This article is a review of basic, but important information about disaster planning considerations for older populations. The recent hurricane experiences in the South confirmed how critical this planning is, and the importance of early evacuation in saving lives. This is highlighted when comparing the official responses during Hurricane Katrina and Hurricane Rita. Advance preparations result in more control and safety in a dangerous situation.
In New Orleans, the delay in evacuation of older adults resulted in panic and confusion, without an easy solution. Those who could not be easily evacuated remained, sometimes at great cost. Gerontological nurses need to advocate for the planning and resources that would assist older adults in a safe and early evacuation if indicated. Adequate support personnel, transportation, and pre-positioned supplies should all be in place for use following a disaster event. Rescue is more costly than evacuation, in both resources and human suffering, and places both rescuers and victims at risk.
Each individual, facility, and community needs disaster and evacuation plans that are widely disseminated in advance of any disaster. These plans must address the unique needs of older adults. Hurricane Katrina demonstrated the importance of evacuation before the impact of disaster. When individuals have advance notice of an impending disaster, evacuation can be conducted in a more orderly, planned way to get older adults to safety. Hurricane Rita proved that even advance evacuation is not problem- free, but is well worth the effort.
Each facility needs to be prepared to be self-sustaining, to "shelter in place" for at least 72 hours. This requires having the resources and supplies to support at least minimal safe function. However, facilities in locations that could be isolated for longer periods of time should consider having even more supplies in reserve. Recent events may prompt gerontological nurses to ask themselves, their facilities, and communities - Are we prepared?
Nurses in large health care facilities and acute care centers in urban areas are likely to have resources for education and disaster planning to assist with disaster preparedness. However, nurses in the community or small or rural facilities may be left to think about disaster planning on their own. Issues specific to older adults are rarely addressed (Perweiler, Roush, & Tumosa, 2004). The purpose of this article is to provide nurses working with older adults with information on disasters and the effects of aging on older adults' response to disasters, and to offer specific suggestions for improving disaster preparedness to reduce adverse consequences for older adults.
A doctor (right) and nurse (left) with a Disaster Medical Assistance Team help a man being evacuated because of Hurricane Katrina at a convention center pickup site in New Orleans. FEMA photo/Win Henderson
Natural disasters are events caused by nature or emerging disease. Examples include earthquakes, hurricanes, floods, tornadoes, mudslides, tsunamis, and epidemics. Natural outbreaks, such as the avian influenza (bird flu), would be considered a natural event unless deliberate use of the organism could be identified. Examples of man-made or human-generated disasters are complex emergencies, technological disasters, material shortages, and other disasters not caused by natural hazards (Noji, 1997). Human-generated disasters include chemical, biological, radiological, and nuclear terrorism, war, transportation accidents, group violence (e.g., riots), and food or water contamination.
Traditionally, nurses have been prepared for natural disasters, and most facilities have plans for addressing those disasters. Until September 11, 2001, few thought about humangenerated disasters. Many nurses still do not feel vulnerable to such an attack, because they assume geographic targets are limited for this kind of disaster. Nurses are encouraged to participate in disaster planning for themselves and their patients that is comprehensive enough to address any kind of disaster, including human-generated disasters, and result in the best possible outcomes for their older patients.
EFFECTS OF DISASTERS OR BIOTERRORISAA EVENTS ON OLDER ADULTS
Studies indicate that older adults are at great risk during and after disasters, and attention needs to be paid to supporting them during these times. Steinberg et al. (2004) found an increase in serious ventricular arrhythmias among older patients in New York during the 3 months following the September 11, 2001 attack, compared to the prior 3 months. They proposed stress was a possible factor. During the same time frame, another study indicated that older adults were less likely to seek formal or informal help than younger adults (Adams, Ford, & Dailey, 2004). Although this study did not address issues related to aging, one would expect that the older participants would have had similar, if not more, psychological and health problems. Older individuals may not have sought assistance because it was not appropriate or accessible to them. So although it could be anticipated that older adults would experience the same or greater effects of disaster, they may not get as much assistance as younger individuals.
In another disaster situation, the Centers for Disease Control and Prevention [CDC] (2004) conducted an assessment 2 weeks after Hurricane Charley in August of 2004. They found that one-third of respondents who had an older individual in the home reported problems with medical conditions and difficulty getting routine care. The authors concluded that rapid community assessment should be conducted after a disaster to identify older adults' needs to plan services most effectively.
EFFECTS OF AGING CHANGES
Physiological changes of aging may make older individuals more vulnerable to biologic agents, early diagnosis more difficult, and responses to disasters more severe. As a result, it is likely that greater morbidity and mortality will result among older adults during and after disasters, whether natural or manmade. For example, illnesses affecting cardiac and respiratory function and mobility are common with advanced age and increase vulnerability to disasters.
The changes in pharmacokinetics may cause more susceptibility to chemical agents, and older individuals may become ill with smaller doses of agents. They are at increased risk of side effects and drug-drug interactions from antibiotics used for treatment or prophylaxis in the case of an infectious agent. Health professionals and caregivers need education on geriatric issues to help them respond appropriately to older adults during a disaster.
Overall, older adults are less likely than younger individuals to survive a serious injury. This may create challenges during a large disaster because triage protocols call for helping those in the best condition and most likely to survive first so they can help others. Ethical issues should be considered in advance of a disaster, such as who will make decisions related to the allocation of scarce resources and what criteria are used. Health professionals performing triage will need to be cognizant of the range of physical conditions among older adults to make accurate triage decisions that are not based solely on age.
Aging results in decreased efficiency of oxygen-C02 exchange and increased residual volume, in a population with a higher risk for respiratory diseases, such as emphysema. These pulmonary changes increase the risk from aerosolized biological or chemical agents that can further damage compromised tissue and result in severe respiratory distress. Decrease in subcutaneous tissue and increased capillary fragility result in thinner, more friable skin. This makes older individuals more vulnerable to agents absorbed through the skin, such as vesicants and corrosives, which may produce greater skin damage.
Older adults are more vulnerable to changes in fluid volume and electrolytes because of cardiovascular changes and the kidneys' decreased efficiency in regulating fluids. As a result, agents that induce vomiting or diarrhea can cause rapid dehydration and electrolyte imbalances. Rapid infusion of fluids coupled with the biologic or chemical agent can compound the effect of either and result in fluid overload, heart failure, or respiratory and renal complications. Disaster responders need to monitor older adults closely.
ALTERED PRESENTATIONS AND CHRONIC DISEASE
Altered presentation of illness is common in older adults and can confound the accurate diagnosis of a biologic agent by the patient's health care provider. Although an older adult might have a quicker and more severe response to an agent, it still may take longer to identify a biologic agent as the cause of an illness. As a result, the window of opportunity to make the diagnosis before others are exposed may be missed, and this can delay action to prevent further contamination.
The classic issues related to changes in presentation of illness include multiple organ pathology, polypharmacy, and significance of symptoms (Henderson, 2001). For example, medications (commonly beta blockers) can effect mental status, cause weakness, or affect heart rate, altering usual symptoms of biological agents. Temperature may be subnormal and the response to infection blunted, including changes in white blood cell count. Finally, symptoms of terrorist agents may be masked by the symptoms of multiple chronic diseases such as respiratory or cardiac illness. The clinician needs to consider aging changes, common conditions, and medications, and be skilled at identifying the patient's normal pattern and alterations in presentation of disease.
Response to a disaster event can also be affected by chronic illness. Diminished motor skills may make it difficult to escape from the release site of a chemical, biological, or other disaster event. Deficits in other activities of daily living can affect how older individuals are evacuated, as well as the type of assistance needed wherever they are taken. Cognitive impairment can affect older individuals' ability to figure out how to escape from danger or to follow directions from those in authority. After evacuation, the older adult may need ongoing care or assistance.
An important consideration when caring for older individuals during and following a disaster is meeting their mental health needs by helping them to cope with fear and anxiety. Their immediate reactions will be related to their cognitive and physical level of functioning, as well as to past experiences. They may experience psychological problems such as posttraumatic stress disorder. They also may have witnessed injuries and deaths in the past that have produced short- and long-term psychological trauma (Langan & James, 2005).
ARE NURSES AND FACILITIES PREPARED?
It is vital that nurses be knowledgeable about disaster preparedness and emergency response systems to be able to teach and prepare others in the community. Nurses are likely to be called on to participate in a disaster situation to some degree. As patient advocates, nurses have an obligation to assure that older adults' needs are addressed during a disaster.
To help develop educational materials, the authors reviewed the literature and training materials available on the topic (e.g., Department of Homeland Security, the American Red Cross, the Federal Emergency Management Agency). The Sidebar on page 24 offers websites for these and other Internet resources. Two of the authors for this article have had extensive training in disaster preparedness and education in the United States and Israel (Langan & James, 2005).
To gain the perspective of practicing geriatric nurses, the authors spoke informally with staff in clinical settings. The following questions were asked:
* What education or training do you feel like you need?
* What special concerns do you have for your geriatric patients related to these issues?
* What training have you had in relation to handling bioterrorism, chemical terrorism, or disasters?
* What preparations have been made in your facility and/or what preparations have you made personally or professionally for a disaster such as a terrorist attack?
As a result, concerns voiced by several parish nurses in the community, acute care nurses, and nurses in a skilled nursing facility were identified. Overall, the nurses did not feel very susceptible to a disaster, but recognized that they needed further education and preparation to effectively manage disasters, especially man-made disasters. Staff in the community and skilled nursing facilities felt especially illprepared, and were interested in resources and information to help them with disaster planning and response. Staff in the acute care setting felt they needed to learn more about the care of patients with problems like emerging infections, and families needed education on what to do in case of disaster. The following information was developed to assist nurses to determine disaster-planning needs for themselves and older adults in the community and in long-term care facilities.
WHAT SHOULD BE TAUGHT?
Nurses, as well as community residents, need general information on disaster preparedness, including bioterroism. Individuals need to be convinced that disasters can happen and that simple preparations can be made in anticipation of any kind of disaster. Various types of disasters should be discussed, as well as their likely consequences, and whether evacuation is necessary or if it is in everyone's best interest to stay and shelter in place.
For specific kinds of disasters, health professionals and older adults need to know who to notify about emergency situations, what their distinct roles are in preparing for and responding to disasters, when and how to evacuate, and who to call for assistance. It is comforting to understand that there are community agencies that will respond and what their roles are in emergency situations. An essential element in any preparedness education is to emphasize the necessity for personal preparedness, a family emergency plan, emergency supplies, medications, treatments, and assistance for those with disabilities. Specific recommendations for community and long-term care settings are given in the following sections.
In the community, the first issue is notification and education. Notification of impending disaster can best be accomplished by television with messages "crawling" across the bottom of the screen, radio announcements, senior center announcements, and by individuals notifying older adults by telephone or in person. Older adults in the community can take an active role in preparing for disasters by being personally prepared. They can assimilate this information and proactively prepare for emergency situations. Education can be provided for older adults through group meetings, lectures, videos, and handouts teaching them about disaster preparedness.
One of the fears mentioned by nurses in the community was that the older individuals would refuse to leave their homes stating, "I gotta go sometime. I am not leaving my house!" Education on planning and preparing may help prevent such reactions from elderly adults during a disaster. Materials could be distributed through senior centers, physician offices, or grocery stores. Marketing of information could target newspapers, radio, and television to encourage planning and preparing.
Frail older adults in the community who may need help, particularly those who are disabled or need assistance, must be identified and located. This can be accomplished through churches, neighborhood associations, community centers, and Meals on Wheels records. It would be very helpful if the most vulnerable could be registered at a local fire station or Emergency Medical Services facility. Perhaps a database could be created listing those in need of assistance in emergencies and their individualized assistive devices and supplies.
Families should be taught how to assist older relatives during a disaster. Older adults in the hospital may be discharged to make room for emergency patients. Even if the older adult is already at home, usual medical care or home health care may not be available, and additional assistance may not be available. Families may have to meet the needs of elderly family members if formal support systems break down during a disaster situation.
It is important for the older adult to maintain an accurate list of current medications, doses, and times of administration in an easily accessible and secure place. They should also keep a packet of information in a portable container that can be moved with them during evacuation, together with a bag or box of necessary supplies in waterproof containers, clearly marked with name, address, and phone number. The Sidebar on page 24 provides a list of evacuation materials suggested by the American Red Cross (2001). In addition, an emergency kit should be assembled to keep on hand at home (Figure 1).
Figure 1. Sample emergency kit.
A mnemonic for EMERGENCIES was developed to review key points in disaster awareness (Sidebar). It explains some basic guidelines to share with older adults related to disaster and emergency preparedness that can be made into a pocket guide for educational use.
During and after a disaster, residential facilities face the management of large numbers of older adults with many medical and physical needs. Disaster plans must be comprehensive and address both supplies and evacuation. Although the goal of community responders is to provide all medical facilities with consistent support and supplies, facilities may need to be self-sufficient for a period of time following a disaster event. The recommendation is to plan for 72 hours. Medications, food, and any other supplies should be available for that time period and portable so they can accompany residents if relocation becomes necessary. Evacuation plans should be specific and address where residents and staff should go, how they will get there, and the details of evacuation.
Medications for older patients are a significant challenge during and after a terrorist attack or disaster. A portable case containing medications for each unit or floor's residents should be ready to be evacuated with residents. Individual medications could be placed in secure containers with medical and medication history and attached to wheelchairs. To assure that medications are current, they would need to be checked regularly by a professional nurse.
Figure 2. Medical Administration Record.
Figure 3. Plastic tubing emergency kit.
Examination of existing items, such as the Medicine Administration Record (MAR), should be conducted to determine their use and portability during a disaster. The MAR, which often includes a photo of the resident, would be very useful if residents are relocated to an evacuation center where nurses unfamiliar with these residents are administering medications. (See Figure 2 for a sample MAR.) Facilities with computerized medication systems may provide a CD-ROM with current medications and patient history that can accompany residents. At one facility, plastic tubing was used to devise emergency kits to hold necessary items for the safe evacuation of residents (Figure 3).
Other supplies should be addressed in disaster plans. Identification bands are critical in the event of the evacuation of residents with dementia who may not be able to tell caregivers their names or their address, and may be helpful for rescuers evacuating the older individual. Light sticks could be pinned onto wheelchairs or clothing to provide an easy way of locating residents relocated during the night or in areas without power.
Masks may provide some protection of the respiratory tract during evacuation, although they are not substitutes for more sophisticated equipment. These can be stored in identified tubes and placed with hook-and-loop fasteners to the arm or back of a wheelchair during an emergency. They could also be stored in a carton or hanging shoe rack, and a primary caregiver could be assigned with attaching them to wheelchairs for evacuation when directed by the professional.
In addition to supplies, advance planning must include methods for moving residents with adequate personnel, or plans to protect residents within the facility itself. When helping older adults who require assistance during evacuation, it is important to speak clearly, to not shout, and to face the individuals so they may lip-read if they are hearing impaired. There may be confusion about what is occurring, causing older individuals to struggle against needed treatments, safety equipment, or evacuation. The health care providers' personal protective equipment can be frightening. Health care providers must remain calm and reassuring, yet firm in their directions. It is important to move quickly and confidently, without causing panic and further disorientation (Langan & James, 2005).
The authors reviewed information about disaster planning with staff at a local skilled nursing facility. Subsequent meetings and discussions revealed that a connection had been established between the facility and the local fire department, including an onsite inspection and discussion of the expectations of the facility and the fire department in case of an emergency. Also, a Disaster Response Committee was set up, held regular meetings, and established protocols to be implemented in the event of a disaster. A computer-based disaster-training program was developed for use with staff and families. Awareness of disasters resulted in a comprehensive planning process so the facility was prepared.
The vulnerability of older adults to the effects of disasters is summed up by Fernandez, Byard, Lin, Benson, and Barbera (2002) as they report their research findings:
[It is] their impaired physical mobility, diminished sensory awareness, chronic health conditions, and social and economic limitations that prevent adequate preparation for disasters, and hinder their adaptability during disasters. Frail elderly, those with serious physical, cognitive, economic, and psycho-social problems, are at especially high risk. (p. 67)
Nurses and others involved in disaster planning need to consider the special needs of this population and take their concerns into account in local, regional, and national planning. In addition, nurses need to work with community-dwelling older adults and long-term care facilities to make sure they are prepared for disasters. Much can be done to educate them and help them plan. This article provides information that the authors hope will encourage geriatric nurses to take an active role in addressing disasters in their local communities to promote disaster planning that may mitigate adverse consequences for older adults.
- Adams, M.L., Ford, J.D., & Dailey, W.F. (2004). Predictors of help seeking among Connecticut adults after September 11, 2001. American Journal of Public Health, 94(9), 1596-1602.
- American Red Cross. (2001). Terrorism: Preparing for the unexpected. Retrieved September 29, 2005, from www.redcross. org/static/file_cont2 1_lang0_15.pdf
- Centers for Disease Control and Prevention. (2004). Rapid assessment of the needs and health status of older adults after Hurricane Charley: Charlotte, DeSoto and Hardee Counties, Florida, August 27-31, 2004. MMWR, 53(36), 837-840.
- Fernandez, L. S., Byard, D., Lin, CC, Benson, S., & Barbera, J.A. (2002). Frail elderly as disaster victims: Emergency management strategies. Prehospital and Disaster Medicine, 17(2), 67-74. Retrieved June 18, 2003, from www.seas.gwu.edu/ ~icdm/67-74%20Fernandez.pdf
- Henderson, M. L. (2001). Assessing the elderly: Altered presentations. In G.R. Hall, MX. Henderson, & M. Smith (Eds.), Assessing the elderly. Philadelphia: Lippincott, Williams & Wilkins.
- Langan, J.C, & James, D.C. (2005). Preparing nurses for disaster management. Upper Saddle River, NJ: Pearson/Prentice Hall.
- Noji, E.K. (Ed.) (1997). The nature of disaster: General characteristics and public health effects. In The public health consequences of disasters (pp. 3-20). New York: Oxford University Press.
- Perweiler, E., Roush, R., & Tumosa, N. (2004). Making preparations: GECs work to advance mission on bioterrorism and emergency preparedness planning for an aging population. Aging Successfully, 14(3), 3-4. Retrieved January 15, 2005, from http://medschool.slu. edu/agingsuccessfully/newsletters/SLU-Fall2004_Vol3.pdf
- Steinberg, J. S., Arshad, A., Kowalski, M., Kukar, A., Suma, V., Vloka, M., Ehlert, F, Herweg, B., Donnelly, J., Philip, J., Reed, G, & Rozanski, A. (2004). Increased incidence of life-threatening ventricular arrhythmias in implantable defibrillator patients after the World Trade Center attack. Journal of the American College of Cardiology, 44(6), 1261-1264.