by Robert E. Roush

House destroyed by Hurricane Katrina in Irish Bayou, New Orleans, August 2005.

Since 1995, flooding, earthquakes and weather-related disasters around the world have affected more than 2.5 billion people and have killed almost a million. Beyond such routine natural disasters, the specter of bioterrorism threats and emerging infections ever looms. Regardless of the type of disaster, older people are disproportionately affected: During the Gulf Coast hurricanes of 2005, for example, 74 percent of those who died were older adults.

Emergency preparedness training for health professionals caring for frail elders has thus become an international imperative. Cities and counties, as well as healthcare and social services organizations, should develop geriatric emergency preparedness and response plans to ensure the safety and security of older adults, whose health requires special consideration in times of disaster.

Knowing who our frail elders are, where they live and what their special needs are is the first step in keeping emergencies from becoming disasters. All agency planners, first responders, first receivers and other healthcare providers, therefore, need special training in geriatric emergency preparedness and response. Sadly, even at the dawn of 2008, too few healthcare professionals have had this training.

Preparedness and response training for frontline healthcare providers and healthcare administrators should take an all-hazards approach, focusing specifically on how older people react differently than younger cohorts in disasters. Such training should cover mental and physical health, culturally and linguistically appropriate services, communication strategies, ethics and planning. (See the sidebar for resources that can be used in continuing education.)

The Vulnerable Populations Collaborative Group, formed by the Association of Schools of Public Health and the Centers on Public Health Preparedness of the Centers for Disease Control and Prevention, has produced work on competencies in geriatric emergency preparedness and response. In addition, the Canadian Division of Aging and Seniors has taken the lead in forming an international group to focus on worldwide issues.

Based on their efforts as well as those of others, training for agencies and professionals working with older adults should at a minimum address the following crucial points regarding the needs and concerns of older adults during disasters:

Physical and Medical Considerations

• Elders may have limitations in mobility due to arthritis and other neurodegenerative diseases.
• People in nursing homes and elders relying on assistive devices such as oxygen tanks, feeding tubes and powered wheelchairs need special attention.
• Dehydration in summer emergencies and loss of thermoregulation of body heat in winter emergencies require immediate treatment.
• Elders with dementia require additional measures for medical, behavioral or psychological attention.
• Elders with comorbid conditions who live alone and elders who fall frequently are particularly vulnerable.

Psychosocial Considerations

• Changes in cognitive abilities impinge on an individual’s capacity to understand impending events and to follow directions.
• Performing psychological first aid as quickly as possible to return the environment to normal and facilitating the use of restorative resources are vital to reduce elders’ stress.
• Older people may experience posttraumatic stress disorder later than younger adults, so six- and 12-month follow-up is needed.

Practical Considerations

• Like frail elders, robust elders who have recently been discharged from acute-care hospital stays may be adversely affected due to their short-term vulnerability.
• Elders who are evacuated must be able to bring along their medications, dentures and eyeglasses and have assurance that their pets will have adequate care.
• If elders are sheltered in place, preventing loss of electricity, supplying potable drinking water, and assuring sufficient numbers of caregivers at the ready are key.

Culture- and Income-Related Considerations

• Differences in elders’ language and cultural influences need to be accommodated.
• An understanding of an elder's level of health literacy is important to providing effective treatment.
• Many frail elders lack financial resources and have little cash to pay for relocation and other emergency expenses. They would be easily classified as impoverished without Meals on Wheels, Medicaid, senior housing and other support services.

Preparedness Planning

The pillars of appropriate disaster preparation and reaction are preparedness, response, recovery and mitigation. Preparedness plans follow a temporal dimension tied to pre-event, event and post-event concerns. Training for agencies and professionals should address the following key issues:

Pre-Event Preparedness. Before an event occurs, health and social services agencies can put the following measures in place to make sure that elders receive adequate attention in the event of an emergency:

• Use geographic information systems to map where frail elders live and what their special needs are so that disaster plans can be adjusted appropriately.
• Work with elders and their caregivers to develop personal plans for evacuating them from their homes or sheltering them in place.
• Employ geriatricians and other aging-services professionals to train other healthcare providers and planning-agency personnel.
• Within one’s clinical, administrative, or planning role conduct periodic drills, tabletop exercises and continuing education programs for your staff or facility on what to do during natural and human-caused disasters.
• Include long-term care facilities in joint planning efforts, both to ensure that the special issues presented by these facilities are addressed in community disaster plans and to look at the possibility of housing community elders in secure facilities during evacuation from a disaster area.
• Retrofit sites designated as possible shelters so they accommodate older adults -- for example, providing cots that are of sufficient height and installing night lighting in bathrooms.

Event Response. During an emergency, healthcare professionals and other frontline responders should take the following measures:

• Use geographic information systems to map where frail elders are moved during emergencies. Recent advances in technology using chips in wristbands can enable care providers to quickly identify and locate elders who have been transported from one location to another. And GPS technology can detect the movement of evacuation busses so that emergency vehicles and alternate transportation can reach them quickly should they break down.
• For elders sheltered in place, minimize their trauma and maintain communication to let them know that emergency responders know their locations and conditions.
• Give special consideration to homebound elders who rely on in-home care.
• For elders who must be evacuated, make provision for pets, dentures, medications, and personal identification.

Post-Event Response. After the emergency has subsided, response personnel should take the following steps:

• Make reuniting elders with their family members and caregivers a priority.
• Protect frail elders in shelters from assaults, wandering, and inadequate sleeping and toileting arrangements.
• Debrief all personnel involved to improve the plans for the next disaster.

Regardless of the amount of time since the last local disaster, always think in the pre-event mode. One never knows where or when a disaster will strike, just that one will someday. Preparedness can prevent an emergency from becoming a disaster.

Robert E. Roush directs the Texas Consortium Geriatric Education Center at the Huffington Center on Aging at the Baylor College of Medicine in Houston. He is a past president of the National Association of Geriatric Education Centers and cochairs that organization’s Bioterrorism and Emergency Preparedness in Aging Committee. Contact Roush at rroush@bcm.edu or (713) 798-4611.

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