At a recent climate and health conference, Gina McCarthy, former Environmental Protection Agency (EPA) Administrator (2013–2017), noted that nurses are the key group of health professionals who can address climate change mitigation and adaptation with their patients and communities. Addressing the impacts of climate on health is particularly important for nurses who practice, teach, and conduct research related to older adults. Scientific evidence indicates that older adults have specific climate-related vulnerabilities that must be addressed through climate mitigation, adaptation, and resilience. Nurse scientists are at a critical juncture to generate the knowledge necessary to address the health needs of older adults related to climate change. This commentary will provide a brief survey of the health impacts of climate change for older adults, identify the gaps in the gerontological nursing research, and highlight areas for research to address the significant gap in nursing science.
The impact of anthropogenic greenhouse gases generated from burning of fossil fuels (e.g., coal, gas, oil) for energy has led to extreme weather events, such as prolonged heat waves, droughts, wildfires, stalled weather patterns, and displacement of people (U.S. Global Change Research Program [USGCRP], 2018). The evidence of climate-related disasters—such as Hurricanes Irma (FL), Harvey (TX), and Maria (Puerto Rico) in 2017; the Northern California wildfires in 2018 and 2019; wildfires in Los Angeles in 2019; severe flooding of the Midwestern United States between January and June 2019; historic heat waves in Europe and India in June 2019 (hottest month ever recorded); and extreme flooding in Japan in July 2019—affect the health of older adults in each of these regions of the United States and globally.
Despite the holistic perspective of professional nursing practice, environmental health (and climate change in particular) has not been an area that has engaged large numbers of nurse scientists. In addition, most nurse scientists have not made the connection between their area of inquiry in the face of the realities of climate change. A review of nurse-authored research related to climate change between 2014 and 2019 using the terms climate change and nursing research or nursing in CINAHL, PubMed, and Scopus yielded only one article that specifically examined the needs of older adults in relation to climate change (Leyva, Beaman, & Davidson, 2017). Although developing the science in this area has the potential to save and improve the lives of older adults, nurse scientists have been slow to produce a climate research agenda (Leffers & Butterfield, 2018).
Climate Health Risks
Climate change creates health risks that are unique to older adults, and these risks require scientific inquiry. Climate-related weather extremes of heat waves, large amounts of precipitation (rain, snow), extreme cold, droughts, wildfires, and increases in air pollution and vector-borne diseases all create additional health challenges for older adults who often are living with comorbidities, a wide variation of age-related changes, and economic and physical limitations. Nurse scientists must consider these climate-related environmental conditions when addressing the science for an aging population.
Climate-related heat waves are often the most obvious health impact for older adults. In fact, according to the U.S. National Oceanic and Atmospheric Administration (NOAA, 2019), 2016–2018 had the hottest recorded land and ocean surface temperatures globally, with 2019 proving to continue the trend of high land temperature. This warming trend is important when studying the needs of older adults, as they have reduced thermoregulatory responses that are influenced by metabolic rate, peripheral circulation, subcutaneous fat, comorbidities, hydration, nutrition, and medication regimens, making them more vulnerable to heat (Miller, 2019). Risk of mortality for older adults is increased during the first heat wave of the season (Liss, Wu, Chui, & Naumova, 2017), and urban heat islands put older adults at greater risk. Heat islands occur when the concentrated human activity of a city generates additional heat that becomes trapped and instead of cooling after dark the area remains hot through the nighttime. Thus, the body is not able to recover from the heat experienced during the day (Opitz-Stapleton, 2014). Despite the risks of heat islands in urban settings, older adults living in rural areas have been found to be at greater risk of heat-related hospitalizations. Researchers speculate that this difference may be related to cities addressing heat risks, such as heat warning communication systems, cooling centers, and community outreach (Jagai, Grossman, Navon, Sambanis, & Dorevitch, 2017). Health disparities and susceptibility to climate change illnesses in older adults in rural communities may also be driven, at least in part, by disparities to access of quality health care and availability of geriatric-focused health care providers, geographic isolation and transportation issues, and economic instability (Durazo et al., 2011).
Older adults' living situations also influence their heat response. Older adults' individual adaptive responses to rising indoor temperatures during heat waves were associated with type of residence (e.g., single family dwelling having higher indoor temperatures); however, regardless of housing type, older adults most frequently opened their windows or doors, used room fans, or left the house in response to heat (White-Newsome et al., 2011). The NOAA (2016) noted that 50% of heat-related deaths in the United States were among people age >59 years, and the greatest risk of succumbing to heat were for people living in their own homes without air conditioning. These findings highlight the double burden that heat and socioeconomics play for low-income older adults who are unable to afford air conditioning or caregiver support during extreme heat events. These social determinants of health, economic, environmental, and social conditions influence older adults' likelihood to exposure and their susceptibility to climate-related issues (National Academies of Sciences, Engineering, and Medicine, 2016). Tips to address heat for older adults are offered by the National Institute on Aging (access https://www.nia.nih.gov/health/hot-weather-safety-older-adults).
Air Quality and Climate Change
Poor air quality from fuel combustion (factors that cause climate change), the changing climate, and extreme weather events (Fiore, Naik, & Leibensperger, 2015) can negatively influence the health of older adults. Rising ground level ozone on hotter sunny days can exacerbate existing respiratory diseases (e.g., chronic obstructive pulmonary disease) and continued exposure to ozone can cause pulmonary irritation of healthy lungs. Currently, particulate matter (PM) has not been noted to be directly impacted by climate change (EPA, n.d.). However, climate-related events, such as wildfires and brush fires, raise levels of fine and ultrafine PM locally and at a distance (Poole et al., 2019). Depending on geography and weather patterns, air pollution from wildfires can travel as far as 5,000 miles from the site of the fire (Loftis, 2015). Exposure to fine PM (PM2.5) has been associated with lower cognitive function in older adults (Ailshire & Clarke, 2015; Power, Adar, Yanosky, & Weuve, 2016; Shou et al., 2019), high blood pressure, and non-fatal myocardial infarctions (Fang, Cassidy, & Christiani, 2010).
Elevated pollen levels have also become an air quality issue for older adults. With an earlier pollen season as the climate warms, pollen concentrations are higher, which lead to greater allergic responses (Poole et al., 2019). Nurse scientists can develop intervention studies to address adaptation to air quality. Such studies can rely on air monitors to measure ambient (outdoor), indoor, or existing air monitoring, such as the EPA's air quality index (AQI), related to health symptoms or decisions about outdoor activities related to ozone and PM levels. In rural areas, the AQI reading may be further from the older adult's home; therefore, using air quality monitors would provide more valid findings.
Another climate-related air quality problem for older adults is mold. Greater frequency of flooding from severe storms and sea level rise have increased mold risk in homes and care settings. With aging, the immune response is weakened (Miller, 2019), thus increasing the health risks from exposure to mold spores, which can range from mild allergic response, such as irritation of the mucus membranes, to long-term impacts, such as cancer or bleeding disorders (Jezak et al., 2016). Nurse scientists can address mold prevention and response measures related to health outcomes of older populations in flood prone areas.
Medication Management in Climate Change
Many older adults have chronic illness with comorbidities that require medication management. Furthermore, with aging, thermoregulation is slowed making some medications, such as diuretics, antihypertensives (e.g., ACE inhibitors, angiotensin II receptor blockers), and psychiatric medications, a greater risk to older adults during heat waves. When new medications, including over-the-counter medications, are added, the risk of heat-related problems, such as dehydration and delirium, can be amplified (Fick, 2018; Fick, Steis, Mion, & Walls, 2011; Westaway et al., 2015). For example, the risk of lithium toxicity is increased when older adults take lithium carbonate during heat waves (Roxane Laboratories Inc., 2011).
Properly storing medications while considering indoor temperatures is an important part of safe medication management. A review of the literature found that there are no empirical studies regarding medication storage during extreme heat events. Newspapers and websites during extreme heat offer advice about storing medications that do not require refrigeration, stating that non-refrigerated medications should be stored at 58°F to 86°F (14.4°C to 30°C) and not above 86°F (McDermott-Levy, Kolanowski, Fick, & Mann, 2019). The nursing evidence related to effective, safe management of medications for older adults during emergency climate-related evacuations must be developed that addresses the unique needs in urban, suburban, and rural settings.
Vector-borne disease is not often addressed when discussing the health impacts for climate change related to older adults. Few studies have examined the proportion of older adults who are physically active outdoors, but one study using GPS data with 117 older adults found 37% to be active outdoors for more than 30 minutes per day. In the United States, the pathogens that are carried by mosquitoes and ticks can be a health risk for physically active older adults (Kerr, Rosenberg, & Frank, 2012). With warming temperatures, mosquito species that transmit pathogens, such as locally acquired Dengue, are moving northward into regions where they were not previously found (Sharp et al., 2014). More rain also creates an environment for greater mosquito breading in rural and urban settings (Franklinos, Jones, Redding, & Abubakar, 2019). The warming climate brings earlier springs, making earlier and longer tick seasons (Ogden & Lindsay, 2016) and more people spending time outdoors. Gerontological nursing researchers should consider the unique needs and interventions necessary related to vector-borne diseases for physically active older adults who spend time outdoors golfing, hiking, or visiting with friends.
Food Security and Nutrition
Nutrition is also affected by climate change. Droughts and floods can destroy crop production that is necessary for human and livestock consumption. These climate-related disasters also affect income and services in farming communities. Climate-stressed oceans and waterways have had decreases in seafood yields and greater risk of pathogen-contaminated seafood (NOAA, 2017). Extreme weather events can disrupt food distribution. In addition, scientists have found that wheat, rice, and soybeans grown in the presence of high CO2 have lower zinc and iron contents (Myers et al., 2014), and barley, wheat, rice, and potatoes have higher carbohydrates and less protein content (Taub, Miller, & Allen, 2008). The changes to the nutritional content of food influence the health of older adults in significant ways. Many low-income older adults are food insecure, and the consequences of older adults' poor nutrition compounds already existing conditions (Ianzito, 2015). These areas are critical to the health of older adults and require interdisciplinary research related to nutrition and food sources.
Shelter and Services
Comorbidities that influence the health outcomes of an aging population, such as cardiovascular, respiratory, renal, and metabolic diseases along with cognitive and mobility problems, make addressing climate-related issues particularly complex for nurse researchers. Many climate-related events, such as severe storms, heat waves, and wildfires, can disrupt health services and shelter, thus leaving older adults without access to health care services, treatments (e.g., medications, therapies), and adequate and safe shelter. Frequently during severe climate-related events, older adults must be evacuated and transported to safer places. This transportation creates risk of disruption of services and plans of care and cognitive changes, including delirium. The evidence for nursing care and responses to address these complex issues of climate mitigation and adaptation for the older population are needed.
Understanding Climate Science
Education regarding the health impacts of climate change is an important first step for nurse researchers (Leffers, McDermott-Levy, Nicholas, & Sweeney, 2017). Nurse scientists must be aware of basic climate science; how the changing climate affects the health of older adults; climate-related policies, such as the Clean Air Act and the Paris Agreement; and the strategies that support climate mitigation, adaptation, and resilience. As gerontological nurse scientists learn about climate and health, they should begin to see the intersection between their area of inquiry and climate impacts. Three reputable, online, free resources are available for nurses to learn more about the impact of climate change on human health. The first is the USGCRP (2016), which is a group of 13 U.S. federal agencies and departments that issues reports by leading scientists about the impacts of climate change on American society, including the health of American older adults. The USGCRP was formed by Congressional mandate and codified by the Global Change Research Act of 1990; therefore, regardless of the political debate that has stalled adequate climate responses, the state of the science regarding the impacts of climate change on society will be made available to government agencies and the public. The most recent report, issued in 2018, Volumes I & II of the Fourth Climate National Assessment, covers human health; however, the 2016 National Climate Assessment offers a comprehensive review of the scientific findings of the climate change influences upon human health (access https://s3.amazonaws.com/climatehealth2016/low/ClimateHealth2016_FullReport_small.pdf).
The second source is from the Intergovernmental Panel on Climate Change (IPCC; access https://www.ipcc.ch). Reports from this global body are issued by the world's leading climate scientists. The IPCC relies on scientific modeling to predict global impacts of climate. The third resource is the Alliance of Nurses for Healthy Environments (ANHE; access https://envirn.org), the only nursing organization that solely addresses environmental health. ANHE provides a variety of resources to learn about climate change and health. Among these resources are an open access electronic textbook with a chapter on climate change; a climate and health toolkit that provides foundational information about climate change; and a report, Climate Change, Health and Nursing: A Call to Action. In addition, ANHE has a global climate change committee and a research workgroup with monthly calls that include environmental health research methods and speakers sharing the current science.
Research Questions and Challenges
Once nurse scientists understand the impact of climate change on the health of the older adult population, it is important to consider moving from an interprofessional health research lens (with other health care professionals) to an interdisciplinary research agenda that may include collaboration with scholars in communications, engineering, political science, health administration, environmental science, law, physics, theology, and public health. The causes and impacts of climate change are complex and require expertise from a variety of fields. For example, nurse scientists could work with environmental scientists and law scholars to examine the impact of air quality policy changes on health outcomes of older adults. Table 1 offers research questions that should be addressed from an interdisciplinary perspective for nurses to support promotion and maintenance of the health of older adults in the face of climate change.
Research Questions for Interdisciplinary Gerontological Research
In 2010, the National Institute of Environmental Health Sciences (NIEHS) of the National Institutes of Health (NIH) published a report outlining the gaps in the research related to climate and health (Portier et al., 2010). Climate-related health risks and vulnerable populations, including older adults, were identified. However, at the time of writing this commentary, the NIEHS is not currently funding climate-related research. The NIEHS website directs investigators to consider a R01 grant that supports investigators' area of research and competencies related to health, which could include climate-related health impacts. Although climate change is clearly a nursing issue, the National Institute of Nursing Research has not identified climate and health as a nursing research priority. Despite this shortcoming, it is important to build capacity of gerontological nurse scientists who can link their current program of research to climate and health. For example, nurse scientists studying cardiovascular disease, dehydration, or delirium in older adults can move into the impact of climate-related influences in those areas. Through R24 grants, the NIH funds infrastructure grants to build science and mentoring in specific areas—climate change could be one of those areas. Large foundations, such as Robert Wood Johnson, have funding priorities that could be met with a climate and health focus. Sufficiently funded research related to climate effects on older adults is critical to address the needs of an aging population.
Once the evidence of climate-related scientific inquiry is analyzed and prepared for publication, gerontological nurse scientists must include climate change as a key term for the publication. Inclusion of this key term is important so that the findings are included in searches about climate change for older adults; that the health impacts are recognized by the scientific community; and that the important role of gerontological nurse scholars related to climate change is acknowledged.
Climate Change Through a Theoretical Lens
There are theoretical frameworks that can support scientific inquiry related to climate change. Three models are addressed herein that may be helpful as gerontological nurse scientists begin climate research related to older adults. Dixon and Dixon's (2002) Integrative Model for Environmental Health Research examines environmental exposures, such as climate change and its associated factors, using four domains: (a) physiological: health risks and consequences; (b) vulnerability: specific risks related to older adults at individual and community levels; (c) epistemological: individual's, health care providers', and community's thinking about climate change; and (d) health protection: actions people will take to reduce their climate risk. The Ecological Planetary Health Model (Leffers et al., 2017) examines climate impact through a systems approach with consideration of social, cultural, economic, and environmental determinants of health and the climate strategies (i.e., mitigation, adaptation, and resilience) that protect and maintain health. Lastly, like the two previously mentioned models, the Conceptual Framework for Climate Health and Wellbeing (Boylan et al., 2018) examines the factors that influence human responses to climate change, but this model also includes the consideration of the environmental degradation that led to human-caused climate change. As nurse scientists investigate climate and health impacts for older adults, these models may be further developed, and others may be modified to address the specific needs of aging adults related to climate change.
As Professor McCarthy shared, nurses play a key role in addressing the needs of the U.S. population related to climate and health. The older adult population in the United States has unique vulnerabilities and needs related to climate and health. Gerontological nurse scientists must begin to examine the health impacts and practices, including policies, that positively influence the health of older adults in the face of the changing climate. In addition, nurse scientists should examine the specific needs of older adults who live independently in the community and in assisted and long-term care facilities and consider the impact of climate change on health outcomes. Once evidence is generated, nurses should share findings not only within peer-reviewed literature but in the popular media and with policymakers. By generating the scientific evidence related to climate and health of older adults and disseminating findings widely, nurse scholars can advance gerontological nursing, influence the nexus of health and environmental policy, and subsequently promote and maintain the health of older adults.
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Research Questions for Interdisciplinary Gerontological Research
|What variables place older adults at greatest health risk during specific seasons or weather patterns?|
|What are the best methods to communicate climate risk and climate action to older adults and their care providers?|
|What do health care providers need to adequately address the specific climate needs of older adults?|
|What is the role of Area Agencies on Aging in helping older adults in extreme weather events?|
|What are effective methods to reduce mortality and morbidity during extreme weather events?|
|Are there unique climate-related responses that influence the health of older adults rela tive to a specific comorbidity?|
|How can health care providers promote self-efficacy for older adults to respond to regional climate changes?|
|How does a climate-related policy influence the health outcomes of older adults?|
|Does a family-based approach that includes grandchildren engage older adults in climate advocacy?|
|How can current older adult grassroots community models, such as Village to Village Network (access https://www.vtvnetwork.org/content.aspx?page_id=0&club_id=691012), address climate change in their community?|