awake proning if tolerated, dexamethasone 6 mg daily for up to 10 days (only if hypoxic), plus tocilizumab or baricitinib in rapidly progressive inflammatory disease; escalate to HFNO/NIV/ventilation according to agreed goals of care. Give LMWH thromboprophylaxis unless contraindicated. Antibiotics only when bacterial co-infection is genuinely suspected. Monitor for hyperglycaemia and steroid-induced delirium.

The geriatric care bundle. Delirium prevention (reorientation, hearing aids and spectacles, hydration, early mobilisation, sleep hygiene, minimising sedatives and restraints); nutrition and swallow assessment; pressure-ulcer prevention; medication review; early rehabilitation for deconditioning and post-COVID functional decline; and explicit advance care planning and goals-of-care discussion with the patient and family. Prevention: updated COVID-19, influenza and pneumococcal vaccination, ventilation, and IPC in long-term care.

The 2025 IDSA guideline update continues to strongly recommend nirmatrelvir/ritonavir for high-risk adults with mild-to-moderate COVID-19. However, the PANORAMIC and CanTreatCOVID platform trials (NEJM 2026), conducted in a largely vaccinated higher-risk community population, found faster symptom recovery but no significant reduction in hospitalisation or death — so the absolute benefit is now understood to be greatest in the unvaccinated, immunocompromised and oldest-old. CDC 2025–2026 guidance recommends COVID-19 vaccination for adults ≥65 years through individual-based (shared clinical) decision-making, and CDC MMWR 2026 data show only about 31% of eligible outpatients ≥65 years receive an antiviral within 7 days — under-treatment, not over-treatment, is the current practice gap. If this appears as a 15-mark question, add: pathophysiology (ACE2, cytokine response, endothelial injury, immunothrombosis); a severity classification table (mild / moderate / severe / critical with SpO and respiratory rate cut-offs); 2 the Indian Ministry of Health clinical management protocol and its home-isolation criteria; specific management of long COVID / post-COVID syndrome in older adults (fatigue, breathlessness, cognitive impairment, deconditioning, and the role of pulmonary rehabilitation); the ethical framework for triage and ceilings of care in frail older adults; and lessons for outbreak management in Indian old-age homes.