* Eldercare during disasters must account for variations in living environments, health status, and capacity of older adults.
* All acute and long-term health care facilities can take steps to prepare for the care of older adults during disasters, including strong collaboration and partnerships with local emergency management agencies.
* Physicians and other providers, including those with and without geriatric special knowledge, can use educational resources and best practices guidelines to improve their ability to care for older adults during disasters.
Many meanings are associated with the word “elderly” in our society. Older Americans differ in their levels of physical and mental health, social and family connectedness, living situation, and income. They also differ in their level of preparedness for and needs during a disaster or large-scale emergency. As described by the United Nations High Commissioner for Refugees, older adults can be an asset to communities that are experiencing a crisis and differ in their amount of emotional and behavioral resilience.1 Although as of 2008, >20% of Hurricane Katrina evacuees aged 55 years and older had still not returned to their prehurricane residence, this age group represents the most likely population to have done so.2
In discussing the unique needs of elderly adults in disasters, we should consider both the risk factors that increase an elder’s vulnerability and the actual risks he or she is exposed to and the associated health outcomes. We also should consider preparedness by elders to care for themselves and preparedness for elders by others.
The Picture of Vulnerable Elders
Potentially vulnerable elderly adults make up a large percentage of the population of the United States. According to the 2010 US Census, between 2000 and 2010 the total US population increased by 9.7%, whereas the population 65 years old and older grew 15.1%. Approximately 1.3 million people 65 years old and older were living in skilled nursing facilities in 2010, representing 3.1% of the total population in that age group. Roughly 10,971,331 US households, or 9.4%, are made up of a single householder 65 years old or older.3
During the 1995 heat wave in Chicago, the risk of heat-related deaths increased for those with known medical problems who were confined to bed, those who did not leave home each day, or who lived alone.4 The vulnerability of older adults during disasters also was clearly evident in the aftermath of Hurricane Katrina in 2005. Approximately 47% of all deaths in Louisiana attributed to Hurricane Katrina were people 75 years old or older, with 103 deaths occurring in nursing facilities.5 In a study of residents of nursing facilities in Louisiana and Mississippi, a significant increase in morbidity, mortality, and functional decline occurred in the months following the storm.6
Older adults reside in many circumstances that influence their ability to cope with disasters and that can affect their physiological response to disasters and their very survival, as described in the following:
1. Independent and Living in the Community with No Need for Assistance with Activities of Daily Living (ADLs) or Major Medical Issues: Even older adults who are living independently benefit from assistance and guidance with personal preparedness and should be considered in a community’s disaster medical planning. Independent elders may be more economically vulnerable and less able to evacuate, relocate, find appropriate medical care, and rebuild their lives than younger people. In addition, the physical and mental conditions of previously robust older adults can deteriorate quickly and leave them more vulnerable than expected to poor health and emotional outcomes. Also, independently living older adults are often targets of fraud and abuse postdisaster.7
2. Living in the Community but Requiring Assistance with ADLs and Major Health Issues: Semi-independent older adults are highly vulnerable to interruption in healthcare services and equipment, including both clinical and home-based care. These interruptions are often present during community disasters because of power failures, supply chain and transportation failures, impassible roadways, and staffing shortages. Elders with critical medical needs experience extreme challenges from disaster evacuations and mass sheltering. In addition, this population of older adults often is socially isolated and overlooked or invisible to emergency services, sometimes even abandoned by caregivers.8
3. Dependent and Living in Healthcare Facilities: Some of the most vulnerable older adults are those with serious health conditions living in short- or long-term institutional care environments.5,9 This population is almost entirely dependent on the facility’s planning for and response to disasters. This planning and response can be incomplete or poorly implemented, leaving millions of elderly adults at serious risk of illness, injury, and death during disasters. Institutional care environments also create a higher risk for communicable diseases, increasing the danger for older adults during disease outbreaks or epidemics.
Risks and Risk Factors for Older Adults during Disasters
The factors that increase the risk of illness, injury, or death caused by disasters or public health emergencies include physical vulnerabilities and external influences. The frail stature and immobility of some older adults can increase the risk of injury. Natural disasters often involve significant damage to structures or other dangerous conditions, and the inability of frail elders to engage in protective or avoidance maneuvers can be fatal. Cognitive impairment can limit the understanding of risk communication, weather warnings, disaster orders, and offers of assistance, thus preventing appropriate protective responses.10 Visual or hearing impairments also can limit understanding and appropriate response. Many older adults are significantly dependent on medication, special nutrition, and medical supplies and equipment to manage health problems and are at risk when these items become unavailable in a community crisis.
Many older adults live in poverty or have limited financial reserves. These conditions make even everyday living a challenge and can become an overwhelming impediment to proper disaster preparation, evacuation, relocation, and recovery. Lack of transportation and reliable communication tools result in elders being left behind. Social isolation, often in the midst of a large community, prevents many older people from receiving important warnings or asking for help and leaves them virtually invisible to rescue and recovery efforts.10
In addition to physical and external factors, older adults express a variety of emotional and behavioral responses to disasters. Many are unwilling to evacuate even the most dangerous environments. The fear of the unknown likely plays a large factor, particularly for older people without the support of a spouse or family. A 2006 study of senior citizens in North Carolina and Georgia showed that knowledge of other disasters, trust in public officials, and the ability to evacuate their pets were predictive of expressed willingness to evacuate.11 Previous disaster experience, including past success and failure to respond, leads some older adults to misinterpret the current situation and hazard and fail to take appropriate action. Many elderly adults have a strong emotional attachment to their pets, which has created barriers to evacuation in past disasters because of the exclusion of pets from public evacuation vehicles or Red Cross shelters. Although much work is being done at the federal level and in most states through the Pets Evacuation and Transportation Standards Act of 2006 (PETS Act),12 which requires consideration of pets in evacuation and shelter planning, the overall response system is not yet completely inclusive of pets. Finally, there is sometimes a forceful and cogent insistence on the part of older adults to remain in their homes, in the path of danger, to “go down with the ship.” Although autonomy and independence are important for older people, it is not acceptable for government agencies to fail to encourage or even require everyone in harm’s way to move to safety and provide support for those in need. The lack of a safe and orderly evacuation during the disaster warning phase can lead to dangerous rescues later that put emergency responders at great risk and can consume valuable time and resources during a disaster.
A serious risk to elders during and after disasters and public health emergencies is the exacerbation of existing medical conditions.9 Many older adults have numerous comorbid conditions that are treated with multiple medications and specialized supplies and equipment. Decline in health can be the result of an interruption in the supply of medications and medical supplies, lack of access to healthcare providers, and disruption of daily eating and healthcare routines. Under such conditions, older people with diabetes risk glycemic instability and a diabetic crisis that can accompany stress and improper food supplies. Older adults with heart disease or hypertension who evacuate without a sufficient supply of their prescriptions and who have no access to a pharmacy can decompensate, particularly under physical and emotional stress. Nutritionally dependent conditions such as renal disease and intestinal conditions can worsen while an older person is in a shelter without sufficient food choices. Interruption of long-term treatment for cancer and other conditions commonly occurs during a community crisis and can cause irreversible setbacks in treatment regimens. Older adults who were functioning independently before a disaster can experience a sudden and significant cognitive decline while under stress or in an unfamiliar environment, a condition that may be unexpected and concerning to the older person and to their family and caregivers. The unique mobility and vision challenges facing some older adults can create difficulties during evacuation and while navigating unfamiliar environments and cause serious falls and injuries.13 Aging-related changes in thermoregulatory mechanisms cause serious increases in the risk to older people from extreme ambient heat and cold.
The psychological and emotional impact of disasters on elderly adults varies, as it does with other population groups. The impact of recent multiple losses common in older adults (eg, spouse, income, independence) can be compounded by the new disaster and can create a difficult psychological environment that is somewhat unique to older people.14 In addition, elders may become victims of scams or criminals in the aftermath of a disaster, further decreasing their ability to recover.7 Although we should seek to protect vulnerable older adults during disasters, some actually may be highly resilient because of their experience with prior disasters and other life crises. Elders often are significant assets to their communities during and following a disaster. They can have a lifetime’s worth of knowledge of their surroundings and community, as well as information about local people and agencies to be contacted for assistance. Although usually retired, older adults often maintain the skills of their trades and can be called upon to augment the institutional response through volunteer efforts.
Perhaps the biggest risks to elders during disasters and public health emergencies are poor or nonexistent disaster planning by healthcare services and lack of coordination of healthcare systems with community emergency managers. Much attention has been placed on the response by long-term care (LTC) facilities during catastrophic disasters, including high-profile descriptions in the popular media of extreme challenges and tragic outcomes faced by nursing facilities during Hurricanes Katrina and Rita. These challenges and outcomes result from both the private and the public sectors’ inadequate response to institutionalized older adults. A 2007 survey conducted of nursing facilities in five states showed inconsistent and inadequate coordination among emergency management agencies and little preparedness for bioterrorism events.15 A survey conducted by the US Department of Health and Human Services (HHS) found that a troubling percentage of community emergency managers considered nursing facilities to be private agencies and therefore responsible for their own preparedness and not likely to receive assistance by public agencies during a disaster.16 A lack of healthcare surge capacity and adequate personal preparation by healthcare staff can leave older adults without care. Inadequate business continuity planning causes gaps in supplies, medication, and consumables.
In an attempt to ensure preparedness, there are general requirements for disaster planning and training mandated by The Joint Commission, the Centers for Medicare & Medicaid Services and most state health facility licensure. Unfortunately, the HHS survey found that there has been little improvement in the past 5 years regarding nursing facility preparedness, in spite of multiple regulatory requirements and the supposed lessons learned during Hurricane Katrina.16
Improving Our Response Through Planning
Like all citizens, older adults living independently can be encouraged to prepare for disasters. Many useful steps can be taken to improve postdisaster health outcomes that have little or no monetary cost. It is important that older adults and their families are aware of emergency prescribing laws in their state or in states they plan to visit and how to fill a prescription while away from home. Transportation and evacuation planning is important for all older people, but especially for those who live in coastal areas. Elders can be encouraged to engage their neighborhood associations or other community groups in discussions with public officials regarding evacuation plans and options for elders. Older adults can maintain an up-to-date list of their medications and keep the list in their wallet or purse, which is likely to be brought along during any health emergency, even a disaster evacuation. Many helpful resources related to personal and family preparedness for vulnerable populations and older adults have been provided by the Centers for Disease Control and Prevention and can be accessed on their Web site.17
Home Healthcare Services
Emergency preparedness and response by home healthcare and medical equipment services are vital to maintaining the health of older adults during disasters. Home healthcare services should seek to be included in community emergency planning and exercises to familiarize government agencies with the scope of their services and the specific needs that will arise. A joint effort is required to develop plans for staff identification and access to disaster zones to continue providing lifesaving in-home services. Home healthcare agencies can develop a backup plan for staffing and have a plan for remote records retrieval and locating clients during a community crisis. A useful toolkit for home healthcare preparedness has been developed by the National Association for Home Care and Hospice.18
Nursing and Other LTC Facilities
The HHS Office of Inspector General has developed several recommendations for federal agencies to help improve preparedness for nursing facilities.16 These recommendations include identifying and including in Centers for Medicare & Medicaid Services’ requirements more detailed and specific elements of emergency plans and training; detailed guidance for surveyors assessing compliance with federal regulations for nursing facility emergency planning and training; the encouragement of the use of emergency preparedness checklists for nursing facilities; and the development of model policies and procedures for state LTC ombudsman programs, surveyors, and the Administration on Aging. Individual nursing facilities can improve their own preparedness by ensuring adequate protection against infectious disease, including designating an influenza preparedness officer, developing an isolation plan, and offering free vaccinations to staff.19 Nursing facilities also can develop a sensible surge staffing plan, develop continuity plans for equipment and supplies, create a risk matrix that evaluates evacuation versus shelter-in-place and the associated risks of each, develop a tracking system for evacuated residents, ensure regular and updated training of staff regarding their emergency plan, and engage local emergency management agencies. Planning efforts should begin with a comprehensive needs assessment, using assessment tools and checklists such as the ones provided by the Agency on Healthcare Research and Quality and Montgomery County, Maryland.15,20
Hospitals and Clinics
Hospitals and community clinics also can improve the health outcomes of older adults during disasters. Physicians, nurses, and other providers can advocate for elder preparedness in their community and provide expert guidance to community leaders. Healthcare providers with experience in gerontology can register with their state’s Emergency System for Advanced Registration of Volunteer Health Professionals to be available to help in an emergency. Providers can discuss with patients the idea of “trusted information resources” that include government and nongovernmental sources and where to look for help, a discussion that will also serve day-to-day health information needs. Healthcare facilities can review and update their institutional disaster plans to ensure that elder issues are addressed, including pharmaceutical needs, palliative care capabilities, allocation of scarce resources, and the identification of alternate care sites for noncritical patient care and medical boarding.21 To augment the ability to care for older adult patients, hospitals can provide continuing education on geriatric care for nongeriatricians to include awareness of aging-related changes in clinical presentation.22,23
The unique health needs of older adult patients, coupled with the need to expand medical care staffing during disasters beyond those who are geriatric specialists, create a gap in knowledge and experience at a time when it is most needed. Resources have been developed to assist with the expansion of the knowledge base for clinical care of elders during disasters. One example is the toolkit for geriatric disaster care developed by the New York City Department of Health and Mental Hygiene.21 The toolkit provides guidance to clinicians regarding the triage and assessment challenges of older patients, including the physiological heterogeneity and unknown baseline functional status upon presentation, misleading clinical findings, and the ethical and legal issues surrounding limited resources. The guide also offers detailed assessment tools for injury and medical risk factors and dementia, guidance regarding the creation of soft care areas and safe havens, and pharmacokinetics and prescribing principles for elders. An additional resource, developed by a team of Houston-area clinicians who provided care for older adult evacuees after Hurricane Katrina, provides a methodology for screening disaster victims by assessing cognition, medical and social services needs, and the ability to perform ADLs. The Seniors Without Families Triage tool was included in best practices guidelines jointly developed by the Baylor School of Medicine, AARP, the American Medical Association, and Texas healthcare facilities.24,25
Health outcomes and recovery can be improved for older adults during disasters. The goal is to develop a community response on behalf of older people that includes active outreach and identification, medical care and support based on the unique needs of elder patients, assisted evacuation, adequate and appropriate shelters, protection against abuse and fraud, and appropriate tracking and rehoming of older adults.
2. Groen JA, Polivka AE. Hurricane Katrina evacuees: who they are, where they are and how they are faring. Mon Labor Rev 2008; 131: 32–51.
4. Semenza JC, Rubin CH, Falter KH, et al.. Heat-related deaths during the July 1995 heat wave in Chicago. N Engl J Med 1996; 335: 84–90.
5. Brunkard J, Namulanda G, Ratard R. Hurricane Katrina deaths, Louisiana, 2005. Disaster Med Public Health Prep 2008; 1: 1–9.
6. Doza D, Feng Z, Hyer K, et al.. Effects of Hurricane Katrina on nursing facility resident mortality, hospitalization, and functional decline. Disaster Med Public Health Prep 2010; 4: S28–S32.
7. Davila M, Marquart JW, Mullings JL. Beyond mother nature: contractor fraud in the wake of natural disasters. Deviant Behav 2005; 26: 271–293.
8. Jellinek I. US Senate Testimony: perspectives from the private sector on emergency preparedness for seniors and persons with disabilities in New York City: lessons learned from our city’s aging services providers from the tragedy of September 11, 2001. Testimony before the US Senate Special Committee on Aging, February 11, 2002. http://anndgross.home.mindspring.com/18SENATE.HTML
. Accessed July 3, 2012.
9. Aldrich N, Benson WF. Disaster preparedness and the chronic disease needs of vulnerable older adults. Prev Chronic Dis 2008; 5: A27.
10. Eisenman DP, Cordasco KM, Asch S, et al.. Disaster planning and risk communication with vulnerable communities: lessons from Hurricane Katrina. Am J Public Health 2007; 97: S109–S115.
11. Rosenkoetter MM, Covan EK, Bunting S, et al.. Disaster evacuation: an exploratory study of older men and women in Georgia and North Carolina. J Gerontol Nurs 2007; 33: 46–54.
13. Uscher-Pines L, Vernick JS, Curriero F, et al.. Disaster-related injuries in the period of recovery: the effect of prolonged displacement on risk of injury in older adults. J Trauma 2009; 67: 834–840.
16. US Department of Health and Human Services, Office of Inspector General. Gaps continue to exist in nursing home emergency preparedness and response during disasters: 2007–2010. http://oig.hhs.gov/oei/reports/oei-06-09-00270.asp
. Accessed April 26, 2012.
19. Pierce JR, Kellie SM, West TA, et al.. Top ten list of long-term care facility preparations for the upcoming influenza season. J Am Geriatr Soc 2009; 57: 2318–2323.
23. Fernandez LS, Byard D, Lin CC, et al.. Frail elderly as disaster victims: emergency management strategies. Prehosp Disaster Med 2002; 17: 67–74.
25. Dyer CB, Regev M, Burnett J, et al.. SWiFT: a rapid triage tool for vulnerable older adults in disaster situations. Disaster Med Public Health Prep 2008; 2: S45–S50.