The Vulnerable Geriatric Casualty

By Rothman, Marc Brown, Lisa M

A daunting challenge. When Hurricane Katrina struck New Orleans in 2005, more than 70 percent of fatalities resulting from the storm were among people age 60 or older. The older population is particularly vulnerable to disasters, which obviously place a severe strain on the medical and social service networks that support them. The events of 2005 challenge us to better understand the needs of vulnerable elders in case of future events (Louisiana Department of Health and Hospitals, 2006). Acute injuries, dangerous evacuations, unfamiliar surroundings, and altered routines can all act as precipitants for a host of adverse medical outcomes among older casualties. And because large numbers of vulnerable older casualties will utilize healthcare resources at a high rate, older people pose a unique challenge for medical planners, first responders, triage and treatment facilities, and recovery efforts alike.

For disaster planning purposes, the vulnerable older population at highest risk consists primarily of those with disabilities, those with dementia or other cognitive impairment, and nursing home residents. They are all at very high risk for a range of adverse outcomes such as worsening disability, immobility, delirium, dehydration, malnutrition, pressure sores, and side effects or withdrawal from medications. What follows is a summary of the particular medical needs of vulnerable older people during and after disasters, strategies for medical triage and treatment, and special considerations for older people during the recovery phase of catastrophic events.

FUNCTIONAL STATUS

Disability, or impaired functional status, is the primary window through which to view the effects of disasters on vulnerable older people. Disability in older people is defined as needing assistance with any activity of daily living (ADL). Basic ADLS include transferring in and out of bed, walking, using the toilet, and bathing (Katz et al., 1963). More complex ADLS, called instrumental activities of daily living (IADLS), include managing finances or medications, meal preparation, and light housework (Stuck et al., 1999). People with any disability are the ones most likely to suffer a decline in their functional status during or after a disaster. Such a decline can lead to further disability, which in turn can cause illness, hospitalization, or even death if not quickly recognized and addressed.

For example, a frail older man who lives alone may have diabetes, vision loss, and an arthritic shoulder. A home attendant assists him with cooking (because of his poor vision and the shoulder), and a visiting nurse assists him with medication management (because of the vision). The man can do well under normal circumstances, dependent on others yet well supported and healthy. But if disaster strikes and he is alone for too long, he can quickly become dehydrated, weak, and dizzy. These symptoms together may cause a fell, and if he is unable to get up because of his arthritic shoulder, he may quickly become delirious or develop a pressure ulcer, which, in a person with diabetes, can easily become infected. By the time the man is found and moved to a safe place, he can no longer walk, is agitated and confused, and requires acute medical care (Henderson, 2005).

This example highlights how the problems of vulnerable older people are like pebbles dropped into still water, creating ripple effects that cause new problems. Such a rapid decline, often seen in older people during and after disasters, mimics the effects of hospitalization and immobility. Research on the hazards of hospitalization for frail older people has shown that within two days the immobile hospitalized elder begins to have skin and muscle breakdown, sensory deprivation, altered sleep patterns, and is at high risk for delirium and confusion (Creditor, 1993). The situation is similar in disasters, where the support systems of vulnerable elders can disappear quickly, and the only direction to go is down. Thus does functional status before a disaster define vulnerability during a disaster.

Assessment and support of functional status in older people are critical for reducing suffering, avoiding life-threatening complications, and improving outcomes before, during, and following a disaster. In inpatient and outpatient settings, geriatricians routinely use comprehensive assessment tools based on a tiered approach, first assessing basic ADLS and then IADLS. Some of these assessment tools have been successfully adapted to the disaster setting (see Burnett, Dyer, and Pickins, this issue).

MOBILITY

One of the most important ADLS is the ability to ambulate. And while it is not absolutely necessary in routine daily life, the ability to walk becomes highly important before, during, and after a disaster. Anyone who is immobile, or becomes so because of the disaster, will have tremendous difficulty evacuating, seeking appropriate shelter, and gaining access to needed relief supplies, personnel, or services.

Keeping older people mobile should be a high priority in the response, mitigation, and recovery phases of any disaster. To that end, mobility assessment should be a routine part of any geriatric casualty evaluation. Does the person use a walker, a cane, or a motorized wheelchair? If so, can these devices be evacuated with the person, or provided at the place of shelter? Mobility aids like canes and walkers should be considered lifesaving equipment for vulnerable elders and should be stockpiled alongside medications and other emergency supplies. In shelters or other impromptu settings, elders can be assessed for mobility by being observed getting up from a chair and walking 10 feet with whatever device they typically use (Mathias, Nayak, and Isaacs, 1986). People who cannot get up without assistance may require a special-needs shelter where aides and resources are within closer reach (if such a shelter is available; expecting them to walk across a crowded shelter or wait in long lines for food or services is unrealistic). Alternatives to standard-issue cots may be needed for those who cannot get up and down from them safely and effectively. Additional changes to the environment that may be necessary include removal of physical hazards that could cause tripping or falling on the floors or in walkways, bringing necessary services closer to the frail elders, or recruiting volunteers to assist them with using the toilet and moving safely from one place to another.

DEMENTIA AND DELIRIUM

People with dementia are at very high risk for isolation, suffering, and even death during disasters (Huus, 2005). Those without a fulltime caregiver or attentive family member can rapidly become confused or delirious in a new environment after being evacuated. They may not be able to express their needs to safety officials, shelter coordinators, or volunteers, and they may not ask for help when in distress. The ability to recognize and distinguish dementia and delirium should be mandatory for all "first responders" and shelter personnel or volunteers.

While dementia is a chronic condition characterized by memory loss and confusion, largely stable over time, delirium, by contrast, is acute, life-threatening, and reversible. It is often heralded by a rapid decline in functional status and is characterized by confusion that waxes and wanes and by inattentiveness. Delirium can be obvious or insidious. While it is easy to recognize a delirious person who is agitated, yelling and screaming, one can easily overlook a delirious older person who sits quietly alone, apparently content. This person may in fact be extremely confused about his or her surroundings, personal needs, or the available resources to meet those needs. Both forms of delirium can be life-threatening, especially if the condition leads to a fall or injury, dehydration, or lack of self-care. Given the association between delirium and increased morbidity, mortality, and costs, no evaluation of geriatric casualties would be complete without assessment of their mental (or cognitive) status (Inouye, 2006).

Tools for screening include the Confusion Assessment Method (CAM) and the Folstein Mini-Mental State Exam (Inouye, 2006; Folstein, Folstein, and McHugh, 1975). The former is geared specifically for delirium, while the latter generally assesses baseline cognitive status. Assessment of mental status has been successfully adapted for the disaster setting; details of that assessment methodology will be discussed in a subsequent chapter (see Brown, this issue).

Once detected, delirium can initially be treated nonpharmacologically. If, however, medications are needed, low doses of antipsychotic medications are considered the safest and most effective approach (Inouye, 2006). By contrast, antianxiety medications frequently cause sedation, falls, or produce an effect opposite that which was intended, agitating instead of calming the older person.

FALLS AND TRAUMA

Falls are common among older people and can lead to fractures, bruising, and delirium. Older people with injuries should always be asked about recent falls and their complications. In addition, service providers should inquire about the possibility of abuse or neglect for elders who appear to have multiple injuries (Geroff and Olshaker, 2006). Injuries play an important role in functional decline among the older population, because even a sprained wrist can create a new disability and have a deleterious effect on performance of ADLS. A bad fall, even without a fracture, can lead to pain, bruising, and immobility, which itself can lead to ulcers, blood dots, or dehydration. Unfortunately, older trauma victims are less likely than younger people to receive appropriate referral from triage in an emergency or disaster (Phillips et al., 1996). This discrepancy occurs despite clinical practice guidelines for triage treatment of older people that recommend a lower threshold for transfer to a higher level of care, and research showing that age alone is a poor predictor of outcomes in such patients (Jacobs et al., 2003; Phillips et al., 1996). Thus, timely assessment, rapid triage, and a low threshold for transfer of viable geriatric trauma victims to a higher level of care are all important strategies for improving survival and preserving function for older people with falls and other disaster-related injuries.

DEHYDRATION AND MALNUTRITION

Dehydration and malnutrition are common problems among older people living alone in the community. While these conditions are often the result of insufficient intake, they may be exacerbated by medications (or combinations of medications) that affect water balance and appetite. Diuretics, for example, are widely used and can cause dehydration. Gastrointestinal side effects of multiple medications can reduce appetite and cause bloating or cramping and can lead to malnutrition over time. Dehydration is a potent risk factor for confusion and falls, while malnutrition causes weakness and impairs wound healing in trauma or surgical patients. Assessment for dehydration in the older person should include examination of a patient’s mucous membranes and skin turgor (elasticity), and measurement of orthostatic blood pressures (first lying down; then again after standing for three minutes). Where oral intake of fluids is not enough to correct dehydration, intravenous resuscitation may be necessary. Malnutrition can be assessed by looking for muscle wasting in the arms, legs, or between the ribs; can be measured by checking plasma albumin or pre-albumin levels; or can be detected by serial weights, a routine practice in nursing homes. Barriers to good nutrition include confusion, forgetfulness, ill-fitting dentures, or chewing and swallowing difficulties caused by neurologic disorders (i.e., Parkinson’s disease or stroke). To maintain healthy eating habits and nutrition in the disaster setting, shelter coordinators should encourage regular meal times, make sure that those who need it receive help cutting their food or eating, and procure nutritional supplements for older people who show signs of having lost weight.

PRESSURE ULCERS

Pressure sores or ulcers in disabled older people are a common problem in everyday lifeexpensive to treat, associated with pain and infection, and causing impairment or hinder functional recovery after a hospitalization, or a disaster (Lyder, 2003). Indeed, in addition to the usual risk factors common to older people, like poor skin tone, malnutrition, and immobility, the shelter environment poses particular risks, which can be mitigated if recognized. For example, older evacuees may have difficulty getting in and out of cots, so they may lie down for long periods, putting undue pressure on some areas of their bodies. Sleeping on floors or chairs can also place such pressure on the buttocks, hips, or heels.

Prevention of pressure ulcers should focus on assessment, maintenance of mobility, and changing the environment as needed (Reddy, Gill, and Rochon, 2006). When pressure sores do develop, initial treatments include keeping the area clean, applying daily dressings, and turning the person frequently. Infected pressure sores will require antibiotic treatment as well.

PROBLEMS WITH MEDICATION

During a disaster, a number of medicationrelated problems can arise for anyone, but older people are particularly at risk because they generally take more medications than younger people do and are more likely to experience adverse effects from the medications they take. They are more likely to experience the adverse effects of drug interaction, including kidney or liver damage, bleeding, or confusion, when they are treated with an added drug for an injury suffered during a disaster (Routledge, O’Mahony, and Woodhouse, 2004). The risk of drug interaction will be heightened by the lack of accurate medical records for casualties during a disaster. Older people taking narcotics for pain, or benzodiazepines for anxiety or sleep, will be at high risk for drug withdrawal if they do not have access to their regular medications during a disaster, with symptoms that can include agitation, hallucinations, hypertension, or seizure. Similar concerns exist for those who use alcohol or recreational drugs on a regular basis and then undergo a period of abstinence during the acute phase of a disaster. Stable continuation of antiseizure medications or insulin will be necessary to avoid bad outcomes in people with seizure disorders or diabetes.

Given the limit on the frequency and number of prescriptions filled by any given pharmacy, stockpiling medications for an emergency is not really a feasible option for most Americans. Instead, older people should maintain an up-to-date list of medications and should forward a copy of that list to a friend or family member in another area if there are warnings of an impending disaster (like a hurricane, fires, or a flood). Care providers at triage and treatment facilities or shelters should have a high suspicion for medication side effects, interactions, or withdrawal when faced with older casualties who are weak, confused, or have any new acute symptom (Blanda, 2006). And care providers need to remember the motto "start low and go slow," when starting older people on new medications.

In summary, the prevention, assessment, and rapid treatment of common geriatric problems like immobility, delirium, trauma, dehydration, malnutrition, pressure ulcers, and adverse drug effects will go a long way in our attempts to prevent death and reduce suffering for vulnerable geriatric casualties when the next disaster strikes.

REFERENCES

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Reddy, M., GiU, S. S., and Rochon, P. A. 2006. "Preventing Pressure Ulcers: A Systematic Review? The Journal of ‘the American Medical Association 296(8): 974-84.

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Marc Rothman, M.D., is a research fellow in geriatric medicine and clinical epidemiology, section of Geriatrics, Yale University School of Medicine, New Haven, Conn. Lisa M. Brown, Ph.D., is assistant professor, Department of Aging and Mental Health, Florida. Mental Health Institute, University of South Florida, Tampa.

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