Understanding respiratory vaccination decisions for older adults

This guide helps geriatricians and practice teams organize respiratory vaccine conversations with older adults. It offers a practical way to review RSV eligibility and timing, consider influenza vaccine options, and respond to common concerns.

Start with age and prior RSV vaccination

For RSV, begin by checking the patient's age and whether they have already received a dose. CDC says RSV vaccine is not currently annual. Its guidance recommends one dose for all adults age 75 and older, and for adults ages 50 to 74 at increased risk of severe RSV illness. Eligible adults who have already received a dose do not need another one each RSV season, according to CDC.

A short intake prompt can make that first step easier to repeat across visits: record age, prior RSV vaccination, and whether a risk factor is documented. For an older adult who has not received RSV vaccine, the age criterion may settle eligibility under CDC guidance. For someone ages 50 to 74, the next step is to review risk rather than treat age alone as the deciding factor. This gives the clinician and patient a clear starting point for the conversation.

• Check age.
• Ask whether an RSV vaccine dose was previously received.
• For adults ages 50 to 74, review increased risk of severe illness.

Review health and living situation for RSV risk

Age is one part of the RSV decision. In a GeriPal discussion, Ken Schmader described a risk based recommendation for people at high risk of severe RSV disease. He listed chronic heart, lung, kidney, or liver disease, diabetes, obesity, and immunocompromising conditions. He also said frailty and nursing home residence were included after advocacy.

A practice can use that list to structure a review, rather than relying on a general impression of whether someone seems vulnerable. For example, a record showing chronic lung disease or diabetes gives the team a specific risk factor to discuss with the clinician. Frailty and nursing home residence are also worth making visible in the review, since Schmader identified them as part of the risk conversation. The list helps clinicians explain why two adults in the same age range may have different RSV recommendations.

• Review chronic heart, lung, kidney, or liver disease, diabetes, obesity, and immunocompromising conditions.
• Include frailty and nursing home residence in the risk discussion.

Choose a practical time for an RSV dose

CDC says eligible adults who have not previously received an RSV vaccine can be vaccinated at any time of year. It says vaccination is likely to provide the most benefit when given in late summer or early fall, just before RSV season. In most of the continental United States, that means August through October.

For a clinic, this supports a seasonal review before the late summer and early fall window. Teams can identify older adults who meet the age or risk criteria and check prior vaccination during routine visits. If an eligible patient is seen at another time of year, CDC guidance still allows vaccination then. A simple workflow can record whether the patient has had a dose, whether eligibility has been reviewed, and whether a discussion is planned at a later visit. The timing window can guide outreach without becoming a reason to leave an eligible person's status unreviewed.

• Use late summer or early fall as the main RSV review window in most of the continental United States.
• Keep eligibility review available year round.

Discuss influenza vaccine options for adults 65 and older

For adults age 65 and older, CDC preferentially recommends high dose inactivated, adjuvanted inactivated, or recombinant influenza vaccine, according to Immunize.org's summary of CDC recommendations. This gives clinicians three preferred vaccine types to consider when reviewing influenza vaccination with an older adult.

A nursing home study described by the authors in Age and Ageing adds context for one of those options. The authors report that nursing home residents face high influenza morbidity and mortality, in part because immunosenescence and comorbidities may reduce vaccine effectiveness. They explain that high dose influenza vaccine contains four times the antigen of standard dose formulations and is intended to compensate for that issue. That finding applies to nursing home residents, so it can inform discussion in that setting without standing in for a full review of an individual patient's circumstances.

• For adults age 65 and older, review high dose inactivated, adjuvanted inactivated, or recombinant influenza vaccine options.
• In nursing homes, note the study's focus on residents and its explanation of high dose vaccine.

Make vaccine conversations clear and repeatable

Sharon Brangman said vaccine hesitancy in older patients calls for patient, nonjudgmental, repeated education. She said clinicians can explain that the flu shot cannot cause flu and that it can help prevent severe illness and hospitalization. A calm answer and a later follow up can keep the conversation open when a patient is unsure during one visit.

Practice teams can make the discussion easier to continue by recording the patient's question and the explanation given, then revisiting it at a future contact. That approach reflects Brangman's emphasis on gentle, repeated education. A patient who is hesitant about influenza vaccination may need a different conversation from someone asking whether an RSV dose is annual. Keeping the concern specific helps the clinician respond to the actual question instead of giving a general vaccine script.

• Ask what concern the patient wants addressed.
• Respond without judgment and leave room to revisit the decision.

Close the visit with a shared plan

A respiratory vaccine review can end with a short record of what was discussed: age and prior RSV dose, relevant RSV risk factors, the influenza vaccine options reviewed for adults 65 and older, and any question the patient wants to revisit. This keeps the conversation tied to the patient's situation and makes the next discussion easier to pick up.

These points are for general education. An older adult should discuss their own vaccine schedule and health decisions with their doctor.

"And so you have to be very patient, nonjudgmental, and just kind of gently educate over and over again and explain that you can't get sick from the flu shot and that it could keep you from being very sick and going to the hospital."

Sharon Brangman, Flu, COVID, RSV, & Shingles Vaccines in Older Adults: Ken Schmader and Sharon Brangman

This page is general education only. It is not medical advice. Talk with your own doctor about your health.

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