STUMP » Articles » Middle-aged Massacre (too!): Increase in Mortality for Ages 40-59 in the U.S. for 2020-2021 Mainly Driven By COVID » 29 July 2022, 06:44

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Middle-aged Massacre (too!): Increase in Mortality for Ages 40-59 in the U.S. for 2020-2021 Mainly Driven By COVID  


29 July 2022, 06:44

Time to start moving up the age groups. As we go up to older ages, the death rates due to COVID increase, and those rates increase faster than any increase in other causes of death by age. We will see that many causes of death did see increases in 2020 and 2021, but they will not be as significant in magnitude as COVID was.

I will have some comments at the end as to that, because there’s one item re: COVID people seem to forget.

One note: age 40-44 is the age group with the largest relative increase in mortality from 2019 to 2021, with an over 50% increase in their death rate:

This is the one graph I have the middle-aged groups on together, and you can see the acceleration of death rates with age pre-pandemic. The reason the relative effect of pandemic mortality increases was the worst for young adults and for young middle-agers is that their mortality rates are fairly low (0.2% and less) to begin with, so that going from 0.2% to 0.3% is a 50% increase, which is essentially what happened to those age 40-44 from 2019 to 2021.

We will come back to the steepness of the mortality curve, something that hits middle-aged people in the face as they start noticing people die, especially their older relatives, but even some people they know among high school classmates (my 30th high-school reunion is coming up.)

Here are my top-level results:

  • Over age 45, the most increase in mortality in 2020 and 2021 came from COVID.
  • For age 40-44, a combination of both COVID and drug overdoses contributed to their increased mortality, and especially having the highest relative increase in mortality for all age groups in the U.S.
  • COVID as a contribution to excess mortality was higher for older people —- for those age 55-59, 76% of their increased mortality came from COVID in 2021. In contrast, for those age 40-44, only 42% of their increased mortality came from COVID
  • Drug overdoses were still a substantial contributor for the age 45-59 age groups, ranging from 7% – 16% of the contribution for 2020-2021.

Below I will share graphs from each age group and some observations for each age group.

Age 40-44

Longer trend, 1999-2021:

For all of these analyses, please pay close attention to the scale of rates. On this graph, the total mortality for 2021 is over 300 per 100,000. This is 0.3%. In 2019, it was about 200, or 0.2%.

As we step to higher ages, we will see this scale expand a lot, and we will see the areas for heart disease and cancer also expand a lot.

Drug overdoses drive the big trend for this age group, similar to the Millennials in the prior mortality post (I will link all the mortality posts at the end of this one). We will see that drug ODs become less and less important at older ages. Drug ODs have the same bad trend as younger ages.

But now that we’re getting into middle age with this group, natural causes such as heart disease and cancer are becoming more significant as a cause of death. If you look at the underlying numbers for these natural causes, the long-term trend pre-pandemic for them was good, with heart disease improving more rapidly than cancer.

Let’s focus just on the pandemic years.

Attribution of increase in mortality, 2020-2021:

I will be doing this analysis for each age group. There will be a table at the end with the percentage breakout for each age group, but for now, let the contributions be the actual numbers and be the visual weight.

What you are seeing here are the rate increases (in per 100,000 per year amounts) by cause of death compared to 2019.

To make it concrete: in 2019, the rate for death for age 40-44 for drug overdoses was 36.4 per 100,000. In 2021, it was 60.9. The difference is 24.5, which is on the graph for 2021.

I did this for the top causes of death (as I broke them out), as well as the remainder (that’s the “other causes” catch-all category). So you can see the total step up in mortality by year, and we can make an attribution by cause of death.

Obviously, COVID made a larger contribution than drug overdoses, but I will note this age group has almost the highest death rate by drug overdoses compared to all age groups — age 35-39 barely has a higher rate.

This age group has the worst of all worlds — old enough to have a substantial enough effect from COVID, and a very substantial drug OD effect as well. Drug ODs drop off in severity with increasing age after this, as we shall see.

COVID is very age-loaded in its risk, with or without vaccinations, and will only grow in effects, as we shall also see. We will also see that heart disease will be having greater and greater effects with increasing age.

Some causes of death increased, but they started at relatively low rates, so we don’t see them so well. Liver disease increased 65% from 2019 to 2021. Heart disease increased by 20%. Others had much smaller effects than that.

Age 45 – 49

Longer trend, 1999-2021:

This is similar to the age 40-44 trend, with cancer and heart disease (and COVID) becoming more prominent, drug overdoses becoming less prominent.

The overall mortality scale is starting to rise.

See that the pre-pandemic mortality trend is becoming more clear: a peak around 2002, and generally decreasing thereafter, then seeing the COVID-driven jump in 2020.

Attribution of increase in mortality, 2020-2021:

COVID is really starting to dominate the graph in attribution, and you can really see liver disease and heart disease.

You can see the negative contribution of suicide (and that’s how suicide was “flat” during the pandemic — it generally increased for young adults and decreased for older adults), and you’ll be starting to see a negative contribution for cancer.

Age 50 – 54

Longer trend, 1999-2021:

Whoa, check out that cancer and heart disease. Also, check out that mortality improvement pre-pandemic. From peak to trough, it was about an 8% total improvement pre-pandemic, but of course, that got wiped out.

Heart disease and cancer had improved a lot, but liver disease and drug ODs had gotten worse pre-pandemic.

Attribution of increase in mortality, 2020-2021:

Well, there’s COVID.

It’s difficult to see much else.

Age 55 – 59

Longer trend, 1999-2021:

Finally, the last group for this post.

Heart disease and cancer make up a very large part of the trend, but now we have this large “other causes” I’ve not broken out. If you go back to my post on top causes of death you will see causes such as stroke and chronic lower respiratory disease would be the next grouping down.

One can see that for the seniors (Boomers age 60-79), I will be needing to change the cause of death breakout, because motor vehicle accidents barely register, and the same for homicide. I will be dropping those causes and replacing them with others.

It’s really not significant enough for the attribution in change, though.

Attribution of increase in mortality, 2020-2021:

I mean, it’s almost all COVID at this point.

I do want to point out the negative contribution of cancer, because we will be seeing more of this at older ages — that there will be so many COVID deaths, it more than 100% explains the increase in mortality, which means some causes actually decreased, like cancer here.

Summary tables of contribution to excess mortality

For 2020

In the first column, I’m indicating how much the mortality increased compared to 2019. So for the age 45-49 years group, their mortality increased 22% from 2019 to 2020, and of that increase, 47% is explained by COVID.

For 2021

Here we see COVID explaining more and more of the increase in mortality. For most of these age groups, it’s the majority of the increased mortality.

Only the 40-44 age group has a substantial increase coming from non-COVID causes.

Yes, there are drug overdoses, and other things, but it’s not like what we saw with the young adult age groups. COVID is really taking its toll as we get to older adults.

Links to all the mortality posts

These will get updated as I fill in the posts

Young Adults — Age 18-39: approximately the Millennials in 2020-2021 Part 1 and Part 2, plus the podcast
Middle Agers — Age 40-59: approximately Gen X – this post
Young Seniors — Age 60-79: approximately Boomers – to come
Old Seniors — Age 80+: mainly Silent Generation (as older generations are mostly dead at this point) – to come

The co-morbidity that is age

What we find, in that COVID contributes more and more to the increase in mortality for 2020-2021, is that we need to think of aging as a co-morbidity itself.

I keep hammering this, but more than anything else, COVID death rates aren’t driven as much by obesity, diabetes, and even vaccination (as far as I can tell), but if you’re old. The oldest people are the most likely to die from COVID. That’s it.

And that shows up in the increased mortality tables I’m finding.

The relative increase in mortality is partly driven by the increase due to non-COVID causes of death — COVID by itself has increased death rates by about 20%, but drug overdoses just adds to that, not to mention items like motor vehicle accidents, homicides, liver disease, heart disease and more.

For the oldest people, we will see different effects, and their mortality increases were less. That may be due to higher vaccination rates in 2021, or worse experience in 2020. We shall see.


Data for deaths in 1999-2020 had been taken from the CDC WONDER Online Database for Underlying Cause of Death, finalized data. Citation: Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 1999-2020 on CDC WONDER Online Database, released in 2021. Data are from the Multiple Cause of Death Files, 1999-2020, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at on Jul 27, 2022.

Data for deaths in 2021 had been taken from the CDC WONDER Online Database for provisional mortality data. Citation: Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Provisional Mortality on CDC WONDER Online Database. Data are from the final Multiple Cause of Death Files, 2018-2020, and from provisional data for years 2021-2022, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at on Jul 27, 2022.

For cause of death, the ICD-10 113 Cause List had been used, and specific causes of death were used for their significance for these specific age groups. If this is on substack, you can download the accompanying spreadsheet to see the specific cause of death codes from the list of 113, and that they were non-overlapping. There was a catch-all “other causes” category used.

To measure the increase in mortality, a comparison against the year 2019 was used.

In all cases, crude death rates (based on population estimates provided in CDC WONDER) are used as provided by the CDC, using the standard rate per 100,000 people per year.

It is to be noted that some of the causes of death showed a decrease in rate in 2020 and 2021 compared to 2019 (most notably, cancer), though these were not large decreases.

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