In 2020, COVID-19 ravaged the state's nursing homes, forcing an end to visitation by family and friends and lockdowns of residents. That in turn appears to have contributed to a hidden toll from the disease for some Colorado seniors.
Starvation.
As many as 100 more seniors than expected, most of them in nursing homes, essentially stopped eating in 2020 and died of what is clinically termed "nutritional deficiencies" on state death certificates.
COVID-19 has now officially claimed more than 5,500 Colorado lives, but as state health officials finish compiling records from the deadliest year in state history, hundreds of additional deaths, which appear to have at least an arm’s length connection to the pandemic, are becoming apparent.
They include those 100 out of 347 people who died last year of starvation, and at least some of those who died of parasitic diseases, drug overdoses, Alzheimer’s and liver diseases too. All those causes of death experienced double-digit percentage increases in 2020. That’s above the average number of deaths from the causes in the three-years prior to the start of the pandemic.
They are all part of 8,222 excess deaths in 2020 above the average for the three previous years.
“Early on in the pandemic, we were calling this 'COVID collateral damage,' ” said Dr. Kyle Leggott, a family medicine physician in Lone Tree. “COVID has disrupted the healthcare landscape beyond the direct impact of people who have been diagnosed or gotten sick from COVID.”
“It’s sad, it’s disheartening.”
A Mass Casualty Event
In 2020, 46,808 people died in Colorado, the most ever recorded in one year in the state, and a 21 percent increase over the average number of deaths for the three prior years.
The percentage increase is indicative of a mass casualty event, the biggest one-year spike in many decades, and the largest since at least the 1918 pandemic.
“I think the closest analog would be the influenza pandemic back in the early 20th century,” said Kirk Bol, the manager of the state’s Vital Statistics Program. “I don't believe we've seen anything to this magnitude in essentially the last century that would compare.”
And while it has been well known that COVID-19 has been hardest on seniors, the hidden toll beyond deaths caused directly by the disease is only now coming to light.
Eileen Doherty, executive director of the Colorado Gerontological Society, which advocates for the state’s elders, described the numbers as “horrible, horrible.” But, given how hard the pandemic has hit the state’s older population, “I guess I’m surprised (the increase in deaths) is not higher, to be honest with you,” she said.
According to the state’s pandemic website, people over 80 account for 54 percent of the state’s COVID-19 deaths, while making up just 3 percent of the population; those between 70 and 79 represent 24 percent of the deaths, though they’re 6 percent of the population.
Death certificates from 2020 are still being counted and causes certified, meaning that the official totals don’t yet match the more than 5,500 deaths from COVID-19 the state has identified from hospitals, physicians and coroners. But it is already likely that the disease caused by the coronavirus will be the state’s third leading cause of death last year, after malignant tumors (8,065) and heart disease (7,676).
An analysis of the state’s data by CPR News found that deaths in 2020 were up across the board, in most of the 30 categories the state classifies, including many often associated with old age.
But certain categories stand out for percentage increases that exceed what would be expected among an aging population. For example, more Coloradans died in 2020, compared to the average from the years 2017-2019, from Alzheimer’s disease (up 19 percent) and Parkinson’s disease (up 14 percent).
More Coloradans also died from causes often associated with substance use, like drug overdoses (up 26 percent) and chronic liver disease and cirrhosis (up 24 percent). More died from homicide/legal intervention (up 15 percent). Also, 186 people died from what’s classified as “other and unspecified infectious and parasitic diseases” (up 42 percent).
The only category that saw a double digit percentage decline was influenza and pneumonia, with 435 deaths in 2020 - down 19 percent. That decrease reflects what’s been seen elsewhere in the world and ascribed to mask wearing and physical distancing by people worried about catching COVID-19. And while the state’s data collection is not yet final, for now at least, there appears to have been a five percent decline in suicides in Colorado in 2020, contrary to concerns expressed by experts about firearm sales and depression during the pandemic.
More than 2,600 cases are still listed as “other, or cause of death not yet coded.” Bol said the data are provisional and subject to change. Final numbers are expected to be released in April. The deaths yet to be coded are disproportionately injury-related deaths, including homicide, suicide and overdose deaths. Those require more time for investigation and coding takes longer, so those categories may yet increase noticeably as April approaches.
The Isolation Is Enormous
“What’s there to live for? Why am I here?”
That’s what one 86-year-old man living alone in Thornton recently told Jayla Sanchez-Warren, who leads a regional agency on aging, as she tried to help him get vaccinated against COVID-19.
“He was struggling to get a vaccine and was frustrated. His wife had died, I think three years ago. He didn’t have family in the area,” she said. “He was feeling this malaise.”
She said his despair is a typical symptom of a “failure to thrive,” a term many experts in aging use to describe what they’ve been seeing a lot of this past year of the pandemic. Other symptoms include isolation, loneliness and depression. That’s often followed by a lack of desire, or inability to eat, or get nutritious food for yourself.
And it appears, experts say, to be a factor in the sharp increase in the number of Coloradans who died in 2020 from “nutritional deficiencies.”
The Colorado Department of Public Health and Environment tracks and classifies death data provided by coroners. The CPR News analysis found the 169 people 65 and older who died of nutritional deficiencies in nursing homes or other long-term care facilities in 2020 was up 50 percent over the average of 113 in the three previous years. The number has been growing annually since at least 2017, but the 2020 number is up 19 percent over the 142 who died that way in nursing homes in 2019.
Nursing homes were home to a narrow majority of the 334 people 65 and older who died last year of nutritional deficiency. The second largest category was those who died of that cause at home.
“It's just hard to overestimate the impact that COVID has at every level on facilities, on staff, on residents, on families,” said Dr. Gregory Gahm, a geriatrician and chief medical officer for Vivage Senior Living, which operates about 40 long-term care and assisted living facilities in Colorado.
“It's been almost a year since we've really allowed people to come in and visit,” he said, due to strict rules aimed at limiting the spread of the virus. It’s also been a year since those residents could eat together, often their main source of interaction and human contact.
“That isolation is just an enormous impact,” Gahm said.
In many facilities, he said, 20 to 25 percent of patients have either died or moved out since the start of the pandemic. And the coronavirus, in part due to stricter rules, has taken a toll on the ability to admit new patients.
“I would guess that the average nursing home facility in Colorado, their census, the number of residents there, is down by a third from what it was a year ago, which of course impacts financial viability,” Gahm said.
As evidence of that, the Estes Park Health Board of Directors voted Feb. 1 to close the town’s board-operated nursing home after it proijected a loss of 20 percent of its revenue in the pandemic. The 13 remaining residents of the Estes Park Health Living Center will have until at least April to find a new place to live and be cared for.
The stress of the pandemic has also hit staff members, who are dealing with many more public health measures to keep themselves and the residents safe. That’s not to mention seeing some residents die and worrying about picking up the virus themselves.
“And they just quit,” Gahm said. “They just walk off the job.”
He said up to 25 percent of the state’s nursing home employees had quit in the last year.
All of these factors, he said, contribute to residents struggling. A lot of younger people might overeat to treat their depression. But for older folks, it’s the opposite.
“You tend not to eat, you lose interests, you lose interest in everything, and you quit eating,” Gahm said, noting the state’s increase in deaths from “nutritional deficiencies” is one likely result. “So I'm not surprised by that.”
He said once people stop taking in a nutritious diet, they become even more vulnerable.
“You get infected, and die,” he said. “But it follows lack of interest,” in eating.
Gahm has seen the impact of COVID-19 from another view: his 93-year-old mother Betty is living in a nursing home in Aurora. She has severe dementia from Alzheimer’s. She’s not picked up the virus, and has now been vaccinated. But the toll on both her and her fellow residents has been hard. Gahm estimates roughly 20 of the 30 people in her unit have been infected, and a couple died.
All these things add up to a greatly diminished quality of life.
“You isolate people month after month after month, you don't get to see your family. You don't get to come in and out of the facility with activities, people get depressed,” Gahm said.
A variety of groups and representatives have worked through the pandemic to try and ease psychosocial issues related to COVID-19 in long-term care, assisted living and other group homes, Gahm said. The state formed a COVID Rapid Strike Force, with members from the health department, the governor’s office, Medicaid, as well as ombudspersons and subject matter experts. It also established a subcommittee to deal with the mental health impacts of the pandemic on older Coloradans.
“The conversations were incredibly difficult,” Gahm said, as the group tried to balance regulatory requirements for facilities, from an alphabet soup of government agencies, with the loneliness, isolation and detrimental effects for residents of a lack of activity due to the implementation of the directives. “Ultimately, we have tried to stay true to the goal of preventing the spread of the disease, which could lead to an increase in deaths and long term consequences, over individual psychosocial needs.”
The group routinely shared ideas about how to make things better for residents, including via activities done with patients in their doorways and games over the intercom.
There have been long stretches where, due to the strict visitation rules, no providers have been allowed into facilities. That led to the acceptance of telemedicine.
“It helped tremendously,” Gahm said, “But there really is just no substitute for the warm touch of another person's hand, calming words, a listening ear and being able to read body language, not just see a face.”
“We struggled with patients and families saying they would rather die of COVID than remain in isolation and away from their families,” he said. In response, they told families they could take their residents home, “but we could not break the rules.”
Since many people are asymptomatic carriers, allowing even this to occur may have led to those patients who moved out inadvertently sharing COVID-19 with others “who then might have had the dire consequences,” Gahm said. “It has been miserable.”
It Will Take Years To Know The Impact
Some of the listed causes of death with big increases are clearly linked to advanced age, like Alzheimer’s or Parkinson’s. Those types of disease might make some people more likely to be in long-term care facilities and more vulnerable to dying from COVID-19. A recent study found that people with dementia, including Alzheimer’s, for example, were at increased risk for COVID-19 from reasons ranging from congregate living to failure to remember a mask or to keep it on.
But for some of those whose deaths were classified as Alzheimer’s or Parkinsons, were they also infected with undetected cases of COVID-19?
“I do wonder how extensive testing for COVID-19 was in some of these categories,” said Denver Health’s Dr. David Wyles, who leads the infectious diseases division. If listed specifically as death due to Alzheimer’s or Parkinson’s, it is important to know what the final cause of death was, he said.
Typically a person doesn't really die from these conditions but eventually succumbs to something else, like pneumonia.
“So some of these folks could have died from undiagnosed COVID,” he said. That’s also true for other causes of death. Or perhaps people died due to “hesitancy to seek medical care” or visit a hospital due to the perceived risk of getting COVID-19.
A CDC report found roughly four in ten U.S. adults reported avoiding medical care, including urgent or emergency care, because of concerns related to COVID-19. The agency cited another study that found states with large numbers of COVID-19-associated deaths also saw large proportional increases in deaths from other underlying causes. That included diabetes and cardiovascular disease.
Leggott said he’d seen the fear and hesitation in older patients at his Lone Tree practice. Some of them used to come in about every three months. But now they don’t show up at all “especially some of my very cautious elderly patients who just don't want to come into the office,” despite all of the appropriate precautions taken. Instead, they do telehealth visits, “but it’s certainly no replacement for in-person visits.”
Wyles said Denver Health’s cardiology and paramedic teams noted an increase in emergency calls for sudden cardiac death last year. But why?
“The question again is that because people wait to seek medical attention due to fears of COVID?” he asked. “Or could it be they are infected with COVID and that caused increased risk of heart attack?”
Increases in some types of deaths like overdoses and perhaps liver disease (some of it from alcohol over-consumption) could be tied to more people struggling with their mental health. A KFF Health Tracking poll last summer found many adults reported difficulty sleeping or eating, increases in alcohol consumption or substance use, and worsening chronic conditions, due to stress and worry over the coronavirus.
Still, in all the categories, Wyles cautioned what caused a death can be hard to determine.
“For almost all categories I could make an argument why COVID itself could increase mortality, but almost as easily make a case it is collateral damage due to COVID,” he said. That could include from decreased healthcare resources available for things like substance use, or fear and avoidance of seeking medical care until it is too late.
Teasing out what drove the increase in deaths, in so many categories, will be a task for researchers and public health experts to explore for years to come.
The 2020 death figures represent “the tip of the iceberg,” said Leggott. “This is data and information that needs a lot more study.”
