Disaster Preparedness and Older Adults

1. Disaster Preparedness and Older Adults Maria D. Llorente MD Professor of Psychiatry Georgetown University School of Medicine Associate Chief of Staff, Washington DC VAMC

2. Members of the AAGP Disaster Preparedness Task Force Kenneth M. Sakauye Joel E. Streim Gary J. Kennedy Paul D. Kirwin Maria D. Llorente Susan K. Schultz Shilpa Srinivasan

3. Disclosures • Grant funding: • Department of Veterans Affairs HSR&D: Memantine v. Vitamin E v. placebo in treatment of Alzheimers Disease. The study received memantine from Forrest Pharmaceuticals

4. Disaster An encounter between forces of harm and a human population in harm’s way, influenced by the ecological context, in which demands exceed the coping capacity of the affected community Schultz et. al. 2006, 2007

5. Characteristics of Disasters • Extraordinary magnitude of harm • Ecological disruption • Disproportionate impact on vulnerable communities • Demands for response that exceed the community’s ability to cope • Necessity for outside assistance Schultz et. al. 2006, 2007

6. On average, a disaster occurs in the world each day TORNADOES EARTHQUAKES FLOODS SHOOTING SPREE TERRORISM

7. Deadliest Natural disasters since 1980 Centre for Research on Epidemiology of Disasters (CRED)

9. Factors that determine whether MH consequences will occur Nature of Disaster Nature of Exposure and severity of harm Individual Vulnerabilities Unique vulnerabilities of elderly

10. Psychosocial Consequences of Disasters Psychosocial outcomes are shaped by the nature of the disaster • Disasters with 2 or more of the following features result in the greatest behavioral impact: • Extensive injury, threat to life or loss of life • Extreme and widespread damage to property • Destruction of social support and ongoing financial problems • Human intentionality Norris et al. 2002

11. Psychosocial Consequences of Disasters Psychosocial outcomes are shaped by the nature of the disaster • Acts of mass violence appear to produce more severe impairment in a higher proportion of survivors than do natural disasters • Human intentionality, unpredictability, unfamiliarity, lack of preventability, societal disruption • Lack of control Norris et al. 2002; Butler et al. 2003

12. Psychosocial Outcomes • Psychiatric Conditions • - PTSD • - Depression • - GAD • - Panic • Non-specific Distress Symptoms • Health Problems • Chronic Living Problems • Loss of Psychosocial Resources

13. Psychosocial consequences of disasters • Most people will report non specific distress, health problems, chronic problems in living (domestic violence increases), resource loss • Most people improve with time • A minority of survivors continue to be distressed long after the event • Risk factors for adverse outcomes: more severe exposure, female gender, middle age, ethnic minority group, prior psychiatric problems, and poor psychosocial resources

14. Hurricane Andrew South Florida, August 24, 1992

15. Hurricane Andrew South Florida, August 24, 1992

16. ANDREW: High Impact Storm • 25% of highly exposed residents of Dade County met criteria for PTSD 6 months later • Many people felt less positive about the quality of social relationships than they had felt before the storm – perceptions of social support may be affected by disaster experience Perilla et.al. 2002

17. Hurricane KatrinaNew Orleans, August 24, 2005

19. Katrina: High impact storm • One year later, 6.4% prevalence of suicidal ideas in general population • Increase in serious mental illness by 89%, PTSD by 32% • Elderly disproportionately affected with highest health decline, mortality and suicide rates Weisler RH, et al Mental Health and Recovery in the Gulf Coast After Hurricanes Katrina and Rita. Journal of the American Medical Association 2006; 296:585-588 Wang PS, et al.: Mental Health Service Use Among Hurricane Katrina Survivors in the Eight Months After the Disaster. Psychiatric Services 2007;58(11):1403-1411 Kessler RC, Galea S, Gruber MJ, Sampson NA, Ursano RJ, Wessly S: Trends in Mental Illness and Suicidality After Hurricane Katrina. Molecular Psychiatry 2008 Apr; 13(4):374-84. Epub 2008 Jan 8.

20. Risk of long-term MH sequelae • Based on degree to which the person was affected (personal injury, loss of property) and proximity to greatest area of destruction • Compared to younger group, most studies suggest elderly have lower rates of MH consequences • 70-90% of older adults report experiencing at least one lifetime traumatic event • Fewer than 2% of >10,000 PTSD studies between 1980 and 2008 focused on elderly

21. Comparisons with young • Elderly Lockerbie survivors had similar prevalence of PTSD, but more likely to have major depression after one year • After Katrina, 15% had PTSD v. 23% of those aged 35-54 and 30% of those 18-34 • Post 9-11, NYC residents older than 55 less likely to have PTSD and depression Livingston HM, et al. Elderly survivors of the Lockerbie air disaster. Int J Geriat Psychiatry. 1992;7(10):725-729). Tracy M, Galea S. Post-traumatic stress disorder and depression among older adults after a disaster: The role of ongoing trauma and stressors. Public Policy and Aging Report. 2006;16(2): 16-19. Shore JH, Vollmer WM, Tatum EL. Community patterns of PTSD. J Nerv and Ment Disease. 1989;177:681-685.

22. “Dose-response” pattern of increased symptoms • Consistent finding among all age groups following Mt. St. Helens explosion • Elderly victims closest to epicenter of Armenian earthquake had greater presence and severity of PTSD than adults further away • Most PTSD studies do not support age-related mental health vulnerability

23. Unique vulnerabilities in elderly • Older adults are more likely to need social support to mitigate effects of disaster than youth • Some studies have found elderly are less likely to evacuate, especially if they have pets • Many elderly live alone and do not have support • “Relocation trauma” for those who are moved long distances • Typically receive less financial aid than younger adults

24. Factors that increase vulnerability of the elderly • Decreased sensory awareness • Impaired Physical mobility • Pre-existing medical conditions • Socioeconomic limitations • Absence of family or other supports Fernandez LS, Byard D, Chien-Chih L, Benson S, Barbera JA. Prehospital Disaster Medicine. 2002;17(2):67-74). Dyer CB, Regev M, Burnett J, Festa N, Cloyd: Disaster Medicine and Public Health Preparedness 2008; 2(Suppl 1): S45-S50.

25. Examples of “Vulnerability” • 13,000 French elderly died in the European heat wave of 2003 • A three-fold increase in MI was seen in people living close to the epicenter of the Kobe earthquake, particularly in elderly women • 25% of residents of New Orleans had at least one chronic illness before Katrina and 75% of deaths were older than 60, 56% of Astrodome persons were older than 65 • 139 Katrina-related deaths reported from NH • Elderly may be “left” in EDs, shelters and nursing homes with no medical records, histories, or medications Geehr EC, et al. Am J Emer Med. 1989;7(6):598-604. Axelrod C, Killarm P, Gaston M, Stinson N. US Dept of HHS Public Health Report 1994;109:601-605. Silverman M, Weston M, Llorente M, Beber C, Tam L. So Med J 1995;88(6):603-608. Morrow BH. Identifying and mapping community vulnerability. Disasters 1999;23(1):1-18. Kario K, Matsuo T Kobayashi H et al. JACC 1997;29:926-933. Dyer CB, et al.Disaster Medicine and Public Health Preparedness 2008; 2(Suppl 1): S45-S50.

26. Stress Reactivity • Higher BP reactivity to stress predicts hypertension in normotensive patients • Increased stress reactivity predicts development of atherosclerosis in healthy adults • Increased cortisol response is associated with atherogenic lipid profile, high fasting insulin, and high glucose levels

27. Stress Reactivity • Stress activates proinflammatory cytokines, which are normally suppressed by secretion of glucocorticoids • Under chronic stress (such as depressive states), sensitivity to glucocorticoids is reduced, sustaining inflammatory state, and leading to development of CVD

28. Daily Cardiac Deaths in Los Angeles Associated With Earthquake. On the day of the earthquake (January 17, 1994), there was a sharp rise in the number of deaths related to atherosclerotic cardiovascular disease (n = 51, relative risk 2.6, 95% confidence interval 1.8 to 3.7). The daily number of deaths related to atherosclerotic cardiovascular disease declined in the 6 days after the earthquake (z = 3.15, p = 0.002).

29. Strokes and Earthquakes From: Sokejima S, et al. Seismic Intensity and risk of cerobrovascular stroke. Prehospital & Disaster Medicine. 2004

30. Cardiac emergencies more than tripled for men and doubled for women on days the German team played Win v. loss not important “Knock-out” games provoked the highest level of stress and resulting events Risk was highest for those with heart disease (4-fold increased risk) MI and World Cup Soccer Wilbert-Lampen U et al. NEJM 358:475-483 Jan 2008

31. MI and World Cup Soccer Wilbert-Lampen U et al. NEJM 358:475-483 Jan 2008

32. Elderly less likely to receive aid • stigma associated with receiving aid • concern about loss of other entitlements • Great Depression self-reliance causes some to feel that others need the help more than they do • difficulty navigating complicated bureaucratic systems • accustomed to having a spouse who took care of these things for them • lack of familiarity with on-line applications or personal computers • low reading skills or language barriers. • As a result, older adults have greater difficultly in achieving economic recovery following a disaster

33. Resilience • Elderly show better overall psychological recovery • Elderly report fewer physiological symptoms of stress and lower rates of MDD, PTSD and GAD compared with younger adults • Factors associated with resilience include higher levels of preparedness, improved coping gained from past experiences

34. Some elderly require special planning for preparedness • Advanced age or frailty • Cognitive impairment • Severe mental illness • Poor physical health, complex medical illness, sensory/mobility impairment • Lack of close family caregivers or local social supports • Need for electricity for medical devices • On-going cancer treatments

35. Phases of disaster response • Preparation for natural disasters one is likely to encounter • Early response • Late response

36. Preparation • Train first responders to deal with frail elderly, including sensitivity to sensory impairment and cognitive impairment. • Establish services for frail elderly or dementia patients and contingency plans in the event the primary plan falls short. • Identify programs that deal with the elderly; make prior arrangements with the state or federal agencies in charge to involve these programs in recovery efforts. • Evacuate elderly to shelters appropriate for their needs if no other option. Best to shelter in place if not in an evacuation zone. • Screen older patients for disaster preparedness and special needs.

37. Preparation Have list of medications and indications Have at least two weeks supply of medication on hand Prepare for loss of electricity (charge phone; motorized wheelchair) Batteries, flashlights, cooler, gasoline in car, Critical papers in a sealed waterproof easy to carry container Know of special needs shelter and have at least one week supply of non perishable food, water (and same if have a pet)

38. Early Response • Administer psychological first aid: safety, information, reassurance, restore psychosocial supports and sense of connectedness, hope, self- and community-efficacy. • Aid distribution should be accessible to the elderly • Outreach to most vulnerable community-residing elderly • Relocation v. Shelter in place • Make primary care and mental health services and medications available. • Attend to grief and spiritual issues • Recognize signs of being overwhelmed (looking glassy-eyed, unresponsive, strong emotional responses, uncontrollable crying, regressed behavior, frantic searching, incapacitating worry) and offer support, care

39. Late Response • Provide geriatrics specific care (primary care and mental health) to deal with the long-term negative impact of disaster on elderly. • Address new transitions in housing and adjustment to new care providers that may result in enduring stressors, particularly for the elderly who require supervised settings such as nursing homes. • Restore routine services and continuity of care.

40. Web resources • AAGP and GMHF Consumer Brochure on Disaster Preparedness. http://www.gmhfonline.org/gmhf/consumer/disaster.html • CDC Disaster Planning Goal: Protect Vulnerable Older Adults. 2007. www.cdc.gov/aging/pdf/disaster_planning_goal.pdf. • Florida Dept. of Elder Affairs. Disaster Preparedness Guide for Elders. http://elderaffairs.state.fl.us. • EM-DAT : The OFDA/CRED International Disaster Database. http://www.em-dat.net, Disaster Ocurrence. Belgium • Disaster Occurr. U.S. Dept. of Health and Human Services. Mental Health All-Hazards Disaster Planning Guidance. DHHS Pub. No. SMA 3829. Rockville, MD: CMHS, SAMHSA 2003. http://download.ncadi.samhsa.gov/ken/pdf/SMA03-3829/All-HazGuide.pdf